# Report denied med nec Dx 780.97, 437.1 for cpt 70545



## she803 (Jul 6, 2012)

Please advise--don't understand why report was denied--should dx on this report be coded otherwise? Thank you.

Examination: MRA neck with and without contrast. 

Clinical indication: Altered mental status.

Technique: Multiplanar multi sequence MR imaging of brain was performed without administration of intravenous contrast material. 3-D time-of-flight MRA images of brain were obtained without administration of contrast material. 2-D time of flight MRA images of neck were obtained without contrast. Contrast enhanced MRA of the neck was also performed. Multiplanar reformats and maximum intensity projections were obtained. There is no prior MRI study for comparison. 

Findings: There is no restricted diffusion to suggest an acute infarct. There is extensive encephalomalacia and gliosis in the posterior frontal lobes, bilateral parietal lobes and occipital lobes probably due to chronic infarcts. Multiple chronic cerebellar infarcts are identified. There are periventricular and subcortical foci of FLAIR signal abnormality consistent with microvascular ischemic disease. There is no intracranial hemorrhage, mass lesion or abnormal extra-axial fluid collection. There is cerebral and cerebellar atrophy. There is no hydrocephalus.

There is a right frontal extracranial lipoma measuring 14 x 6 mm. A polyp or a mucous retention cyst is seen in the right frontal sinus. 

MRA head and neck: 

The aortic arch and origin of great vessels are normal. The left vertebral artery arises from the proximal aspect of the left subclavian artery in close proximity to the aortic arch. 

The left common carotid artery is normal in caliber and bifurcation pattern. The cervical segment of the left internal carotid artery is normal in caliber. There is irregularity of the cavernous segment of the left internal carotid artery probably due to atherosclerotic disease. The left middle cerebral artery, posterior communicating artery and anterior cerebral artery are normal. 

There is an irregular plaque at the right carotid bulb for a length of 9 mm resulting in approximately 20% stenosis by NASCET criteria. The remaining cervical segment of the right internal carotid artery is normal. There is irregularity of the right cavernous internal carotid artery consistent with atherosclerotic disease. The right middle cerebral artery, posterior communicating artery and anterior cerebral artery are normal. 

The vertebral arteries and basilar artery are normal. The right vertebral artery is dominant. There is diminished flow-related signal in the P2 segments of bilateral posterior cerebral arteries with normal flow-related signal distally; given the symmetry of these findings an artifactual etiology is likely however severe stenosis is also considered.

Impression: 

No acute infarction.
Extensive chronic infarcts.
Microvascular ischemic disease. 
Diffuse cerebral and cerebellar atrophy.
20% stenosis of the right carotid bulb. 
Decreased flow related signal in P2 segments of posterior cerebral arteries which are probably due to artifact however severe stenosis is also considered.


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## mhstrauss (Jul 6, 2012)

You'll need to check with your MAC or whichever payer is denying the claim, for LCD info on 70545.  I checked ours (Pinnacle) just to get an idea, and neither of the dx codes you listed is approved for 70545.  Not sure if this helps, but its a starting point!


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## she803 (Jul 6, 2012)

Is there any other dx i should code this report? Physician billed the above dx codes--i only handle denials. been stuck on this report few days now.


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## mitchellde (Jul 6, 2012)

It is an MRA of the neck, look in the report, there is a stenosis of 20% of the right carotid, this could be the cause of the altered mental status as well as some of the other issues. Also within the report the statement that says"There is extensive encephalomalacia.... "  I would code this as well, under findings it states "Diffuse cerebral and cerebellar atrophy"... I am just pointing out that there are numerous specific findings within this report, any one of which could indicate medical necessity.
437.1 is too vague of a diagnosis but it is probably what the provider had listed on the "cheat sheet" provided to him.  Most providers do not have the time to look codes up using a book which is why again I suggest all provider selected codes need to be reviewed with the documentation prior to claim submission.


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## she803 (Jul 6, 2012)

Thanks again. I wish I had that control but I don't. I don't submit the billing nor receive reports before they submit the claim. That's a totally different department they handle or their end. Unfortunately, I only get to review and code reports after they're denied.


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