Radiology Coding Alert

Question: We’ve got a patient who was placed into the magnetic resonance imaging (MRI) scanner for an MRI cervical spine without contrast, had scout images taken, and then requested to terminate the scan due to pain. Can I still code for the scan and apply a discontinued procedure modifier?

New Hampshire Subscriber

Answer: The short answer as to whether or not this procedure can be submitted for reimbursement is: it depends. If enough preliminary scout images were obtained that the radiologist was able to formulate a dictation report, then you may append modifier 53 (Discontinued Procedure) to code 72141 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material). However, if the physician did not dictate a formal report, then you should not seek reimbursement for the professional component.

As for the facility component, if the machine begins taking scout images in any capacity, the facility may submit code 72141 with modifier 53. Whether you’re submitting for the professional or technical component of 72141 with modifier 53, you’ll want to submit the claim electronically in addition to a separate submission paper. On the paper claim, include documentation, such as the dictation report, that justifies the use of the modifier and details how far in the imaging process the patient went before requesting it be stopped.