LOWER EXTREMTIY JOINT MRI UPPER EXTREMITY JOINT MRI - …...

National Imaging Associates, Inc.

Clinical guidelines

LOWER EXTREMTIY JOINT MRI

UPPER EXTREMITY JOINT MRI

TMJ

Original Date: March 2011

of 16

“FOR CMS (MEDICARE) MEMBERS

ONLY”

CPT4 Codes:

TMJ – 70336

Upper Extremity Joint MRI – 73221, 73222,

73223

Lower Extremity Joint MRI – 73721, 73722,

73723

Last Effective Date: October 2014

LCD ID Number: L31750

J – 11 (NC, SC, VA, WV)

Last Revised Date:

Responsible Department:

Clinical Operations

Implementation Date: February 2015

1—LE_UE Joint MRI/TMJ – CMS

“FOR CMS (MEDICARE) MEMBERS ONLY”

Coverage Indications, Limitations, and/or Medical Necessity

Diagnostic examinations of joint(s) performed on Magnetic Resonance Imaging (MRI) units

are covered if they are:

Reasonable and medically necessary for the individual patient.

Performed on a unit that has received Food and Drug Administration (FDA) approval.

Such a unit(s) must be operated within the parameters specified by that approval.

Compliant with American College of Radiology (ACR) quality standards. Note: Refer to

the guidelines listed below for office-based MRI.

Office-Based MRI

In order to maintain appropriate quality in office-based MRI, the ACR MRI Accreditation

Program Requirements (http://www.acr.org/accreditation/mri/documents/mri_reqs.pdf)

serve as a pertinent performance benchmark, and, using such as a reference document, it is

intended that the following guidelines be followed with respect to:

Staff Competency

A provider who performs the interpretation and written report of an MRI of a joint

(professional component) must possess the knowledge, skills, training and experience

minimally necessary for this component of the service. Medicare coverage of these services

is conditional on the competence of the individual who performs and interprets the service.

Medicare expects that any provider who seeks and receives payment for the professional

components of these radiographic services will be prepared to substantiate his training

and/or experience if asked by Medicare to do so. Numerous pathways for achieving and

maintaining competency for providing these services by physicians and technologists exist.

2— LE_UE Joint MRI/TMJ – CMS

The qualified physician’s continuing education should be in accordance with the ACR

Practice Guideline for Continuing Medical Education (CME) OR should include CME in

MRI as is appropriate to the physician’s practice needs. Technologists practicing MRI

scanning should be licensed in the jurisdiction in which he practices, if state licensure for

MRI technologists exists. The continuing education for a technologist should be 15 hours of

Category A CME in MRI every three years.

An MRI of a joint may be personally performed by a physician or a technologist. When

performed by a technologist, one of the following standards must be met:

Facility must be accredited for MRI by the American College of Radiology (ACR)

For testing performed in non-ACR accredited office facilities, the technologist must have

received credentials in MRI technology as a Certified Radiologic Technologist (CRT)

from the American Registry of Radiologic Technologists (ARRT).

Quality Control and Quality Assurance

There should be a well-documented office protocol for performing continuous quality control

testing of instrumentation, in tandem with periodic preventive maintenance, which is also

properly documented in service records maintained by the MRI site. In addition,

appropriately documented physician peer-review activities should be an integral portion of

the staff competency guidelines discussed above.

The choice of the appropriate imaging modality should be determined at an individual level.

In some cases, MRI may be an appropriate initial choice; in others, standard X-rays should

be used for the initial evaluation. Generally, MRI of a joint is considered medically

necessary when the following disorders are present or suspected and/or the necessary

information is not available from standard X-rays. Joint MRIs are indicated for the

following clinical conditions:

Tumors/masses or swelling involving or contiguous to a joint.

Rotator cuff tears or impingement.

Joint instability, deformities or internal derangement.

Intra-articular osteocartilaginous body(ies).

Occult joint injury, e.g., osteochondral injury.

Suspected nerve entrapment or mass close to a joint.

Suspected ligament or tendon injury.

Kienböck’s Disease of the wrist.

Bone abnormalities of a joint related to soft tissue abnormalities.

Occult Avascular Necrosis (AVN) or follow-up of this condition.

Acute joint injuries.

Actual or suspected infection or inflammation on joints or surrounding structures.

Effect of other single or multiple system, non-joint disorders on joints and surrounding

structures.

Pain/other sensory disturbances in joints or surrounding structures.


Weakness/other motor disturbances in joints or surrounding structures.

Decreased range of motion; stiffness, popping/clicking, instability or discoordination

related to joints and surrounding structures.

Characterization of an abnormal finding in joints or surrounding structures detected on

another test.

Meniscal and/or ligamentous tears.

Tendinopathy.

Assessment of joints and surrounding structures in preparation for an interventional

procedure.

Usually, an MRI of a joint is performed when standard X-rays are inconclusive and the

patient may have failed a treatment regime for a disorder clinically diagnosed from medical

history and examination. MRIs of a joint are generally not indicated when a surgical

exploration of the joint (arthroscopic or open) will be performed regardless of the results of

the MRI, unless the MRI results are to be used to provide information for planning the

optimal surgical approach.

The clinical necessity of performing a joint MRI must be noted in the medical record or

easily inferred from the medical record. “Screening” imaging or unnecessary duplication of

imaging is not considered medically necessary.

There are relative contraindications to MRI scanning. These include cardiac pacemakers

that do NOT meet CED criteria outlined in NCD 220.2.C.1, ferromagnetic clips, intraocular

metal, and cochlear implants. MRI scanning under these circumstances is only covered

when the medical situation is clearly explained.

Documentation Requirements

Documentation supporting the medical necessity should be legible, maintained in the

patient’s medical record, and made available to Medicare upon request.

