LCD/NCD Portal

L28905 MAGNETIC RESONANCE IMAGING OF THE ORBIT, FACE, AND/OR NECK

 

 

07/07/2011

 

 

Indications and Limitations of Coverage and/or Medical Necessity

 

Medicare will consider MRI of the Orbit, Face, and/or Neck medically reasonable and necessary when used to diagnose and characterize pathology of the:

 

• Nasopharynx.

• Oropharynx.

• Neck including:

o Tumors.

o Infection.

o Soft tissue pathologies.

o Congenital abnormalities.

The MRI is not covered when the following patient-specific contraindications are present:

• MRI is NOT covered for patients with cardiac pacemakers or with metallic clips on vascular aneurysms unless the Medicare beneficiary meets the provisions of the following exceptions:

o Effective for claims with dates of service on or after July 7, 2011, the contraindications will not apply to pacemakers when used according to the FDA-approved labeling in an MRI environment, or effective for claims with dates of service on or after February 24, 2011, CMS believes that the evidence is promising although not yet convincing that MRI will improve patient health outcomes if certain safeguards are in place to ensure that the exposure of the device to an MRI environment adversely affects neither the interpretation of the MRI result nor the proper functioning of the implanted device itself.

 We believe that specific precautions (as listed below) could maximize benefits of MRI exposure for beneficiaries enrolled in clinical trials designed to assess the utility and safety of MRI exposure.

 Therefore, CMS determines that MRI will be covered by Medicare when provided in a clinical study under section 1862(a)(1)(E) (consistent with section 1142 of the Act) through the Coverage with Study Participation (CSP) form of Coverage with Evidence Development (CED) if the study meets the criteria in each of the three paragraphs in CMS Pub 100-03, CMS National Coverage Determination Manual, Chapter 1, Section 220.2.C.1

• MRI during a viable pregnancy is also contraindicated at this time.

• The danger inherent in bringing ferromagnetic materials within range of MRI units generally constrains the use of MRI on acutely ill patients requiring life support systems and monitoring devices that employ ferromagnetic materials.

• In addition, the long imaging time and the enclosed position of the patient may result in claustrophobia, making patients who have a history of claustrophobia unsuitable candidates for MRI procedures.

Nationally Non-Covered Indications:

• CMS has determined that MRI of cortical bone and calcifications, and procedures involving spatial resolution of bone and calcifications, are NOT considered reasonable and necessary indications within the meaning of section 1862(a)(1)(A) of the Act, and are therefore non-covered.

• When Magnetic Resonance Imaging is used for an investigational purpose, an acceptable advance notice of Medicare’s denial of payment must be given to the patient when the provider does not want to accept financial responsibility for the service.

• In some instances, MRI of the brain, as well as MRI of the orbit, face, and/or neck may be medically necessary on the same day.

o The medical record should document the medical necessity for these two procedures being performed on the same day.

• Initial imaging of the thyroid should be done with ultrasound or nuclear medicine, unless there is a known carcinoma present.

Coding Information

 

 

Bill Type Codes

 

• Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.

• Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.

• Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

 

12x Hospital Inpatient (Medicare Part B only)

13x Hospital Outpatient

14x Hospital - Laboratory Services Provided to Non-patients

21x Skilled Nursing - Inpatient (Including Medicare Part A)

22x Skilled Nursing - Inpatient (Medicare Part B only)

23x Skilled Nursing - Outpatient

75x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF)

85x Critical Access Hospital

 

Revenue Codes

 

• Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service.

• In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination.

• Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

 

0320 Radiology - Diagnostic - General Classification

0321 Radiology - Diagnostic - Angiocardiology

0322 Radiology - Diagnostic - Arthrography

0323 Radiology - Diagnostic - Arteriography

0324 Radiology - Diagnostic - Chest X-Ray

0329 Radiology - Diagnostic - Other Radiology - Diagnostic

0610 Magnetic Resonance Technology (MRT) - General Classification

0611 Magnetic Resonance Technology (MRT) - MRI - Brain/Brainstem

0612 Magnetic Resonance Technology (MRT) - MRI - Spinal Cord/Spine

0614 Magnetic Resonance Technology (MRT) - MRI - Other

0615 Magnetic Resonance Technology (MRT) - MRA - Head and Neck

0616 Magnetic Resonance Technology (MRT) - MRA - Lower Extremities

0618 Magnetic Resonance Technology (MRT) - MRA - Other

0619 Magnetic Resonance Technology (MRT) - Other MRT

 

 

CPT/HCPCS Codes

 

70540 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S)

