Magnetic Resonance Angiography (L31355)
Contractor Information
|
Contractor Name Wisconsin Physicians Service Insurance Corporation |
Contractor Number 00951, 00952, 00953, 00954, 52280, 05101, 05201, 05301, 05401, 05102, 05202, 05302, 05402 |
Contractor Type Carrier - FI - MAC |
LCD Information
L31355 LCD Title Magnetic Resonance Angiography Contractor's Determination Number RAD-023 AMA CPT/ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. |
Primary Geographic Jurisdiction
Oversight Region Original Determination Effective Date For services performed on or after 04/15/2011 Original Determination Ending Date Revision Effective Date For services performed on or after 12/01/2011 Revision Ending Date |
Title XVIII of the Social Security Act, Section 1833(e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
Pub 100-3, Ch. 1, Part 4, §220.2
MRA can thus be used to demonstrate obstructive vascular lesions, eliminating the risk associated with angiography and the use of contrast material. Accordingly, MRA is generally covered only to the extent that it is used as a substitute for contrast angiography (CA). However, if the MRA is not conclusive, a CA may then be medically necessary.
Advantages of MRA include:
1. It is considered non-invasive
2. Multiple angles and three-dimensional images can be visualized
3. Conventional angiography utilizes contrast materials and sedation, which has a significant risk of
adverse reactions
4. There is essentially no risk of arterial puncture-associated complications
5. MRA may be used for those patients with whom conventional angiography is contraindicated
6. MRA allows adjacent structures to be visualized; and
7. MRA is capable of evaluating any vessel of the body, regardless of its location. In contrast,
ultrasonography (US) is limited to vessels, which are not obscured by bone, calcification, air or
excessive fat.
In summary, Magnetic resonance angiography (MRA) is an application of magnetic resonance imaging (MRI) that provides visualization of blood flow, as well as images of normal and diseased blood vessels
A. Qualifications of the provider:
The physician should be qualified to perform these procedures and have advanced knowledge of the anatomy and the disease process of the study area.
B. Contraindications:
1. Patients with non-removable intradural and/or intraorbital devices including:
a. metallic clips on vascular or intracranial aneurysms; or
b. intraorbital metallic foreign body.
C. Patients with devices containing ferromagnetic materials (metal that could be magnetized) that cannot be removed or substituted for MRA compatible devices, including, but not limited to non-MRA compatible life support equipment or monitoring equipment.
In the absence of symptoms or signs of neurological concern, an MRA of the head and neck would be considered to be screening, thus non-payable by Medicare.
While the intent of this policy is to provide reimbursement for either MRA or CA, CMS is also allowing flexibility for physicians to make appropriate decisions concerning the use of these tests based on the needs of individual patients. CMS anticipates, however, low utilization of the combined use of MRA and CA. As a result, CMS has encouraged contractors to monitor the use of these tests and, where indicated, and require evidence of the need to perform both MRA and CA.
All other uses of MRA for which CMS has not specifically indicated coverage continue to be noncovered.
Compliance with the provisions in this policy is subject to monitoring by post payment data analysis and subsequent medical review.
Coding Information
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
| 011x | Hospital Inpatient (Including Medicare Part A) |
| 012x | Hospital Inpatient (Medicare Part B only) |
| 013x | Hospital Outpatient |
| 085x | Critical Access Hospital |
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Revenue codes only apply to providers who bill these services to the fiscal intermediary or Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.
All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review.
