Radiology Coding Alert

Question: A physician ordered a hip MRI for an infant, but the exam reads as follows: MRI of the chest and abdomen. Sequences include coronal and axial T1 and STIR of the pelvis and the right shoulder. Given the patient's size, this was imaged as one unit. Which CPT code(s) should I report?

Alabama Subscriber

Answer: You have an order only for the hip MRI, so you should report this with a code from the 73721-73723 series (Magnetic resonance [e.g., proton] imaging, any joint of lower extremity ...).

The ordering physician may have wanted an interpretation for both the hip and shoulder but ordered only the hip because he knew the patient's small size would allow imaging as one unit. But you should not code MRIs of the additional anatomical areas based on this assumption.