ICD-9 Codes that Support Medical Necessity

Group 1 Paragraph: The CPT/HCPCS codes included in this LCD will be subjected to

"procedure to diagnosis" editing. The following lists include only those diagnoses for which

the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the

claim, the edit will automatically deny the service as not medically necessary.

Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on

their claim forms and electronic claims.


Medicare is establishing the following limited coverage for CPT/HCPCS code 70336:

Group 1 Codes:

238.0 NEOPLASM OF UNCERTAIN BEHAVIOR OF BONE AND ARTICULAR

CARTILAGE

524.01 MAJOR ANOMALIES OF JAW SIZE MAXILLARY HYPERPLASIA

524.02 MAJOR ANOMALIES OF JAW SIZE MANDIBULAR HYPERPLASIA

524.03 MAJOR ANOMALIES OF JAW SIZE MAXILLARY HYPOPLASIA

524.04 MAJOR ANOMALIES OF JAW SIZE MANDIBULAR HYPOPLASIA

524.05 MAJOR ANOMALIES OF JAW SIZE MACROGENIA

524.06 MAJOR ANOMALIES OF JAW SIZE MICROGENIA

524.61 TEMPOROMANDIBULAR JOINT DISORDERS ADHESIONS AND ANKYLOSIS

(BONY OR FIBROUS)

524.62 TEMPOROMANDIBULAR JOINT DISORDERS ARTHRALGIA OF

TEMPOROMANDIBULAR JOINT

524.63 TEMPOROMANDIBULAR JOINT DISORDERS ARTICULAR DISC DISORDER

(REDUCING OR NON-REDUCING)

682.0 CELLULITIS AND ABSCESS OF FACE

682.1 CELLULITIS AND ABSCESS OF NECK

695.9 UNSPECIFIED ERYTHEMATOUS CONDITION

714.0 RHEUMATOID ARTHRITIS

714.30 CHRONIC OR UNSPECIFIED POLYARTICULAR JUVENILE RHEUMATOID

ARTHRITIS

714.9 UNSPECIFIED INFLAMMATORY POLYARTHROPATHY

715.18 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING OTHER SPECIFIED

SITES

715.28 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING OTHER

SPECIFIED SITES

715.38 OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR

SECONDARY INVOLVING OTHER SPECIFIED SITES

715.98 OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR

LOCALIZED INVOLVING OTHER SPECIFIED SITES

716.68 UNSPECIFIED MONOARTHRITIS INVOLVING OTHER SPECIFIED SITES

716.88 OTHER SPECIFIED ARTHROPATHY INVOLVING OTHER SPECIFIED SITES

716.98 UNSPECIFIED ARTHROPATHY INVOLVING OTHER SPECIFIED SITES

718.08 ARTICULAR CARTILAGE DISORDER INVOLVING OTHER SPECIFIED SITES

718.98 UNSPECIFIED DERANGEMENT OF JOINT OF OTHER SPECIFIED SITES

719.08 EFFUSION OF JOINT OF OTHER SPECIFIED SITES

730.08 ACUTE OSTEOMYELITIS INVOLVING OTHER SPECIFIED SITES

733.45 ASEPTIC NECROSIS OF BONE, JAW

782.3 EDEMA

784.0* HEADACHE

784.92 JAW PAIN

848.1 JAW SPRAIN

Group 1 Medical Necessity ICD-9 Codes Asterisk Explanation: ** Note: 784.0 - Use this


code when the headache is suspected to be caused by temporomandibular joint problems.

Group 2 Paragraph: Note: Providers should continue to submit ICD-9-CM diagnosis codes

without decimals on their claim forms and electronic claims.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 73221, 73222,

73223, 73721, 73722 and 73723:

Group 2 Codes:

