Description of Measure OP-8: MRI LUMBAR SPINE FOR LOW BACK PAIN This measure calculates the percentage of MRI of the Lumbar Spine studies with a diagnosis of low back pain on the imaging claim and for which the patient did not have prior claims-based evidence of antecedent conservative therapy. Antecedent conservative therapy may include (see subsequent details for codes): 1. Claim(s) for physical therapy in the 60 days preceding the Lumbar Spine MRI. 2. Claim(s) for chiropractic evaluation and manipulative treatment in the 60 days preceding the Lumbar Spine MRI. 3. Claim(s) for evaluation and management in the period >28 days and <60 days preceding the Lumbar Spine MRI. Numerator Statement MRI of the lumbar spine studies with a diagnosis of low back pain (from the denominator) without the patient having claims-based evidence of prior antecedent conservative therapy. Technical Note: The numerator measurement of prior conservative therapy is based on the claim date of the MRI of the lumbar spine from the denominator, with the prior conservative therapy within the defined time periods relative to each MRI lumbar spine claim (i.e., a patient can be included in the numerator count more than once, if the patient had more than one MRI lumbar spine procedure in the measurement period and the MRI lumbar spine procedure occurred on different days). Denominator Statement MRI of the lumbar spine studies with a diagnosis of low back pain on the imaging claim. Technical Notes: 1. The diagnosis of low back pain must be on the MRI lumbar spine claim (i.e., the lumbar spine MRI must be billed with a low back pain diagnosis in one of the diagnoses fields on the claim). MRI lumbar spine studies without a diagnosis of low back pain on the claim are not included in the denominator count. 2. If a patient had more than one MRI lumbar spine study for a diagnosis of low back pain on the same day only one study would be counted, but if a patient had multiple MRI lumbar spine studies with a diagnosis of low back pain on the claim during the measurement period each study would be counted (i.e., a patient can be included in the denominator count more than once). 1 Revised April 2014
Numerator Codes CPT Codes: 72148 MRI Lumbar Spine without Contrast 72149 MRI Lumbar Spine with Contrast 72158 MRI Lumbar Spine with and without Contrast Indications of claims based antecedent conservative therapy include any procedure codes in the three following groups: Claim(s) for physical therapy with the following CPT codes in the 60 days preceding the Lumbar Spine MRI: - 97110 Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercise to develop strength and endurance, range of motion and flexibility - 97112 Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities - 97113 Aquatic therapy with therapeutic exercises - 97124 Massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) - 97140 Manual therapy technical (e.g. mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes Claim(s) for chiropractic evaluation and manipulative treatment with the following CPT codes in the 60 days preceding the Lumbar Spine MRI: - 98940 Chiropractic manipulative treatment (CMT); spinal, one to two regions - 98941 Spinal, three to four regions - 98942 Spinal, five regions - 98943 Extraspinal, one or more regions Claim(s) for evaluation and management with the following CPT codes >28 days and <60 days preceding the Lumbar Spine MRI: 99201-99205 99347-99350 99401-99404 99211-99215 99354-99357 99455-99456 99241-99245 99385-99387 99499 99341-99345 99395-99397 2 Revised April 2014
