Practice Management

Does anyone know how much documentation is necessary to be able to add on MR safety CPT codes to those exams that clinical staff vetted for implanted/foreign body identification? 

Hi Jessica!

I listened to a webinar hosted by RCCSI and it has really good information around the new safety codes and the RCCB Winter 2024 Newsletter has some good info too.

On-demand: https://zoom.us/rec/share/eJKsHtR3FlFZ1cCAu7IAE2JqcyQ6DzZg32UDy3cLgoiYTlTwpFtg-2bZ5ikHQgK4.maTti7ijswq3pEak?startTime=1734454809000

Does anyone know how much documentation is necessary to be able to add on MR safety CPT codes to those exams that clinical staff vetted for implanted/foreign body identification? 

Hi Jessica!

I listened to a webinar hosted by RCCSI and it has really good information around the new safety codes and the RCCB Winter 2024 Newsletter has some good info too.

On-demand: https://zoom.us/rec/share/eJKsHtR3FlFZ1cCAu7IAE2JqcyQ6DzZg32UDy3cLgoiYTlTwpFtg-2bZ5ikHQgK4.maTti7ijswq3pEak?startTime=1734454809000

Does anyone know how much documentation is necessary to be able to add on MR safety CPT codes to those exams that clinical staff vetted for implanted/foreign body identification? 

This link says the Zoom webinar does not exist.  Are you able to see it on your end?

Hi Jessica!

I listened to a webinar hosted by RCCSI and it has really good information around the new safety codes and the RCCB Winter 2024 Newsletter has some good info too.

On-demand: https://zoom.us/rec/share/eJKsHtR3FlFZ1cCAu7IAE2JqcyQ6DzZg32UDy3cLgoiYTlTwpFtg-2bZ5ikHQgK4.maTti7ijswq3pEak?startTime=1734454809000

Does anyone know how much documentation is necessary to be able to add on MR safety CPT codes to those exams that clinical staff vetted for implanted/foreign body identification? 

This link says the Zoom webinar does not exist.  Are you able to see it on your end?

Hi Jessica!

I listened to a webinar hosted by RCCSI and it has really good information around the new safety codes and the RCCB Winter 2024 Newsletter has some good info too.

On-demand: https://zoom.us/rec/share/eJKsHtR3FlFZ1cCAu7IAE2JqcyQ6DzZg32UDy3cLgoiYTlTwpFtg-2bZ5ikHQgK4.maTti7ijswq3pEak?startTime=1734454809000

Does anyone know how much documentation is necessary to be able to add on MR safety CPT codes to those exams that clinical staff vetted for implanted/foreign body identification? 

This link says the Zoom webinar does not exist.  Are you able to see it on your end?

Hi Jessica!

I listened to a webinar hosted by RCCSI and it has really good information around the new safety codes and the RCCB Winter 2024 Newsletter has some good info too.

On-demand: https://zoom.us/rec/share/eJKsHtR3FlFZ1cCAu7IAE2JqcyQ6DzZg32UDy3cLgoiYTlTwpFtg-2bZ5ikHQgK4.maTti7ijswq3pEak?startTime=1734454809000

Does anyone know how much documentation is necessary to be able to add on MR safety CPT codes to those exams that clinical staff vetted for implanted/foreign body identification? 

This link says the Zoom webinar does not exist.  Are you able to see it on your end?

Hi Jessica!

I listened to a webinar hosted by RCCSI and it has really good information around the new safety codes and the RCCB Winter 2024 Newsletter has some good info too.

On-demand: https://zoom.us/rec/share/eJKsHtR3FlFZ1cCAu7IAE2JqcyQ6DzZg32UDy3cLgoiYTlTwpFtg-2bZ5ikHQgK4.maTti7ijswq3pEak?startTime=1734454809000

Does anyone know how much documentation is necessary to be able to add on MR safety CPT codes to those exams that clinical staff vetted for implanted/foreign body identification? 

