Radiology Coding Alert

Question: Which codes should I report for a brain MRI with and without contrast? The diagnosis is cerebral hemorrhage.

Kentucky Subscriber

Answer: For the MRI, you should report 70553 (Magnetic resonance [e.g., proton] imaging, brain [including brain stem]; without contrast material, followed by contrast material[s] and further sequences).

The diagnosis is one of the few reportable three-digit ICD-9 codes, 431 (Intracerebral hemorrhage). Most ICD-9 codes have fourth or fifth digits that you must use for added specificity, but 431 does not have any fourth or fifth digit options.

Don't forget: The combination of 431 and 70553 falls under the eligible cases for Physician Quality Reporting Initiative (PQRI) measure 10.

If the patient is 18 years old or older and you're participating in the PQRI, you should report the appropriate CPT II codes:

1. If the patient had the MRI within 24 hours of arriving at the hospital and the physician documents absence or presence of hemorrhage, mass lesion and acute infarction, you should report the following two codes in addition to your CPT and ICD-9 code:

• 3110F -- Presence or absence of hemorrhage and mass lesion and acute infarction documented in final CT or MRI report

• 3111F -- CT or MRI of the brain performed within 24 hours of arrival to the hospital.

2. If the patient had the MRI more than 24 hours after arriving at the hospital, you should report 3112F (CT or MRI of the brain performed greater than 24 hours after arrival to the hospital) in addition to 70553 and 431.

3. Or if the patient had the MRI within 24 hours of arrival at the hospital, but the radiologist does not document absence or presence of hemorrhage, mass lesion and acute infarction, you should report 3110F-8P (Presence or absence of hemorrhage and mass lesion and acute infarction was not documented in final CT or MRI report, reason not otherwise specified) and 3111F with 70553 and 431.