| 0615 | Magnetic Resonance Technology (MRT) - MRA - Head and Neck |
| 0616 | Magnetic Resonance Technology (MRT) - MRA - Lower Extremities |
| 0618 | Magnetic Resonance Technology (MRT) - MRA - Other |
CPT/HCPCS Codes (70544, 70545, 70546, 70547, 70548, 70549, 71555, 72198, 73725, 74185, C8900, C2901, C8902, C8909, C8910, C28911, C8912, C8913, C8914, C8914, C8918, C8919, C8920)
| 70544 | MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S) |
| 70545 | MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITH CONTRAST MATERIAL(S) |
| 70546 | MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES |
| 70547 | MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST MATERIAL(S) |
| 70548 | MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITH CONTRAST MATERIAL(S) |
| 70549 | MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES |
| 71555 | MAGNETIC RESONANCE ANGIOGRAPHY, CHEST (EXCLUDING MYOCARDIUM), WITH OR WITHOUT CONTRAST MATERIAL(S) |
| 72198 | MAGNETIC RESONANCE ANGIOGRAPHY, PELVIS, WITH OR WITHOUT CONTRAST MATERIAL(S) |
| 73725 | MAGNETIC RESONANCE ANGIOGRAPHY, LOWER EXTREMITY, WITH OR WITHOUT CONTRAST MATERIAL(S) |
| 74185 | MAGNETIC RESONANCE ANGIOGRAPHY, ABDOMEN, WITH OR WITHOUT CONTRAST MATERIAL(S) |
| C8900 | MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, ABDOMEN |
| C8901 | MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, ABDOMEN |
| C8902 | MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, ABDOMEN |
| C8909 | MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, CHEST (EXCLUDING MYOCARDIUM) |
| C8910 | MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, CHEST (EXCLUDING MYOCARDIUM) |
| C8911 | MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, CHEST (EXCLUDING MYOCARDIUM) |
| C8912 | MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, LOWER EXTREMITY |
| C8913 | MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, LOWER EXTREMITY |
| C8914 | MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, LOWER EXTREMITY |
| C8918 | MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, PELVIS |
| C8919 | MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, PELVIS |
| C8920 | MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, PELVIS |
ICD-9 Codes that Support Medical Necessity
For CPT Codes 70544, 70545, 70546, 70547, 70548 and 70549 (MRA of Head and Neck)
| 094.81 - 094.89 | SYPHILITIC ENCEPHALITIS - OTHER SPECIFIED NEUROSYPHILIS |
| 140.0 - 140.9 | MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER - MALIGNANT NEOPLASM OF LIP UNSPECIFIED VERMILION BORDER |
| 141.0 - 141.9 | MALIGNANT NEOPLASM OF BASE OF TONGUE - MALIGNANT NEOPLASM OF TONGUE UNSPECIFIED |
| 142.0 - 142.9 | MALIGNANT NEOPLASM OF PAROTID GLAND - MALIGNANT NEOPLASM OF SALIVARY GLAND UNSPECIFIED |
| 143.0 - 143.9 | MALIGNANT NEOPLASM OF UPPER GUM - MALIGNANT NEOPLASM OF GUM UNSPECIFIED |
| 144.0 - 144.9 | MALIGNANT NEOPLASM OF ANTERIOR PORTION OF FLOOR OF MOUTH - MALIGNANT NEOPLASM OF FLOOR OF MOUTH PART UNSPECIFIED |
| 145.0 - 145.9 | MALIGNANT NEOPLASM OF CHEEK MUCOSA - MALIGNANT NEOPLASM OF MOUTH UNSPECIFIED |
| 146.0 - 146.9 | MALIGNANT NEOPLASM OF TONSIL - MALIGNANT NEOPLASM OF OROPHARYNX UNSPECIFIED SITE |
| 147.0 - 147.9 | MALIGNANT NEOPLASM OF SUPERIOR WALL OF NASOPHARYNX - MALIGNANT NEOPLASM OF NASOPHARYNX UNSPECIFIED SITE |
| 148.0 - 148.9 | MALIGNANT NEOPLASM OF POSTCRICOID REGION OF HYPOPHARYNX - MALIGNANT NEOPLASM OF HYPOPHARYNX UNSPECIFIED SITE |
| 149.0 - 149.9 | MALIGNANT NEOPLASM OF PHARYNX UNSPECIFIED - MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE LIP AND ORAL CAVITY |
| 170.0 | MALIGNANT NEOPLASM OF BONES OF SKULL AND FACE EXCEPT MANDIBLE |
| 171.0 | MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF HEAD FACE AND NECK |
| 191.0 - 191.9 | MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES - MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE |
