Musculoskeletal Imaging Guidelines

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Cost Management Tool Released by MedSolutions, Inc. Common symptoms and symptom complexes are addressed by this tool. Offers appropriate imaging protocols based upon symptoms or diagnosis and their relevant CPT coding equivalents.©2014 MedSolutions, Inc. Musculoskeletal Imaging Guidelines

Text of Musculoskeletal Imaging Guidelines

  • 2014 MedSolutions, Inc. Musculoskeletal Imaging Guidelines

    MUSCULOSKELETAL IMAGING GUIDELINES Version 16.0; Effective 02-21-2014

    MedSolutions, Inc. Clinical Decision Support Tool for Advanced Diagnostic Imaging

    Common symptoms and symptom complexes are addressed by this tool. Imaging requests for patients with atypical symptoms or clinical presentations that are not specifically addressed will require physician review. Consultation with the referring physician may provide additional insight.

    This version incorporates MSI accepted revisions prior to 12/31/13

    CPT (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT five digit codes, nomenclature and other data are copyright 2014 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in the CPT book. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein.

    MedSolutions, Inc. This tool addresses common symptoms and symptom complexes. Imaging requests for patients with atypicalClinical Decision Support Tool symptoms or clinical presentations that are not specifically addressed will require physician review. Diagnostic Strategies Consultation with the referring physician, specialist and/or patients Primary Care Physician (PCP) may provide additional insight.

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    Musculoskeletal Imaging Guidelines Abbreviations 3

    MS-1~General Guidelines 4

    MS-2~Imaging Techniques 6

    MS-3~3D Rendering 8 DISEASE/ INJURY CATEGORY (Alphabetical Order)

    MS-4~Avascular Necrosis (AVN) 9

    MS-5~Fracture and Dislocation 9

    MS-6~Foreign Body 10

    MS-7~Ganglion Cysts 10

    MS-8~Gout, Pseudogout and Crystal Deposition Disease 10

    MS-9~Infection/Osteomyelitis 11

    MS-10~Mass 12

    MS-11~Muscle/Tendon Unit Injuries/Disease 13

    MS-12~Osteoarthritis 13

    MS-13~Osteochondritis 14

    MS-14~OsteoPorosis 15

    MS-15~Pagets Disease 17

    MS-16~Post-Operative Evaluation 17

    MS-17~Rheumatoid Arthritis and Inflammatory Arthritis 18

    MS-18~Tendonitis/Bursitis 19

    MS-19~Total Joint Prosthesis 19 ANATOMICAL AREAS

    MS-20~Shoulder 20

    MS-21~Elbow 24

    MS-22~Wrist 25

    MS-23~Hand 26

    MS-24~Pelvis 27

    MS-25~Hip 28

    MS-26~Knee 31

    MS-27~Leg Length Discrepancy 34

    MS-28~Leg Pain/Calf Tenderness 35

    MS-29~Ankle 36

    MS-30~Foot 38

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    AP anteroposterior view

    AVN avascular necrosis/aseptic necrosis

    CMS Centers for Medicare and Medicaid Services

    CPK creatinine phosphokinase

    CT computed tomography

    DEXA (DXA) dual energy x-ray absorptiometry

    DMARDS disease modifying anti-rheumatic drugs

    EMG electromyogram

    ESR erythrocyte sedimentation rate

    FROM full range of motion

    MRI magnetic resonance imaging

    NCV nerve conduction velocity

    NSAIDS non steroidal anti-inflammatory drugs

    OA osteoarthritis

    OCD osteochondritis dissecans

    RA rheumatoid arthritis

    RCT rotator cuff tear

    RICE rest, ice, compression, elevation

    SI sacro-iliac

    TFCC triangular fibrocartilage complex

    TNF tumor necrosis factor

    WBC white blood cell count

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    A current clinical evaluation (within 60 days) is required before advanced imaging can be considered.

    The clinical evaluation should include a relevant history and physical examination, appropriate laboratory studies, and non-advanced imaging modalities such as x-ray. o Other meaningful contact (telephone call, electronic mail or messaging) by an

    established patient can substitute for a face-to-face clinical evaluation. o A clinical diagnosis for many musculoskeletal bone, joint and soft tissue pain,

    and injury disorders are based on examination and plain x-ray.