70542 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITH CONTRAST MATERIAL(S)

70543 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES

 

 

ICD-9 Codes that Support Medical Necessity

 

017.30 TUBERCULOSIS OF EYE UNSPECIFIED EXAMINATION

017.31 TUBERCULOSIS OF EYE BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE

017.32 TUBERCULOSIS OF EYE BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION RESULTS UNKNOWN (AT PRESENT)

017.33 TUBERCULOSIS OF EYE TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY

017.34 TUBERCULOSIS OF EYE TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY BUT FOUND BY BACTERIAL CULTURE

017.35 TUBERCULOSIS OF EYE TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY

017.36 TUBERCULOSIS OF EYE TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)

017.40 TUBERCULOSIS OF EAR UNSPECIFIED EXAMINATION

017.41 TUBERCULOSIS OF EAR BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE

017.42 TUBERCULOSIS OF EAR BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION RESULTS UNKNOWN (AT PRESENT)

017.43 TUBERCULOSIS OF EAR TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY

017.44 TUBERCULOSIS OF EAR TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY BUT FOUND BY BACTERIAL CULTURE

017.45 TUBERCULOSIS OF EAR TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY

017.46 TUBERCULOSIS OF EAR TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)

017.50 TUBERCULOSIS OF THYROID GLAND UNSPECIFIED ORIGIN

017.51 TUBERCULOSIS OF THYROID GLAND BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE

017.52 TUBERCULOSIS OF THYROID GLAND BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION RESULTS UNKNOWN (AT PRESENT)

017.53 TUBERCULOSIS OF THYROID GLAND TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY

017.54 TUBERCULOSIS OF THYROID GLAND TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY BUT FOUND BY BACTERIAL CULTURE

