Wiki MRI w/wo Contrast - Incomplete Procedure

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tfrick2

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We had a patient come in who was scheduled for an MRI Brain w/wo Contrast. The procedure was explained to him, and the IV for the contrast was placed prior to beginning the scan. The scan without contrast proceeded as normal. When it came time to inject the contrast, the patient refused the injection, stating that he did not want any contrast injected for the exam. The exam was then terminated.

What is the best way to code this procedure? My thought is to code only for the MRI Brain w/o Contrast, while a colleague feels that we might be able to code for scans w/wo contrast with a -52 modifier attached, because we did place the IV in preparation for using contrast.

Thanks,
Tracy
 
No, I feel MRI brain W/o and With contrast with 53 modifier suits this well,

as the intention of the proceudure is to perform a w/o and with contrast study, and the procedure was terminated due to patient's condition.
 
The tech should have changed the exam to a w/o contrast before ending the exam. Modifier 53 seems to relate to a procedure, not a simple imaging study. Patient's refusal here, is not a situation where the physician discontinues the procedure. And this is not anesthesia, just an IV placement for intended use.
 
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