Does anyone know how much documentation is necessary to be able to add on MR safety CPT codes to those exams that clinical staff vetted for implanted/foreign body identification? 

Hi Jessica,

This is a very popular topic right now, and I am happy to share what I know and have been sharing with radiologists and groups in our industry. Properly documenting and billing MR safety codes 76014 and 76015 is essential to ensure compliance and accurate reimbursement. Remember, 76014-76015 are technical component (TC) codes reported by the facility, not individual practitioners. Below are key points to consider:

Minimum Documentation Requirements:

1. Time Spent (Critical for Time-Based Codes):
• CPT 76014: Document at least 7.5 minutes of time spent researching and verifying device safety to meet the "rule of half" for this 15-minute code.
• CPT 76015: Document time in 30-minute increments for any additional research beyond the initial 15 minutes.
2. Tasks Performed:
• Clearly outline all tasks performed by the clinical staff or MRI safety officer to verify the safety status of the implanted device or foreign body. This may include:
• Reviewing the patient's medical record and screening form.
• Researching manufacturer guidelines or product specifications online.
• Contacting manufacturers (if applicable).
• Consulting internal device safety databases.
3. Findings and Determination:
• Document the final safety status of the device or implant:
• MR Safe, MR Conditional, or MR Unsafe.
• Include the rationale and resources used to determine the device's status (e.g., manufacturer documentation, institutional database, or external database).
4. Written Report for the Radiologist:
• Provide a written summary of findings to the radiologist. This report should include:
• The identified device or foreign body (make, model, and any available details).
• Steps taken to verify the safety status.
• The final determination including the "risk benefit analysis" and any safety recommendations for the MR exam will be determined by the radiologist by reporting CPT 76016.
5. Technical Component (TC) Considerations:
• As CPT 76014 and 76015 are TC-only codes, ensure the following:
• These codes are billed by the facility, not by individual practitioners.
• Documentation must clearly indicate that the work was performed by technical staff employed by the facility (e.g., MRI technologist or safety officer).
• The facility retains and provides access to the written report as part of the patient's medical record.
6. What to Document:
• Date and time of work performed.
• Total time spent on research (with breakdowns if using CPT 76015 for additional time).
• Name and credentials of the facility staff performing the research.
• Resources consulted (e.g., websites, manuals, patient records).
• Specific device details (e.g., make, model, identifying numbers).
7. Billing Exclusions:
• If no significant work is required (e.g., the device is already known to be MR Safe), these codes should not be billed.

Example Documentation Entry for Facility Use:

Date: [Insert Date]
Time Spent: 32 minutes
Task Performed: Clinical staff reviewed patient screening form and identified implanted orthopedic device ([Device Name, Model Number]). Researched manufacturer's guidelines and consulted institutional database for safety confirmation. Device determined to be MR Conditional under the following parameters: [Insert Parameters]. Generated written report for radiologist review.
Performed By: [Staff Name, Credentials]
Facility: [Facility Name]

This level of documentation will ensure compliance with reporting standards and provide clear justification for the use of CPT 76014 and 76015, while recognizing that these are facility-reported technical codes.

Does anyone know how much documentation is necessary to be able to add on MR safety CPT codes to those exams that clinical staff vetted for implanted/foreign body identification? 

Hi Jessica,

This is a very popular topic right now, and I am happy to share what I know and have been sharing with radiologists and groups in our industry. Properly documenting and billing MR safety codes 76014 and 76015 is essential to ensure compliance and accurate reimbursement. Remember, 76014-76015 are technical component (TC) codes reported by the facility, not individual practitioners. Below are key points to consider:

Minimum Documentation Requirements:

