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Minerva Posted Thu 10th of March, 2011 13:32:21 PM

I have a dictation for a lumbar MRI but the dictation states the physician also viewed the sacrum,coccyx. Is there a cpt for MRI of sacrum/coccyx or it is included with the lumbar MRI?and if there is a separate cpt for the sacrum/coccyx can these two be billed together on the same DOS.

SuperCoder Answered Fri 11th of March, 2011 15:03:40 PM

MRI lumbar documentation also documents some lines on view details of sacrum/coccyx. Otherwise, for MRI sacrum/coccyx, normally MRI lumbar spine is coded. If a radiological report titled as "MRI sacrum/coccyx", but the body of the report thoroughly documents lumbar spine abnormalites,etc, even if includes findings on sacrum/coccyx bony abnormalites, we should code it for MRI lumbar spine.

Sometimes the a true MRI joint lower extremity documenting bony details of pelvis often includes the bony abonromalities of sacrum/coccyx also. In such cases, the report may be wrongly titled as "MRI Sacrum/Coccyx", but the focus of documentation in body of the report is not on Lumbar Spine, then we should code MRI joint lower extremity.

In all such cases, follow this rule to decide for the CPT:
1. What is the Indication or Reason for Visit.
2. What is the focus of the Body of the Report.
3. Whether findings seems Conclusive or Incidental.

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