Billing and Coding: Lumbar MRI

Title XVIII of the Social Security Act (SSA), §1862(a)(1)(A) states that no Medicare payment shall be made for items or services that "are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member."

Title XVIII of the Social Security Act, §1862(a)(7) and 42 Code of Federal Regulations (CFR), §411.15 particular services excluded from coverage.

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.

Title XVIII of the Social Security Act, §1842(p)(1)states that each claim submitted by a physician or practitioner shall include the appropriate diagnosis code (or codes)...". §1842(b)(18)(C) defines a practitioner. For services from physicians and (§1842(b)(18)(C)) practitioner submitted with an ICD-10 code that is missing, invalid, or truncated, contractors must return the billed service to the provider as unprocessable in accordance with CR 1910, Transmittal 1728, dated November 1, 2001 (MCM Part 3, Claim Process §3005.4(p)).

42 CFR §411.15(k) excludes specific services that are not reasonable and necessary.

CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, §3.4.1.3, Diagnosis Code Requirement

42 CFR 410.32 and 410.33 indicates that diagnostic tests are payable only when ordered by the physician who is treating the beneficiary for a specific medical problem and who uses the results in such treatment.

CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §§60, 60.1, 60.2, 60.3, 60.4, 60.4.1 and 80 indicate that the technical component of diagnostic tests is not covered as "incident to" physician healthcare services, but under a distinct coverage category and subject to supervision levels found in the Physician Fee Schedule database.

CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 10, §§5-5.7.2 indicates that non-physician owned facilities performing primarily diagnostic tests should be enrolled as IDTFs rather than billing under physician PINs. See also 42 CFR 410.33.

CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §80.4.1 and §250 govern payment for X-ray services supplied for patients in a Part A stay in a skilled nursing facility, or other facility, including payments under arrangement.

CFR 486.100 stipulates that portable X-rays must comply with Federal, State, and local laws and regulations.

CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, §§40, 40.1.4 Magnetic Resonance Imaging (MRI) Procedures and Payment Requirements. Effective January 1, 2017 separate payment for the contrast media and the need to use the appropriate HCPCS “Q” code (Q9945 – Q9954; Q9958-Q9964) for the contrast medium utilized in performing the service. §40 allows beneficiaries with implanted PMs or cardioverter defibrillators (ICDs) for use in an MRI environment in a Medicare approved clinical study. §40.1.4, Medicare will allow for coverage of MRI for beneficiaries with implanted pacemakers (PMs) when the PMs are used according to the Food and Drug Administration (FDA)-approved labeling for use in an MRI environment as described in section 220.2.C.1 of the NCD manual, effective July 7, 2011.

CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, §100.1 describes how physicians should handle billing when two providers read a diagnostic radiologic procedure.

CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §220.2; Magnetic Resonance Imaging (MRI), the contraindications section 220.2.C.1 of the NCD was revised to read that the contraindications will not apply to pacemakers when used according to the FDA-approved labeling in an MRI environment or in clinical trials.

CMS publication 100-3, Medicare National Coverage Determinations, Sections 220.1 "Computerized Tomography", and 220.2-220.2.B.2d and Section 220.2.c-220.D "Magnetic Resonance Imaging".

Denies Coverage of MRI for:

1. Imaging of cortical bone and calcification

2. Procedures involving spatial resolution of bone or calcification

3. MRI is not covered for patients with metallic clips on vascular aneurysms.

CMS publication 100-04 Medicare Claims Processing Manual Chapter 13 Section 40 denies coverage of MRI for: Measurement of blood flow and spectroscopy

The following coding and billing guidance is to be used with its associated Local coverage determination.

Documentation Requirements

Supportive documentation evidencing the condition and treatment is expected to be documented in the medical record and be available upon request.

The patient’s medical record must be legible and clearly indicate the necessity and reasonableness of the service.

The documentation must clearly support the ICD-10-CM code(s) reported on the claim.

An attending/treating physician’s order is required for each test. The order must be properly signed and dated.

Lumbar MRI abnormalities alone do not validate the need for the test without other supporting clinical rationale. Radiologists and/or ordering physicians should include sufficient clinical information in the report to justify its necessity.

The clinical findings and relevant prior treatment that support the need for the MRI must be documented in the MRI report or clinical record and made available to the contractor upon request.

The medical record of the referring physician must support a contemplated diagnosis or treatment change derived from the MRI findings. The contractor may request medical records from the referring physician if the radiologist’s documentation does not validate that the service is reasonable and necessary.

According to national regulations, clinics which are (a) not physician owned and which are (b) billing Medicare primarily for diagnostic tests may be required to enroll as IDTFs. For example, a nonphysician owner who establishes a Magnetic Resonance Imaging clinic by leasing office space, equipment, and hiring technicians, and hires a retired ophthalmologist to provide off-site (general) supervision of diagnostic testing without treatment would be more appropriately enrolled as an IDTF rather than merely billing all services through the physician's PIN.

Utilization Guidelines

Normally only one lumbar MRI is sufficient to diagnose the patient's condition. However, a second lumbar MRI, for the same patient, may be allowed providing the documentation indicates that comparative test results were needed to make a more definitive treatment decision.

Payment will be allowed for multiple scans of different areas of the body performed on the same day for the same patient when reasonable and necessary.