McLaren MRI User manual

MRI Pre-Authorization Guide
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MRI/MRA Categories:
Head/Brain
Cervical Spine
Thoracic Spine
Lumbosacral Spine
Orbits, Face or Neck
Tempomandibular Joints (TMJ)
Abdomen
Lower Extremity Joint (Hip, Knee, Ankle)
Lower Extremity Non Joint (Femur, Lower Leg, Foot)
Upper Extremity Joint (Shoulder, Elbow, Wrist)
Upper Extremity Non Joint (Humerus, Forearm, Hand)
Chest
Pelvis/SI Joints
Breast
MRA/MRV
Other Misc Codes
Helpful Links
MRI Health History Screening Form
Outpatient MRI Order Form
Breast MRI Order Form
Prep Reference Guide

MRI Pre-Authorization Guide
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Brain/Head (Non-MRA/MRV) (IAC’s, Pituitary, Etc…)
1. 70551 - MRI Brain without contrast
2. 70552 - MRI Brain with contrast
3. 70553 - MRI Brain with and without contrast
Note:
Due to differing scan protocols or other possible contraindications to contrast at the time of
exam, if possible, we ask that all three codes be pre-authorized.
If MRA or MRV is also being requested, please pre-authorize separately using the MRA codes.
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MRI Pre-Authorization Guide
Page | 3
MRI Cervical Spine
1. 72141 - MRI Cervical Spine without contrast
2. 72142 - MRI Cervical Spine with contrast
3. 72156 - MRI Cervical Spine with and without contrast
Note:
Due to differing scan protocols or other possible contraindications to contrast at the time of
exam, if possible, we ask that all three codes be pre-authorized.
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MRI Pre-Authorization Guide
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MRI Thoracic Spine
1. 72146 - MRI Thoracic Spine without contrast
2. 72147 - MRI Thoracic Spine with contrast
3. 72157 - MRI Thoracic Spine with and without contrast
Note:
Due to differing scan protocols or other possible contraindications to contrast at the time of
exam, if possible, we ask that all three codes be pre-authorized.
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MRI Pre-Authorization Guide
Page | 5
MRI Lumbosacral Spine
1. 72148 - MRI Lumbosacral Spine without contrast
2. 72149 - MRI Lumbosacral Spine with contrast
3. 72158 - MRI Lumbosacral Spine with and without contrast
Note:
Due to differing scan protocols or other possible contraindications to contrast at the time of
exam, if possible, we ask that all three codes be pre-authorized.
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MRI Pre-Authorization Guide
Page | 6
MRI Orbits, Face, Neck
1. 70540 - MRI Face Neck Orbit without contrast
2. 70542 - MRI Face Neck Orbit with contrast
3. 70543 - MRI Face Neck Orbit with and without contrast
Note:
Due to differing scan protocols or other possible contraindications to contrast at the time of
exam, if possible, we ask that all three codes be pre-authorized.
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MRI Pre-Authorization Guide
Page | 7
MRI Abdomen
1. 74181 - MRI Abdomen without contrast
2. 74182 - MRI Abdomen with contrast
3. 74183 - MRI Abdomen with and without contrast
Note:
Due to differing scan protocols or other possible contraindications to contrast at the time of
exam, if possible, we ask that all three codes be pre-authorized.
If MRA or MRV is also being requested, please pre-authorize separately using the MRA codes.
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MRI Pre-Authorization Guide
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MRI Pelvis
1. 72195 - MRI Pelvis without contrast
2. 72196 - MRI Pelvis with contrast
3. 72197 - MRI Pelvis with and without contrast
Note:
Due to differing scan protocols or other possible contraindications to contrast at the time of
exam, if possible, we ask that all three codes be pre-authorized.
If MRA or MRV is also being requested, please pre-authorize separately using the MRA codes.
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MRI Pre-Authorization Guide
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MRI Chest
1. 71550 - MRI Chest without contrast
2. 71551 - MRI Chest with contrast
3. 71552 - MRI Chest with and without contrast
Note:
Due to differing scan protocols or other possible contraindications to contrast at the time of
exam, if possible, we ask that all three codes be pre-authorized.
If MRA or MRV is also being requested, please pre-authorize separately using the MRA codes.