| 192.1 | MALIGNANT NEOPLASM OF CEREBRAL MENINGES |
| 194.3 | MALIGNANT NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT |
| 194.4 | MALIGNANT NEOPLASM OF PINEAL GLAND |
| 194.5 | MALIGNANT NEOPLASM OF CAROTID BODY |
| 194.6 | MALIGNANT NEOPLASM OF AORTIC BODY AND OTHER PARAGANGLIA |
| 195.0 | MALIGNANT NEOPLASM OF HEAD FACE AND NECK |
| 198.3 | SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD |
| 198.4 | SECONDARY MALIGNANT NEOPLASM OF OTHER PARTS OF NERVOUS SYSTEM |
| 225.0 | BENIGN NEOPLASM OF BRAIN |
| 225.1 | BENIGN NEOPLASM OF CRANIAL NERVES |
| 225.2 | BENIGN NEOPLASM OF CEREBRAL MENINGES |
| 227.3 | BENIGN NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT |
| 227.4 | BENIGN NEOPLASM OF PINEAL GLAND |
| 227.5 | BENIGN NEOPLASM OF CAROTID BODY |
| 227.6 | BENIGN NEOPLASM OF AORTIC BODY AND OTHER PARAGANGLIA |
| 228.02 | HEMANGIOMA OF INTRACRANIAL STRUCTURES |
| 228.03 | HEMANGIOMA OF RETINA |
| 228.09 | HEMANGIOMA OF OTHER SITES |
| 237.0 - 237.73 | NEOPLASM OF UNCERTAIN BEHAVIOR OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT - SCHWANNOMATOSIS |
| 237.79 | OTHER NEUROFIBROMATOSIS |
| 239.6 | NEOPLASM OF UNSPECIFIED NATURE OF BRAIN |
| 290.40 - 290.43 | VASCULAR DEMENTIA, UNCOMPLICATED - VASCULAR DEMENTIA, WITH DEPRESSED MOOD |
| 325 | PHLEBITIS AND THROMBOPHLEBITIS OF INTRACRANIAL VENOUS SINUSES |
| 326 | LATE EFFECTS OF INTRACRANIAL ABSCESS OR PYOGENIC INFECTION |
| 342.00 - 342.92 | FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE - UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE |
| 345.00 - 345.91 | GENERALIZED NONCONVULSIVE EPILEPSY WITHOUT INTRACTABLE EPILEPSY - EPILEPSY UNSPECIFIED WITH INTRACTABLE EPILEPSY |
| 346.00 - 346.93 | MIGRAINE WITH AURA, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS - MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS |
| 348.0 | CEREBRAL CYSTS |
| 348.1 | ANOXIC BRAIN DAMAGE |
| 348.4 | COMPRESSION OF BRAIN |
| 348.5 | CEREBRAL EDEMA |
| 350.1 - 350.9 | TRIGEMINAL NEURALGIA - TRIGEMINAL NERVE DISORDER UNSPECIFIED |
| 351.9 | FACIAL NERVE DISORDER UNSPECIFIED |
| 362.30 - 362.37 | RETINAL VASCULAR OCCLUSION UNSPECIFIED - VENOUS ENGORGEMENT OF RETINA |
| 362.81 | RETINAL HEMORRHAGE |
| 368.11 | SUDDEN VISUAL LOSS |
| 368.12 | TRANSIENT VISUAL LOSS |
| 368.2 | DIPLOPIA |
| 368.40 - 368.47 | VISUAL FIELD DEFECT UNSPECIFIED - HETERONYMOUS BILATERAL FIELD DEFECTS |
| 374.31 | PARALYTIC PTOSIS |
| 377.01 | PAPILLEDEMA ASSOCIATED WITH INCREASED INTRACRANIAL PRESSURE |
| 377.04 | FOSTER-KENNEDY SYNDROME |
| 377.41 - 377.49 | ISCHEMIC OPTIC NEUROPATHY - OTHER DISORDERS OF OPTIC NERVE |
| 377.51 - 377.54 | DISORDERS OF OPTIC CHIASM ASSOCIATED WITH PITUITARY NEOPLASMS AND DISORDERS - DISORDERS OF OPTIC CHIASM ASSOCIATED WITH INFLAMMATORY DISORDERS |
| 377.61 | DISORDERS OF OTHER VISUAL PATHWAYS ASSOCIATED WITH NEOPLASMS |
| 377.62 | DISORDERS OF OTHER VISUAL PATHWAYS ASSOCIATED WITH VASCULAR DISORDERS |
| 377.71 | DISORDERS OF VISUAL CORTEX ASSOCIATED WITH NEOPLASMS |
| 377.72 | DISORDERS OF VISUAL CORTEX ASSOCIATED WITH VASCULAR DISORDERS |
| 378.51 | THIRD OR OCULOMOTOR NERVE PALSY PARTIAL |
| 378.52 | THIRD OR OCULOMOTOR NERVE PALSY TOTAL |
| 388.02 | TRANSIENT ISCHEMIC DEAFNESS |
| 388.30 - 388.32 | TINNITUS UNSPECIFIED - OBJECTIVE TINNITUS |
| 430 | SUBARACHNOID HEMORRHAGE |
| 431 | INTRACEREBRAL HEMORRHAGE |
| 432.0 | NONTRAUMATIC EXTRADURAL HEMORRHAGE |
| 432.1 | SUBDURAL HEMORRHAGE |
| 432.9 | UNSPECIFIED INTRACRANIAL HEMORRHAGE |
| 433.00 - 433.91 | OCCLUSION AND STENOSIS OF BASILAR ARTERY WITHOUT CEREBRAL INFARCTION - OCCLUSION AND STENOSIS OF UNSPECIFIED PRECEREBRAL ARTERY WITH CEREBRAL INFARCTION |
| 434.00 - 434.91 | CEREBRAL THROMBOSIS WITHOUT CEREBRAL INFARCTION - CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITH CEREBRAL INFARCTION |
| 435.0 - 435.9 | BASILAR ARTERY SYNDROME - UNSPECIFIED TRANSIENT CEREBRAL ISCHEMIA |