017.55 TUBERCULOSIS OF THYROID GLAND TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY

017.56 TUBERCULOSIS OF THYROID GLAND TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)

036.81 MENINGOCOCCAL OPTIC NEURITIS

140.0 MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER

140.1 MALIGNANT NEOPLASM OF LOWER LIP VERMILION BORDER

140.3 MALIGNANT NEOPLASM OF UPPER LIP INNER ASPECT

140.4 MALIGNANT NEOPLASM OF LOWER LIP INNER ASPECT

140.5 MALIGNANT NEOPLASM OF LIP UNSPECIFIED INNER ASPECT

140.6 MALIGNANT NEOPLASM OF COMMISSURE OF LIP

140.8 MALIGNANT NEOPLASM OF OTHER SITES OF LIP

140.9 MALIGNANT NEOPLASM OF LIP UNSPECIFIED VERMILION BORDER

141.0 MALIGNANT NEOPLASM OF BASE OF TONGUE

141.1 MALIGNANT NEOPLASM OF DORSAL SURFACE OF TONGUE

141.2 MALIGNANT NEOPLASM OF TIP AND LATERAL BORDER OF TONGUE

141.3 MALIGNANT NEOPLASM OF VENTRAL SURFACE OF TONGUE

141.4 MALIGNANT NEOPLASM OF ANTERIOR TWO-THIRDS OF TONGUE PART UNSPECIFIED

141.5 MALIGNANT NEOPLASM OF JUNCTIONAL ZONE OF TONGUE

141.6 MALIGNANT NEOPLASM OF LINGUAL TONSIL

141.8 MALIGNANT NEOPLASM OF OTHER SITES OF TONGUE

141.9 MALIGNANT NEOPLASM OF TONGUE UNSPECIFIED

142.0 MALIGNANT NEOPLASM OF PAROTID GLAND

142.1 MALIGNANT NEOPLASM OF SUBMANDIBULAR GLAND

142.2 MALIGNANT NEOPLASM OF SUBLINGUAL GLAND

142.8 MALIGNANT NEOPLASM OF OTHER MAJOR SALIVARY GLANDS

142.9 MALIGNANT NEOPLASM OF SALIVARY GLAND UNSPECIFIED

143.0 MALIGNANT NEOPLASM OF UPPER GUM

143.1 MALIGNANT NEOPLASM OF LOWER GUM

143.8 MALIGNANT NEOPLASM OF OTHER SITES OF GUM

143.9 MALIGNANT NEOPLASM OF GUM UNSPECIFIED

144.0 MALIGNANT NEOPLASM OF ANTERIOR PORTION OF FLOOR OF MOUTH

144.1 MALIGNANT NEOPLASM OF LATERAL PORTION OF FLOOR OF MOUTH

144.8 MALIGNANT NEOPLASM OF OTHER SITES OF FLOOR OF MOUTH

144.9 MALIGNANT NEOPLASM OF FLOOR OF MOUTH PART UNSPECIFIED

145.0 MALIGNANT NEOPLASM OF CHEEK MUCOSA

145.1 MALIGNANT NEOPLASM OF VESTIBULE OF MOUTH

145.2 MALIGNANT NEOPLASM OF HARD PALATE

145.3 MALIGNANT NEOPLASM OF SOFT PALATE

145.4 MALIGNANT NEOPLASM OF UVULA

145.5 MALIGNANT NEOPLASM OF PALATE UNSPECIFIED

145.6 MALIGNANT NEOPLASM OF RETROMOLAR AREA

145.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED PARTS OF MOUTH

145.9 MALIGNANT NEOPLASM OF MOUTH UNSPECIFIED

146.0 MALIGNANT NEOPLASM OF TONSIL

146.1 MALIGNANT NEOPLASM OF TONSILLAR FOSSA

146.2 MALIGNANT NEOPLASM OF TONSILLAR PILLARS (ANTERIOR) (POSTERIOR)

146.3 MALIGNANT NEOPLASM OF VALLECULA EPIGLOTTICA

146.4 MALIGNANT NEOPLASM OF ANTERIOR ASPECT OF EPIGLOTTIS

146.5 MALIGNANT NEOPLASM OF JUNCTIONAL REGION OF OROPHARYNX

146.6 MALIGNANT NEOPLASM OF LATERAL WALL OF OROPHARYNX

146.7 MALIGNANT NEOPLASM OF POSTERIOR WALL OF OROPHARYNX

146.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF OROPHARYNX

146.9 MALIGNANT NEOPLASM OF OROPHARYNX UNSPECIFIED SITE

147.0 MALIGNANT NEOPLASM OF SUPERIOR WALL OF NASOPHARYNX

147.1 MALIGNANT NEOPLASM OF POSTERIOR WALL OF NASOPHARYNX

147.2 MALIGNANT NEOPLASM OF LATERAL WALL OF NASOPHARYNX

147.3 MALIGNANT NEOPLASM OF ANTERIOR WALL OF NASOPHARYNX

147.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF NASOPHARYNX

147.9 MALIGNANT NEOPLASM OF NASOPHARYNX UNSPECIFIED SITE

148.0 MALIGNANT NEOPLASM OF POSTCRICOID REGION OF HYPOPHARYNX

148.1 MALIGNANT NEOPLASM OF PYRIFORM SINUS

148.2 MALIGNANT NEOPLASM OF ARYEPIGLOTTIC FOLD HYPOPHARYNGEAL ASPECT

148.3 MALIGNANT NEOPLASM OF POSTERIOR HYPOPHARYNGEAL WALL

148.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF HYPOPHARYNX

148.9 MALIGNANT NEOPLASM OF HYPOPHARYNX UNSPECIFIED SITE

149.0 MALIGNANT NEOPLASM OF PHARYNX UNSPECIFIED

149.1 MALIGNANT NEOPLASM OF WALDEYER'S RING

149.8 MALIGNANT NEOPLASM OF OTHER SITES WITHIN THE LIP AND ORAL CAVITY

149.9 MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE LIP AND ORAL CAVITY

160.0 MALIGNANT NEOPLASM OF NASAL CAVITIES

160.1 MALIGNANT NEOPLASM OF AUDITORY TUBE MIDDLE EAR AND MASTOID AIR CELLS

160.2 MALIGNANT NEOPLASM OF MAXILLARY SINUS

160.3 MALIGNANT NEOPLASM OF ETHMOIDAL SINUS

160.4 MALIGNANT NEOPLASM OF FRONTAL SINUS

160.5 MALIGNANT NEOPLASM OF SPHENOIDAL SINUS

160.8 MALIGNANT NEOPLASM OF OTHER ACCESSORY SINUSES

160.9 MALIGNANT NEOPLASM OF ACCESSORY SINUS UNSPECIFIED

161.0 MALIGNANT NEOPLASM OF GLOTTIS

161.1 MALIGNANT NEOPLASM OF SUPRAGLOTTIS

161.2 MALIGNANT NEOPLASM OF SUBGLOTTIS

161.3 MALIGNANT NEOPLASM OF LARYNGEAL CARTILAGES

161.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF LARYNX

161.9 MALIGNANT NEOPLASM OF LARYNX UNSPECIFIED

170.0 MALIGNANT NEOPLASM OF BONES OF SKULL AND FACE EXCEPT MANDIBLE

170.1 MALIGNANT NEOPLASM OF MANDIBLE

171.0 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF HEAD FACE AND NECK

171.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF CONNECTIVE AND OTHER SOFT TISSUE