170.4 MALIGNANT NEOPLASM OF SCAPULA AND LONG BONES OF UPPER LIMB

170.5 MALIGNANT NEOPLASM OF SHORT BONES OF UPPER LIMB

170.7 MALIGNANT NEOPLASM OF LONG BONES OF LOWER LIMB

170.8 MALIGNANT NEOPLASM OF SHORT BONES OF LOWER LIMB

171.2 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF

UPPER LIMB INCLUDING SHOULDER


LOWER LIMB INCLUDING HIP


PELVIS

195.4 MALIGNANT NEOPLASM OF UPPER LIMB

195.5 MALIGNANT NEOPLASM OF LOWER LIMB

196.3 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH

NODES OF AXILLA AND UPPER LIMB

196.5 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH

NODES OF INGUINAL REGION AND LOWER LIMB

198.5 SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW

213.3 BENIGN NEOPLASM OF RIBS STERNUM AND CLAVICLE

213.4 BENIGN NEOPLASM OF SCAPULA AND LONG BONES OF UPPER LIMB

213.5 BENIGN NEOPLASM OF SHORT BONES OF UPPER LIMB

213.6 BENIGN NEOPLASM OF PELVIC BONES SACRUM AND COCCYX

213.7 BENIGN NEOPLASM OF LONG BONES OF LOWER LIMB

213.8 BENIGN NEOPLASM OF SHORT BONES OF LOWER LIMB

213.9 BENIGN NEOPLASM OF BONE AND ARTICULAR CARTILAGE SITE

UNSPECIFIED

214.9 LIPOMA UNSPECIFIED SITE

238.0 NEOPLASM OF UNCERTAIN BEHAVIOR OF BONE AND ARTICULAR

CARTILAGE

239.2 NEOPLASM OF UNSPECIFIED NATURE OF BONE SOFT TISSUE AND SKIN

274.00 GOUTY ARTHROPATHY, UNSPECIFIED

274.01 ACUTE GOUTY ARTHROPATHY

274.02 CHRONIC GOUTY ARTHROPATHY WITHOUT MENTION OF TOPHUS (TOPHI)

274.03 CHRONIC GOUTY ARTHROPATHY WITH TOPHUS (TOPHI)

681.00 UNSPECIFIED CELLULITIS AND ABSCESS OF FINGER

681.10 UNSPECIFIED CELLULITIS AND ABSCESS OF TOE

682.2 CELLULITIS AND ABSCESS OF TRUNK


682.3 CELLULITIS AND ABSCESS OF UPPER ARM AND FOREARM

682.4 CELLULITIS AND ABSCESS OF HAND EXCEPT FINGERS AND THUMB

682.5 CELLULITIS AND ABSCESS OF BUTTOCK

682.6 CELLULITIS AND ABSCESS OF LEG EXCEPT FOOT

682.7 CELLULITIS AND ABSCESS OF FOOT EXCEPT TOES

695.9 UNSPECIFIED ERYTHEMATOUS CONDITION

696.0 PSORIATIC ARTHROPATHY

707.01 PRESSURE ULCER, ELBOW

707.02 PRESSURE ULCER, UPPER BACK

707.03 PRESSURE ULCER, LOWER BACK

707.04 PRESSURE ULCER, HIP

707.05 PRESSURE ULCER, BUTTOCK

707.06 PRESSURE ULCER, ANKLE

707.07 PRESSURE ULCER, HEEL

707.10 UNSPECIFIED ULCER OF LOWER LIMB

707.11 ULCER OF THIGH

707.12 ULCER OF CALF

707.13 ULCER OF ANKLE

707.14 ULCER OF HEEL AND MIDFOOT

707.15 ULCER OF OTHER PART OF FOOT

707.19 ULCER OF OTHER PART OF LOWER LIMB

711.01 PYOGENIC ARTHRITIS INVOLVING SHOULDER REGION

711.02 PYOGENIC ARTHRITIS INVOLVING UPPER ARM

711.03 PYOGENIC ARTHRITIS INVOLVING FOREARM

711.04 PYOGENIC ARTHRITIS INVOLVING HAND

711.05 PYOGENIC ARTHRITIS INVOLVING PELVIC REGION AND THIGH

711.06 PYOGENIC ARTHRITIS INVOLVING LOWER LEG

711.07 PYOGENIC ARTHRITIS INVOLVING ANKLE AND FOOT

711.41 ARTHROPATHY INVOLVING SHOULDER REGION ASSOCIATED WITH

OTHER BACTERIAL DISEASES

711.42 ARTHROPATHY INVOLVING UPPER ARM ASSOCIATED WITH OTHER

BACTERIAL DISEASES

711.43 ARTHROPATHY INVOLVING FOREARM ASSOCIATED WITH OTHER

BACTERIAL DISEASES

711.44 ARTHROPATHY INVOLVING HAND ASSOCIATED WITH OTHER BACTERIAL

DISEASES

711.45 ARTHROPATHY INVOLVING PELVIC REGION AND THIGH ASSOCIATED

WITH OTHER BACTERIAL DISEASES

711.46 ARTHROPATHY INVOLVING LOWER LEG ASSOCIATED WITH OTHER

BACTERIAL DISEASES

711.47 ARTHROPATHY INVOLVING ANKLE AND FOOT ASSOCIATED WITH OTHER

BACTERIAL DISEASE

711.61 ARTHROPATHY INVOLVING SHOULDER REGION ASSOCIATED WITH

MYCOSES


711.62 ARTHROPATHY INVOLVING UPPER ARM ASSOCIATED WITH MYCOSES

711.63 ARTHROPATHY INVOLVING FOREARM ASSOCIATED WITH MYCOSES

711.64 ARTHROPATHY INVOLVING HAND ASSOCIATED WITH MYCOSES

711.65 ARTHROPATHY INVOLVING PELVIC REGION AND THIGH ASSOCIATED

WITH MYCOSES

711.66 ARTHROPATHY INVOLVING LOWER LEG ASSOCIATED WITH MYCOSES

711.67 ARTHROPATHY INVOLVING ANKLE AND FOOT ASSOCIATED WITH

MYCOSES

711.91 UNSPECIFIED INFECTIVE ARTHRITIS INVOLVING SHOULDER REGION

711.92 UNSPECIFIED INFECTIVE ARTHRITIS INVOLVING UPPER ARM

711.93 UNSPECIFIED INFECTIVE ARTHRITIS INVOLVING FOREARM

711.94 UNSPECIFIED INFECTIVE ARTHRITIS INVOLVING HAND

711.95 UNSPECIFIED INFECTIVE ARTHRITIS INVOLVING PELVIC REGION AND

THIGH

711.96 UNSPECIFIED INFECTIVE ARTHRITIS INVOLVING LOWER LEG

711.97 UNSPECIFIED INFECTIVE ARTHRITIS INVOLVING ANKLE AND FOOT

713.5* ARTHROPATHY ASSOCIATED WITH NEUROLOGICAL DISORDERS

714.0 RHEUMATOID ARTHRITIS

714.30 CHRONIC OR UNSPECIFIED POLYARTICULAR JUVENILE RHEUMATOID

ARTHRITIS

714.31 ACUTE POLYARTICULAR JUVENILE RHEUMATOID ARTHRITIS

714.9 UNSPECIFIED INFLAMMATORY POLYARTHROPATHY

715.11 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING SHOULDER REGION

715.12 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING UPPER ARM

715.13 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING FOREARM

715.14 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING HAND

715.15 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING PELVIC REGION AND

