Radiology Coding Alert

Question: A physician performs a pre-MRI eye screening. The indication states nothing more than “pre-MRI metal check”. Is this sufficient documentation to apply a diagnosis and procedure code? If so, what codes will I use in this circumstance?

Pennsylvania Subscriber

Answer: For patients with a documented history of metal exposure, a pre-MRI (magnetic resonance imaging) screening is a routinely performed exam to rule out any potential retained metal foreign bodies (FBs). In regards to procedure coding, you’ll want to apply 70030 (Radiologic examination, eye, for detection of foreign body) to any pre-MRI orbital X-ray screens.  

The diagnosis code will depend on whether or not a retained foreign body (FB) was found during the screening. If so, you’ll first want to submit the screening code Z03.89 (Encounter for observation for other suspected diseases and conditions ruled out). If, for instance, a nonmagnetic metal fragment was found during the screening, you’ll apply Z18.12 (Retained nonmagnetic metal fragments) as a secondary code.

Remember: Retained foreign body Z codes are notapplicable as primary diagnoses. If the dictation report does not provide documentation that a screening procedure is performed, the coder will have to send the report back to the physician for anaddendum.