| 436 | ACUTE BUT ILL-DEFINED CEREBROVASCULAR DISEASE |
| 437.0 - 437.9 | CEREBRAL ATHEROSCLEROSIS - UNSPECIFIED CEREBROVASCULAR DISEASE |
| 438.0 - 438.9 | COGNITIVE DEFICITS - UNSPECIFIED LATE EFFECTS OF CEREBROVASCULAR DISEASE |
| 442.81 | ANEURYSM OF ARTERY OF NECK |
| 442.82 | ANEURYSM OF SUBCLAVIAN ARTERY |
| 443.21 | DISSECTION OF CAROTID ARTERY |
| 446.0 | POLYARTERITIS NODOSA |
| 446.20 | HYPERSENSITIVITY ANGIITIS UNSPECIFIED |
| 446.29 | OTHER SPECIFIED HYPERSENSITIVITY ANGIITIS |
| 446.5 | GIANT CELL ARTERITIS |
| 446.6 | THROMBOTIC MICROANGIOPATHY |
| 446.7 | TAKAYASU'S DISEASE |
| 447.0 | ARTERIOVENOUS FISTULA ACQUIRED |
| 447.1 | STRICTURE OF ARTERY |
| 447.2 | RUPTURE OF ARTERY |
| 447.8 | OTHER SPECIFIED DISORDERS OF ARTERIES AND ARTERIOLES |
| 453.9 | EMBOLISM AND THROMBOSIS OF UNSPECIFIED SITE |
| 459.9 | UNSPECIFIED CIRCULATORY SYSTEM DISORDER |
| 710.0 | SYSTEMIC LUPUS ERYTHEMATOSUS |
| 723.1 | CERVICALGIA |
| 747.10 | COARCTATION OF AORTA (PREDUCTAL) (POSTDUCTAL) |
| 747.81 | CONGENITAL ANOMALIES OF CEREBROVASCULAR SYSTEM |
| 753.10 - 753.19 | CYSTIC KIDNEY DISEASE UNSPECIFIED - OTHER SPECIFIED CYSTIC KIDNEY DISEASE |
| 756.83 | EHLERS-DANLOS SYNDROME |
| 757.39 | OTHER SPECIFIED CONGENITAL ANOMALIES OF SKIN |
| 759.82 | MARFAN SYNDROME |
| 780.01 - 780.4 | COMA - DIZZINESS AND GIDDINESS |
| 780.93 | MEMORY LOSS |
| 780.97 | ALTERED MENTAL STATUS |
| 781.0 - 781.8 | ABNORMAL INVOLUNTARY MOVEMENTS - NEUROLOGIC NEGLECT SYNDROME |
| 784.0 | HEADACHE |
| 784.2 | SWELLING MASS OR LUMP IN HEAD AND NECK |
| 784.3 | APHASIA |
| 784.59 | OTHER SPEECH DISTURBANCE |
| 784.69 | OTHER SYMBOLIC DYSFUNCTION |
| 784.99 | OTHER SYMPTOMS INVOLVING HEAD AND NECK |
| 785.9 | OTHER SYMPTOMS INVOLVING CARDIOVASCULAR SYSTEM |
| 793.0 | NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF SKULL AND HEAD |
| 794.09 | OTHER NONSPECIFIC ABNORMAL RESULTS OF FUNCTION STUDY OF BRAIN AND CENTRAL NERVOUS SYSTEM |
| 800.20 - 800.29 | CLOSED FRACTURE OF VAULT OF SKULL WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - CLOSED FRACTURE OF VAULT OF SKULL WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED |
| 800.30 - 800.39 | CLOSED FRACTURE OF VAULT OF SKULL WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - CLOSED FRACTURE OF VAULT OF SKULL WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED |
| 800.70 - 800.79 | OPEN FRACTURE OF VAULT OF SKULL WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OPEN FRACTURE OF VAULT OF SKULL WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED |
| 800.80 - 800.89 | OPEN FRACTURE OF VAULT OF SKULL WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OPEN FRACTURE OF VAULT OF SKULL WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED |
| 801.20 - 801.29 | CLOSED FRACTURE OF BASE OF SKULL WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - CLOSED FRACTURE OF BASE OF SKULL WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED |
| 801.30 - 801.39 | CLOSED FRACTURE OF BASE OF SKULL WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - CLOSED FRACTURE OF BASE OF SKULL WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED |
| 801.70 - 801.79 | OPEN FRACTURE OF BASE OF SKULL WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OPEN FRACTURE OF BASE OF SKULL WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED |
| 801.80 - 801.89 | OPEN FRACTURE OF BASE OF SKULL WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OPEN FRACTURE OF BASE OF SKULL WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED |
| 803.20 - 803.29 | OTHER CLOSED SKULL FRACTURE WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER CLOSED SKULL FRACTURE WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED |
| 803.30 - 803.39 | OTHER CLOSED SKULL FRACTURE WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH STATE OF UNCONSCIOUSNESS UNSPECIFIED - OTHER CLOSED SKULL FRACTURE WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED |
| 803.70 - 803.79 | OTHER OPEN SKULL FRACTURE WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER OPEN SKULL FRACTURE WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED |
| 803.80 - 803.89 | OTHER OPEN SKULL FRACTURE WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER OPEN SKULL FRACTURE WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED |
| 804.20 - 804.29 | CLOSED FRACTURES INVOLVING SKULL OR FACE WITH OTHER BONES WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - CLOSED FRACTURES INVOLVING SKULL OR FACE WITH OTHER BONES WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED |
| 804.30 - 804.39 | CLOSED FRACTURES INVOLVING SKULL OR FACE WITH OTHER BONES WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - CLOSED FRACTURES INVOLVING SKULL OR FACE WITH OTHER BONES WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED |
| 804.70 - 804.79 | OPEN FRACTURES INVOLVING SKULL OR FACE WITH OTHER BONES WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OPEN FRACTURES INVOLVING SKULL OR FACE WITH OTHER BONES WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED |
| 804.80 - 804.89 | OPEN FRACTURES INVOLVING SKULL OR FACE WITH OTHER BONES WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OPEN FRACTURES INVOLVING SKULL OR FACE WITH OTHER BONES WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED |
| 805.10 - 805.18 | OPEN FRACTURE OF CERVICAL VERTEBRA UNSPECIFIED LEVEL - OPEN FRACTURE OF MULTIPLE CERVICAL VERTEBRAE |
| 806.00 - 806.09 | CLOSED FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - CLOSED FRACTURE OF C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY |
| 806.10 - 806.19 | OPEN FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - OPEN FRACTURE OF C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY |
| 852.00 - 852.59 | SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED - EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED |
| 853.00 - 853.19 | OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED |
| 900.00 - 900.9 | INJURY TO CAROTID ARTERY UNSPECIFIED - INJURY TO UNSPECIFIED BLOOD VESSEL OF HEAD AND NECK |
| 908.3 | LATE EFFECT OF INJURY TO BLOOD VESSEL OF HEAD NECK AND EXTREMITIES |
| 959.01 | OTHER AND UNSPECIFIED INJURY TO HEAD |
| 959.09 | OTHER AND UNSPECIFIED INJURY TO FACE AND NECK |
| 998.11 | HEMORRHAGE COMPLICATING A PROCEDURE |
| 998.12 | HEMATOMA COMPLICATING A PROCEDURE |
| 998.13 | SEROMA COMPLICATING A PROCEDURE |
| 093.0 | ANEURYSM OF AORTA SPECIFIED AS SYPHILITIC |
| 415.0 | ACUTE COR PULMONALE |
| 415.11 | IATROGENIC PULMONARY EMBOLISM AND INFARCTION |
| 415.13 | SADDLE EMBOLUS OF PULMONARY ARTERY |
| 415.19 | OTHER PULMONARY EMBOLISM AND INFARCTION |
| 416.0 - 416.9 | PRIMARY PULMONARY HYPERTENSION - CHRONIC PULMONARY HEART DISEASE UNSPECIFIED |
| 417.0 | ARTERIOVENOUS FISTULA OF PULMONARY VESSELS |
| 417.1 | ANEURYSM OF PULMONARY ARTERY |
| 441.00 - 441.9 | DISSECTION OF AORTA ANEURYSM UNSPECIFIED SITE - AORTIC ANEURYSM OF UNSPECIFIED SITE WITHOUT RUPTURE |
| 442.82 | ANEURYSM OF SUBCLAVIAN ARTERY |
| 444.1 | EMBOLISM AND THROMBOSIS OF THORACIC AORTA |
| 447.5 | NECROSIS OF ARTERY |
| 447.8 | OTHER SPECIFIED DISORDERS OF ARTERIES AND ARTERIOLES |
| 453.89 | ACUTE VENOUS EMBOLISM AND THROMBOSIS OF OTHER SPECIFIED VEINS |
| 511.81 | MALIGNANT PLEURAL EFFUSION |
| 511.89 | OTHER SPECIFIED FORMS OF EFFUSION, EXCEPT TUBERCULOUS |
| 511.9 | UNSPECIFIED PLEURAL EFFUSION |
| 794.2 | NONSPECIFIC ABNORMAL RESULTS OF FUNCTION STUDY OF PULMONARY SYSTEM |
| V12.51 | PERSONAL HISTORY OF VENOUS THROMBOSIS AND EMBOLISM |
| V12.55 | PERSONAL HISTORY OF PULMONARY EMBOLISM |
| V12.59 | PERSONAL HISTORY OF OTHER DISEASES OF CIRCULATORY SYSTEM NOT ELSEWHERE CLASSIFIED |
| V14.8 | PERSONAL HISTORY OF ALLERGY TO OTHER SPECIFIED MEDICINAL AGENTS |
Note: codes 440.8 and 747.69 may be used only when the specified
artery or site is the iliac artery.