THIGH

715.16 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING LOWER LEG

715.17 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING ANKLE AND FOOT

715.21 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING SHOULDER

REGION

715.22 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING UPPER ARM

715.23 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING FOREARM

715.24 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING HAND

715.25 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING PELVIC REGION

AND THIGH

715.26 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING LOWER LEG

715.27 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING ANKLE AND FOOT


SECONDARY INVOLVING SHOULDER REGION


SECONDARY INVOLVING UPPER ARM


SECONDARY INVOLVING FOREARM



SECONDARY INVOLVING HAND


SECONDARY INVOLVING PELVIC REGION AND THIGH


SECONDARY INVOLVING LOWER LEG


SECONDARY INVOLVING ANKLE AND FOOT

715.89 OSTEOARTHROSIS INVOLVING OR WITH MULTIPLE SITES BUT NOT

SPECIFIED AS GENERALIZED

715.90 OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED

INVOLVING UNSPECIFIED SITE


INVOLVING SHOULDER REGION


INVOLVING UPPER ARM


INVOLVING FOREARM


INVOLVING HAND


INVOLVING PELVIC REGION AND THIGH


INVOLVING LOWER LEG


INVOLVING ANKLE AND FOOT


INVOLVING OTHER SPECIFIED SITES

716.11 TRAUMATIC ARTHROPATHY INVOLVING SHOULDER REGION

716.12 TRAUMATIC ARTHROPATHY INVOLVING UPPER ARM

716.13 TRAUMATIC ARTHROPATHY INVOLVING FOREARM

716.14 TRAUMATIC ARTHROPATHY INVOLVING HAND

716.15 TRAUMATIC ARTHROPATHY INVOLVING PELVIC REGION AND THIGH

716.16 TRAUMATIC ARTHROPATHY INVOLVING LOWER LEG

716.17 TRAUMATIC ARTHROPATHY INVOLVING ANKLE AND FOOT

716.81 OTHER SPECIFIED ARTHROPATHY INVOLVING SHOULDER REGION

716.82 OTHER SPECIFIED ARTHROPATHY INVOLVING UPPER ARM

716.83 OTHER SPECIFIED ARTHROPATHY INVOLVING FOREARM

716.84 OTHER SPECIFIED ARTHROPATHY INVOLVING HAND

716.85 OTHER SPECIFIED ARTHROPATHY INVOLVING PELVIC REGION AND

THIGH

716.86 OTHER SPECIFIED ARTHROPATHY INVOLVING LOWER LEG

716.87 OTHER SPECIFIED ARTHROPATHY INVOLVING ANKLE AND FOOT

716.88 OTHER SPECIFIED ARTHROPATHY INVOLVING OTHER SPECIFIED SITES

716.89 OTHER SPECIFIED ARTHROPATHY INVOLVING MULTIPLE SITES


716.91 UNSPECIFIED ARTHROPATHY INVOLVING SHOULDER REGION

716.92 UNSPECIFIED ARTHROPATHY INVOLVING UPPER ARM

716.93 UNSPECIFIED ARTHROPATHY INVOLVING FOREARM

716.94 UNSPECIFIED ARTHROPATHY INVOLVING HAND

716.95 UNSPECIFIED ARTHROPATHY INVOLVING PELVIC REGION AND THIGH

716.96 UNSPECIFIED ARTHROPATHY INVOLVING LOWER LEG

716.97 UNSPECIFIED ARTHROPATHY INVOLVING ANKLE AND FOOT

716.98 UNSPECIFIED ARTHROPATHY INVOLVING OTHER SPECIFIED SITES

716.99 UNSPECIFIED ARTHROPATHY INVOLVING MULTIPLE SITES

717.0 OLD BUCKET HANDLE TEAR OF MEDIAL MENISCUS

717.1 DERANGEMENT OF ANTERIOR HORN OF MEDIAL MENISCUS

717.2 DERANGEMENT OF POSTERIOR HORN OF MEDIAL MENISCUS

717.3 OTHER AND UNSPECIFIED DERANGEMENT OF MEDIAL MENISCUS

717.40 DERANGEMENT OF LATERAL MENISCUS UNSPECIFIED

717.41 BUCKET HANDLE TEAR OF LATERAL MENISCUS

717.42 DERANGEMENT OF ANTERIOR HORN OF LATERAL MENISCUS

717.43 DERANGEMENT OF POSTERIOR HORN OF LATERAL MENISCUS

717.5 DERANGEMENT OF MENISCUS NOT ELSEWHERE CLASSIFIED

717.6 LOOSE BODY IN KNEE

717.7 CHONDROMALACIA OF PATELLA

717.81 OLD DISRUPTION OF LATERAL COLLATERAL LIGAMENT

717.82 OLD DISRUPTION OF MEDIAL COLLATERAL LIGAMENT

717.83 OLD DISRUPTION OF ANTERIOR CRUCIATE LIGAMENT

717.84 OLD DISRUPTION OF POSTERIOR CRUCIATE LIGAMENT

717.85 OLD DISRUPTION OF OTHER LIGAMENTS OF KNEE

