# Mri/mra



## tfrick2 (Sep 4, 2013)

Can I bill for separate MRI & MRA for the following report?


 Examination: MRA HEAD W AND WO CONTRAST
 Exam Number: 
EXAMINATION:
MRI BRAIN WITH AND WITHOUT CONTRAST,  
MRA HEAD WITHOUT AND WITH CONTRAST, 
MR VENOGRAM HEAD WITH CONTRAST: 


HISTORY:
Headaches, prior surgical resection of a lesion - verbal report of an 
AVM with connection to superior sagittal sinus. 

COMPARISON:
CT brain without contrast 

TECHNIQUE:
Sagittal T1, axial T1, FLAIR, GRASE T2, gradient echo, diffusion 
weighted images with ADC map reconstruction, and post-gadolinium T1 
axial, sagittal and coronal images, post-gadolinium axial T1-weighted 
3D MPRAGE and axial T1 postcontrast fat-suppressed images of the 
brain. MultiHance 4 mL i.v. 
Routine 3D time-of-flight MRA of the head and gadolinium-enhanced MRA 
and MRV of the head are evaluated with source images and MIP 
reconstructions. 

FINDINGS:
Metallic artifact from the plate in the parietal bones limits the 
examination. A persistent falcine sinus is noted. The left sigmoid 
sinus is atrophic. On the postcontrast images there is a small 
outpouching from the superior sagittal sinus to the region of the 
plate seen on 1601-119.   

The soft tissue nodular density is seen to be rim enhancing on the 
post-contrast fat saturated examination seen on series 1701 image 27. 
There additionally multiple scalp veins in this region surrounding 
the lesion.  It is not clear on this examination if any of these 
veins traverse parietal sulci to the sagittal sinus. 

No intra axial mass, hemorrhage or mass effect. The ventricles, sulci 
and basal cisterns are not effaced. No brain parenchymal signal 
abnormality or abnormal enhancement.  

The orbits and visualized sinuses appear unremarkable.   

No focal suspicious bone marrow signal abnormality. 

IMPRESSION:

There is postsurgical change with a metallic plate covering the small 
midline parietal skull defect better demonstrated on CT.  
There is a 1 cm soft tissue nodule in the scalp posterior to the 
plate with mild peripheral enhancement based on fat-suppressed 
post-contrast sequence (series 1701, image 27). Enhancement may be 
secondary to granulation tissue or vs residual/recurrent lesion. No 
abnormal flow voids in this area. 

There are several small adjacent vessels in the scalp - communication 
with the superior sagittal sinus is not definitely demonstrated, 
however, there may be limitation due to susceptibility artifact from 
the metallic plate. The skull is thin with a small outpouching of the 
superior sagittal sinus underlying the plate - this is best 
demonstrated on post-contrast MP RAGE images (series 1601, image 
124).  

Post-contrast sagittal images and the MR Venogram demonstrate a 
persistent falcine sinus (variant course of the straight sinus). No 
dramatically enlarged vessels in the scalp. 
MR venogram demonstrates relatively hypoplastic left transverse and 
sigmoid sinuses and internal jugular vein. No evidence of venous 
sinus thrombosis.  

Sulci, ventricles and cisterns are otherwise unremarkable. No 
parenchymal signal abnormality, intra-axial or extra-axial mass, 
hemorrhage or infarct is detected. No abnormal parenchymal or 
meningeal enhancement is detected following contrast administration.  

MRA exams of the head without and with contrast are within normal 
limits. Signal loss of the right ICA as it enters the skull base is 
consistent with artifact related to pneumatized petrous apex. No 
abnormal vascularity noted on MRA in the region of the scalp lesion.  

IMPRESSION:

Post-operative changes and nonspecific midline parietal scalp nodule. 
These findings are nonspecific and correlation with prior pathology 
report and pre/post-operative imaging will be important. Differential 
includes sinus pericranii or atretic parietal encephalocele with 
persistent falcine sinus.


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## mhstrauss (Sep 4, 2013)

I was taught that in order to be able to bill an MRI and MRA separately, there has to be 2 completely different scans, 2 different reports...and also 2 different orders.  I don't have any specific references to post.

Hope this helps.


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## tfrick2 (Sep 4, 2013)

mhstrauss said:


> I was taught that in order to be able to bill an MRI and MRA separately, there has to be 2 completely different scans, 2 different reports...and also 2 different orders.  I don't have any specific references to post.
> 
> Hope this helps.




I do have the 2 different orders in the computer. I can see 2 reports within the single document here, although they could definitely be separated better, showing the tissues and structures for the MRI, and the vascular components for the MRA. As for the 2 different scans, the documentation does state that the MRA is evaluated with source images and reconstructions.


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## Radcoder1313 (Sep 5, 2013)

Based on the technique and the seperate documentation of vessels, I would say you are fine to bill both.


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## nkknav4 (Oct 25, 2013)

*MRI and MRA of the head*

I work for a Radiologist Company, and I am looking everywhere for guidelines on the subject can I bill a MRI of the brain with MRA of the head.  I can not find anything in CMS.GOV.  We have a Coder who just started with our company who insist we can NOT bill bill together.  She states the MRI should be billed, but not the MRA of head.  Please help me before I go crazy... Thank you so much.


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