Find comprehensive information on Magnetic Resonance Imaging (MRI) diagnosis coding, including ICD-10 codes, CPT codes, and clinical documentation requirements. This guide covers healthcare best practices for MRI procedure coding, accurate medical billing, and compliant documentation for various MRI scan types like brain MRI, spine MRI, and musculoskeletal MRI. Learn about common MRI diagnostic impressions and improve your medical coding accuracy for optimized reimbursement. Explore resources for radiologists, physicians, and other healthcare professionals involved in MRI diagnostic reporting.
Also known as
Persons encountering health services
Encounters for examinations, not diagnosis or treatment.
Abnormal findings on diagnostic imaging
Abnormal findings seen on imaging, not a diagnosis itself.
Factors influencing health status
Personal history of medical treatment, including imaging.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is MRI for diagnostic purposes?
Yes
Specific body part imaged?
No
Is MRI for screening?
When to use each related code
| Description |
|---|
| Magnetic Resonance Imaging |
| Computed Tomography |
| Ultrasound Imaging |
Using unlisted MRI codes (e.g., 7418X) without proper justification and documentation creates compliance and reimbursement risks.
Incorrect laterality or anatomical site coding for MRI (e.g., wrong modifier or code) leads to claim denials and audit issues.
Lack of documentation supporting the medical necessity of MRI contrast media can cause coding errors and rejected claims.
Magnetic Resonance Imaging (MRI) of [body part specified, e.g., the brain, lumbar spine, left knee] was performed on [date] utilizing a [field strength specified, e.g., 1.5 Tesla, 3.0 Tesla] MRI scanner. The examination was performed without contrast media, with contrast media, or with and without contrast media (specify type of contrast if used, e.g., Gadolinium-based contrast agent). Patient tolerated the procedure well. Indications for the MRI included [list indications, e.g., headache, low back pain, knee pain, suspected disc herniation, neurological deficit]. Relevant clinical history includes [list relevant history, e.g., hypertension, diabetes, previous surgery, trauma]. Comparison was made to prior imaging studies dated [date of prior study] if applicable. Findings: [Detailed description of findings, using anatomical and radiological terminology, e.g., normal appearance of the brain parenchyma, no evidence of acute intracranial hemorrhage, mild degenerative disc disease at L4-L5 and L5-S1, tear of the medial meniscus]. Impression: [Summary of findings and diagnostic impression, e.g., Normal brain MRI, Lumbar spine MRI demonstrating multilevel degenerative disc disease, Left knee MRI demonstrating medial meniscus tear]. Recommendations: [Recommendations based on findings, e.g., Clinical correlation recommended, Follow up MRI in 6 months, Referral to orthopedics]. This MRI report contributes to medical coding for diagnostic imaging procedures and is relevant to medical billing and healthcare reimbursement. It adheres to EHR documentation standards and encompasses clinical documentation best practices for improved patient care.