1. Time Spent (Critical for Time-Based Codes):
• CPT 76014: Document at least 7.5 minutes of time spent researching and verifying device safety to meet the "rule of half" for this 15-minute code.
• CPT 76015: Document time in 30-minute increments for any additional research beyond the initial 15 minutes.
2. Tasks Performed:
• Clearly outline all tasks performed by the clinical staff or MRI safety officer to verify the safety status of the implanted device or foreign body. This may include:
• Reviewing the patient's medical record and screening form.
• Researching manufacturer guidelines or product specifications online.
• Contacting manufacturers (if applicable).
• Consulting internal device safety databases.
3. Findings and Determination:
• Document the final safety status of the device or implant:
• MR Safe, MR Conditional, or MR Unsafe.
• Include the rationale and resources used to determine the device's status (e.g., manufacturer documentation, institutional database, or external database).
4. Written Report for the Radiologist:
• Provide a written summary of findings to the radiologist. This report should include:
• The identified device or foreign body (make, model, and any available details).
• Steps taken to verify the safety status.
• The final determination including the "risk benefit analysis" and any safety recommendations for the MR exam will be determined by the radiologist by reporting CPT 76016.
5. Technical Component (TC) Considerations:
• As CPT 76014 and 76015 are TC-only codes, ensure the following:
• These codes are billed by the facility, not by individual practitioners.
• Documentation must clearly indicate that the work was performed by technical staff employed by the facility (e.g., MRI technologist or safety officer).
• The facility retains and provides access to the written report as part of the patient's medical record.
6. What to Document:
• Date and time of work performed.
• Total time spent on research (with breakdowns if using CPT 76015 for additional time).
• Name and credentials of the facility staff performing the research.
• Resources consulted (e.g., websites, manuals, patient records).
• Specific device details (e.g., make, model, identifying numbers).
7. Billing Exclusions:
• If no significant work is required (e.g., the device is already known to be MR Safe), these codes should not be billed.

Example Documentation Entry for Facility Use:

Date: [Insert Date]
Time Spent: 32 minutes
Task Performed: Clinical staff reviewed patient screening form and identified implanted orthopedic device ([Device Name, Model Number]). Researched manufacturer's guidelines and consulted institutional database for safety confirmation. Device determined to be MR Conditional under the following parameters: [Insert Parameters]. Generated written report for radiologist review.
Performed By: [Staff Name, Credentials]
Facility: [Facility Name]

This level of documentation will ensure compliance with reporting standards and provide clear justification for the use of CPT 76014 and 76015, while recognizing that these are facility-reported technical codes.

Does anyone know how much documentation is necessary to be able to add on MR safety CPT codes to those exams that clinical staff vetted for implanted/foreign body identification? 

Hi Jessica,

This is a very popular topic right now, and I am happy to share what I know and have been sharing with radiologists and groups in our industry. Properly documenting and billing MR safety codes 76014 and 76015 is essential to ensure compliance and accurate reimbursement. Remember, 76014-76015 are technical component (TC) codes reported by the facility, not individual practitioners. Below are key points to consider:

Minimum Documentation Requirements:

1. Time Spent (Critical for Time-Based Codes):
• CPT 76014: Document at least 7.5 minutes of time spent researching and verifying device safety to meet the "rule of half" for this 15-minute code.
• CPT 76015: Document time in 30-minute increments for any additional research beyond the initial 15 minutes.
2. Tasks Performed:
• Clearly outline all tasks performed by the clinical staff or MRI safety officer to verify the safety status of the implanted device or foreign body. This may include:
• Reviewing the patient's medical record and screening form.
• Researching manufacturer guidelines or product specifications online.
• Contacting manufacturers (if applicable).
• Consulting internal device safety databases.
3. Findings and Determination:
• Document the final safety status of the device or implant:
• MR Safe, MR Conditional, or MR Unsafe.
• Include the rationale and resources used to determine the device's status (e.g., manufacturer documentation, institutional database, or external database).
4. Written Report for the Radiologist:
• Provide a written summary of findings to the radiologist. This report should include:
• The identified device or foreign body (make, model, and any available details).
• Steps taken to verify the safety status.
• The final determination including the "risk benefit analysis" and any safety recommendations for the MR exam will be determined by the radiologist by reporting CPT 76016.
5. Technical Component (TC) Considerations:
• As CPT 76014 and 76015 are TC-only codes, ensure the following:
• These codes are billed by the facility, not by individual practitioners.
• Documentation must clearly indicate that the work was performed by technical staff employed by the facility (e.g., MRI technologist or safety officer).
• The facility retains and provides access to the written report as part of the patient's medical record.
6. What to Document:
• Date and time of work performed.
• Total time spent on research (with breakdowns if using CPT 76015 for additional time).
• Name and credentials of the facility staff performing the research.
• Resources consulted (e.g., websites, manuals, patient records).
• Specific device details (e.g., make, model, identifying numbers).
7. Billing Exclusions:
• If no significant work is required (e.g., the device is already known to be MR Safe), these codes should not be billed.