172.0 MALIGNANT MELANOMA OF SKIN OF LIP

172.1 MALIGNANT MELANOMA OF SKIN OF EYELID INCLUDING CANTHUS

172.2 MALIGNANT MELANOMA OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL

172.3 MALIGNANT MELANOMA OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE

172.4 MALIGNANT MELANOMA OF SKIN OF SCALP AND NECK

176.2 KAPOSI'S SARCOMA PALATE

176.8 KAPOSI'S SARCOMA OTHER SPECIFIED SITES

190.0 MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID

190.1 MALIGNANT NEOPLASM OF ORBIT

190.2 MALIGNANT NEOPLASM OF LACRIMAL GLAND

190.3 MALIGNANT NEOPLASM OF CONJUNCTIVA

190.4 MALIGNANT NEOPLASM OF CORNEA

190.5 MALIGNANT NEOPLASM OF RETINA

190.6 MALIGNANT NEOPLASM OF CHOROID

190.7 MALIGNANT NEOPLASM OF LACRIMAL DUCT

190.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF EYE

190.9 MALIGNANT NEOPLASM OF EYE PART UNSPECIFIED

193 MALIGNANT NEOPLASM OF THYROID GLAND

194.1 MALIGNANT NEOPLASM OF PARATHYROID GLAND

195.0 MALIGNANT NEOPLASM OF HEAD FACE AND NECK

196.0 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF HEAD FACE AND NECK

196.8 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF MULTIPLE SITES

198.5 SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW

198.89 SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES

200.01 RETICULOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

200.11 LYMPHOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

200.21 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

200.31 MARGINAL ZONE LYMPHOMA,LYMPH NODES OF HEAD, FACE, AND NECK

200.41 MANTLE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK

200.51 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK

200.61 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK

200.71 LARGE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK

200.81 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.01 HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.11 HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.21 HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.41 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.51 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.61 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.71 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.01 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.71 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK

202.81 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF HEAD FACE AND NECK

210.2 BENIGN NEOPLASM OF MAJOR SALIVARY GLANDS

210.3 BENIGN NEOPLASM OF FLOOR OF MOUTH

210.4 BENIGN NEOPLASM OF OTHER AND UNSPECIFIED PARTS OF MOUTH

210.5 BENIGN NEOPLASM OF TONSIL

210.6 BENIGN NEOPLASM OF OTHER PARTS OF OROPHARYNX

210.7 BENIGN NEOPLASM OF NASOPHARYNX

210.8 BENIGN NEOPLASM OF HYPOPHARYNX

210.9 BENIGN NEOPLASM OF PHARYNX UNSPECIFIED

212.0 BENIGN NEOPLASM OF NASAL CAVITIES MIDDLE EAR AND ACCESSORY SINUSES

212.1 BENIGN NEOPLASM OF LARYNX

213.0 BENIGN NEOPLASM OF BONES OF SKULL AND FACE

213.1 BENIGN NEOPLASM OF LOWER JAW BONE

215.0 OTHER BENIGN NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF HEAD FACE AND NECK

224.0 BENIGN NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID

224.1 BENIGN NEOPLASM OF ORBIT

224.2 BENIGN NEOPLASM OF LACRIMAL GLAND

224.3 BENIGN NEOPLASM OF CONJUNCTIVA

224.4 BENIGN NEOPLASM OF CORNEA

224.5 BENIGN NEOPLASM OF RETINA

224.6 BENIGN NEOPLASM OF CHOROID

224.7 BENIGN NEOPLASM OF LACRIMAL DUCT

224.8 BENIGN NEOPLASM OF OTHER SPECIFIED PARTS OF EYE

224.9 BENIGN NEOPLASM OF EYE PART UNSPECIFIED

226 BENIGN NEOPLASM OF THYROID GLANDS

227.1 BENIGN NEOPLASM OF PARATHYROID GLAND

230.0 CARCINOMA IN SITU OF LIP ORAL CAVITY AND PHARYNX

231.0 CARCINOMA IN SITU OF LARYNX

234.0 CARCINOMA IN SITU OF EYE

235.0 NEOPLASM OF UNCERTAIN BEHAVIOR OF MAJOR SALIVARY GLANDS

235.1 NEOPLASM OF UNCERTAIN BEHAVIOR OF LIP ORAL CAVITY AND PHARYNX

235.6 NEOPLASM OF UNCERTAIN BEHAVIOR OF LARYNX

238.1 NEOPLASM OF UNCERTAIN BEHAVIOR OF CONNECTIVE AND OTHER SOFT TISSUE

238.8 NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER SPECIFIED SITES

239.2 NEOPLASM OF UNSPECIFIED NATURE OF BONE SOFT TISSUE AND SKIN

240.9 GOITER UNSPECIFIED

245.0 ACUTE THYROIDITIS

246.2 CYST OF THYROID

246.3 HEMORRHAGE AND INFARCTION OF THYROID

246.8 OTHER SPECIFIED DISORDERS OF THYROID

252.8 OTHER SPECIFIED DISORDERS OF PARATHYROID GLAND

360.00 PURULENT ENDOPHTHALMITIS UNSPECIFIED

360.01 ACUTE ENDOPHTHALMITIS

360.02 PANOPHTHALMITIS

360.03 CHRONIC ENDOPHTHALMITIS

360.04 VITREOUS ABSCESS

360.11 SYMPATHETIC UVEITIS

360.12 PANUVEITIS

360.13 PARASITIC ENDOPHTHALMITIS UNSPECIFIED

360.14 OPHTHALMIA NODOSA

360.19 OTHER ENDOPHTHALMITIS

368.10 SUBJECTIVE VISUAL DISTURBANCE UNSPECIFIED

368.11 SUDDEN VISUAL LOSS

368.12 TRANSIENT VISUAL LOSS

368.13 VISUAL DISCOMFORT

368.14 VISUAL DISTORTIONS OF SHAPE AND SIZE

368.15 OTHER VISUAL DISTORTIONS AND ENTOPTIC PHENOMENA

368.2 DIPLOPIA

368.30 BINOCULAR VISION DISORDER UNSPECIFIED

368.40 VISUAL FIELD DEFECT UNSPECIFIED

368.41 SCOTOMA INVOLVING CENTRAL AREA

368.42 SCOTOMA OF BLIND SPOT AREA

368.43 SECTOR OR ARCUATE VISUAL FIELD DEFECTS

368.44 OTHER LOCALIZED VISUAL FIELD DEFECT

368.45 GENERALIZED VISUAL FIELD CONTRACTION OR CONSTRICTION

368.46 HOMONYMOUS BILATERAL FIELD DEFECTS

368.47 HETERONYMOUS BILATERAL FIELD DEFECTS

376.00 ACUTE INFLAMMATION OF ORBIT UNSPECIFIED

376.01 ORBITAL CELLULITIS

376.02 ORBITAL PERIOSTITIS

376.03 ORBITAL OSTEOMYELITIS

376.04 ORBITAL TENONITIS

376.10 CHRONIC INFLAMMATION OF ORBIT UNSPECIFIED

376.11 ORBITAL GRANULOMA

376.12 ORBITAL MYOSITIS

376.13 PARASITIC INFESTATION OF ORBIT

376.21 THYROTOXIC EXOPHTHALMOS

