Radiology Coding Alert

Question: A patient was referred to us for an MRI of the orbit (CPT 70540 , magnetic resonance [e.g., proton] imaging, orbit, face, and neck), due to an enlargement of the left tonsil. The diagnosis code assigned was 474.11 (hypertrophy of tonsils and adenoids [tonsils alone]) and subsequently codes as 238.9 (neoplasm, site unspecified). This was denied by Medicare. The first code was from the referrer and the second code from our report. What could be the problem?

Anonymous Connecticut Subscriber

Answer: According to Cheryl Schad, BA, CPCM, CPC, owner of Schad Medical Management, a coding and billing firm in Woodbury, N.J., it is likely that the insurance carrier perceived the order for an MRI as "overkill."

I would imagine that this patient had undergone prior diagnostic tests, which were most likely inconclusive and caused the ordering physician to request the MRI," Schad notes. "These abnormal findings should have been listed as the reason for the MRI instead of swollen tonsils. Adding the neoplasm code probably didn't sway Medicare's response, either, since there appeared to be no medical necessity for the MRI based on the original ICD-9 code."