717.89 OTHER INTERNAL DERANGEMENT OF KNEE

718.01 ARTICULAR CARTILAGE DISORDER INVOLVING SHOULDER REGION

718.02 ARTICULAR CARTILAGE DISORDER INVOLVING UPPER ARM

718.03 ARTICULAR CARTILAGE DISORDER INVOLVING FOREARM

718.04 ARTICULAR CARTILAGE DISORDER INVOLVING HAND

718.05 ARTICULAR CARTILAGE DISORDER INVOLVING PELVIC REGION AND

THIGH

718.07 ARTICULAR CARTILAGE DISORDER INVOLVING ANKLE AND FOOT

718.08 ARTICULAR CARTILAGE DISORDER INVOLVING OTHER SPECIFIED SITES

718.09 ARTICULAR CARTILAGE DISORDER INVOLVING MULTIPLE SITES

718.11 LOOSE BODY IN JOINT OF SHOULDER REGION

718.12 LOOSE BODY IN UPPER ARM JOINT

718.13 LOOSE BODY IN FOREARM JOINT

718.14 LOOSE BODY IN HAND JOINT

718.15 LOOSE BODY IN JOINT OF PELVIC REGION AND THIGH

718.17 LOOSE BODY IN ANKLE AND FOOT JOINT

718.18 LOOSE BODY IN JOINT OF OTHER SPECIFIED SITES

718.19 LOOSE BODY IN JOINT OF MULTIPLE SITES

718.21 PATHOLOGICAL DISLOCATION OF JOINT OF SHOULDER REGION


718.22 PATHOLOGICAL DISLOCATION OF UPPER ARM JOINT

718.23 PATHOLOGICAL DISLOCATION OF FOREARM JOINT

718.24 PATHOLOGICAL DISLOCATION OF HAND JOINT

718.25 PATHOLOGICAL DISLOCATION OF JOINT OF PELVIC REGION AND THIGH

718.26 PATHOLOGICAL DISLOCATION OF JOINT OF LOWER LEG

718.27 PATHOLOGICAL DISLOCATION OF ANKLE AND FOOT JOINT

718.29 PATHOLOGICAL DISLOCATION OF JOINT OF MULTIPLE SITES

718.31 RECURRENT DISLOCATION OF JOINT OF SHOULDER REGION

718.32 RECURRENT DISLOCATION OF UPPER ARM JOINT

718.33 RECURRENT DISLOCATION OF FOREARM JOINT

718.34 RECURRENT DISLOCATION OF HAND JOINT

718.35 RECURRENT DISLOCATION OF JOINT OF PELVIC REGION AND THIGH

718.36 RECURRENT DISLOCATION OF LOWER LEG JOINT

718.37 RECURRENT DISLOCATION OF ANKLE AND FOOT JOINT

718.39 RECURRENT DISLOCATION OF JOINT OF MULTIPLE SITES

718.41 CONTRACTURE OF JOINT OF SHOULDER REGION

718.42 CONTRACTURE OF UPPER ARM JOINT

718.43 CONTRACTURE OF FOREARM JOINT

718.44 CONTRACTURE OF HAND JOINT

718.45 CONTRACTURE OF JOINT OF PELVIC REGION AND THIGH

718.46 CONTRACTURE OF LOWER LEG JOINT

718.47 CONTRACTURE OF ANKLE AND FOOT JOINT

718.49 CONTRACTURE OF JOINT OF MULTIPLE SITES

718.51 ANKYLOSIS OF JOINT OF SHOULDER REGION

718.52 ANKYLOSIS OF UPPER ARM JOINT

718.53 ANKYLOSIS OF FOREARM JOINT

718.54 ANKYLOSIS OF HAND JOINT

718.55 ANKYLOSIS OF JOINT OF PELVIC REGION AND THIGH

718.56 ANKYLOSIS OF LOWER LEG JOINT

718.57 ANKYLOSIS OF ANKLE AND FOOT JOINT

718.59 ANKYLOSIS OF JOINT OF MULTIPLE SITES

718.77 DEVELOPMENTAL DISLOCATION OF JOINT ANKLE AND FOOT

718.98 UNSPECIFIED DERANGEMENT OF JOINT OF OTHER SPECIFIED SITES

719.01 EFFUSION OF JOINT OF SHOULDER REGION

719.02 EFFUSION OF UPPER ARM JOINT

719.03 EFFUSION OF FOREARM JOINT

719.04 EFFUSION OF HAND JOINT

719.05 EFFUSION OF JOINT OF PELVIC REGION AND THIGH

719.06 EFFUSION OF LOWER LEG JOINT

719.07 EFFUSION OF ANKLE AND FOOT JOINT

719.41 PAIN IN JOINT INVOLVING SHOULDER REGION

719.42 PAIN IN JOINT INVOLVING UPPER ARM

719.43 PAIN IN JOINT INVOLVING FOREARM

719.44 PAIN IN JOINT INVOLVING HAND


719.45 PAIN IN JOINT INVOLVING PELVIC REGION AND THIGH

719.46 PAIN IN JOINT INVOLVING LOWER LEG

719.47 PAIN IN JOINT INVOLVING ANKLE AND FOOT

719.51 STIFFNESS OF JOINT NOT ELSEWHERE CLASSIFIED INVOLVING

SHOULDER REGION

719.52 STIFFNESS OF JOINT NOT ELSEWHERE CLASSIFIED INVOLVING UPPER

ARM

719.53 STIFFNESS OF JOINT NOT ELSEWHERE CLASSIFIED INVOLVING FOREARM

719.54 STIFFNESS OF JOINT NOT ELSEWHERE CLASSIFIED INVOLVING HAND

719.55 STIFFNESS OF JOINT NOT ELSEWHERE CLASSIFIED INVOLVING PELVIC

REGION AND THIGH

