Brief Guide to CPT Code 70553

Creating accurate claims and billing for advanced diagnostic imaging services is not just an administrative task that you can ignore. It is an integral step that ensures the financial health and operational efficiency of any healthcare facility, particularly those performing complex radiology procedures.

Radiology departments often struggle to navigate these intricacies, leading to a high denial rate and uncompensated care. Therefore, we decided to empower you with knowledge! Yes, with the correct knowledge, you can differentiate between similar imaging codes, such as those with and without contrast, and ensure precision in billing.

This guide is dedicated to discussing an essential magnetic resonance imaging (MRI) procedure code, CPT code 70553. We will cover everything, from explaining its descriptor to billing and reimbursement guidelines.

If you are completely new to this system, check out our complete guide to CPT codes to get familiar with the basics.

So, without further ado, let’s get started.

70553 CPT Code Description

CPT code 70553 covers Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences.

This procedure is a comprehensive diagnostic study. It requires the radiologist to perform two distinct sets of image acquisition:

1. Non-contrast sequences: Initial images are taken to establish baseline anatomy and detect conditions like hemorrhage.
2. Contrast-enhanced sequences: A paramagnetic contrast agent (typically gadolinium-based) is intravenously administered, and subsequent images are taken. The contrast helps “light up” areas where the blood-brain barrier is compromised, enhancing the visibility of tumors, abscesses, or active inflammation.

CPT code 70553 is the gold standard for detailed brain pathology requiring the highest level of diagnostic specificity, as the combination of images provides superior information compared to either sequence alone.

Scenarios Where CPT Code 70553 is Applicable

Discussed below are some of the real-world clinical scenarios where CPT code 70553 applies:

Suspected Primary or Metastatic Brain Tumor

Picture a 58-year-old male patient who visits his neurologist complaining of new-onset seizures, persistent headaches, and recent personality changes. 

The neurologist suspects an intracranial mass. The physician orders an MRI of the brain with and without contrast because the contrast agent is essential for clearly delineating the margins of a tumor, assessing its vascularity, and determining the presence of surrounding edema. Here, CPT code 70553 applies.

Evaluation of Multiple Sclerosis (MS)

Assume a 35-year-old female patient with a known diagnosis of MS comes for a routine follow-up. She reports new symptoms, including worsening numbness and vision problems. The physician orders CPT 70553. 

The non-contrast sequence will identify older lesions (plaques), while the contrast-enhanced sequence will highlight any new, active inflammation, indicating disease progression. This differentiation is critical for treatment planning. In this situation, CPT code 70553 will be reported for accurate reimbursement.

Investigation of CNS Infection or Abscess

Imagine a 45-year-old patient with a recent history of a systemic infection who develops unexplained fever, severe headache, and signs of increased intracranial pressure. The physician orders a brain MRI with and without contrast to screen for meningitis, encephalitis, or a brain abscess. These infectious processes often cause characteristic “ring-enhancement” on the contrast-enhanced images. CPT code 70553 precisely covers the performed diagnostic study.

Applicable Modifiers for CPT Code 70553

What happens when you encounter a situation where the service provided needs to be split between the facility and the interpreting physician? Will the payer pay you for the whole procedure? Reporting CPT 70553 without the appropriate modifier may result in a claim denial or underpayment.

Here are the essential modifiers to know:

• Modifier 26 (Professional Component): This identifies that the claim is only for the physician’s work in interpreting the images and generating a report, not for the technical cost of the machine and staff.
• Modifier TC (Technical Component): This identifies that the claim is only for the facility (e.g., hospital or imaging center) costs, including the MRI machine, supplies, and technical staff.
• Modifier 59 (Distinct Procedural Service): This is critical. It is used if another distinct service, which is not typically bundled with the MRI, is performed on the same day. For example, if a separate, medically necessary CPT code is performed on the same day, modifier 59 helps clarify the distinction. This is similar to how modifiers work with other services like E/M visits captured by CPT code 99213.
• Modifier 52 (Reduced Services): Used if the service is partially reduced, such as if the contrast was ordered but could not be administered (e.g., patient allergic reaction), though in this case, CPT 70551 (MRI without contrast) may be more appropriate.

For detailed guidance on modifier usage for imaging services, consult resources provided by the American College of Radiology (ACR).

CPT Code 70553 – Billing & Reimbursement Guidelines

The following are the essential reimbursement and billing requirements for MRI Brain with and without contrast:

Demonstrate Medical Necessity

You can never unlock a locked door with the wrong key. The payer will never compensate for care services if the procedure is deemed medically unnecessary. Thus, the top requirement to fulfill while billing for CPT code 70553 is to justify its medical necessity. You can do this by using a specific, high-level ICD-10 diagnosis code (e.g., suspected neoplasm, multiple sclerosis, or stroke) that supports the need for contrast.

Ensure Detailed Documentation

Comprehensive and accurate documentation is another integral requirement. It directly helps in demonstrating medical necessity. Therefore, your documentation must include the following:

• Indication: The specific clinical reason necessitating the use of contrast.
• Contrast Used: Document the type and amount of contrast material administered.
• Findings: Report the findings from both the non-contrast and post-contrast sequences.
• Ordering Physician: Document the ordering physician’s details, including name and NPI number.

Contrast Material Billing

The contrast material itself (e.g., Gadolinium) is typically billed separately using a specific HCPCS Level II code (e.g., Q9967 or A9576), in addition to the CPT code 70553. Do not assume the cost of the material is bundled into the procedure code, check your payer’s policy.

Pre-Authorization is Mandatory

Due to the high cost and complexity of the procedure, CPT 70553 almost universally requires prior authorization from the payer before the service is rendered. Failure to secure this authorization will almost certainly result in a claim denial. Providers should always check the guidelines set by the Centers for Medicare & Medicaid Services (CMS) or relevant commercial payers.

Conclusion

We have covered a lot of ground in this comprehensive guide. So, let’s quickly summarize all key takeaways to reiterate all the critical details related to CPT code 70553.

• First, we explained that CPT 70553 covers a comprehensive MRI of the brain, including sequences performed without contrast, followed by sequences with contrast.
• Next, we shared clinical scenarios where this CPT code applies, including suspected tumors, active Multiple Sclerosis, and CNS infections.
• We shared that the correct use of Modifier 26 or TC is necessary to split professional and technical charges.
• Finally, we discussed the billing guidelines, emphasizing the need for specific ICD-10 codes, separate billing for contrast material, and mandatory pre-authorization.

With all this information, if you still struggle to receive timely reimbursements for your advanced diagnostic imaging procedures, feel free to acquire expert radiology billing services from professionals.