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MRI Pre-Authorization Guide
Page | 10
MRI Upper Extremity Joint (Shoulder, Elbow, Wrist)
1. 73221 - MRI Upper Extremity Joint without contrast
2. 73222 - MRI Upper Extremity Joint with contrast
3. 73223 - MRI Upper Extremity Joint with and without contrast
Note:
Due to differing scan protocols or other possible contraindications to contrast at the time of
exam, if possible, we ask that all three codes be pre-authorized.
If MRA or MRV is also being requested, please pre-authorize separately using the MRA codes.
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MRI Pre-Authorization Guide
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MRI Upper Extremity Non-Joint (Humerus, Forearm, Hand)
1. 73218 - MRI Upper Extremity without contrast
2. 73219 - MRI Upper Extremity with contrast
3. 73220 - MRI Upper Extremity with and without contrast
Note:
Due to differing scan protocols or other possible contraindications to contrast at the time of
exam, if possible, we ask that all three codes be pre-authorized.
If MRA or MRV is also being requested, please pre-authorize separately using the MRA codes.
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MRI Pre-Authorization Guide
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MRI Lower Extremity Non-Joint (Femur, Lower Leg, Foot)
1. 73718 - MRI Lower Extremity without contrast
2. 73719 - MRI Lower Extremity with contrast
3. 73720 - MRI Lower Extremity with and without contrast
Note:
Due to differing scan protocols or other possible contraindications to contrast at the time of
exam, if possible, we ask that all three codes be pre-authorized.
If MRA or MRV is also being requested, please pre-authorize separately using the MRA codes.
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MRI Pre-Authorization Guide
Page | 13
MRI Lower Extremity Joint (Hip, Knee, Ankle)
1. 73721 - MRI Lower Extremity Joint without contrast
2. 73722 - MRI Lower Extremity Joint with contrast
3. 73723 - MRI Lower Extremity Joint with and without contrast
Note:
Due to differing scan protocols or other possible contraindications to contrast at the time of
exam, if possible, we ask that all three codes be pre-authorized.
If MRA or MRV is also being requested, please pre-authorize separately using the MRA codes.
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MRI Pre-Authorization Guide
Page | 14
MRI Breast
1. 77058 - MRI Breast Unilateral
1. 77059 - MRI Breast Bilateral
Note:
These codes cover any variation of contrast or non-contrast imaging.
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MRI Pre-Authorization Guide
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MRI Temporomandibular Joint(s) (TMJ)
1. 70336 - MRI TMJ without contrast
2. 70336 - MRI TMJ with contrast
3. 70336 - MRI TMJ with and without contrast
Note:
This code covers any variation of contrast or non-contrast imaging.
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MRI Pre-Authorization Guide
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MRA/MRV
Magnetic Resonance Angiography (MRA), optimized for arterial structures.
Magnetic Resonance Venography (MRV), optimized for venous structures.
MRV will bill using the same codes as MRA.
1. 74185, 73725 MRA Abdomen Pelvis with Bilateral Lower Extremities (Runoff)
2. 74185 - MRA Abdomen
3. 71555 - MRA Chest
4. 70544 - MRA Head/Brain without contrast
5. 70545 - MRA Head/Brain with contrast
6. 70546 - MRA Head/Brain with and without contrast
7. 73725 - MRA Lower Extremity
8. 70547 - MRA Neck without contrast
9. 70548 - MRA Neck with contrast
10. 70549 - MRA Neck with and without contrast
11. 72198 - MRA Pelvis
12. 73225 - MRA Upper Extremity
13. 74185 - MRV Abdomen
14. 70544 - MRV Head/Brain without contrast
15. 70545 - MRV Head/Brain with contrast
16. 70546 - MRV Head/Brain with and without contrast
17. 72198 - MRV Pelvis
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MRI Pre-Authorization Guide
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MRI Misc Codes
77084 - MRI Bone Marrow Blood Supply
73721 - MRI Extremity Signature Protocol
77021 - MRI Guidance for Needle Placement
77022 - MRI Guided Tissue Ablation
76498 - MRI Radiation Therapy Treatment Planning
70551 - MRI Stroke Protocol
159T - CAD for Breast MRI
19085 - MRI Breast Biopsy or Localization
19086 - MRI Breast Biopsy or Localization Additional Lesions
If you have any questions or comments, please email [e-mail]
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Rev date-01/06/2017