The diagnosis and the E/M codes were billed correctly because they met the criteria to be billed as recorded in the patient’s medical record. It is not appropriate to report CPT code 73218, magnetic resonance (e.g., proton) imaging, upper extremity, other than joint, without contrast material(s), because the MRI was performed for pain in her joint. The correct procedure code for the procedure is CPT code 73221, magnetic resonance (e.g., proton) imaging, any joint of upper extremity; without contrast material(s).
You would use procedure code 73218 for the following scenario:
A patient is seen by her rheumatologist for weakness in the shoulders. The patient explains that it is hard for her to lift her arms or get out of a chair. The weakness in her arm is not associated with any stiffness but lasts for about two to four hours. It is incompletely relieved with ibuprofen, and the level of pain is a one out of 10.
Review of systems: Musculoskeletal: negative for myalgias, or joint redness or warmth. Cardiovascular: negative for chest pain and orthopnea. The physician requests labs and performs a detailed examination, noting that the patient has proximal muscle weakness. The physician sends the patient to have an MRI of one of the involved arms to support the medical decision making.
The patient is sent to the imaging room and gowned to have an MRI done. The imaging technician performs the procedure without contrast material and runs the report of the findings. The physician reads the report and sees that the patient might have polymyositis. The physician decides that the patient should schedule to have a biopsy before starting any treatment.
E/M Visit: 99214-25
MRI has opened new horizons in the detection of early joint damage, assessment of synovial inflammation, and therapeutic management of patients with RA. The key to understanding the correct coding for MRI services is vital for proper reimbursement and disease management for patients. For additional information and coding guidelines, contact the ACR’s coding specialists at (404) 633-3777.