Billing and Coding: MRI and CT Scans of the Head and Neck

Title XVIII of the Social Security Act, Section 1862(a)(7) excludes routine physical examinations. This provision excludes screening examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) allows coverage and payment for only those services that are considered reasonable and necessary.

Title XVIII of the Social Security Act, Section 1833(e) prohibits Medicare payment for any claim, which lacks the necessary information to process the claim.

Title XVIII of the Social Security Act, Section 1862(a)(1)(D) prohibits Medicare payment for services and items that are experimental or investigational.

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-220.2.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:

1. Measurement of blood flow and spectroscopy

The following coding and billing guidance is to be used with its associated Local Coverage Determination.

Documentation Guidelines

Diagnostic evaluation of the head and neck (head/neck scans) performed by computerized tomography (CT) scanners is covered when the documentation supports that the scan is reasonable and necessary. Accurate coding information must be provided with claims to differentiate CT and/or MRI scans from other radiology services and to make coverage determinations. Sufficient documentation such as, history and physical notes, laboratory results, signs and symptoms of the disease to warrant the diagnostic test and to support the claim of reasonable and necessary must be included in the medical records. This information must be available to Medicare upon request.

Coding Guidelines

The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits in addition to guidance in this LCD. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare. Whichever guidance is more restrictive should be adhered to.