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Radiology Coding Alert

You Be the Coder:

Coding for 'Callback'

Published on Tue Apr 19, 2005

Question: Our radiologist did an MRI of the brain and on a subsequent date of service requested that the patient return for "thin section T2 and FLAIR axial and coronal through the temporal lobes in an attempt to further characterize." There was a second order from the referring physician, and the study was done at an independent testing facility. Can we code for two studies or just one?


Illinois Subscriber


Answer: If your documentation shows medical necessity for the "callback," code both studies separately. Most payers will reimburse you for two separate studies.

Best bet: For the first date of service, report the proper code from CPT 70551 -CPT 70553 (Magnetic resonance [e.g., proton] imaging, brain [including brain stem]...). On the next date of service, report the appropriate code from the same range. Note: As an IDTF, you wouldn't report codes 70557-70559 (Magnetic resonance [e.g., proton] imaging, brain [including brain stem and skull base], during open intracranial procedure [e.g., to assess for residual tumor or residual vascular formation] ...), because they are intraoperative.

Caution: If you don't have an order for the second study or have no evidence of medical necessity, coding the second study could lead to trouble during an audit. As always, remember that individual payer guidelines vary and should rule your decision.

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