Radiology Coding Alert

Here's what the 70554 and 70555 rules mean for you

CPT guidelines lay down the law that you can't report 70555 "unless 96020 is performed." Our experts spell out exactly how you should apply this rule and when you're most likely to need these codes for your radiology claims.

The service: Functional magnetic resonance imaging (fMRI) uses MR imaging to measure the tiny metabolic changes that take place in an active part of the brain.

The codes: For fMRI, you need to know the following codes:

• 70554 -- Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration

• 70555 -- ... requiring physician or psychologist administration of entire neurofunctional testing

• 96020 -- Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or psychologist, with review of test results and report.

See if 1 Claim Must Show 70555/96020

CPT designed 70555 and 96020 "to be used together but not necessarily on the same claim form," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CPC-EMS, RCC, CodeRyte coding analyst and coding review teacher.

"Code 96020 is the testing code, and 70555 is the actual imaging code," Jandroep says. "One physician could do one procedure, and another physician could do the other."

For example: Neurosurgeons and neurologists use functional brain mapping as a noninvasive way to help predict the potential for neurological problems that tumor growths, surgical interventions or other factors might cause. Conducting the test helps the physician and patient make informed decisions concerning surgery or other appropriate treatments.

Benefit: "Preoperative, noninvasive neurofunctional mapping is an alternative to direct cortical stimulation or somatosensory evoked potentials, which may be unsuccessful and be associated with visual distortion, seizure and longer surgical time," says Neil Busis, MD, clinical associate professor in the University of Pittsburgh School of Medicine.

If a neurosurgeon performs the testing, but you're coding for the radiologist who performed the MRI, then you should report 70555 and the neurosurgeon should report 96020.

Note: You won't find technical component payment for 70555 or 96020 on the Medicare physician fee schedule. Providers rarely -- if ever -- perform these services in an office. Physicians who perform the test in the office setting rather than a facility must negotiate with the carrier for reimbursement.

Key Phrases Explain the 70554/96020 Ban

Sometimes a technologist or physicist -- instead of a physician or psychologist -- performs the MRI and the testing. In that case, report 70554. You should not report 70554 with 96020.

Here's why: The codes conflict because of physician involvement. Code 70554's descriptor states, "not requiring physician or psychologist administration," while 96020 states, "with test administered entirely by a physician or psychologist."

Also, the 70554 and 96020 services overlap. "Both the testing methodology and the imaging are encompassed in" 70554, according to AMA's CPT Changes 2007: An Insider's View.

Keep These MRI/fMRI Edits in Mind

In addition to the 96020 rules, CPT and Correct Coding Initiative (CCI) edits create many more rules for which codes you may report with fMRI codes.

CPT guidelines state that -- unless you perform a separate diagnostic MRI -- you should not report 70554 and 70555 with 70551-70553 (Magnetic resonance [e.g., proton] imaging, brain [including brain stem] ...).

Edit alert: CCI places fMRIs in the column 2 (component, unpaid) position of its bundles with one exception. CCI bundles a brain MRI without contrast (70551) into 70554, as shown in this chart:

Each of the edits has a modifier indicator of "1," which means you may use a modifier to override the edit.

Important: Providers typically perform fMRI when the patient has a known intracranial abnormality, so you're unlikely to report a diagnostic MRI with an fMRI, according to The ACR Radiology Coding Source, Sept./Oct. 2006.

Play it safe: Don't bill diagnostic and functional MRIs together unless you have separate orders and documentation that the provider performed the diagnostic MRI to make a diagnosis.

Match fMRI With Proper Diagnosis

Some payers are creating policies that explain when they find fMRI medically necessary.

CIGNA HealthCare covers fMRI when you meet two conditions:

1. the fMRI is part of a preoperative evaluation for a planned craniotomy and

2. the fMRI "is required for localization of eloquent areas of the brain such as those responsible for speech, language, motor function, and senses, which might potentially be put at risk during the proposed surgery."

Resource: You can find Cigna's policy online at http://www.cigna.com/customer_care/healthcare_professional/coverage_positions/. Search the medical index for "functional magnetic resonance imaging."

ICD-9: Diagnoses that Jandroep and others believe you might see associated with functional brain mapping include the following:

• arteriovenous malformations, 747.x (Other congenital anomalies of circulatory system)
• epilepsy, 345.x (Epilepsy and recurrent seizures)
• traumatic brain injury, 854.x (Intracranial injury of other and unspecified nature)
• Parkinson's disease, 332.x
• schizophrenia, 295.x (Schizophrenic disorders)
• Huntington's disease, 333.4 (Huntington's chorea).

As always, you should choose the diagnosis code based on your provider's documentation.