719.56 STIFFNESS OF JOINT NOT ELSEWHERE CLASSIFIED INVOLVING LOWER

LEG

719.57 STIFFNESS OF JOINT NOT ELSEWHERE CLASSIFIED INVOLVING ANKLE

AND FOOT

719.61 OTHER SYMPTOMS REFERABLE TO JOINT OF SHOULDER REGION

719.62 OTHER SYMPTOMS REFERABLE TO UPPER ARM JOINT

719.63 OTHER SYMPTOMS REFERABLE TO FOREARM JOINT

719.64 OTHER SYMPTOMS REFERABLE TO HAND JOINT

719.65 OTHER SYMPTOMS REFERABLE TO JOINT OF PELVIC REGION AND THIGH

719.66 OTHER SYMPTOMS REFERABLE TO LOWER LEG JOINT

719.67 OTHER SYMPTOMS REFERABLE TO ANKLE AND FOOT JOINT

719.81 OTHER SPECIFIED DISORDERS OF JOINT OF SHOULDER REGION

719.82 OTHER SPECIFIED DISORDERS OF UPPER ARM JOINT

719.83 OTHER SPECIFIED DISORDERS OF FOREARM JOINT

719.84 OTHER SPECIFIED DISORDERS OF HAND JOINT

719.85 OTHER SPECIFIED DISORDERS OF JOINT OF PELVIC REGION AND THIGH

719.86 OTHER SPECIFIED DISORDERS OF LOWER LEG JOINT

719.87 OTHER SPECIFIED DISORDERS OF ANKLE AND FOOT JOINT

726.0 ADHESIVE CAPSULITIS OF SHOULDER

726.10 DISORDERS OF BURSAE AND TENDONS IN SHOULDER REGION

UNSPECIFIED

726.11 CALCIFYING TENDINITIS OF SHOULDER

726.12 BICIPITAL TENOSYNOVITIS

726.13 PARTIAL TEAR OF ROTATOR CUFF

726.19 OTHER SPECIFIED DISORDERS OF BURSAE AND TENDONS IN SHOULDER

REGION

726.2 OTHER AFFECTIONS OF SHOULDER REGION NOT ELSEWHERE

CLASSIFIED

726.31 MEDIAL EPICONDYLITIS

726.32 LATERAL EPICONDYLITIS

726.33 OLECRANON BURSITIS

726.4 ENTHESOPATHY OF WRIST AND CARPUS

726.5 ENTHESOPATHY OF HIP REGION


726.60 ENTHESOPATHY OF KNEE UNSPECIFIED

726.61 PES ANSERINUS TENDINITIS OR BURSITIS

726.62 TIBIAL COLLATERAL LIGAMENT BURSITIS

726.63 FIBULAR COLLATERAL LIGAMENT BURSITIS

726.64 PATELLAR TENDINITIS

726.65 PREPATELLAR BURSITIS

726.69 OTHER ENTHESOPATHY OF KNEE

726.70 ENTHESOPATHY OF ANKLE AND TARSUS UNSPECIFIED

726.71 ACHILLES BURSITIS OR TENDINITIS

726.72 TIBIALIS TENDINITIS

726.73 CALCANEAL SPUR

726.79 OTHER ENTHESOPATHY OF ANKLE AND TARSUS

727.00 SYNOVITIS AND TENOSYNOVITIS UNSPECIFIED

727.03 TRIGGER FINGER (ACQUIRED)

727.05 OTHER TENOSYNOVITIS OF HAND AND WRIST

727.06 TENOSYNOVITIS OF FOOT AND ANKLE

727.41 GANGLION OF JOINT

727.51 SYNOVIAL CYST OF POPLITEAL SPACE

727.61 COMPLETE RUPTURE OF ROTATOR CUFF

727.63 NONTRAUMATIC RUPTURE OF EXTENSOR TENDONS OF HAND AND WRIST

727.64 NONTRAUMATIC RUPTURE OF FLEXOR TENDONS OF HAND AND WRIST

727.66 NONTRAUMATIC RUPTURE OF PATELLAR TENDON

727.67 NONTRAUMATIC RUPTURE OF ACHILLES TENDON

727.68 NONTRAUMATIC RUPTURE OF OTHER TENDONS OF FOOT AND ANKLE

729.81 SWELLING OF LIMB

730.01 ACUTE OSTEOMYELITIS INVOLVING SHOULDER REGION

730.02 ACUTE OSTEOMYELITIS INVOLVING UPPER ARM

730.03 ACUTE OSTEOMYELITIS INVOLVING FOREARM

730.04 ACUTE OSTEOMYELITIS INVOLVING HAND

730.05 ACUTE OSTEOMYELITIS INVOLVING PELVIC REGION AND THIGH

730.06 ACUTE OSTEOMYELITIS INVOLVING LOWER LEG

730.07 ACUTE OSTEOMYELITIS INVOLVING ANKLE AND FOOT

730.08 ACUTE OSTEOMYELITIS INVOLVING OTHER SPECIFIED SITES

730.11 CHRONIC OSTEOMYELITIS INVOLVING SHOULDER REGION

730.12 CHRONIC OSTEOMYELITIS INVOLVING UPPER ARM

730.13 CHRONIC OSTEOMYELITIS INVOLVING FOREARM

730.14 CHRONIC OSTEOMYELITIS INVOLVING HAND

730.15 CHRONIC OSTEOMYELITIS INVOLVING PELVIC REGION AND THIGH

730.16 CHRONIC OSTEOMYELITIS INVOLVING LOWER LEG

730.17 CHRONIC OSTEOMYELITIS INVOLVING ANKLE AND FOOT

730.18 CHRONIC OSTEOMYELITIS INVOLVING OTHER SPECIFIED SITES

730.19 CHRONIC OSTEOMYELITIS INVOLVING MULTIPLE SITES

730.21 UNSPECIFIED OSTEOMYELITIS INVOLVING SHOULDER REGION

730.22 UNSPECIFIED OSTEOMYELITIS INVOLVING UPPER ARM


730.23 UNSPECIFIED OSTEOMYELITIS INVOLVING FOREARM