Denominator Codes CPT Codes 72148 MRI Lumbar Spine without Contrast 72149 MRI Lumbar Spine with Contrast 72158 MRI Lumbar Spine with and without Contrast ICD-9 codes 721.3 Lumbosacral spondylosis without myelopathy 721.90 Spondylosis of unspecified site without mention of myelopathy 722.10 Displacement of lumbar intervertebral disc without myelopathy 722.52 Degeneration of lumbar or lumbosacral intervertebral disc 722.6 Degeneration of intervertebral disc, site unspecified 722.93 Other unspecified disc disorder of lumbar region 724.02 Spinal stenosis of lumbar region 724.2 Lumbago 724.3 Sciatica 724.5 Unspecified backache 724.6 Disorders of sacrum 724.70 Unspecified disorder of coccyx 724.71 Hypermobility of coccyx 724.79 Other disorder of the coccyx 738.5 Other acquired deformity of back or spine 739.3 Nonallopathic lesion of lumbar region, not elsewhere classified 739.4 Nonallopathic lesion of sacral regions, not elsewhere classified 846.0 Sprain and strain of lumbosacral (joint) (ligament) 846.1 Sprain and strain of sacroiliac (ligament) 846.2 Sprain and strain of sacrospinatus (ligament) 846.3 Sprain and strain of sacrotuberous (ligament) 846.8 Other specified sites of sacroiliac region sprain and strain 846.9 Unspecified site of sacroiliac region sprain and strain 847.2 Lumbar sprain and strain Denominator Exclusion Codes Indications for measure exclusion include any patients with the following procedures or diagnosis codes: Patients with lumbar spine surgery in the 90 days prior to MRI: CPT codes: 22010-22865 and 22899 Cancer (Within twelve months prior to MRI procedure. A cancer exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-9 codes: 140-208, 230-234, 235-239 3 Revised April 2014
Congenital Spine and Spinal Cord Malformations (Within five years prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-9 codes: 741, 742.5X, 742.8, 742.9, 754.2, 756.1X, 759.7, 759.89, 759.9 Inflammatory and Autoimmune Disorders (Within five years prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-9 codes: 323.6X, 323.8X, 323.9, 340, 341, 357.0, 696.0, 701.0, 710, 714, 756.83, 759.82 Infectious Conditions (Within one year prior to MRI procedure. An exclusion ICD-9 codes: 013.1X, 013.4X, 013.5X, 013.6X, 015.0X, 094, 730.08, 730.18, 730.28, 730.38, 730.88, 730.98 Spinal Vascular Malformations and/or the Cause of Occult Subarachnoid Hemorrhage (Within five years prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-9 codes: 228.00, 228.09, 430, 442.89, 442.9, 447.0, 747.82 Spinal Cord Infarction (Within one year prior to MRI procedure. An exclusion ICD-9 codes: 336.1, 349.9 Neoplastic Abnormalities (Within five years prior to MRI procedure. An exclusion ICD-9 codes: 198.3, 213.2, 213.6, 225.3, 225.4, 225.9, 742.59 Treatment Fields for Radiation Therapy (Within five years prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-9 codes: 990 Spinal Abnormalities Associated with Scoliosis (Within five years prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-9 codes: 737, 756.5X Syringohydromyelia (Within five years prior to MRI procedure. An exclusion ICD-9 code: 336.0 4 Revised April 2014