376.22 EXOPHTHALMIC OPHTHALMOPLEGIA

376.30 EXOPHTHALMOS UNSPECIFIED

376.31 CONSTANT EXOPHTHALMOS

376.32 ORBITAL HEMORRHAGE

376.33 ORBITAL EDEMA OR CONGESTION

376.34 INTERMITTENT EXOPHTHALMOS

376.35 PULSATING EXOPHTHALMOS

376.36 LATERAL DISPLACEMENT OF GLOBE

376.40 DEFORMITY OF ORBIT UNSPECIFIED

376.41 HYPERTELORISM OF ORBIT

376.42 EXOSTOSIS OF ORBIT

376.43 LOCAL DEFORMITIES OF ORBIT DUE TO BONE DISEASE

376.44 ORBITAL DEFORMITIES ASSOCIATED WITH CRANIOFACIAL DEFORMITIES

376.45 ATROPHY OF ORBIT

376.46 ENLARGEMENT OF ORBIT

376.47 DEFORMITY OF ORBIT DUE TO TRAUMA OR SURGERY

376.50 ENOPHTHALMOS UNSPECIFIED AS TO CAUSE

376.51 ENOPHTHALMOS DUE TO ATROPHY OF ORBITAL TISSUE

376.52 ENOPHTHALMOS DUE TO TRAUMA OR SURGERY

376.6 RETAINED (OLD) FOREIGN BODY FOLLOWING PENETRATING WOUND OF ORBIT

376.81 ORBITAL CYSTS

376.82 MYOPATHY OF EXTRAOCULAR MUSCLES

376.89 OTHER ORBITAL DISORDERS

376.9 UNSPECIFIED DISORDER OF ORBIT

377.00 PAPILLEDEMA UNSPECIFIED

377.01 PAPILLEDEMA ASSOCIATED WITH INCREASED INTRACRANIAL PRESSURE

377.02 PAPILLEDEMA ASSOCIATED WITH DECREASED OCULAR PRESSURE

377.03 PAPILLEDEMA ASSOCIATED WITH RETINAL DISORDER

377.04 FOSTER-KENNEDY SYNDROME

377.10 OPTIC ATROPHY UNSPECIFIED

377.11 PRIMARY OPTIC ATROPHY

377.12 POSTINFLAMMATORY OPTIC ATROPHY

377.13 OPTIC ATROPHY ASSOCIATED WITH RETINAL DYSTROPHIES

377.14 GLAUCOMATOUS ATROPHY (CUPPING) OF OPTIC DISC

377.15 PARTIAL OPTIC ATROPHY

377.16 HEREDITARY OPTIC ATROPHY

377.21 DRUSEN OF OPTIC DISC

377.22 CRATER-LIKE HOLES OF OPTIC DISC

377.23 COLOBOMA OF OPTIC DISC

377.24 PSEUDOPAPILLEDEMA

377.30 OPTIC NEURITIS UNSPECIFIED

377.31 OPTIC PAPILLITIS

377.32 RETROBULBAR NEURITIS (ACUTE)

377.33 NUTRITIONAL OPTIC NEUROPATHY

377.34 TOXIC OPTIC NEUROPATHY

377.39 OTHER OPTIC NEURITIS

377.41 ISCHEMIC OPTIC NEUROPATHY

377.42 HEMORRHAGE IN OPTIC NERVE SHEATHS

377.43 OPTIC NERVE HYPOPLASIA

377.49 OTHER DISORDERS OF OPTIC NERVE

377.51 DISORDERS OF OPTIC CHIASM ASSOCIATED WITH PITUITARY NEOPLASMS AND DISORDERS

377.52 DISORDERS OF OPTIC CHIASM ASSOCIATED WITH OTHER NEOPLASMS

377.53 DISORDERS OF OPTIC CHIASM ASSOCIATED WITH VASCULAR DISORDERS

377.54 DISORDERS OF OPTIC CHIASM ASSOCIATED WITH INFLAMMATORY DISORDERS

377.61 DISORDERS OF OTHER VISUAL PATHWAYS ASSOCIATED WITH NEOPLASMS

377.62 DISORDERS OF OTHER VISUAL PATHWAYS ASSOCIATED WITH VASCULAR DISORDERS

377.63 DISORDERS OF OTHER VISUAL PATHWAYS ASSOCIATED WITH INFLAMMATORY DISORDERS

377.71 DISORDERS OF VISUAL CORTEX ASSOCIATED WITH NEOPLASMS

377.72 DISORDERS OF VISUAL CORTEX ASSOCIATED WITH VASCULAR DISORDERS

377.73 DISORDERS OF VISUAL CORTEX ASSOCIATED WITH INFLAMMATORY DISORDERS

377.75 CORTICAL BLINDNESS

377.9 UNSPECIFIED DISORDER OF OPTIC NERVE AND VISUAL PATHWAYS

378.50 PARALYTIC STRABISMUS UNSPECIFIED

378.51 THIRD OR OCULOMOTOR NERVE PALSY PARTIAL

378.52 THIRD OR OCULOMOTOR NERVE PALSY TOTAL

378.53 FOURTH OR TROCHLEAR NERVE PALSY

378.54 SIXTH OR ABDUCENS NERVE PALSY

378.55 EXTERNAL OPHTHALMOPLEGIA

378.56 TOTAL OPHTHALMOPLEGIA

378.60 MECHANICAL STRABISMUS UNSPECIFIED

378.61 BROWN'S (TENDON) SHEATH SYNDROME

378.62 MECHANICAL STRABISMUS FROM OTHER MUSCULOFASCIAL DISORDERS

378.63 LIMITED DUCTION ASSOCIATED WITH OTHER CONDITIONS

