How To Use CPT Code 70540

CPT 70540 describes the use of magnetic resonance imaging (MRI) to examine the orbit, face, and/or neck without the use of contrast material. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 70540?

CPT 70540 can be used to describe the use of MRI to examine the orbit, face, and/or neck without the administration of contrast material. This code is used when a healthcare provider utilizes MRI technology to create detailed cross-sectional images of the specified areas to identify tumors, anatomic abnormalities, and foreign bodies.

2. Official Description

The official description of CPT code 70540 is: ‘Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s).’ This code does not involve the use of contrast material during the MRI procedure.

3. Procedure

1. The patient is positioned on a table that slides into the MRI machine, which resembles a large tube.
2. The healthcare provider uses the MRI machine to create detailed images of the orbit, face, and/or neck without the use of contrast material.
3. The machine generates a magnetic field and directs radio waves at the patient’s body, aligning the hydrogen atoms in the patient’s tissues.
4. The aligned atoms produce signals that a computer translates into cross-sectional images, providing a detailed view of the targeted areas.
5. The images help the healthcare provider identify tumors, anatomic abnormalities, and foreign bodies in the orbit, face, and/or neck.

4. Qualifying circumstances

CPT 70540 is used when a healthcare provider performs an MRI of the orbit, face, and/or neck without the use of contrast material. This procedure is typically conducted to evaluate specific conditions or symptoms related to these areas, such as tumors, anatomic abnormalities, or foreign bodies. The absence of contrast material distinguishes this code from other MRI procedures that involve contrast administration.

5. When to use CPT code 70540

CPT code 70540 should be used when a healthcare provider performs an MRI of the orbit, face, and/or neck without the use of contrast material. It is important to ensure that the procedure aligns with the specific indications for this code and that contrast material is not administered during the MRI.

6. Documentation requirements

To support a claim for CPT 70540, the healthcare provider must document the following information:

• Indication for the MRI of the orbit, face, and/or neck
• Confirmation that the procedure was performed without the use of contrast material
• Date and time of the MRI
• Specific areas imaged (orbit, face, and/or neck)
• Findings or abnormalities identified during the MRI
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 70540, it is important to ensure that the MRI procedure was performed without the use of contrast material. This code should not be reported if contrast material was administered during the MRI. Additionally, it is essential to follow payer guidelines regarding the reporting of contrast administration and any applicable modifiers.

8. Historical information

CPT 70540 was added to the Current Procedural Terminology system on January 1, 1990. Since its addition, there have been historical changes to the code, including code changes on January 1, 2001, and January 1, 2007. These changes reflect updates to the code’s description and ensure accurate reporting of the MRI procedure without contrast material.

9. Examples

1. A healthcare provider performs an MRI of the orbit to evaluate a patient with suspected orbital tumor.
2. An MRI of the face is conducted to assess a patient with facial trauma and suspected fractures.
3. A healthcare provider orders an MRI of the neck to investigate a patient with persistent neck pain and suspected cervical spine abnormalities.
4. An MRI of the orbit and face is performed to evaluate a patient with chronic sinusitis and suspected sinus abnormalities.
5. A healthcare provider utilizes MRI to examine the neck of a patient with a history of thyroid cancer for surveillance purposes.
6. An MRI of the orbit and face is conducted to assess a patient with proptosis and suspected orbital cellulitis.
7. A healthcare provider orders an MRI of the neck to evaluate a patient with suspected lymphadenopathy.
8. An MRI of the face is performed to investigate a patient with craniofacial abnormalities.
9. A healthcare provider utilizes MRI to examine the orbit and neck of a patient with suspected vascular malformations.
10. An MRI of the face is conducted to assess a patient with suspected temporomandibular joint disorder.