| 403.00 - 403.91 | HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED - HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE |
| 404.00 - 404.93 | HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED - HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE |
| 405.01 | MALIGNANT RENOVASCULAR HYPERTENSION |
| 405.11 | BENIGN RENOVASCULAR HYPERTENSION |
| 405.91 | UNSPECIFIED RENOVASCULAR HYPERTENSION |
| 440.0 | ATHEROSCLEROSIS OF AORTA |
| 440.1 | ATHEROSCLEROSIS OF RENAL ARTERY |
| 440.8 | ATHEROSCLEROSIS OF OTHER SPECIFIED ARTERIES |
| 441.01 - 441.9 | DISSECTION OF AORTA THORACIC - AORTIC ANEURYSM OF UNSPECIFIED SITE WITHOUT RUPTURE |
| 442.1 | ANEURYSM OF RENAL ARTERY |
| 442.2 | ANEURYSM OF ILIAC ARTERY |
| 442.83 | ANEURYSM OF SPLENIC ARTERY |
| 442.84 | ANEURYSM OF OTHER VISCERAL ARTERY |
| 444.01 | SADDLE EMBOLUS OF ABDOMINAL AORTA |
| 444.09 | OTHER ARTERIAL EMBOLISM AND THROMBOSIS OF ABDOMINAL AORTA |
| 444.1 | EMBOLISM AND THROMBOSIS OF THORACIC AORTA |
| 444.81 | EMBOLISM AND THROMBOSIS OF ILIAC ARTERY |
| 445.81 | ATHEROEMBOLISM OF KIDNEY |
| 447.0 - 447.5 | ARTERIOVENOUS FISTULA ACQUIRED - NECROSIS OF ARTERY |
| 453.89 | ACUTE VENOUS EMBOLISM AND THROMBOSIS OF OTHER SPECIFIED VEINS |
| 747.69 | ANOMALIES OF OTHER SPECIFIED SITES OF PERIPHERAL VASCULAR SYSTEM |
| 902.0 | INJURY TO ABDOMINAL AORTA |
| 996.81 | COMPLICATIONS OF TRANSPLANTED KIDNEY |
| 997.72 | VASCULAR COMPLICATIONS OF RENAL ARTERY |
| 040.0 | GAS GANGRENE |
| 250.70 - 250.73 | DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE], UNCONTROLLED |
| 415.11 | IATROGENIC PULMONARY EMBOLISM AND INFARCTION |
| 415.13 | SADDLE EMBOLUS OF PULMONARY ARTERY |
| 415.19 | OTHER PULMONARY EMBOLISM AND INFARCTION |
| 440.20 - 440.29 | ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES UNSPECIFIED - OTHER ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES |
| 440.30 - 440.32 | ATHEROSCLEROSIS OF UNSPECIFIED BYPASS GRAFT OF THE EXTREMITIES - ATHEROSCLEROSIS OF NONAUTOLOGOUS BIOLOGICAL BYPASS GRAFT OF THE EXTREMITIES |
| 442.2 | ANEURYSM OF ILIAC ARTERY |
| 442.3 | ANEURYSM OF ARTERY OF LOWER EXTREMITY |
| 443.0 | RAYNAUD'S SYNDROME |
| 443.1 | THROMBOANGIITIS OBLITERANS (BUERGER'S DISEASE) |
| 443.22 | DISSECTION OF ILIAC ARTERY |
| 443.29 | DISSECTION OF OTHER ARTERY |
| 443.81 | PERIPHERAL ANGIOPATHY IN DISEASES CLASSIFIED ELSEWHERE |
| 443.89 | OTHER PERIPHERAL VASCULAR DISEASE |
| 443.9 | PERIPHERAL VASCULAR DISEASE UNSPECIFIED |
| 444.22 | ARTERIAL EMBOLISM AND THROMBOSIS OF LOWER EXTREMITY |
| 444.81 | EMBOLISM AND THROMBOSIS OF ILIAC ARTERY |
| 444.89 | EMBOLISM AND THROMBOSIS OF OTHER ARTERY |
| 445.02 | ATHEROEMBOLISM OF LOWER EXTREMITY |
| 447.0 - 447.8 | ARTERIOVENOUS FISTULA ACQUIRED - OTHER SPECIFIED DISORDERS OF ARTERIES AND ARTERIOLES |
| 451.0 | PHLEBITIS AND THROMBOPHLEBITIS OF SUPERFICIAL VESSELS OF LOWER EXTREMITIES |
