Radiology Coding Alert

Medicare supplies you with a national coverage determination (NCD) for magnetic resonance angiography (MRA), but that doesn't mean coding these services is cut-and- dried. Make sure you're making the grade with this in-depth look at head MRA coding.

CPT lists the following head MRA codes:

• 70544 -- Magnetic resonance angiography, head; without contrast material(s)
• 70545 -- ... with contrast material(s)
• 70546 -- .. without contrast material(s), followed by contrast material(s) and further sequences.

Key: Do not report 70544 with 70545 for head MRA without contrast followed by head MRA with contrast. Report only 70546 for these services.

The contrast supply codes you're most likely to report with these services (when your facility bears the cost of the contrast) are the following, said Debra P. Ferenc, BS, CPC, CPC-H, CMSCS, CMC, senior consultant and educator with MRCE, during her audioconference for The Coding Institute, "Radiology Coding Fundamentals":

• Q9952 -- Injection, gadolinium-based magnetic resonance contrast agent, per ml
• Q9953 -- Injection, iron-based magnetic resonance contrast agent, per ml
• Q9954 -- Oral magnetic resonance contrast agent, per 100 ml.

Watch out: CPT guidelines state that "with contrast" in a code descriptor means "contrast material administered intravascularly, intra-articularly or intrathecally." You should not consider a study to be "with contrast" if the patient only receives oral and/or rectal contrast.

In other words, don't think that just because you report contrast code Q9954 (oral contrast) you should report "with contrast" MRA code 70545. You can't count oral contrast as "with contrast," according to CPT.

Tip: If HCPCS doesn't have a code for the contrast used, you should report A4641 (Radiopharmaceutical, diagnostic, not otherwise classified).

The MRA NCD describes covered conditions but does not list covered ICD-9 codes.

Crucial: Diagnosis codes that payers cover for MRA may differ, but you should never choose a diagnosis code based on coverage. Stick to coding the diagnosis your physician's documentation supports.

Check it out: You can find the MRA NCD by searching the Medicare NCD database available at www.cms.hhs.gov/mcd/search.asp. Search for document ID "220.3."

Payers may consider head MRA services (70544-70546) medically necessary for the following, Ferenc points out:

• vascular dementia
• hemiplegia
• migraine
• trigeminal nerve disorders
• occlusion and stenosis
• visual disturbances
• paralytic strabismus
• cerebral thrombosis or embolism
• fracture
• subdural or extradural hemorrhage following injury
• arterial or venous injury.

Example: The physician documents a head MRA without/with contrast for a patient diagnosed with cerebral thrombosis, so you report 70546 and a code from the 434.0x range (Cerebral thrombosis ...).

Head MRA codes 70544-70546 all have both technical and professional components, Ferenc says.

This means that if you're reporting only the technical component (such as equipment use and actually performing the MRA), you should append modifier TC (Technical component) to the appropriate MRA code.

If instead you're only reporting the radiologist's MRA interpretation and report, append modifier 26 (Professional component).

If you're reporting the global service (technical and professional), simply report the appropriate code without TC or 26.

Supervision level: Global 70544-70546 and their respective professional components have a physician supervision level of "09," which means the supervision level concept doesn't apply.

The story is different for the technical component. The Medicare Physician Fee Schedule (MPFS) lists 70544's required physician supervision level as "general," Ferenc says. You'll see this denoted with "01" in the physician supervision column.

What this means: For general supervision, the physician must provide overall direction and control of the imaging procedure.

This includes ensuring appropriate imaging staff training and proper imaging equipment maintenance.

But "the physician wouldn't be required to be in the room," says Shelley Bellm, CPC, a coder at Colorado Mountain Medical. In fact, he doesn't have to be at the imaging facility during the exam.

The technical components of 70545 and 70546 require direct physician supervision, Ferenc says. The MPFS denotes this with supervision level "02."

What this means: The physician must be present in the office suite and immediately available to furnish assistance and direction. But the physician does not have to be in the room where the patient undergoes the test.