378.71 DUANE'S SYNDROME

378.72 PROGRESSIVE EXTERNAL OPHTHALMOPLEGIA

378.73 STRABISMUS IN OTHER NEUROMUSCULAR DISORDERS

378.81 PALSY OF CONJUGATE GAZE

378.82 SPASM OF CONJUGATE GAZE

378.83 CONVERGENCE INSUFFICIENCY OR PALSY

378.84 CONVERGENCE EXCESS OR SPASM

378.85 ANOMALIES OF DIVERGENCE

378.86 INTERNUCLEAR OPHTHALMOPLEGIA

379.40 ABNORMAL PUPILLARY FUNCTION UNSPECIFIED

379.41 ANISOCORIA

379.42 MIOSIS (PERSISTENT) NOT DUE TO MIOTICS

379.43 MYDRIASIS (PERSISTENT) NOT DUE TO MYDRIATICS

379.45 ARGYLL ROBERTSON PUPIL ATYPICAL

379.46 TONIC PUPILLARY REACTION

379.49 OTHER ANOMALIES OF PUPILLARY FUNCTION

379.50 NYSTAGMUS UNSPECIFIED

379.51 CONGENITAL NYSTAGMUS

379.52 LATENT NYSTAGMUS

379.53 VISUAL DEPRIVATION NYSTAGMUS

379.54 NYSTAGMUS ASSOCIATED WITH DISORDERS OF THE VESTIBULAR SYSTEM

379.55 DISSOCIATED NYSTAGMUS

379.56 OTHER FORMS OF NYSTAGMUS

379.57 DEFICIENCIES OF SACCADIC EYE MOVEMENTS

379.58 DEFICIENCIES OF SMOOTH PURSUIT MOVEMENTS

379.59 OTHER IRREGULARITIES OF EYE MOVEMENTS

379.60 INFLAMMATION (INFECTION) OF POSTPROCEDURAL BLEB, UNSPECIFIED

379.61 INFLAMMATION (INFECTION) OF POSTPROCEDURAL BLEB, STAGE 1

379.62 INFLAMMATION (INFECTION) OF POSTPROCEDURAL BLEB, STAGE 2

379.63 INFLAMMATION (INFECTION) OF POSTPROCEDURAL BLEB, STAGE 3

379.91 PAIN IN OR AROUND EYE

379.92 SWELLING OR MASS OF EYE

471.0 POLYP OF NASAL CAVITY

471.1 POLYPOID SINUS DEGENERATION

471.8 OTHER POLYP OF SINUS

471.9 UNSPECIFIED NASAL POLYP

478.11 NASAL MUCOSITIS (ULCERATIVE)

478.19 OTHER DISEASE OF NASAL CAVITY AND SINUSES

478.20 UNSPECIFIED DISEASE OF PHARYNX

478.21 CELLULITIS OF PHARYNX OR NASOPHARYNX

478.22 PARAPHARYNGEAL ABSCESS

478.24 RETROPHARYNGEAL ABSCESS

478.25 EDEMA OF PHARYNX OR NASOPHARYNX

478.26 CYST OF PHARYNX OR NASOPHARYNX

478.29 OTHER DISEASES OF PHARYNX OR NASOPHARYNX

478.70 UNSPECIFIED DISEASE OF LARYNX

478.71 CELLULITIS AND PERICHONDRITIS OF LARYNX

478.74 STENOSIS OF LARYNX

478.75 LARYNGEAL SPASM

478.79 OTHER DISEASES OF LARYNX

682.0 CELLULITIS AND ABSCESS OF FACE

682.1 CELLULITIS AND ABSCESS OF NECK

784.0 HEADACHE

784.1 THROAT PAIN

784.2 SWELLING MASS OR LUMP IN HEAD AND NECK

784.3 APHASIA

784.40 VOICE AND RESONANCE DISORDER, UNSPECIFIED

784.41 APHONIA

784.42 DYSPHONIA

784.43 HYPERNASALITY

784.44 HYPONASALITY

784.49 OTHER VOICE AND RESONANCE DISORDERS

784.51 DYSARTHRIA

784.52 FLUENCY DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE

784.59 OTHER SPEECH DISTURBANCE

784.7 EPISTAXIS

784.8 HEMORRHAGE FROM THROAT

784.92 JAW PAIN

793.0 NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF SKULL AND HEAD

870.3 PENETRATING WOUND OF ORBIT WITHOUT FOREIGN BODY

870.4 PENETRATING WOUND OF ORBIT WITH FOREIGN BODY

V10.02 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED PARTS OF ORAL CAVITY AND PHARYNX

V10.21 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF LARYNX

V10.22 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF NASAL CAVITIES MIDDLE EAR AND ACCESSORY SINUSES

 

 

Documentation Requirements

 

• The documentation of the study requires:

o a formal written report, with clear identifying demographics.

o the name of the interpreting provider.

o reason for the test.

o Interpretive report and copies of all images obtained.