| 451.11 - 451.19 | PHLEBITIS AND THROMBOPHLEBITIS OF FEMORAL VEIN (DEEP) (SUPERFICIAL) - PHLEBITIS AND THROMBOPHLEBITIS OF OTHER |
| 451.2 | PHLEBITIS AND THROMBOPHLEBITIS OF LOWER EXTREMITIES UNSPECIFIED |
| 451.81 | PHLEBITIS AND THROMBOPHLEBITIS OF ILIAC VEIN |
| 453.89 | ACUTE VENOUS EMBOLISM AND THROMBOSIS OF OTHER SPECIFIED VEINS |
| 459.11 - 459.19 | POSTPHLEBETIC SYNDROME WITH ULCER - POSTPHLEBETIC SYNDROME WITH OTHER COMPLICATION |
| 671.22 - 671.24 | SUPERFICIAL THROMBOPHLEBITIS WITH DELIVERY WITH POSTPARTUM COMPLICATION - POSTPARTUM SUPERFICIAL THROMBOPHLEBITIS |
| 671.31 | DEEP PHLEBOTHROMBOSIS ANTEPARTUM WITH DELIVERY |
| 671.33 | DEEP PHLEBOTHROMBOSIS ANTEPARTUM |
| 671.42 | DEEP PHLEBOTHROMBOSIS POSTPARTUM WITH DELIVERY |
| 671.44 | DEEP PHLEBOTHROMBOSIS POSTPARTUM |
| 682.6 | CELLULITIS AND ABSCESS OF LEG EXCEPT FOOT |
| 682.7 | CELLULITIS AND ABSCESS OF FOOT EXCEPT TOES |
| 747.64 | LOWER LIMB VESSEL ANOMALY |
| 747.69 | ANOMALIES OF OTHER SPECIFIED SITES OF PERIPHERAL VASCULAR SYSTEM |
| 782.5 | CYANOSIS |
| 785.4 | GANGRENE |
| 904.0 - 904.7 | INJURY TO COMMON FEMORAL ARTERY - INJURY TO OTHER SPECIFIED BLOOD VESSELS OF LOWER EXTREMITY |
| 906.7 | LATE EFFECT OF BURN OF OTHER EXTREMITIES |
| 928.00 - 928.9 | CRUSHING INJURY OF THIGH - CRUSHING INJURY OF UNSPECIFIED SITE OF LOWER LIMB |
| 959.6 | OTHER AND UNSPECIFIED INJURY TO HIP AND THIGH |
| 959.7 | OTHER AND UNSPECIFIED INJURY TO KNEE LEG ANKLE AND FOOT |
| 996.1 | MECHANICAL COMPLICATION OF OTHER VASCULAR DEVICE IMPLANT AND GRAFT |
| 996.62 | INFECTION AND INFLAMMATORY REACTION DUE TO OTHER VASCULAR DEVICE IMPLANT AND GRAFT |
| 996.74 | OTHER COMPLICATIONS DUE TO OTHER VASCULAR DEVICE IMPLANT AND GRAFT |
| 996.95 | COMPLICATION OF REATTACHED FOOT AND TOE(S) |
| 996.96 | COMPLICATION OF REATTACHED LOWER EXTREMITY OTHER AND UNSPECIFIED |
| 997.2 | PERIPHERAL VASCULAR COMPLICATIONS NOT ELSEWHERE CLASSIFIED |
| 997.62 | INFECTION (CHRONIC) OF AMPUTATION STUMP |
| 997.69 | OTHER LATE AMPUTATION STUMP COMPLICATION |
| V43.4 | BLOOD VESSEL REPLACED BY OTHER MEANS |
Diagnoses that Support Medical Necessity
Diagnoses listed in this LCD
ICD-9 Codes that DO NOT Support Medical Necessity
| XX000 | Not Applicable |
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
Diagnoses not listed in this LCD
General Information
1) When the frequency of examination can be anticipated to exceed that considered reasonable and necessary as accepted in general medical practice
2) When both MRA and CA (defined earlier in this LCD under Indications and Limitations of Coverage and/or Medical Necessity) are required in the clinical decision making process, for the same disease (diagnosis)
3) This policy contains all the symptoms that reasonably suggest pathology of the vessels in question
If a contrast angiography of the cerebral arteries is done on the same day as the MRA of the head or neck, the medical record must justify this combination of imaging tests.