Postoperative Fluid Collections and Soft Tissue Changes (Within one year prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-9 codes: 998.13, 998.89, 998.9 Trauma: (Within 45 days prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-9 codes: 800-839, 850-854, 860-869, 905-909, 926.11, 926.12, 929, 952, 958-959 IV Drug Abuse: (Within twelve months prior to MRI procedure. An exclusion ICD-9 codes: 304.0X, 304.1X, 304.2X, 304.4X, 305.4X, 305.5X, 305.6X, 305.7X Neurologic Impairment: (Within twelve months prior to MRI procedure. An exclusion ICD-9 codes: 344.60, 344.61, 729.2 Human Immunodeficiency Virus (HIV): (Within twelve months prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-9 codes: 042 Unspecified Immune Deficiencies: (Within twelve months prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-9 code: 279.3 Intraspinal abscess: (An exclusion diagnosis must be in one of the diagnoses fields on the MRI lumbar spine claim.) ICD-9 codes: 324.1, 324.9. Technical Note: If the diagnosis code is a three-digit ICD-9 code, then all codes starting with the three digits are used in the measure calculation, that is, all inclusive. If the diagnosis code is specified as a four-digit ICD-9 code, then only the specific four-digit diagnosis code is used. If the diagnosis code is a five-digit code, the code used is either the specific five-digit diagnosis code if all five numeric digits are shown, or if the fifth digit is designated with an x then this is designating an all inclusive range to the fifth digit. 5 Revised April 2014
OP-8: MRI LUMBAR SPINE FOR LOW BACK PAIN ICD-10 DRAFT SPECIFICATIONS Description of Measure This measure calculates the percentage of MRI of the Lumbar Spine studies with a diagnosis of low back pain on the imaging claim and for which the patient did not have prior claims-based evidence of antecedent conservative therapy. Antecedent conservative therapy may include (see subsequent details for codes): 1. Claim(s) for physical therapy in the 60 days preceding the Lumbar Spine MRI. 2. Claim(s) for chiropractic evaluation and manipulative treatment in the 60 days preceding the Lumbar Spine MRI. 3. Claim(s) for evaluation and management in the period >28 days and <60 days preceding the Lumbar Spine MRI. Numerator Statement MRI of the lumbar spine studies with a diagnosis of low back pain (from the denominator) without the patient having claims-based evidence of prior antecedent conservative therapy. Technical Note: The numerator measurement of prior conservative therapy is based on the claim date of the MRI of the lumbar spine from the denominator, with the prior conservative therapy within the defined time periods relative to each MRI lumbar spine claim (i.e., a patient can be included in the numerator count more than once, if the patient had more than one MRI lumbar spine procedure in the measurement period and the MRI lumbar spine procedure occurred on different days). Denominator Statement MRI of the lumbar spine studies with a diagnosis of low back pain on the imaging claim. Technical Notes: 1. The diagnosis of low back pain must be on the MRI lumbar spine claim (i.e., the lumbar spine MRI must be billed with a low back pain diagnosis in one of the diagnoses fields on the claim). MRI lumbar spine studies without a diagnosis of low back pain on the claim are not included in the denominator count. 