Example Documentation Entry for Facility Use:

Date: [Insert Date]
Time Spent: 32 minutes
Task Performed: Clinical staff reviewed patient screening form and identified implanted orthopedic device ([Device Name, Model Number]). Researched manufacturer's guidelines and consulted institutional database for safety confirmation. Device determined to be MR Conditional under the following parameters: [Insert Parameters]. Generated written report for radiologist review.
Performed By: [Staff Name, Credentials]
Facility: [Facility Name]

This level of documentation will ensure compliance with reporting standards and provide clear justification for the use of CPT 76014 and 76015, while recognizing that these are facility-reported technical codes.

Does anyone know how much documentation is necessary to be able to add on MR safety CPT codes to those exams that clinical staff vetted for implanted/foreign body identification? 

Does anyone know how much documentation is necessary to be able to add on MR safety CPT codes to those exams that clinical staff vetted for implanted/foreign body identification? 

This is a very popular topic right now, and I am happy to share what I know and have been sharing with radiologists and groups in our industry. Properly documenting and billing MR safety codes 76014 and 76015 is essential to ensure compliance and accurate reimbursement. Remember, 76014-76015 are technical component (TC) codes reported by the facility, not individual practitioners. Below are key points to consider:

Minimum Documentation Requirements:

1. Time Spent (Critical for Time-Based Codes):
• CPT 76014: Document at least 7.5 minutes of time spent researching and verifying device safety to meet the "rule of half" for this 15-minute code.
• CPT 76015: Document time in 30-minute increments for any additional research beyond the initial 15 minutes.
2. Tasks Performed:
• Clearly outline all tasks performed by the clinical staff or MRI safety officer to verify the safety status of the implanted device or foreign body. This may include:
• Reviewing the patient's medical record and screening form.
• Researching manufacturer guidelines or product specifications online.
• Contacting manufacturers (if applicable).
• Consulting internal device safety databases.
3. Findings and Determination:
• Document the final safety status of the device or implant:
• MR Safe, MR Conditional, or MR Unsafe.
• Include the rationale and resources used to determine the device's status (e.g., manufacturer documentation, institutional database, or external database).
4. Written Report for the Radiologist:
• Provide a written summary of findings to the radiologist. This report should include:
• The identified device or foreign body (make, model, and any available details).
• Steps taken to verify the safety status.
• The final determination including the "risk benefit analysis" and any safety recommendations for the MR exam will be determined by the radiologist by reporting CPT 76016.
5. Technical Component (TC) Considerations:
• As CPT 76014 and 76015 are TC-only codes, ensure the following:
• These codes are billed by the facility, not by individual practitioners.
• Documentation must clearly indicate that the work was performed by technical staff employed by the facility (e.g., MRI technologist or safety officer).
• The facility retains and provides access to the written report as part of the patient's medical record.
6. What to Document:
• Date and time of work performed.
• Total time spent on research (with breakdowns if using CPT 76015 for additional time).
• Name and credentials of the facility staff performing the research.
• Resources consulted (e.g., websites, manuals, patient records).
• Specific device details (e.g., make, model, identifying numbers).
7. Billing Exclusions:
• If no significant work is required (e.g., the device is already known to be MR Safe), these codes should not be billed.

