Billing and Coding: Lumbar MRI

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.