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Magnetic resonance imaging (MRI) is a sophisticated imaging technique utilized to visualize the spinal canal and its contents, specifically in the cervical region. This noninvasive procedure employs the magnetic properties of hydrogen nuclei found in the body, allowing for detailed imaging without the use of ionizing radiation. During the MRI process, a powerful magnetic field is generated, which aligns the hydrogen atoms in the body. Subsequently, radiowaves are transmitted through this magnetic field, causing the protons in various tissues to emit specific radiofrequency signals. These signals are captured by a computer, which processes the data to produce high-resolution tomographic images in three-dimensional slices. The MRI of the cervical spine is particularly indicated when conservative treatments for neck or back pain have failed, or when there is a need to assess the condition following surgical interventions. The procedure involves taking initial images without the use of contrast material, followed by the administration of contrast agents to enhance the visibility of the spinal structures. This dual-phase imaging allows physicians to evaluate critical aspects such as spinal alignment, the presence of diseases or injuries affecting the vertebrae, intervertebral disc conditions, and the overall size of the spinal canal. Additionally, it aids in identifying any nerve compression or inflammation, as well as monitoring changes post-surgery. For coding purposes, the specific CPT® code for this MRI procedure is 72156, which pertains to the cervical spine, while codes 72157 and 72158 are designated for thoracic and lumbar spine MRIs, respectively.
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Evaluation of Neck Pain MRI of the cervical spine is often performed when conservative treatment options for neck pain have been ineffective, indicating a need for further investigation.
Assessment Post-Surgery This imaging technique is utilized to monitor the cervical spine following surgical procedures, allowing for the evaluation of any changes or complications that may arise.
Investigation of Neurological Symptoms MRI is indicated for patients presenting with neurological symptoms, such as weakness, numbness, or tingling in the arms, which may suggest nerve compression or other spinal issues.
Detection of Spinal Pathologies The procedure is also indicated for identifying various spinal pathologies, including intervertebral disc herniation, degeneration, or dehydration, as well as abnormalities in spinal alignment.
Step 1: Patient Preparation The patient is positioned on a motorized table that slides into the MRI scanner. It is essential to ensure that the patient is comfortable and understands the procedure, as they will need to remain still during imaging to obtain clear images.
Step 2: Initial Imaging Without Contrast The MRI begins with the acquisition of images of the cervical spine without the use of contrast material. This initial phase captures baseline images that help in assessing the overall structure and any obvious abnormalities.
Step 3: Administration of Contrast Material After the initial imaging, contrast material is administered to enhance the visibility of certain structures within the cervical spine. This step is crucial for providing a clearer view of the spinal canal and its contents.
Step 4: Further Imaging Sequences Following the administration of contrast, additional imaging sequences are performed. These sequences are designed to capture detailed images that can reveal subtle changes or pathologies that may not have been visible in the initial scans.
Step 5: Image Review Once the imaging is complete, the acquired images are reviewed by the physician. They analyze the images for specific findings that correlate with the patient's symptoms, such as abnormalities in spinal alignment, the presence of disease or injury in the vertebral bodies, and any signs of nerve compression or inflammation.
After the MRI procedure, patients can typically resume their normal activities immediately, as there are no invasive elements involved. However, they may be advised to wait for the results, which will be interpreted by the physician. The physician will discuss the findings with the patient and determine the next steps based on the results of the imaging. It is important for patients to follow up with their healthcare provider to address any further treatment options or interventions that may be necessary based on the MRI findings.
| Short Descr | MRI NECK SPINE W/O & W/DYE | Medium Descr | MRI SPINAL CANAL CERVICAL W/O & W/CONTR MATRL | Long Descr | Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical | Status Code | Active Code | Global Days | XXX - Global Concept Does Not Apply | PC/TC Indicator (26, TC) | 1 - Diagnostic Tests for Radiology Services | Multiple Procedures (51) | 4 - Special payment adjustment rules on the technical component (TC) of multiple diagnostic imaging procedures apply... | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 88 - | APC Status Indicator | Codes That May Be Paid Through a Composite APC | ASC Payment Indicator | Radiology service paid separately when provided integral to a surgical procedure on ASC list; payment based on OPPS relative payment weight. | Type of Service (TOS) | 4 - Diagnostic Radiology | Berenson-Eggers TOS (BETOS) | I2D - Advanced imaging - MRI/MRA: other | MUE | 1 | CCS Clinical Classification | 198 - Magnetic resonance imaging |
This is a primary code that can be used with these additional add-on codes.
| 0649T | Add-on Code MPFS Status: Carrier Priced APC S Quantitative magnetic resonance for analysis of tissue composition (eg, fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation and report, obtained with diagnostic MRI examination of the same anatomy (eg, organ, gland, tissue, target structure); single organ (List separately in addition to code for primary procedure) | 0698T | Add-on Code Resequenced Code MPFS Status: Carrier Priced APC S ASC Z2 Quantitative magnetic resonance for analysis of tissue composition (eg, fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation and report, obtained with diagnostic MRI examination of the same anatomy (eg, organ, gland, tissue, target structure); multiple organs (List separately in addition to code for primary procedure) |
| 26 | Professional component: certain procedures are a combination of a physician or other qualified health care professional component and a technical component. when the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number. | X5 | Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | GC | This service has been performed in part by a resident under the direction of a teaching physician | TC | Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier tc; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles | MG | The order for this service does not have applicable appropriate use criteria in the qualified clinical decision support mechanism consulted by the ordering professional | ME | The order for this service adheres to appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional | MH | Unknown if ordering professional consulted a clinical decision support mechanism for this service, related information was not provided to the furnishing professional or provider | MF | The order for this service does not adhere to the appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | GA | Waiver of liability statement issued as required by payer policy, individual case | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | 77 | Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | CR | Catastrophe/disaster related | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | MA | Ordering professional is not required to consult a clinical decision support mechanism due to service being rendered to a patient with a suspected or confirmed emergency medical condition | MC | Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of electronic health record or clinical decision support mechanism vendor issues | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | ET | Emergency services | GQ | Via asynchronous telecommunications system | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | GW | Service not related to the hospice patient's terminal condition | GZ | Item or service expected to be denied as not reasonable and necessary | JZ | Zero drug amount discarded/not administered to any patient | KX | Requirements specified in the medical policy have been met | LT | Left side (used to identify procedures performed on the left side of the body) | MB | Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of insufficient internet access | MD | Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of extreme and uncontrollable circumstances | PD | Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days | Q4 | Service for ordering/referring physician qualifies as a service exemption | QJ | Services/items provided to a prisoner or patient in state or local custody, however the state or local government, as applicable, meets the requirements in 42 cfr 411.4 (b) | RT | Right side (used to identify procedures performed on the right side of the body) | U6 | Medicaid level of care 6, as defined by each state | X4 | Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period | XP | Separate practitioner, a service that is distinct because it was performed by a different practitioner | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 1992-01-01 | Added | First appearance in code book in 1992. |
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