Example Documentation Entry for Facility Use:

Date: [Insert Date]
Time Spent: 32 minutes
Task Performed: Clinical staff reviewed patient screening form and identified implanted orthopedic device ([Device Name, Model Number]). Researched manufacturer's guidelines and consulted institutional database for safety confirmation. Device determined to be MR Conditional under the following parameters: [Insert Parameters]. Generated written report for radiologist review.
Performed By: [Staff Name, Credentials]
Facility: [Facility Name]

This level of documentation will ensure compliance with reporting standards and provide clear justification for the use of CPT 76014 and 76015, while recognizing that these are facility-reported technical codes.

Does anyone know how much documentation is necessary to be able to add on MR safety CPT codes to those exams that clinical staff vetted for implanted/foreign body identification? 

Hi,

We have been working on a somewhat manual process to capture the information needed to bill this, thanks for all the insight.  Does anyone know or have a suggestion on the how to bill this?  Since it doesn't require a doctor to bill who is the rendering and ordering provider?  What gets included on the bill for a diagnosis?

Thanks,

George

This is a very popular topic right now, and I am happy to share what I know and have been sharing with radiologists and groups in our industry. Properly documenting and billing MR safety codes 76014 and 76015 is essential to ensure compliance and accurate reimbursement. Remember, 76014-76015 are technical component (TC) codes reported by the facility, not individual practitioners. Below are key points to consider:

Minimum Documentation Requirements:

1. Time Spent (Critical for Time-Based Codes):
• CPT 76014: Document at least 7.5 minutes of time spent researching and verifying device safety to meet the "rule of half" for this 15-minute code.
• CPT 76015: Document time in 30-minute increments for any additional research beyond the initial 15 minutes.
2. Tasks Performed:
• Clearly outline all tasks performed by the clinical staff or MRI safety officer to verify the safety status of the implanted device or foreign body. This may include:
• Reviewing the patient's medical record and screening form.
• Researching manufacturer guidelines or product specifications online.
• Contacting manufacturers (if applicable).
• Consulting internal device safety databases.
3. Findings and Determination:
• Document the final safety status of the device or implant:
• MR Safe, MR Conditional, or MR Unsafe.
• Include the rationale and resources used to determine the device's status (e.g., manufacturer documentation, institutional database, or external database).
4. Written Report for the Radiologist:
• Provide a written summary of findings to the radiologist. This report should include:
• The identified device or foreign body (make, model, and any available details).
• Steps taken to verify the safety status.
• The final determination including the "risk benefit analysis" and any safety recommendations for the MR exam will be determined by the radiologist by reporting CPT 76016.
5. Technical Component (TC) Considerations:
• As CPT 76014 and 76015 are TC-only codes, ensure the following:
• These codes are billed by the facility, not by individual practitioners.
• Documentation must clearly indicate that the work was performed by technical staff employed by the facility (e.g., MRI technologist or safety officer).
• The facility retains and provides access to the written report as part of the patient's medical record.
6. What to Document:
• Date and time of work performed.
• Total time spent on research (with breakdowns if using CPT 76015 for additional time).
• Name and credentials of the facility staff performing the research.
• Resources consulted (e.g., websites, manuals, patient records).
• Specific device details (e.g., make, model, identifying numbers).
7. Billing Exclusions:
• If no significant work is required (e.g., the device is already known to be MR Safe), these codes should not be billed.

Example Documentation Entry for Facility Use:

Date: [Insert Date]
Time Spent: 32 minutes
Task Performed: Clinical staff reviewed patient screening form and identified implanted orthopedic device ([Device Name, Model Number]). Researched manufacturer's guidelines and consulted institutional database for safety confirmation. Device determined to be MR Conditional under the following parameters: [Insert Parameters]. Generated written report for radiologist review.
Performed By: [Staff Name, Credentials]
Facility: [Facility Name]

This level of documentation will ensure compliance with reporting standards and provide clear justification for the use of CPT 76014 and 76015, while recognizing that these are facility-reported technical codes.