    Many episodes of pain, particularly those involving the joints, should be evaluated with appropriate plain x-rays and then managed with at least 6 weeks of non-surgical care prior to considering advanced imaging.

    Conservative treatment may include NSAIDS, oral steroids, injection; a physician directed home exercise program or physical therapy, or bracing/immobilization.

    Orthopedic specialist evaluation can be helpful in determining the need for advanced imaging. o The need for repeat advanced imaging should be carefully considered and may not

    be indicated if prior imaging has been performed. o Serial advanced imaging, whether CT or MRI, for surveillance of healing or

    recovery from musculoskeletal disease is not supported in the majority of musculoskeletal conditions.


    Ultrasound Coding for Examination of a Soft-Tissue Mass CPT Extremity 76882 Axilla 76882 Chest wall 76604 Upper back 76604 Lower back 76705 Abdominal wall 76705 Other soft-tissue areas 76999

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    Computer-Assisted Musculoskeletal Surgical Navigation Procedures: The Category III code used to describe computer-assisted navigation in orthopedic

    surgery with CT/MRI image guidance is: +0055T. o Computer-assisted navigation (CAN) in orthopedic procedures describes the use of

    computer-enabled tracking systems to facilitate alignment in a variety of surgical procedures and verification of an intended implant placement.

    o Code +0055T is intended to be used in addition to the code for the primary surgical procedure.

    o CT/MRI imaging acquisition for preoperative planning, in the absence of written payor instructions, is not to be reported with a diagnostic CT or MRI code

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    MS-2~Imaging Techniques

    Plain X-Ray

    Should be done prior to advanced imaging in most musculoskeletal conditions to rule out those situations that do not require advanced imaging, such as osteoarthritis, acute/healing fracture, dislocation, osteomyelitis, acquired/congenital deformities, and tumors of bone amenable to biopsy or radiation therapy (in known metastatic disease), etc.

    MRI or CT

    MRI is often the preferred imaging modality in musculoskeletal conditions because it is superior in imaging the soft tissues and can also define physiological processes in some instances, e.g. edema, loss of circulation (AVN), and increased vascularity (tumors).

    CT is better at imaging bone and joint anatomy; thus, it is useful for studying complex fractures (particularly of the joints and vertebra), dislocations, and assessing delayed union or non-union of fractures if plain x-rays are equivocal. CT may be the procedure of choice in patients who cannot have MRI, such as those with pacemakers.

    Contrast Issues

    Most musculoskeletal imaging (MRI or CT) is without contrast, except for the following: o Tumors and osteomyelitis (without and with contrast) o Post-MR arthrography (with contrast only) o MRI for rheumatoid arthritis (contrast as requested) o In postoperative MRIs of the joints, MRI arthrography can be approved if

    requested, MRI without contrast is indeterminate.

    PET At the present time there is inadequate evidence to support the medical necessity of

    this study for the routine assessment of musculoskeletal disorders, other than for neoplastic disease. It should be considered experimental or investigational and will be forwarded to Medical Director Review.

    See also: MS-16, MS-19, MS 30.7 and MS-30.8.

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    References 1. ACR Appropriateness Criteria, Musculoskeletal Imaging topics. 2. ACRSPRSSR Practice Guideline for the performance of radiography of the extremities in

    adults and children, revised 2008. 3. Feller F. MR Arthrography Update. Advanced MRI. 2002. From Head to Toe. 4. Hsu, W. and T. M. Hearty (2012). Radionuclide Imaging in the Diagnosis and Management of

    Orthopaedic Disease. Journal of the American Academy of Orthopaedic Surgeons 20(3): 151-159.

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    Indications for musculoskeletal 3-D image post-processing: o Complex fractures (comminuted or displaced) of any joint or the pelvis/acetabulum o Spine fractures o Preoperative planning when conventional imaging is insufficient

    The code assignment for 3-D rendering depends upon whether the 3-D post-processing is performed on the scanner workstation (CPT76376) or on an independent workstation (CPT76377). o 2-dimensional reconstruction (i.e., reformatting axia