2. If a patient had more than one MRI lumbar spine study for a diagnosis of low back pain on the same day only one study would be counted, but if a patient had multiple MRI lumbar spine studies with a diagnosis of low back pain on the claim during the measurement period each study would be counted (i.e., a patient can be included in the denominator count more than once). 6 Revised April 2014
Numerator Codes CPT Codes 72148 MRI Lumbar Spine without Contrast 72149 MRI Lumbar Spine with Contrast 72158 MRI Lumbar Spine with and without Contrast Indications of claims based antecedent conservative therapy include any procedure codes in the three following groups: Claim(s) for physical therapy with the following CPT codes in the 60 days preceding the Lumbar Spine MRI: 97110 Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercise to develop strength and endurance, range of motion and flexibility 97112 Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities 97113 Aquatic therapy with therapeutic exercises 97124 Massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) 97140 Manual therapy technical (e.g. mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes Claim(s) for chiropractic evaluation and manipulative treatment with the following CPT codes in the 60 days preceding the Lumbar Spine MRI: 98940 Chiropractic manipulative treatment (CMT); spinal, one to two regions 98941 Spinal, three to four regions 98942 Spinal, five regions 98943 Extraspinal, one or more regions Claim(s) for evaluation and management with the following CPT codes >28 days and <60 days preceding the Lumbar Spine MRI: 99201-99205 99347-99350 99401-99404 99211-99215 99354-99357 99455-99456 99241-99245 99385-99387 99499 99341-99345 99395-99397 7 Revised April 2014
Denominator Codes CPT Codes: 72148 MRI Lumbar Spine without Contrast 72149 MRI Lumbar Spine with Contrast 72158 MRI Lumbar Spine with and without Contrast ICD-10 codes Other deforming dorsopathies: M43.20, M43.25-M43.28, M43.5X5-M43.5X9, M43.8X5-M43.8X9, M43.9 Spondylopathies: M46.46-M46.47, M47.20, M47.26-M47.28, M47.816-M47.819, M47.896-M47.9, M48.06-M48.07 Other dorsopathies: M51.26-M51.27, M51.34-M51.37, M51.86-M51.87, M53.2X7-M53.2X8, M53.3, M53.86-M53.88, M54.30-M54.32, M54.40-M54.42, M54.5, M54.89, M54.9 Biomechanical lesion, not elsewhere classified: M99.03-M99.04, M99.23, M99.33, M99.43, M99.53, M99.63, M99.73, M99.83-M99.84 Dislocation and sprain of joints and ligaments of lumbar spine and pelvis: S33.5XX*-S33.9XX* Denominator Exclusion Codes Indications for measure exclusion include any patients with the following procedures or diagnosis codes: Patients with lumbar spine surgery in the 90 days prior to MRI: CPT codes: 22010-22865 and 22899 Cancer (Within twelve months prior to MRI