Does anyone know how much documentation is necessary to be able to add on MR safety CPT codes to those exams that clinical staff vetted for implanted/foreign body identification? 

Hi George,

When billing for CPT codes 76014-76015, which are time-based codes and technical component (TC) only, the process is slightly different since these services do not involve a physician's professional interpretation at the point of service. Here's a breakdown of the billing process:

1. Facility as the Billing Entity

• For technical-only charges, such as those involving the use of equipment, supplies, and technical staff, the facility is considered the billing entity.
• These services are typically billed under the facility's Tax Identification Number (TIN) and National Provider Identifier (NPI) number.

2. No Rendering Physician Required

• For technical component (TC) services, a rendering physician is not required because the service does not include the professional interpretation component.
• The claim does not need to include a rendering physician's NPI. Instead, you include the ordering provider's NPI on the claim, which refers to the physician or other qualified healthcare professional who requested the service.

3. Ordering Provider's Role

• The ordering provider is responsible for initiating the request for the diagnostic test. Their name and NPI must be included on the claim as the referring/ordering provider.
• Ensure the documentation supports that the test was ordered and why it was necessary (the diagnosis or clinical indication).

4. Diagnosis Code Requirements

• The diagnosis code included on the claim should reflect the reason for the test, as indicated by the ordering provider. This ensures medical necessity is established.

5. Modifier Use

• If the procedure code is inherently a technical component (e.g., codes like 76014 or 76015), it is not necessary to append a TC modifier unless required by the payer.
• For global codes, you would append the TC modifier to indicate that only the technical portion is being billed.

6. Payer-Specific Requirements

• Check with the payer regarding specific billing rules. While most payers do not require a rendering provider for technical-only services, it's a good practice to verify their guidelines.

Example Claim Details for a Technical-Only Charge:

• Billing Entity: Facility's name, TIN, and NPI.
• Ordering Provider: Name and NPI of the physician who requested the test.
• Diagnosis Code: Based on the clinical indication for the test.
• CPT Code: Procedure code (e.g., 76014-76015).
• Modifiers (if applicable): Add a TC modifier if billing for a global code.

Hi,

We have been working on a somewhat manual process to capture the information needed to bill this, thanks for all the insight.  Does anyone know or have a suggestion on the how to bill this?  Since it doesn't require a doctor to bill who is the rendering and ordering provider?  What gets included on the bill for a diagnosis?

Thanks,

George

This is a very popular topic right now, and I am happy to share what I know and have been sharing with radiologists and groups in our industry. Properly documenting and billing MR safety codes 76014 and 76015 is essential to ensure compliance and accurate reimbursement. Remember, 76014-76015 are technical component (TC) codes reported by the facility, not individual practitioners. Below are key points to consider:

Minimum Documentation Requirements:

1. Time Spent (Critical for Time-Based Codes):
• CPT 76014: Document at least 7.5 minutes of time spent researching and verifying device safety to meet the "rule of half" for this 15-minute code.
• CPT 76015: Document time in 30-minute increments for any additional research beyond the initial 15 minutes.
2. Tasks Performed:
• Clearly outline all tasks performed by the clinical staff or MRI safety officer to verify the safety status of the implanted device or foreign body. This may include:
• Reviewing the patient's medical record and screening form.
• Researching manufacturer guidelines or product specifications online.
• Contacting manufacturers (if applicable).
• Consulting internal device safety databases.
3. Findings and Determination:
• Document the final safety status of the device or implant:
• MR Safe, MR Conditional, or MR Unsafe.
• Include the rationale and resources used to determine the device's status (e.g., manufacturer documentation, institutional database, or external database).
4. Written Report for the Radiologist:
• Provide a written summary of findings to the radiologist. This report should include:
• The identified device or foreign body (make, model, and any available details).
• Steps taken to verify the safety status.
• The final determination including the "risk benefit analysis" and any safety recommendations for the MR exam will be determined by the radiologist by reporting CPT 76016.
5. Technical Component (TC) Considerations:
• As CPT 76014 and 76015 are TC-only codes, ensure the following:
• These codes are billed by the facility, not by individual practitioners.
• Documentation must clearly indicate that the work was performed by technical staff employed by the facility (e.g., MRI technologist or safety officer).
• The facility retains and provides access to the written report as part of the patient's medical record.
6. What to Document:
• Date and time of work performed.
• Total time spent on research (with breakdowns if using CPT 76015 for additional time).
• Name and credentials of the facility staff performing the research.
• Resources consulted (e.g., websites, manuals, patient records).
• Specific device details (e.g., make, model, identifying numbers).
7. Billing Exclusions:
• If no significant work is required (e.g., the device is already known to be MR Safe), these codes should not be billed.

Example Documentation Entry for Facility Use:

Date: [Insert Date]
Time Spent: 32 minutes
Task Performed: Clinical staff reviewed patient screening form and identified implanted orthopedic device ([Device Name, Model Number]). Researched manufacturer's guidelines and consulted institutional database for safety confirmation. Device determined to be MR Conditional under the following parameters: [Insert Parameters]. Generated written report for radiologist review.
Performed By: [Staff Name, Credentials]
Facility: [Facility Name]

This level of documentation will ensure compliance with reporting standards and provide clear justification for the use of CPT 76014 and 76015, while recognizing that these are facility-reported technical codes.

Does anyone know how much documentation is necessary to be able to add on MR safety CPT codes to those exams that clinical staff vetted for implanted/foreign body identification? 

Hi George,

When billing for CPT codes 76014-76015, which are time-based codes and technical component (TC) only, the process is slightly different since these services do not involve a physician's professional interpretation at the point of service. Here's a breakdown of the billing process:

1. Facility as the Billing Entity

• For technical-only charges, such as those involving the use of equipment, supplies, and technical staff, the facility is considered the billing entity.
• These services are typically billed under the facility's Tax Identification Number (TIN) and National Provider Identifier (NPI) number.

2. No Rendering Physician Required

• For technical component (TC) services, a rendering physician is not required because the service does not include the professional interpretation component.
• The claim does not need to include a rendering physician's NPI. Instead, you include the ordering provider's NPI on the claim, which refers to the physician or other qualified healthcare professional who requested the service.

3. Ordering Provider's Role

• The ordering provider is responsible for initiating the request for the diagnostic test. Their name and NPI must be included on the claim as the referring/ordering provider.
• Ensure the documentation supports that the test was ordered and why it was necessary (the diagnosis or clinical indication).

4. Diagnosis Code Requirements

• The diagnosis code included on the claim should reflect the reason for the test, as indicated by the ordering provider. This ensures medical necessity is established.

5. Modifier Use

• If the procedure code is inherently a technical component (e.g., codes like 76014 or 76015), it is not necessary to append a TC modifier unless required by the payer.
• For global codes, you would append the TC modifier to indicate that only the technical portion is being billed.

6. Payer-Specific Requirements

• Check with the payer regarding specific billing rules. While most payers do not require a rendering provider for technical-only services, it's a good practice to verify their guidelines.

Example Claim Details for a Technical-Only Charge:

• Billing Entity: Facility's name, TIN, and NPI.
• Ordering Provider: Name and NPI of the physician who requested the test.
• Diagnosis Code: Based on the clinical indication for the test.
• CPT Code: Procedure code (e.g., 76014-76015).
• Modifiers (if applicable): Add a TC modifier if billing for a global code.

Hi,

We have been working on a somewhat manual process to capture the information needed to bill this, thanks for all the insight.  Does anyone know or have a suggestion on the how to bill this?  Since it doesn't require a doctor to bill who is the rendering and ordering provider?  What gets included on the bill for a diagnosis?

