Post on 27-Aug-2019
National Imaging Associates, Inc.
Clinical guidelines
LOWER EXTREMTIY JOINT MRI
UPPER EXTREMITY JOINT MRI
TMJ
Original Date: March 2011
Page 1 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.
3— LE_UE Joint MRI/TMJ – CMS
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.
4— LE_UE Joint MRI/TMJ – CMS
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
5— LE_UE Joint MRI/TMJ – CMS
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
171.3 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF
LOWER LIMB INCLUDING HIP
171.6 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF
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
6— LE_UE Joint MRI/TMJ – CMS
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
7— LE_UE Joint MRI/TMJ – CMS
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
715.31 OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR
SECONDARY INVOLVING SHOULDER REGION
715.32 OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR
SECONDARY INVOLVING UPPER ARM
715.33 OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR
SECONDARY INVOLVING FOREARM
8— LE_UE Joint MRI/TMJ – CMS
715.34 OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR
SECONDARY INVOLVING HAND
715.35 OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR
SECONDARY INVOLVING PELVIC REGION AND THIGH
715.36 OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR
SECONDARY INVOLVING LOWER LEG
715.37 OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR
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
715.91 OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED
INVOLVING SHOULDER REGION
715.92 OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED
INVOLVING UPPER ARM
715.93 OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED
INVOLVING FOREARM
715.94 OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED
INVOLVING HAND
715.95 OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED
INVOLVING PELVIC REGION AND THIGH
715.96 OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED
INVOLVING LOWER LEG
715.97 OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED
INVOLVING ANKLE AND FOOT
715.98 OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED
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
9— LE_UE Joint MRI/TMJ – CMS
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
10— LE_UE Joint MRI/TMJ – CMS
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
11— LE_UE Joint MRI/TMJ – CMS
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
12— LE_UE Joint MRI/TMJ – CMS
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
13— LE_UE Joint MRI/TMJ – CMS
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
14— LE_UE Joint MRI/TMJ – CMS
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
15— LE_UE Joint MRI/TMJ – CMS
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
16— LE_UE Joint MRI/TMJ – CMS
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.