procedure. A cancer exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-10 codes: C00.0-C14.8, C15.3-C26.9, C30.0-C39.9, C40.0-C41.9, C43.0-C43.9, C44.00-C44.99, C45.0-C49.9, C50.011-C50.929, C51.0-C58, C60.1-C63.9, C64.1- C68.9, C69.00-C72.9, C73-C75.9, C76.0-C80.2, C81.00-C86.6, C88.2-C93.Z1, C93.90-C96.4, C96.A-C96.9, D00.00-D09.9, D37.01-D47.1, D47.3, D47.Z1-D48.9, D49.0-D49.9, Q85.00-Q85.09 Congenital Spine and Spinal Cord Malformations (Within five years prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-10 codes: G90.1, Q05.0- Q07.03, Q07.8-Q07.9, Q67.5, Q76.0-Q76.419, Q76.425-Q76.429, Q76.49, Q79.8-Q79.9, Q87.2-Q87.3, Q87.5-Q87.89, Q89.7-Q89.9 8 Revised April 2014
Inflammatory and Autoimmune Disorders (Within five years prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-10 codes: G04.00-G04.02, G04.30-G04.31, G04.39-G04.91, G05.4, G35-G37.9, G61.0, L40.50-L40.59, L90.0, L94.0-L94.1, L94.3, M05.00-M08.99, M12.00- M12.09, M32.0-M32.9, M33.00-M33.99, M34.0-M34.9, M35.0-M35.1, M35.5, M35.8-M35.9, M36.0, M36.8, Q79.6, Q87.40 Infectious Conditions (Within one year prior to MRI procedure. An exclusion ICD-10 codes: A17.1-A17.83, A18.01, A52.10-A52.17, A52.19, A52.2-A52.3, M46.20-M46.39, M86.08, M86.18, M86.28, M86.38, M86.48, M86.58, M86.68, M86.8X8, M86.9, M90.88 Spinal Vascular Malformations and/or the Cause of Occult Subarachnoid Hemorrhage (Within five years prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-10 codes: D18.00, D18.09, I60.00-I60.9, I72.8-I72.9, I77.0, Q27.9 Spinal Cord Infarction (Within one year prior to MRI procedure. An exclusion ICD-10 codes: G95.11, G95.19, G96.9 Neoplastic Abnormalities (Within five years prior to MRI procedure. An exclusion ICD-10 codes: C79.31, D16.6, D16.8, D32.1, D33.4, D33.9, Q06.0-Q06.1, Q06.3, Q06.8 Treatment Fields for Radiation Therapy (Within five years prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-10 code: T66.XXXA Spinal Abnormalities Associated with Scoliosis (Within five years prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-10 codes: M40.00, M40.05, M40.10, M40.15, M40.205, M40.209, M40.295, M40.299, M40.35-M40.37, M40.40, M40.45-M40.47, M40.50, M40.55-M40.57, M41.00, M41.05-M41.07, M41.115-M41.117, M41.125-M41.127, M41.20, M41.25- M41.27, M41.30, M41.35, M41.40, M41.45-M41.47, M41.50, M41.55-M41.57, M41.80, M41.85-M41.87, M41.9, M43.8X9, M96.2-M96.5, Q77.6, Q78.0-Q78.3, Q78.5-Q78.9 Syringohydromyelia (Within five years prior to MRI procedure. An exclusion ICD-10 code: G95.0 9 Revised April 2014
Postoperative Fluid Collections and Soft Tissue Changes (Within one year prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-10 codes: T81.89X*, T81.9XX*, T88.8XX* Trauma: (Within 45 days prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-10 codes: M48.40X*-M48.58X*, M67.90, M84.30X*-M84.38X*, M84.40X*- M84.48X*, M84.50X*-M84.58X*, M84.60X*-M84.68X*, M99.10-M99.19, S00.00X*-S09.93X*, S10.0XX*-S19.9XX*, S20.00X*-S29.9XX*, S30.0XX* - S32.811*, S32.89X -S39.94X*, S40.011*-S49.92X*, S50.00X*-S59.919*, S60.00X*-S69.92X*, S70.00X*-S79.929*, S80.00X*-S89.92X*, S90.00X*- S99.929*, T07, T14.8-T14.91, T15.00X*-T15.92X*, T16.1XX*-T17.998*, T18.0XX*-T18.9XX*, T19.0XX*-T19.9XX*, T20.00X*-T20.79X*, T21.00X*- T21.79X*, T22.00X*-T22.099*, T22.10X*-T22.199*, T22.20X*-T22.299*, T22.30X*-T22.399*, T22.40X*-T22.499*, T22.50X*-T22.599*, T22.60X*- T22.699*, T22.70X*-T22.799*, T23.001*-T23.099*, T23.101*-T23.199*, T23.201*- T23.299*, T23.301*-T23-399*, T23.401*-T23.499*, T23.501*-T23.599*, T23.601*- T23.699*, T23.701*-T23.799*, T24.001*-T24.099*, T24.101*-T24.199*, T24.201*- T24.299*, T24.301*-T24.399*, T24.401*-T24.499*, T24.501*-T24.599*, T24.601*- T24.699*, T24.701*-T24.799*, T25.011*-T25.799*, T26.00X*-T26.92X*, T27.0XX*-T27.7XX*, T28.00X*-T28.99X*, T33.011*-T33.99X*, T34.011*- T34.99X*, T36.0X1*-T36.0X5*, T36.1X1*-T36.1X5*, T36.2X1*-T36.2X5*, T36.3X1*-T36.3X5*, T36.4X1*-T36.4X5*, T36.5X1*-T36.5X5*, T36.6X1*- T36.6X5*, T36.7X1*-T36.7X5*, T36.8X1*-T36.8X5*, T36.91X*-T36.95X*, T37.0X1*-T37.0X5*, T37.1X1*-T37.1X5*, T37.2X1*-T37.2X5*, T37.3X1*- T37.3X5*, T37.4X1*-T37.4X5*, T37.5X1*-T37.5X5*, T37.8X1*-T37.8X5*, T37.91X*-T37.95X*, T38.0X1*-T38.0X5*, T38.1X1*-T38.1X5*, T38.2X1*- T38.2X5*, T38.3X1*-T38.3X5*, T38.4X1*-T38.4X5*, T38.5X1*-T38.5X5*, T38.6X1*-T38.6X5*, T38.7X1*-T38.7X5*, T38.801*-T38.805*, T38.811*- T38.815*, T38.891*-T38.895*, T38.901*-T38.905*, T38.991*-T38.995*, T39.011*- T39.015*, T39.091*-T39.095*, T39.1X1*-T39.1X5*, T39.2X1*-T39.2X5*, T39.311*-T39.315*, T39.391*-T39.395*, T39.4X1*-T39.4X5*, T39.8X1*- T39.8X5*, T39.91X*-T39.95X*, T40.0X1*-T40.0X5*, T40.1X1*-T40.1X4*, T40.2X1*-T40.2X5*, T40.3X1*-T40.3X5*, T40.4X1*-T40.4X5*, T40.5X1*- T40.5X5*, T40.601*-T40.605*, T40.691*-T40.695*, T40.7X1*-T40.7X5*, T40.8X1*-T40.8X4*, T40.901*-T40.905*, T40.991*-T40.995*, T41.0X1*- T41.0X5*, T41.1X1*-T41.1X5*, T41.201*-T41.205*, T41.291*-T41.295*, T41.3X1*-T41.3X5*, T41.41X*-T41.45X*, T41.5X1*-T41.5X5*, T42.0X1*- T42.0X5*, T42.1X1*-T42.1X5*, T42.2X1*-T42.2X5*, T42.3X1*-T42.3X5*, T42.4X1*-T42.4X5*, T42.5X1*-T42.5X5*, T42.6X1*-T42.6X5*, T42.71X*- T42.75X*, T42.8X1*-T42.8X5*, T43.011*-T43.015*, T43.021*-T43.025*, T43.1X1*-T43.1X5*, T43.201*-T43.205*, T43.211*-T43.215*, T43.221*-T43.225*, T43.291*-T43.295*, T43.3X1*-T43.3X5*, T43.4X1*-T43.4X5*, T43.501*- T43.505*, T43.591*-T43.595*, T43.601*-T43.605*, T43.611*-T43.615*, T43.621*- T43.625*, T43.631*-T43.635*, T43.691*-T43.695*, T43.8X1*-T43.8X5*, T43.91X*-T43.95X*, T44.0X1*-T44.0X5*, T44.1X1*-T44.1X5*, T44.2X1*- 10 Revised April 2014
T44.2X5*, T44.3X1*-T44.3X5*, T44.4X1*-T44.4X5*, T44.5X1*-T44.5X5*, T44.6X1*-T44.6X5*, T44.7X1*-T44.7X5*, T44.8X1*-T44.8X5*, T44.901*- T44.906*, T44.991*-T44.995*, T45.0X1*-T45.0X5*, T45.1X1*-T45.1X5*, T45.2X1*-T45.2X5*, T45.3X1*-T45.3X5*, T45.4X1*-T45.4X5*, T45.511*- T45.515*, T45.521*-T45.525*, T45.601*-T45.605*, T45.611*-T45.615*, T45.621*- T45.625*, T45.691*-T45.695*, T45.7X1*-T45.7X5*, T45.8X1*-T45.8X5*, T45.91X*-T45.95X*, T46.0X1*-T46.0X5*, T46.1X1*-T46.1X5*, T46.2X1*- T46.2X5*, T46.3X1*-T46.3X5*, T46.4X1*-T46.4X5*, T46.5X1*-T46.5X5*, T46.6X1*-T46.6X5*, T46.7X1*-T46.7X5*, T46.8X1*-T46.8X5*, T46.901*- T46.905*, T46.991*-T46.995*, T47.0X1*-T47.0X5*, T47.1X1*-T47.1X5*, T47.2X1*-T47.2X5*, T47.3X1*-T47.3X5*, T47.4X1*-T47.4X5*, T47.5X1*- T47.5X5*, T47.6X1*-T47.6X5*, T47.7X1*-T47.7X5*, T47.8X1*-T47.8X5*, T47.91X*-T47.95X*, T48.0X1*-T48.0X5*, T48.1X1*-T48.1X5*, T48.201*- T48.205*, T48.291*