Radiology Coding Alert

Last months article, How to Code Arthrographies for Increased Pay Up, on page 62 was missing information intended to clarify the differences between the magnetic resonance imaging (MRI) and magnetic resonance (MR) arthrography of the shoulder, when each is used and how each should be coded.

The two procedures are similar and are used to determine conditions and diseases of the shoulder region, specifically for evaluation of the soft tissue (like ligaments, cartilage, tendons and muscles, rotator cuffs, and so forth). The biggest difference between the two is the contrast injection.

During an MRI with contrast, the medium is injected intravenously and images are taken to show the enhancement of the structures in the limb, explains Ellen Ratnofsky, RN, BSN, CS, of Healthcare Administrative Partners Inc., which provides medical billing and practice management services in seven states. MR arthrography of the shoulder, however, would include an intra-articular injection of contrast, usually gadolinium. In other words, the agent is delivered directly into the cavity of the joint. The injection often is aided by fluoroscopic guidance to ensure that the needle is positioned correctly. This is then followed by an MRI study.

A standard MRI with contrast typically is reported using CPT 73220 (magnetic resonance [e.g., proton] imaging, upper extremity, other than joint), Ratnofsky says. A diagnosis code that could be associated with an MRI of the shoulder is ICD-9 171.2 (malignant neoplasm of connective tissue of upper limb, including shoulder).

The MR arthrogram would be assigned codes 23350 (injection procedure for shoulder arthrography) for the shoulder injection , followed by the MRI code 73221 (magnetic resonance [e.g., proton] imaging, any joint of upper extremity). Fluoroscopic guidance, if used, would be coded 76000 (fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]). It frequently is conducted to diagnose problems with the rotator cuff, i.e., 726.10-726.19 (rotator cuff syndrome of shoulder and allied disorders) and 840.4 (sprains and strains of shoulder and upper arm; rotator cuff [capsule]).

Ratnofsky adds a cautionary note to Radiology Practices using MR arthrography. In many areas it is considered investigational. Coders should check with local carriers at least once every year and ask that requirements and guidelines for these studies be provided in writing.

Although some practices may have radiologists conduct MR arthrography, others rely on the technologists to perform the injection. In addition, the concerns about radiation and adverse reactions to contrast agents with MRIs that were stated are not universally accepted.