 The computerized data with image reconstruction should also be maintained.

• The medical record must contain documentation, including a written or electronic request/order for the procedure which fully supports the medical necessity of the procedure performed.

o This documentation includes, but is not limited to relevant medical history, physical examination, diagnosis (if known), pertinent signs and symptoms and results of pertinent diagnostic tests and/or procedures.

o This entire documentation-not just the test report or the findings/diagnosis on the order, must be made available to Medicare upon request.

• When a CT scan and MRI are performed on the same day for the same anatomical area, the medical record must clearly reflect the medical necessity for performing both tests.

• If the provider of the service is other than the ordering/referring physician, that provider must maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physician’s order for the study.

o The physician must state the clinical indication/medical necessity for the study in his order for the test.

• Rules for Testing Facility to Furnish Additional Tests:

o If the testing facility cannot reach the treating physician/practitioner to change the order or obtain a new order and documents this in the medical record, then the testing facility may furnish the additional diagnostic test if all of the following criteria apply:

 The testing center performs the diagnostic test ordered by the treating physician/practitioner.

 The interpreting physician at the testing facility determines and documents that, because of the abnormal result of the diagnostic test performed, an additional diagnostic test is medically necessary.

 Delaying the performance of the additional diagnostic test would have an adverse effect on the care of the beneficiary.

 The result of the test is communicated to and is used by the treating physician/practitioner in the treatment of the beneficiary.

 The interpreting physician at the testing facility documents in his/her report why additional testing was done.

• Rules for Testing Facility Interpreting Physician to Furnish Different or Additional Tests:

o The following applies to an interpreting physician of a testing facility who furnishes a diagnostic test to a beneficiary who is not a hospital inpatient or outpatient.

o The interpreting physician must document accordingly in his/her report to the treating physician/practitioner.

• Test Design:

o Unless specified in the order, the interpreting physician may determine, without notifying the treating physician/practitioner, the parameters of the diagnostic test.

 (e.g., number of radiographic views obtained, thickness or tomographic sections acquired, use or non-use of contrast media).

 

 

Treatment Logic

 

• Magnetic Resonance Imaging (MRI) is a noninvasive diagnostic imaging modality used to diagnose a variety of central nervous system disorders.

• MRI provides superior tissue contrast when compared to CT, is able to image in multiple planes, is not affected by bone artifact, provides vascular imaging capability, and makes use of safer contrast media (gadolinium chelate agents).

• Its major disadvantage over CT is the longer scanning time required for study, making it less useful for emergency evaluations.

• Contraindications include patients with cardiac pacemakers, implanted neurostimulators, cochlear implants, metal in the eye and older ferromagnetic intracranial aneurysm clips.

• All of these may be potentially displaced when exposed to the powerful magnetic fields used in MRI.

 

 

Sources of Information and Basis for Decision

 

American College of Radiology (2010). Practice guideline for communication of diagnostic imaging findings. Retrieved from http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines.aspx

 

American College of Radiology-American Society of Neuroradiology(2007). Practice guideline for he performance of magnetic resonance imaging (MRI) of the head and neck. Retrieved from http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines.aspx

 

American College of Radiology. (2003). ACR Practice Guideline for Performing and Interpreting Magnetic Resonance Imaging (MRI). (1)(1) 31-35.

 

Cummings, (2005). Otolaryngology: Head and Neck Surgery, 4th ed. (Mosby).

 

FCSO LCD 29221, Magnetic Resonance Imaging of the Orbit, Face, and/or Neck, 07/07/2011. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

Illustrated Guide to Diagnostic Tests (2nd ed). Diagnostic procedures. Springhouse Corp., PA.

 

Langford, R. & Thompson, J. (2000). Mosby’s handbook of diseases, 2nd ed. Mosby, St. Louis, MO.

 

Wong, W. (2002). MR Imaging of the lower face and salivary glands. UCSD Neuroradiology Teaching File Database. Retrieved from the World Wide Web on November 4, 2002, at http://spinwarp.ucsd.edu/NeuroWeb/.

 

Wong, W. (2002). Deep spaces, paranasal sinuses, and nasopharynx. UCSD Neuroradiology Teaching File Database. Retrieved from the World Wide Web on November 4, 2002, at http://spinwarp.ucsd.edu/NeuroWeb/.

 

 

AMA CPT Copyright Statement

 

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

 

 

CMS LCD MAGNETIC RESONANCE IMAGING OF THE ORBIT, FACE, AND/OR NECK