ࡱ> c %-bjbj .xY\xY\$1(((8`d( %($$$$$$$$&T)n$$$###~$#$### [ 1#w$$0 %#)$)#)##$$# %)> :  MRI Standard Operating Procedures Body PartReason For ExamIV ContrastProcedure to Pre-CertCPT Code Brain IAC Pituitary Pituitary Alzheimers Confusion CVA Dementia Dizziness Headache w/o Focal Symptoms Memory Loss Mental Status Changes Stroke TIA Trauma Vertigo Vision Changes Adenoma Cranial Nerve Lesions HIV Infection Multiple Sclerosis Neurofibromatosis Seizures Tumor/Mass/Cancer/Mets Vascular Lesions IAC/Hearing Loss Elevated Prolactin Pituitary Lesion To guide surgery planning, radiation therapy, or other surgical treatments for the brain, such as laser ablation; for preoperative planning to localize language dominance and for functional localization of memory; to localize abnormal brain functionfor epilepsy surgery  No Yes Yes Yes Yes MRI Without Contrast MRI With & Without Contrast MRI With & Without Contrast fMRI 70551 70553 70553 70555 96020 MRA Brain Stroke CVA TIA Aneurysm Arterial Venous  No  MRA Brain Without Contrast  70544 Brain Spectroscopy Alzheimers Dementia Seizures Encephalopathy Ischemia Hypoxia Brain Injury Tumor/Mass/Cancer/Mets Infection Multiple Sclerosis Toxic Metabolic (peds)  No Yes  MRI Spectroscopy Without Contrast MRI Spectroscopy With and/or Without Contrast  76390 76390 Body PartReason For ExamIV ContrastProcedure to Pre-CertCPT Code MRV Brain  Venous Thrombosis  No MRA Without Contrast  70544  Orbits Demyelination/Multiple Diplopia Dysthyroid Eye Disease Exopthalmos Graves Disease Proptosis Pseudotumor Sclerosis Trauma Tumor/Mass/Cancer/Mets Vascular Lesions  Yes  MRI Orbits/Face/Neck With & Without Contrast  70543  Neck  Infection Tumor/Mass/Cancer/Mets Vocal Cord Paralysis  Yes  MRI Orbits/Face/Neck With & Without Contrast  70543  MRA Neck Aneurysm Arterial Venous Malformation CVA Stroke Subclavian Steal TIA  Yes  MRA Neck With & Without Contrast  70549  MRA Arch & Great Vessels  Aneurysm(Neck specific) Arterial Venous Malformation CVA Stroke Subclavian Steal TIA  Yes  MRA Neck With & Without Contrast  70549  Spine: Cervical  Arm/Shoulder Pain and/or Weakness Degenerative Disease Disc Herniation Neck Pain Radiculopathy Post-op for tumor Abscess/Infection Discitis Multiple Sclerosis Myelopathy Osteomyelitis Syrinx Tumor/Mass/Cancer/Mets Vascular Lesions/AVM  No Yes  MRI Cervical Spine Without Contrast MRI Cervical Spine With & Without Contrast  2141 72156 Body PartReason For ExamIV ContrastProcedure to Pre-CertCPT Code Spine: Thoracic  Back Pain Compression Fracture (no hx cancer/mets) Degenerative Disease Disc Herniation Radiculopathy Trauma Vertebroplasty Planning (no hx of cancer/mets) Compression Fracture (with hx of cancer/mets) Post-op for tumor Abscess/Infection AVM Discitis Multiple Sclerosis Myelopathy Osteomyelitis Syrinx Tumor/Mass/Cancer/Mets Vascular Lesions Vertebroplasty Planning (with hx of cancer/mets)  No Yes  MRI Thoracic Without Contrast MRI Thoracic With & Without Contrast  72146 72157 Spine: Lumbar  Back Pain Compression Fracture (no hx cancer/mets) Degenerative Disease Disc Herniation Radiculopathy Sciatica Spondylolithesis Stenosis Trauma Vertebroplasty (no hx of cancer/mets) Postop (any hx lumbar surgery within 2 yrs) Abscess/Infection Compression Fracture (with hx of cancer/mets) Demyelinating Discitis Osteomyelitis Tumor/Mass/Cancer/Mets Vertebroplasty Planning (with hx of cancer/mets)  No Yes MRI Lumbar Without Contrast MRI Lumbar With & Without Contrast  72148 72158 Body PartReason For ExamIV ContrastProcedure to Pre-CertCPT Code Chest Mediastinum Tumor/Mass/Cancer/Mets  Yes  MRI Chest/Mediastinum With & Without Contrast  71552  MRA Chest  Aneurysm Arterial Venous Malformation Coarctation Dissection Pulmonary Embolism Thoracic Aorta (other than the heart) Thoracic Outlet Syndrome Vascular Anomalies Subclavian Vessels  Yes  MRA Chest With or Without Contrast  71555  MRV Chest  Arterial Venous Malformation Venous Occlusion/ Thrombosis  Yes  MRA Chest With or Without Contrast 71555 Breast Implant Rupture Abnormal Mammogram Abnormal Ultrasound Dense Breast/High Risk Mass/Lesion/Cancer Palpable Mass  No Yes  MRI Breast Without Contrast Bilateral Unilateral (specify breast) MRI Breast Bilateral With & or Without Contrast MRI Breast Unilateral With & or Without Contrast (Specify Side)  77059 77058 77059 77058  Brachial Plexus  Brachial Plexus Injury Nerve Avulsion Tumor/Mass/Cancer/Mets