How To Use CPT Code 70558

CPT 70558 describes the use of magnetic resonance imaging (MRI) during an open intracranial procedure to assess for residual tumor or residual vascular malformation in the brain. 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 70558?

CPT 70558 is used to describe the performance of an MRI of the brain, including the brain stem and skull base, during an open intracranial procedure. This procedure is done to assess for any remaining tumor or vascular malformation after the surgery. The MRI is performed with the use of contrast material to enhance the visibility of internal structures.

2. Official Description

The official description of CPT code 70558 is: ‘Magnetic resonance (eg, proton) imaging, brain (including brain stem and skull base), during open intracranial procedure (eg, to assess for residual tumor or residual vascular malformation); with contrast material(s)’

3. Procedure

1. During an open intracranial procedure, the healthcare provider performs an MRI of the brain, including the brain stem and skull base.
2. The MRI is performed to assess for any remaining tumor or vascular malformation after the surgery.
3. The patient is positioned under the MRI scanner, and radio waves manipulate the magnetic position of atoms in the body.
4. A powerful radio antenna picks up the location of the atoms and sends the information to a computer.
5. The computer generates cross-sectional black and white images of the brain, brain stem, and skull base.
6. The provider may use the MRI multiple times during the procedure to plan the path, preserve healthy tissue, verify removal of diseased tissue, and detect any problems.
7. The MRI is performed with the use of contrast material, which is injected into the patient to enhance the visibility of internal structures.

4. Qualifying circumstances

CPT 70558 is used when an MRI of the brain, including the brain stem and skull base, is performed during an open intracranial procedure. This procedure is done to assess for residual tumor or residual vascular malformation. The use of contrast material is also a qualifying circumstance for this code.

5. When to use CPT code 70558

CPT code 70558 should be used when an MRI of the brain, including the brain stem and skull base, is performed during an open intracranial procedure to assess for residual tumor or residual vascular malformation. It is important to note that this code should not be used if the MRI is performed without the use of contrast material.

6. Documentation requirements

To support a claim for CPT 70558, the healthcare provider must document the following information:

• Indication for the open intracranial procedure
• Reason for performing the MRI during the procedure
• Date and time of the procedure
• Use of contrast material
• Findings from the MRI
• Signature of the healthcare provider

7. Billing guidelines

When billing for CPT 70558, it is important to ensure that the procedure is performed during an open intracranial procedure and that contrast material is used. If the MRI is performed without the use of contrast material, a different code should be used. It is also important to follow any specific billing guidelines provided by individual payers.

8. Historical information

CPT 70558 was added to the Current Procedural Terminology system on January 1, 2004. There have been no updates to the code since its addition.

9. Examples

1. A neurosurgeon performs an open intracranial procedure to remove a brain tumor. During the procedure, an MRI of the brain, including the brain stem and skull base, is performed with contrast material to ensure complete removal of the tumor.
2. An oncologist performs an open intracranial procedure to treat a vascular malformation in the brain. An MRI of the brain, including the brain stem and skull base, is performed during the procedure with contrast material to assess the success of the treatment.
3. A patient undergoes open brain surgery to remove a tumor. An MRI of the brain, including the brain stem and skull base, is performed with contrast material to confirm the complete removal of the tumor.
4. A neurologist performs an open intracranial procedure to address a residual vascular malformation in the brain. An MRI of the brain, including the brain stem and skull base, is performed with contrast material to evaluate the effectiveness of the procedure.
5. A patient undergoes open brain surgery to correct a vascular malformation. An MRI of the brain, including the brain stem and skull base, is performed with contrast material to ensure the successful correction of the malformation.
6. A neurosurgeon performs an open intracranial procedure to remove a residual tumor in the brain. An MRI of the brain, including the brain stem and skull base, is performed with contrast material to verify the complete removal of the tumor.
7. An oncologist performs an open intracranial procedure to treat a vascular malformation in the brain. An MRI of the brain, including the brain stem and skull base, is performed with contrast material to assess the outcome of the treatment.
8. A patient undergoes open brain surgery to remove a tumor. An MRI of the brain, including the brain stem and skull base, is performed with contrast material to confirm the absence of any remaining tumor.
9. A neurologist performs an open intracranial procedure to address a residual vascular malformation in the brain. An MRI of the brain, including the brain stem and skull base, is performed with contrast material to evaluate the success of the procedure.