730.24 UNSPECIFIED OSTEOMYELITIS INVOLVING HAND

730.25 UNSPECIFIED OSTEOMYELITIS INVOLVING PELVIC REGION AND THIGH

730.26 UNSPECIFIED OSTEOMYELITIS INVOLVING LOWER LEG

730.27 UNSPECIFIED OSTEOMYELITIS INVOLVING ANKLE AND FOOT

730.28 UNSPECIFIED OSTEOMYELITIS INVOLVING OTHER SPECIFIED SITES

730.29 UNSPECIFIED OSTEOMYELITIS INVOLVING MULTIPLE SITES

730.91 UNSPECIFIED INFECTION OF BONE OF SHOULDER REGION

730.92 UNSPECIFIED INFECTION OF UPPER ARM BONE

730.93 UNSPECIFIED INFECTION OF FOREARM BONE

730.94 UNSPECIFIED INFECTION OF HAND BONE

730.95 UNSPECIFIED INFECTION OF BONE OF PELVIC REGION AND THIGH

730.96 UNSPECIFIED INFECTION OF LOWER LEG BONE

730.97 UNSPECIFIED INFECTION OF ANKLE AND FOOT BONE

731.0 OSTEITIS DEFORMANS WITHOUT BONE TUMOR

731.3 MAJOR OSSEOUS DEFECTS

732.1 JUVENILE OSTEOCHONDROSIS OF HIP AND PELVIS

732.3 JUVENILE OSTEOCHONDROSIS OF UPPER EXTREMITY

732.4 JUVENILE OSTEOCHONDROSIS OF LOWER EXTREMITY EXCLUDING FOOT

732.5 JUVENILE OSTEOCHONDROSIS OF FOOT

732.9 UNSPECIFIED OSTEOCHONDROPATHY

733.41 ASEPTIC NECROSIS OF HEAD OF HUMERUS

733.42 ASEPTIC NECROSIS OF HEAD AND NECK OF FEMUR

733.43 ASEPTIC NECROSIS OF MEDIAL FEMORAL CONDYLE

733.44 ASEPTIC NECROSIS OF TALUS

733.49 ASEPTIC NECROSIS OF OTHER BONE SITES

782.2 LOCALIZED SUPERFICIAL SWELLING MASS OR LUMP

782.3 EDEMA

831.00 CLOSED DISLOCATION OF SHOULDER UNSPECIFIED SITE

831.01 CLOSED ANTERIOR DISLOCATION OF HUMERUS

831.02 CLOSED POSTERIOR DISLOCATION OF HUMERUS

831.03 CLOSED INFERIOR DISLOCATION OF HUMERUS

831.04 CLOSED DISLOCATION OF ACROMIOCLAVICULAR (JOINT)

831.09 CLOSED DISLOCATION OF OTHER SITE OF SHOULDER

831.10 OPEN DISLOCATION OF SHOULDER UNSPECIFIED

831.11 OPEN ANTERIOR DISLOCATION OF HUMERUS

831.12 OPEN POSTERIOR DISLOCATION OF HUMERUS

831.13 OPEN INFERIOR DISLOCATION OF HUMERUS

831.14 OPEN DISLOCATION OF ACROMIOCLAVICULAR (JOINT)

831.19 OPEN DISLOCATION OF OTHER SITE OF SHOULDER

832.00 CLOSED DISLOCATION OF ELBOW UNSPECIFIED SITE

832.01 CLOSED ANTERIOR DISLOCATION OF ELBOW

832.02 CLOSED POSTERIOR DISLOCATION OF ELBOW

832.03 CLOSED MEDIAL DISLOCATION OF ELBOW


832.04 CLOSED LATERAL DISLOCATION OF ELBOW

832.10 OPEN DISLOCATION OF ELBOW UNSPECIFIED SITE

832.11 OPEN ANTERIOR DISLOCATION OF ELBOW

832.12 OPEN POSTERIOR DISLOCATION OF ELBOW

832.13 OPEN MEDIAL DISLOCATION OF ELBOW

832.14 OPEN LATERAL DISLOCATION OF ELBOW

833.00 CLOSED DISLOCATION OF WRIST UNSPECIFIED PART

833.01 CLOSED DISLOCATION OF RADIOULNAR (JOINT) DISTAL

833.02 CLOSED DISLOCATION OF RADIOCARPAL (JOINT)

833.03 CLOSED DISLOCATION OF MIDCARPAL (JOINT)

833.04 CLOSED DISLOCATION OF CARPOMETACARPAL (JOINT)

833.05 CLOSED DISLOCATION OF METACARPAL (BONE) PROXIMAL END

833.09 CLOSED DISLOCATION OF OTHER PART OF WRIST

833.10 OPEN DISLOCATION OF WRIST UNSPECIFIED PART

833.11 OPEN DISLOCATION OF RADIOULNAR (JOINT) DISTAL

833.12 OPEN DISLOCATION OF RADIOCARPAL (JOINT)

833.13 OPEN DISLOCATION OF MIDCARPAL (JOINT)

833.14 OPEN DISLOCATION OF CARPOMETACARPAL (JOINT)

833.15 OPEN DISLOCATION OF METACARPAL (BONE) PROXIMAL END

833.19 OPEN DISLOCATION OF OTHER PART OF WRIST

834.00 CLOSED DISLOCATION OF FINGER UNSPECIFIED PART

834.01 CLOSED DISLOCATION OF METACARPOPHALANGEAL (JOINT)

834.02 CLOSED DISLOCATION OF INTERPHALANGEAL (JOINT) HAND

834.10 OPEN DISLOCATION OF FINGER UNSPECIFIED PART

834.11 OPEN DISLOCATION OF METACARPOPHALANGEAL (JOINT)

834.12 OPEN DISLOCATION INTERPHALANGEAL (JOINT) HAND

835.00 CLOSED DISLOCATION OF HIP UNSPECIFIED SITE

835.01 CLOSED POSTERIOR DISLOCATION OF HIP

