Basics about CPT code 70553 for MRI Brain or Head

Radiology procedures are very useful for studying any structure of the body. Brain, which is a very vital part of human body, is also studied very carefully using radiology techniques. Having knowledge about anatomy and physiology helps in coding ICD 10 and CPT codes. If you are perfect in coding medical report, it will helps in preparing for certification exam like CPC without taking any training.  MRI, a three-dimensional scan to study any structure of body, is also used for studying head or brain. In MRI, a dye or a contrast can also be introduced to study the particular area of the body. We have separate CPT code 70553 for MRI brain or head with or without using of contrast. We will just learn how to use these CPT codes for coding Radiology medical charts.

Description of CPT code 70553 for MRI brain or Head

We have three CPT codes for MRI brain exam. The codes are categorized of the basis of use of contrast. If the exam is done without use of contrast/dye or with use of contrast/dye, we have a separate CPT code for each of these scenarios. Like we have separate CPT code for CT and CTA, we have separate CPT code for MRI brain with or without contrast. Hence, we have all the specific CPT codes for different scenarios for MRI Brain or Head exam. Below, are the CPT codes used for MRI brain/head exam.

70551 –MRI Brain or Head without contrast material

70552 –MRI Brain or Head with contrast material

70553 –MRI Brain or Head without and with contrast material

Read also: How to prepare and clear CPC exam

Oral & IV contrast for CPT code 70553 for MRI brain

Use for both oral and Intravenous (IV) contrast is used for MRI brain exam.  However, only IV contrast is considered as with contrast for MRI procedures. Hence, we should never code an oral contrast as with contrast (70552) for MRI brain procedures. This is very confusing for immature coders who are not known with oral or IV contrast. Hope, now you people can easily code these MRI brain CPT codes in future.

Read : How to code CTA exam for Pulmonary embolism

Related CPT code 70553 for MRI brain

We have separate MRI CPT Code different parts of body. There are specific CPT code upper and lower extremity joints as well as non-joints. These CPT codes are similar to MRI brain procedures codes, in these procedures also codes differ based on use of dye or contrast. Below is the list of codes for upper and lower extremity joints

73221 – Magnetic resonance (eg, proton) imaging, any joint of upper extremity (shoulder, elbow, wrist); without contrast material(s)

73222 – Magnetic resonance (eg, proton) imaging, any joint of upper extremity; with contrast material(s)

73223 – Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without and with contrast material(s)

73721 – Magnetic resonance (eg, proton) imaging, any joint of lower extremity (hip, knee, ankle); without contrast material

73722 – Magnetic resonance (eg, proton) imaging, any joint of lower extremity; with contrast material

73723 – Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without and with contrast material

Sample Coded report for CPT code 70553

CLINICAL INDICATION
A 30-year-old female with a history of demyelinating disease was referred by a neurologist for a brain MRI examination, including qMRI assessment.

PROCEDURE
An MRI of the brain with and without contrast, qMRI analysis of the brain with comparison to an MRI acquired 8 months earlier.

TECHNIQUE
Three-dimensional (3D) T1-weighted imaging was performed before and after the uneventful intravenous administration of 14 mL of gadoterate meglumine, including delayed 3D fluid-attenuated inversion recovery (FLAIR). All 3D sequences were evaluated interactively on the workstation.

Brain magnetic resonance (MR) images were archived in the picture archiving and communication system (PACS) and were prepared for transfer to the cloud. Data pseudonymization, encryption, compression, and transfer were performed using a secure digital imaging and communications in medicine router.

The quantitative analysis software package was executed, including pre-processing (decompressing, file sorting, scan selection, file conversion), image processing, and automated comparison of the current and previous MRI examination (including quality assessment and corrections, brain structure segmentation, detection and segmentation of image abnormalities, image registration, change assessments, and volumetric extractions), and output generated (including annotated scans, a pre-populated reporting template, and a quantitative analysis report).

