72158
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
2.23
Facility
$11.42
Non-Facility
$11.42
Documentation Required
- Claims must meet the reasonable and necessary documentation requirements specified in LCD L35391; refer to that LCD for required medical record elements and prior authorization rules.
- A legible medical record must document the condition, clinical findings, relevant prior treatment, and clearly justify the necessity and reasonableness of the lumbar MRI.
- The documentation must clearly support the ICD-10-CM code(s) reported on the claim.
- An attending or treating physician's order, properly signed and dated, is required for each lumbar MRI test.
Key Coverage Criteria
- Multiple imaging studies in oncology are covered only when reasonable and necessary as defined by Local Coverage Determination L35391.
- Initial lumbar MRI is covered when the test is medically reasonable and necessary and the medical record documents clinical rationale and supports the ICD-10-CM code(s) billed.
- A second lumbar MRI for the same patient is allowable when documentation shows comparative test results are needed to make a more definitive treatment decision.
- Multiple scans of different body areas performed on the same day for the same patient are payable when each scan is reasonable and necessary.
- T82.535S | Leakage of umbrella device, sequela
- M84.38XP | Stress fracture, other site, subsequent encounter for fracture with malunion
20 Active Policies
L33693 — Peripheral Venous Ultrasound
J09
A56848 — Billing and Coding: Multiple Imaging in Oncology
J12
L35391 — Multiple Imaging in Oncology
J12
A53252 — Billing and Coding: Independent Diagnostic Testing Facility (IDTF)
J12
L35007 — Vestibular and Audiologic Function Studies
Related Codes
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