Thanks,

George

This is a very popular topic right now, and I am happy to share what I know and have been sharing with radiologists and groups in our industry. Properly documenting and billing MR safety codes 76014 and 76015 is essential to ensure compliance and accurate reimbursement. Remember, 76014-76015 are technical component (TC) codes reported by the facility, not individual practitioners. Below are key points to consider:

Minimum Documentation Requirements:

1. Time Spent (Critical for Time-Based Codes):
• CPT 76014: Document at least 7.5 minutes of time spent researching and verifying device safety to meet the "rule of half" for this 15-minute code.
• CPT 76015: Document time in 30-minute increments for any additional research beyond the initial 15 minutes.
2. Tasks Performed:
• Clearly outline all tasks performed by the clinical staff or MRI safety officer to verify the safety status of the implanted device or foreign body. This may include:
• Reviewing the patient's medical record and screening form.
• Researching manufacturer guidelines or product specifications online.
• Contacting manufacturers (if applicable).
• Consulting internal device safety databases.
3. Findings and Determination:
• Document the final safety status of the device or implant:
• MR Safe, MR Conditional, or MR Unsafe.
• Include the rationale and resources used to determine the device's status (e.g., manufacturer documentation, institutional database, or external database).
4. Written Report for the Radiologist:
• Provide a written summary of findings to the radiologist. This report should include:
• The identified device or foreign body (make, model, and any available details).
• Steps taken to verify the safety status.
• The final determination including the "risk benefit analysis" and any safety recommendations for the MR exam will be determined by the radiologist by reporting CPT 76016.
5. Technical Component (TC) Considerations:
• As CPT 76014 and 76015 are TC-only codes, ensure the following:
• These codes are billed by the facility, not by individual practitioners.
• Documentation must clearly indicate that the work was performed by technical staff employed by the facility (e.g., MRI technologist or safety officer).
• The facility retains and provides access to the written report as part of the patient's medical record.
6. What to Document:
• Date and time of work performed.
• Total time spent on research (with breakdowns if using CPT 76015 for additional time).
• Name and credentials of the facility staff performing the research.
• Resources consulted (e.g., websites, manuals, patient records).
• Specific device details (e.g., make, model, identifying numbers).
7. Billing Exclusions:
• If no significant work is required (e.g., the device is already known to be MR Safe), these codes should not be billed.

Example Documentation Entry for Facility Use:

Date: [Insert Date]
Time Spent: 32 minutes
Task Performed: Clinical staff reviewed patient screening form and identified implanted orthopedic device ([Device Name, Model Number]). Researched manufacturer's guidelines and consulted institutional database for safety confirmation. Device determined to be MR Conditional under the following parameters: [Insert Parameters]. Generated written report for radiologist review.
Performed By: [Staff Name, Credentials]
Facility: [Facility Name]

This level of documentation will ensure compliance with reporting standards and provide clear justification for the use of CPT 76014 and 76015, while recognizing that these are facility-reported technical codes.

Does anyone know how much documentation is necessary to be able to add on MR safety CPT codes to those exams that clinical staff vetted for implanted/foreign body identification? 

Does anyone know how much documentation is necessary to be able to add on MR safety CPT codes to those exams that clinical staff vetted for implanted/foreign body identification? 

Does anyone know how much documentation is necessary to be able to add on MR safety CPT codes to those exams that clinical staff vetted for implanted/foreign body identification? 

Hi Jessica, 

Attached is a matrix for the MR Safety codes. CMS and the AMA should be publishing clarifying information on some of the issues with these new codes as stated in the narrative attachment. For a list and details of the new 2025 codes, see the following link.

2025 CPT Changes for Radiology, Interventional & Cardiology Specialists - StreamlineMD

Does anyone know how much documentation is necessary to be able to add on MR safety CPT codes to those exams that clinical staff vetted for implanted/foreign body identification?