A provider may bill for an MRA of the lower extremity (73725) when it is a runoff study following an MRA of the abdomen (74185) or pelvis (72198) only if that study (73725) is itself both reasonable and medically necessary.
If mobile MRA services are furnished at an ambulatory test care facility other than a hospital based facility (e.g... a free standing physician directed clinic), the diagnostic procedure must be performed by or under the direct supervision of a radiologist or other qualified physician. In addition, the facility must maintain a record of the attending physician's order for a scan performed in a mobile unit.
— These services must be performed in a setting, in which a physician is present and immediately available to furnish assistance and direction throughout the performance of the procedure, or in an approved mobile unit in which a physician is always in attendance, for clinical and reimbursement purposes.
- Please select the correct indication for the test to be performed. Note that not all covered ICD-9-CM codes apply to each CPT code.
- When both MRA and CA are billed, documentation to support medical necessity for both procedures must be present in the medical record.
Examples of circumstances in which CA may be performed as an adjunct to MRA:
1. To clarify conditions where test results or clinical information are contradictory (for example, CE-MRA and duplex Doppler ultrasound are discordant with the clinical differential diagnosis and conventional angiography, with its ability to directly measure pressure gradients across stenosis of questionable hemodynamic significance, can provide more definitive information).
2. To verify the site of clinically important vascular stenosis and help map out the surgical/endovascular approach (for example, to determine which lesions should have an angioplasty and/or stent vs. which lesions require surgical bypass graft or no treatment at all).
3. To identify situations where MRA is inconclusive or degraded by metallic artifact.
4. To demonstrate anatomic abnormalities.
The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.
The patient's medical record must clearly support the medical necessity of the test. These records must be available to Medicare upon request.
When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.
When requesting a written redetermination (formerly appeal), providers must include all relevant documentation with the request.
Other Carriers' LCDs
*- An asterisk indicates a revision to that section of the policy.
Notes
This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the MAC contractor this policy was developed in cooperation with advisory groups which include representatives from various specialties, and adapted for the purpose of converting to MAC jurisdiction.
Italicized font represents CMS national policy language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national policy language/wording. Providers, through their associations/societies, should contact CMS to request changes to national policy through the Medicare Coverage Policy Process at http://www.cms.gov/center/coverage.asp
NCDs are binding on all carriers, fiscal intermediaries, MAC Contractors, quality improvement organizations, health maintenance organizations, competitive medical plans, and health care prepayment plans. Under 42 CFR 422.256(b), an NCD that expands coverage is also binding on Medicare Advantage Organizations. In addition, an administrative law judge may not review an NCD. (See §1869(f)(1)(A)(i) of the Social Security Act.)
Wisconsin 09/24/2010
Illinois 09/22/2010
Michigan 09/15/2010
Minnesota 09/16/2010
Iowa, Kansas, Missouri, Nebraska 10/07/2010
Open Meeting: 09/02/2010
10/01/2011: ICD-9-CM 2012 revisions; For CPT code 71555, added new ICD-9-CM codes 415.13 and V12.55. For CPT codes 72198 and 74185, ICD-9-CM code 444.0 truncated, added new codes 444.01 and 444.09. For CPT code 73725, added new ICD-9-CM code 415.13. Effective 10/01/2011 (one).
12/01/2011: Inadvertent omission from ICD-9 list for CPT code 71555, new ICD-9 code V12.55. Effective 10/01/2011 (two).
LCD Attachments
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Page Last Updated: Wednesday, 07-Dec-2011 14:08:18 CST
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