Billing and Coding: Magnetic Resonance Angiography (MRA)

This article contains coding and other guidelines that complement the Local
Coverage Determination (LCD) for Magnetic Resonance Angiography (MRA).

**National Coverage Provisions:**

_Magnetic Resonance Angiography (MRA) is a non-invasive diagnostic test that
is an application of MRI. By analyzing the amount of energy released from
tissues exposed to a strong magnetic field, MRA provides images of normal and
diseased blood vessels as well as visualization and quantification of blood
flow through these vessels._ (CMS Publication 100-03, _Medicare National
Coverage Determinations Manual_ , Chapter 1, Part 4, Section 220.2A.1).

_Contrast-enhanced MRA (CE-MRA) involves blood flow imaging after the patient
receives an intravenous injection of a contrast agent. Gadolinium, a non-ionic
element, is the foundation of all contrast agents currently in use. Gadolinium
affects the way in which tissues respond to magnetization, resulting in better
visualization of structures when compared to un-enhanced studies. Unlike ionic
(i.e. iodine-based) contrast agents used in conventional contrast angiography
(CA), allergic reactions to gadolinium are extremely rare. Additionally,
gadolinium does not cause the kidney failure occasionally seen with ionic
contrast agents. Digital subtraction angiography (DSA) is a computer-augmented
form of CA that obtains digital blood flow images as contrast agent courses
through a blood vessel. The computer "subtracts" bone and other tissue from
the image, thereby improving visualization of blood vessels. Physicians elect
to use a specific MRA or CA technique based upon clinical information from
each patient_ (CMS Publication 100-03, _Medicare National Coverage
Determinations Manual_ , Chapter 1, Part 4, Section 220.2A.1).(Please note
that since the publication by CMS of the preceding narrative, it has been
noted that gadolinium-based contrast agents may also be nephrotoxic,
especially in patients with pre-existing renal disease.)

The related local coverage determination and this article are a restatement of
the National Coverage Determination for MRI and MRA documented in CMS
Publication 100-03, _Medicare National Coverage Determinations Manual,_ Part
4: 220.2.A.2 Magnetic Resonance Imaging (MRI). Restrictions noted in Medicare
National Coverage Determinations are binding on all Medicare contractors and
providers.

**MRA (MRI for Blood flow)**

_Currently covered indications include using MRA for specific conditions to
evaluate flow in internal carotid vessels of the head and neck, peripheral
arteries of lower extremities, abdomen and pelvis, and the chest. Coverage is
limited to MRA units that have received FDA premarket approval, and such units
must be operated within the parameters specified by the approval. In addition,
the services must be reasonable and necessary for the diagnosis or treatment
of the specific patient involved._ (CMS Publication 100-03, _Medicare National
Coverage Determinations Manual,_ Chapter 1, Part 4, Section 220.2.B.2).  


_Effective April 15, 2003, studies have proven that MRA is effective for
evaluating flow in internal carotid vessels of the head and neck. However, not
all potential applications of MRA have been shown to be reasonable and
necessary._

**Peripheral Arteries of Lower Extremities**

_Effective April 15, 2003, studies have proven that MRA of peripheral arteries
is useful in determining the presence and extent of peripheral vascular
disease in lower extremities. This procedure is non-invasive and has been
shown to find occult vessels in some patients for which those vessels were not
apparent when CA was performed._

_Medicare will cover either MRA or CA to evaluate peripheral arteries of the
lower extremities. However, both MRA and CA may be useful in some cases._

  1. _Pre-operative Evaluation of Patients Undergoing Elective Abdominal Aortic Aneurysm (AAA) Repair_

_Effective July 1, 1999, MRA is covered for pre-operative evaluation of
patients undergoing elective AAA repair if the scientific evidence reveals MRA
is considered comparable to CA in determining the extent of AAA, as well as in
evaluating aortoiliac occlusion disease and renal artery pathology that may be
necessary in the surgical planning of AAA repair. These studies also reveal
that MRA could provide a net benefit to the patient. If preoperative CA is
avoided, then patients are not exposed to the risks associated with invasive
procedures, contrast media, end-organ damage, or arterial injury._

_ii. Imaging the Renal Arteries and the Aortoiliac Arteries in the Absence of
AAA or Aortic Dissection_

_Effective July 1, 2003, MRA coverage is expanded to include imaging the renal
arteries and the aortoiliac arteries in the absence of AAA or aortic
dissection. MRA should be obtained in those circumstances in which using MRA
is expected to avoid obtaining CA, when physician history, physical
examination, and standard assessment tools provide insufficient information
for patient management, and obtaining an MRA has a high probability of
positively affecting patient management. However, CA may be ordered after
obtaining the results of an MRA in those rare instances where medical
necessity is demonstrated._ (CMS Publication 100-03, _Medicare National
Coverage Determinations Manual,_ Chapter 1, Part 4, Section 220.2.B.2.c).

**Chest**

_i. Diagnosis of Pulmonary Embolism_

_Current scientific data has shown that diagnostic pulmonary MRAs are
improving due to recent developments such as faster imaging capabilities and
gadolinium-enhancement. However, these advances in MRA are not significant
enough to warrant replacement of pulmonary angiography in the diagnosis of
pulmonary embolism for patients who have no contraindication to receiving
intravenous iodinated contrast material. Patients who are allergic to
iodinated contrast material face a high risk of developing complications if
they undergo pulmonary angiography or computed tomography angiography.
Therefore, Medicare will cover MRA of the chest for diagnosing a suspected
pulmonary embolism when it is contraindicated for the patient to receive
intravascular iodinated contrast material._

_ii. Evaluation of Thoracic Aortic Dissection and Aneurysm_

_Studies have shown that MRA of the chest has a high level of diagnostic
accuracy for pre-operative and post-operative evaluation of aortic dissection
of aneurysm. Depending on the clinical presentation, MRA may be used as an
alternative to other non-invasive imaging technologies, such as
transesophageal echocardiography and CT. Generally, Medicare will provide
coverage only for MRA or for CA when used as a diagnostic test. However, if
both MRA and CA of the chest are used, the physician must demonstrate the
medical need for performing these tests._

_While the intent of this _policy is to provide reimbursement for either MRA
or CA, CMS is also allowing flexibility for physicians to make appropriate
decisions concerning the use of these tests based on the needs of individual
patients. CMS anticipates, however, low utilization of the combined use of MRA
and CA. As a result, CMS encourages contractors to monitor the use of these
tests and, where indicated, requires evidence of the need to perform both MRA
and CA._ (CMS Publication 100-03, _Medicare National Coverage Determinations
Manual,_ Chapter 1, Part 4, Section 220.2.B.2.d). _

All other uses of MRA are nationally non-covered unless coverage is
specifically indicated.

**Coding Information:**

Procedure codes may be subject to National Correct Coding Initiative (NCCI)
edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to
billing Medicare.

For services requiring a referring/ordering physician, the name and NPI of the
referring/ordering physician must be reported on the claim.

A claim submitted without a valid ICD-10-CM diagnosis code will be returned to
the provider as an incomplete claim under Section 1833(e) of the Social
Security Act.

The diagnosis code(s) must best describe the patient's condition for which the
service was performed. For diagnostic tests, report the result of the test if
known; otherwise the symptoms prompting the performance of the test should be
reported.  

**Documentation Requirements:**

The patient's medical record must contain documentation that fully supports
the medical necessity for services included within the LCD. (See "Indications
and Limitations of Coverage.") This documentation includes, but is not limited
to, relevant medical history, physical examination, and results of pertinent
diagnostic tests or procedures.