The quantitative report contains the following assessments:

Whole brain and gray matter volume, and the corresponding percentile scores compared to a healthy reference population.
Changes in whole brain and gray matter volume compared to the previous MRI examination.
FLAIR white matter hyperintensities, foci of gadolinium enhancement, and T1 hypointensities in terms of dissemination in space (juxtacortical, infratentorial, periventricular, and deep white matter).
Changes of FLAIR white matter hyperintensities, foci of gadolinium enhancement, and T1 hypointensities compared to the previous scan (total volume changes, as well as new, enlarging, and shrinking volume of the abnormalities).
 

The quantitative information was transferred and made available in the PACS system in the format of a quantitative report, including color-coded annotated images.

The radiologist reviewed the brain imaging in combination with the information from the qMRI reports and the annotated color-coded images.

FINDINGS
Foci of FLAIR and T2 hyperintensities are seen scattered in the cerebral white matter, with an overall pattern that favors demyelinating disease. In addition, there is mild intracranial plaque burden. Overall, nine supratentorial and zero infratentorial foci are seen, which are suspicious for demyelinating plaques.

In addition, a few FLAIR hyperintense perivascular spaces are noted in the high bifrontal subcortical white matter. None of the presumed plaques enhance on the post-contrast images, and there is no evidence of abnormal parenchymal or meningeal enhancement.

The largest supratentorial focus is located along the ependymal margin of the frontal horn of the left lateral ventricle and measures 1.9 cm anteroposterior. A 6.5-mm left periventricular lesion is oriented perpendicular to the corpus callosum in a Dawson’s finger-type distribution and a small focus is noted along the right optic radiation. No convincing plaques arise from the midline undersurface of the corpus callosum, despite the presence of several pericallosal lesions.

Compared to the previous MRI from 8 months earlier, there has been no interval change in the size or number of intracranial lesions.

There is no evidence of intracranial mass, hemorrhage, or acute infarct. The cerebral and cerebellar volumes appear normal. Incidental note is made of a 7 mm pineal cyst with minor internal loculations, which is consistent with a normal congenital variance of no clinical significance. The proximal flow voids are adequately patent. The mastoid air cells are clear. A small mucous retention cyst is noted in the left maxillary sinus, but the paranasal sinuses are otherwise clear.

The FLAIR hyperintense plaque burden measures 2.49 mL, not significantly changed, with only a 0.03-mL volume change since the prior examination when both studies are reprocessed using the current version of the software. The software detected 0.02-mL new, 0.04-mL enlarging, and 0.03-mL shrinking lesions. Most of the plaques remain periventricular in location (95%). There is a 0% infratentorial plaque burden.

The whole brain volume measures 1663 mL, which is normal for age (86th percentile), and has not significantly changed since the prior examination (previously, 1665 mL at 87th percentile). The gray matter volume measures 999 mL, which is unchanged and normal for age (83rd percentile).

IMPRESSION
 Contrast-enhanced MRI of the brain is essentially stable since the previous scan. None of the plaques enhance on the post-contrast images.
Several foci of FLAIR hyperintensity are again seen scattered in the cerebral white matter in a pattern indicative of demyelinating disease. There is mild intracranial plaque burden. Overall, nine supratentorial and zero infratentorial plaques are suspected.
When compared to the prior MRI 8 months earlier, there has been no interval change in the size or number of intracranial lesions.
Quantitative analysis demonstrates the FLAIR hyperintense plaque burden measures 2.49 mL, which is essentially stable in quantity since the previous scan from 8 months earlier. Most of the plaques remain periventricular in location (95%).
Incidental small 7 mm pineal cyst, a congenital finding of no clinical significance.
Please see the included report for complete quantitative MRI analysis.
 

HOW TO CODE
For dates of service performed on or after January 1, 2024, coding should be reported as follows:

70553 Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences
0866T Quantitative magnetic resonance image (MRI) analysis of the brain with comparison to prior magnetic resonance (MR) study(ies), including lesion detection, characterization, and quantification, with brain volume(s) quantification and/or severity score, when performed, data preparation and transmission, interpretation and report, obtained with diagnostic MRI examination of the brain (List separately in addition to code for primary procedure)

A9579 x14 Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (NOS), per mL
G37.9 Demyelinating disease of central nervous system, unspecified

Reference : CPT assistant 2024 february