-T48.295*, T48.3X1*-T48.3X5*, T48.4X1*-T48.4X5*, T48.5X1*-T48.5X5*, T48.6X1*-T48.6X5*, T48.901*-T48.905*, T48.991*- T48.995*, T49.0X1*-T49.0X5*, T49.1X1*-T49.1X5*, T49.2X1*-T49.2X5*, T49.3X1*-T49.3X5*, T49.4X1*-T49.4X5*, T49.5X1*-T49.5X5*, T49.6X1*- T49.6X5*, T49.7X1*-T49.7X5*, T49.8X1*-T49.8X5*, T49.91X*-T49.95X*, T50.0X1*-T50.0X5*, T50.1X1*-T50.1X5*, T50.2X1*-T50.2X5*, T50.3X1*- T50.3X5*, T50.4X1*-T50.4X5*, T50.5X1*-T50.5X5*, T50.6X1*-T50.6X5*, T50.7X1*-T50.7X5*, T50.8X1*-T50.8X5*, T50.901*-T50.905*, T50.991*- T50.995*, T50.A11*-T50.A15*, T50.A21*-T50.A25*, T50.A91*-T50.A95*, T50.B11*-T50.B15*, T50.B91*-T50.B95*, T50.Z11*-T50.Z15*, T50.Z91*- T50.Z95*, T50.0X1*-T51.94X*, T52.0X1*-T52.94X*, T53.0X1*-T53.94X*, T54.0X1*-T54.94X*, T55.0X1*-T55.1X4*, T56.0X1*-T56.94X*, T57.0X1*- T57.94X*, T58.01X*-T58.94X*, T59.0X1*-T59.94X*, T60.0X1*-T60.94X*, T61.01X*-T61.94X*, T62.0X1*-T62.94X*, T63.001*-T63.094*, T63.111*- T63.194*, T63.2X1*-T63.2X4*, T63.301*-T63.394*, T63.411*-T63.484*, T63.511*-T63.594*, T63.611*-T63.694*, T63.711*-T63.794*, T63.811*-T63.894*, T63.91X*-T63.94X*, T64.01X*-T64.84X*, T65.0X1*-T65.94X*, T66.XXX*, T67.0XX*-T67.9XX*, T68.XXX*, T69.011*-T69.9XX*, T70.0XX*-T70.9XX*, T71.111*-T71.9XX*, T73.0XX*-T73.9XX*, T74.01X*-T74.92X*, T75.00X*- T75.89X*, T76.01X*-T76.92X*, T78.00X*-T78.8XX*, T79.0XX*-T79.9XX*, T80.0XX*-T80.1XX*, T80.29X*-T80.92X*, T81.30X*-T81.9XX*, T82.01X*- T82.9XX*, T83.010*-T83.6XX*, T83.81X*-T83.99X*, T84.010*-T84.099*, T84.110*-T84.199*, T84.210*-T84.298*, T84.310*-T84.398*, T84.410*-T84.498*, T84.50X*-T84.59X*, T84.60X*-T84.69X*, T84.7XX*, T84.81X*-T84.89X*, T84.9XX*, T85.01X*-T85.9XX*, T88.0XX*-T88.9XX* IV Drug Abuse: (Within twelve months prior to MRI procedure. An exclusion ICD-10 codes: F11.10-F11.120, F11.129, F11.20-F11.29, F13.10-F13.120, F13.20- F13.21, F14.10-F14.120, F14.20-F14.29, F15.10-F15.120, F15.20-F15.29 11 Revised April 2014
Neurologic Impairment: (Within twelve months prior to MRI procedure. An exclusion ICD-10 codes: G83.4, M54.10, M54.18, M79.2 Human Immunodeficiency Virus (HIV): (Within twelve months prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-10 codes: B20 Unspecified Immune Deficiencies: (Within twelve months prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-10 code: D84.8-D84.9 Intraspinal abscess: (An exclusion diagnosis must be in one of the diagnoses fields on the MRI lumbar spine claim.) ICD-10 codes: G06.1-G07 Technical Note: Please note that an asterisk (*) represents a wildcard for that digit. Technical Note: The draft specifications included in this document represent a crosswalk of the ICD-9 specifications to ICD-10 specifications based on both a forward and backward crosswalk of the General Equivalence Mapping (GEM) file. The contractor made additional modifications to the ICD-10 specifications as a result of public comment and review by contractor clinicians and ICD-10 subject matter experts. Additional refinement of the ICD-10 specifications may occur as data comes available for testing. Disclaimer: CPT codes, descriptions, and other data only are copyright 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS\DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. 12 Revised April 2014