835.02 CLOSED OBTURATOR DISLOCATION OF HIP

835.03 OTHER CLOSED ANTERIOR DISLOCATION OF HIP

835.10 OPEN DISLOCATION OF HIP UNSPECIFIED SITE

835.11 OPEN POSTERIOR DISLOCATION OF HIP

835.12 OPEN OBTURATOR DISLOCATION OF HIP

835.13 OTHER OPEN ANTERIOR DISLOCATION OF HIP

836.0 TEAR OF MEDIAL CARTILAGE OR MENISCUS OF KNEE CURRENT

836.1 TEAR OF LATERAL CARTILAGE OR MENISCUS OF KNEE CURRENT

836.2 OTHER TEAR OF CARTILAGE OR MENISCUS OF KNEE CURRENT

836.3 DISLOCATION OF PATELLA CLOSED

836.4 DISLOCATION OF PATELLA OPEN

836.50 CLOSED DISLOCATION OF KNEE UNSPECIFIED PART

836.51 ANTERIOR DISLOCATION OF TIBIA PROXIMAL END CLOSED

836.52 POSTERIOR DISLOCATION OF TIBIA PROXIMAL END CLOSED

836.53 MEDIAL DISLOCATION OF TIBIA PROXIMAL END CLOSED

836.54 LATERAL DISLOCATION OF TIBIA PROXIMAL END CLOSED


836.59 OTHER DISLOCATION OF KNEE CLOSED

836.60 DISLOCATION OF KNEE UNSPECIFIED PART OPEN

836.61 ANTERIOR DISLOCATION OF TIBIA PROXIMAL END OPEN

836.62 POSTERIOR DISLOCATION OF TIBIA PROXIMAL END OPEN

836.63 MEDIAL DISLOCATION OF TIBIA PROXIMAL END OPEN

836.64 LATERAL DISLOCATION OF TIBIA PROXIMAL END OPEN

836.69 OTHER DISLOCATION OF KNEE OPEN

837.0 CLOSED DISLOCATION OF ANKLE

837.1 OPEN DISLOCATION OF ANKLE

840.0 ACROMIOCLAVICULAR (JOINT) (LIGAMENT) SPRAIN

840.3 INFRASPINATUS (MUSCLE) (TENDON) SPRAIN

840.4 ROTATOR CUFF (CAPSULE) SPRAIN

840.5 SUBSCAPULARIS (MUSCLE) SPRAIN

840.6 SUPRASPINATUS (MUSCLE) (TENDON) SPRAIN

840.8 SPRAIN OF OTHER SPECIFIED SITES OF SHOULDER AND UPPER ARM

840.9 SPRAIN OF UNSPECIFIED SITE OF SHOULDER AND UPPER ARM

841.0 RADIAL COLLATERAL LIGAMENT SPRAIN

841.1 ULNAR COLLATERAL LIGAMENT SPRAIN

841.2 RADIOHUMERAL (JOINT) SPRAIN

841.3 ULNOHUMERAL (JOINT) SPRAIN

841.8 SPRAIN OF OTHER SPECIFIED SITES OF ELBOW AND FOREARM

841.9 SPRAIN OF UNSPECIFIED SITE OF ELBOW AND FOREARM

842.00 SPRAIN OF UNSPECIFIED SITE OF WRIST

842.01 SPRAIN OF CARPAL (JOINT) OF WRIST

842.02 SPRAIN OF RADIOCARPAL (JOINT) (LIGAMENT) OF WRIST

842.09 OTHER WRIST SPRAIN

842.11 SPRAIN OF CARPOMETACARPAL (JOINT) OF HAND

842.19 OTHER HAND SPRAIN

843.8 SPRAIN OF OTHER SPECIFIED SITES OF HIP AND THIGH

843.9 SPRAIN OF UNSPECIFIED SITE OF HIP AND THIGH

844.0 SPRAIN OF LATERAL COLLATERAL LIGAMENT OF KNEE

844.1 SPRAIN OF MEDIAL COLLATERAL LIGAMENT OF KNEE

844.2 SPRAIN OF CRUCIATE LIGAMENT OF KNEE

844.3 SPRAIN OF TIBIOFIBULAR (JOINT) (LIGAMENT) SUPERIOR OF KNEE

844.8 SPRAIN OF OTHER SPECIFIED SITES OF KNEE AND LEG

844.9 SPRAIN OF UNSPECIFIED SITE OF KNEE AND LEG

845.00 UNSPECIFIED SITE OF ANKLE SPRAIN

845.01 DELTOID (LIGAMENT) ANKLE SPRAIN

845.02 CALCANEOFIBULAR (LIGAMENT) ANKLE SPRAIN

845.03 TIBIOFIBULAR (LIGAMENT) SPRAIN DISTAL

845.09 OTHER ANKLE SPRAIN

845.10 UNSPECIFIED SITE OF FOOT SPRAIN

845.11 TARSOMETATARSAL (JOINT) (LIGAMENT) SPRAIN

845.12 METATARSAOPHALANGEAL (JOINT) SPRAIN


845.13 INTERPHALANGEAL (JOINT) TOE SPRAIN

845.19 OTHER FOOT SPRAIN

848.1 JAW SPRAIN

848.41 STERNOCLAVICULAR (JOINT) (LIGAMENT) SPRAIN

848.42 CHONDROSTERNAL (JOINT) SPRAIN

848.5 PELVIC SPRAIN

V10.79 PERSONAL HISTORY OF OTHER LYMPHATIC AND HEMATOPOIETIC

NEOPLASMS

Group 2 Medical Necessity ICD-9 Codes Asterisk Explanation: **Note: Use 713.5 for

Charcot’s joints

Associated Information

Documentation Requirements

Documentation supporting the medical necessity should be legible, maintained in the

patient’s medical record, and made available to Medicare upon request.

LOWER EXTREMTIY JOINT MRI UPPER EXTREMITY JOINT MRI - …...

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