Neuropathy  No Yes  MRI Chest/Mediastinum With & Without Contrast  71552  Cardiac  Anomalous Coronary Artery -CCTA If looking for Valve Insuffciency/Regurgilation, ASD/VSD and the patient is unable to receive a contrast agent. ARVD Mass Myocardial Infarction Pericardial Disease Sarcoldosis Viability Valve Insuffciency/Regurgilation Atrial/Ventricular Septal Defect  No No Yes No  Morphology & Function Without Contrast Morphology & Function Without Contrast; With Flow/Velocity Quantification Morphology & Function Without and With Contrast and Further Sequences Morphology & Function Without Contrast; With Flow/Velocity Quantification  75557 75557 75565 75561 75561 75565 Body PartReason For ExamIV ContrastProcedure to Pre-CertCPT Code Abdomen  Abnormal Enzymes MRCP (Biliary/Pancreatic Ducts, Stones, Jaundice) r/o appy or renal stone in pregnant pt. Fetal MRI Abdominal Pain Abscess/Ascites Adrenal Mass Liver Pancreatic Mass/Lesion Renal Lesion Tumor/Mass/Cancer/Mets  No No Yes  MRI Abdomen Without Contrast MRI Abdomen & Pelvis Without Contrast MRI Abdomen With & Without Contrast  74181 74181 & 72195 74183  MRA Abdomen  AAA(abdominal aortic aneurysm) Dissection Mesenteric Ischemia Renal Artery Stenosis Pre Liver Transplant Pre Kidney Transplant Renal Mass  Yes Yes MRA Abdomen With or Without contrast Order 2 Studies MRA Abdomend With or Without Contrast MRI Abdomen With Or Without Contrast 74185 74185 74183 MRV Abdomen  Venous Anomaly Venous Occlusion Venous Thrombosis  Yes MRA Abdomen With or Without Contrast  74185  Pelvis  Fracture Muscle/Tendon Tear Urethral Diveticulum Rectal Cancer Placenta Accreta/Previa/Increta Abscess Adenomyosis Embolization Endometrioma Fibroid Osteomyetits Plexopathy Pre/Post Fibroid Prostate Cancer Septic Arthritis Tumor/Mass/Cancer/Mets  No No Yes  MRI Pelvis Without Contrast MRI Abdomen & Pelvis Without Contrast MRI Pelvis With & Without Contrast  72195 74181 & 72195 72197  MRA Pelvis Or MRV Pelvis  Aneurysm AVM (artriovenous malformation) May Thurner Syndrome Pelvic Congestion Venous Occlusion  Yes Yes  MRA Pelvis With or Without Contrast Order 2 Exams: MRA Pelvis With or Without Contrast MRI Pelvis With and Without Contrast 72198 72198 72197 Body PartReason For ExamIV ContrastProcedure to Pre-CertCPT Code MRA Peripheral (Run-off)  Claudication Cold foot Gangrene Pain Ulcer Yes Yes Order 3 Exams: MRA Abdomen with/without contrast & MRA Lower Extremity with/without contrast LEFT & MRA Lower Extremity with/without contrast RIGHT  74185 73725 73725  MRA Extremity or MRV Extremity Aneurysm Arterial Occlusion/Stenosis Venous Occlusion  Yes  MRA Extremity with & without contrast Upper Extremity Lower Extremity  73225 73725  Extremity, Non-Joint Arm Hand Finger Femur Lower Leg Foot Toe Fracture Muscle/Tendon tear Stress Fracture Abscess Cellultis Fasciitis Myositis Osteomyelitis Soft Tissue Tumor/Mass/ Cancer/Mets Ulcer  No Yes  MRI Non-Joint Without Contrast Lower-Extremity Upper-Extremity MRI Non-Joint Without & With Contrast Lower-Extremity Upper-Extremity  73718 73218 73720 73220  Extremity, Joint Shoulder Elbow Wrist Hip Knee Ankle Foot  Arthritis AVN (Avascular Necrosis) Cartilage Tear Fracture Internal Derangement Joint Pain (specify joint) Labral Tear Ligament Tear Meniscus Tear Muscle Tear Osteochondritis Dessicans (OCD) Stress Fracture Sprain/Strain Tendon Tear  No MRI Joint Without Contrast Lower-Extremity Upper-Extremity  73721 73221  Extremity, Joint Shoulder Elbow Wrist Hip Knee Ankle  Abscess Cellulitis Fasciitis Inflamatory Arthritis Myositis Osteomyelitis Septic Arthritis Tumor/Mass/Cancer/Mets Ulcer  Yes  MRI Joint Without & With Contrast Lower-Extremity Upper-Extremity  73723 73223 Body PartReason For ExamIV ContrastProcedure to Pre-CertCPT Code MR Arthrography  Labral Tear Loose Bodies OCD Stability Post-op shoulder Post-op meniscus repair  Yes  MRI Joint with Contrast-Order 2 Exams Lower Extremity With Contrast Upper Extremity With Contrast Fluoroscopy Guided Joint Injection Please state which joint in comments  73722 73222 76000      Page # PAGE 7 of  NUMPAGES 7 #=Ii|0 ?  % & 5 Y ̲̽̽̽vk\QFh Vh~FCJaJh VhCJaJh Vh2SCJaJmH sH h Vh2SCJaJh Vh~FCJaJmH sH h Vht^CJaJmH sH h VhCJaJmH sH h VhCJaJmH sH hhCJaJhhfCJaJmH sH hh~FCJaJmH sH hhCJaJmH sH hCJaJhh5CJaJ#-=I_h $$Ifa$$a$hijklmnopNFFFFFFF$1$Ifkd$$IflrD@!|); u   t0644 lapqrstu|}~$If $Ifgd~F$1$If  ! 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