Radiology Coding Alert

Hint:Third time's the charm for A4647 reimbursement

If your radiologist's brain MRI documentation leaves you seeing triple, you may be entitled to contrast payment.

Although most insurers bundle payment for contrast (such as gadolinium) into your initial magnetic resonance imaging (MRI) codes, they will reimburse your A4647 (Supply of paramagnetic contrast material [e.g., gadolinium]) claims if the radiologist performs a third MRI with a double dose of contrast -- this additional contrast is not included the basic single dose scan's price.

Suppose your radiologist's documentation states that he performed a brain MRI without contrast, followed by "with contrast," followed by "with a double dose of contrast."

You might think it's easier to submit one unit of CPT 70551 (Magnetic resonance [e.g., proton] imaging, brain [including brain stem]; without contrast material) and two units of CPT 70552 (...with contrast material[s]), but this is incorrect coding.

Tip: "If the radiologist's report states that he administered contrast prior to obtaining the MRI brain images, you should report 70552," says Rehna Burge, radiology coder at North Oaks Health System, a Hammond, La., medical center. "If the report describes MRI brain without contrast or if the report doesn't mention contrast at all, you should report 70551."

But if the physician performs an MRI brain without contrast, then he administers contrast and obtains further images, you should report 70553 (Magnetic resonance [eg, proton] imaging, brain [including brain stem]; without contrast material, followed by contrast material[s] and further sequences), Burge says.

"The report may not specifically state, 'contrast,'but may have the name brand of the contrast, such as ProHance, OmniRay, Magnevist, Gad or gadolinium," Burge says.

Even if your physician specifically documents that he used gadolinium, carriers will not separately reimburse your practice for the contrast (A4647) that you administer during your first and second brain MRIs. According to Chapter 13 of the Medicare Claims Processing Manual, payment for gadolinium is included in the MRI's technical portion.

Local payer policy reigns: Although most Medicare carriers advise practices not to separately report A4647 with 70551-70553, carrier direction varies. The policy for Palmetto GBA, a South Carolina Part B carrier, states, "When billing for contrast media used with MRI of the brain, HCPCS code A4647 should be used."

If your carrier publishes similar advice, you should report A4647, but payers will probably still deny the contrast. "Since it appears that some payers in our region do reimburse for gadolinium separately, we at least bill for it," says Sherry Wilkerson, RHIT, CCS, CCS-P, coding and compliance manager at Esse Health in St. Louis. "We thought that the coding for the contrast would be beneficial for internal reporting/tracking purposes since this is a new service that we just added to our imaging center."

If your physician performs an MRI without contrast, followed by an MRI with contrast, then an MRI with a double dose of contrast, you can bill A4647 for additional contrast that the physician used during the third MRI. The catch? You cannot bill 70551-70553 for the third MRI so, your claim should include 70553 and A4647.

According to Empire Medicare's brain MRI policy, "A third MRI would not be separately payable (and submission should not be made) as these codes include 'and further sequences.'If the third MRI uses a higher dose of contrast agent (A4647), the additional contrast material should be submitted for reimbursement."

Bottom line: Your carrier will will likely reimburse for the additional contrast used in high dose MRI studies, but will not increase the payment for the physician service itself.