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By: Teri Bedard, RT(R)(T), CPC
New MR Safety Codes For 2025The 2025 CPT® code set includes six new codes representing MR safety services. The new codes portray safety services that are beyond the standard safety screening performed for all patients receiving an MR examination, which are not reported separately. In addition, not all patients with a medical device or foreign body will need the safety services represented by the new code set. For example, if a patient has a medical device known to be MR-safe and requires no modifications to the exam, the safety services represented by the new code set are not needed.
As stated in the 2025 CPT® Manual: “Implants may have FDA-approved labeling specifying conditions under which an MR examination could be safely performed. These conditions can specify the type of MR equipment to use, preparation of the implant before the MR procedure, anatomical regions that should be excluded from the MR examination, limitations on MR scan time and energy deposition, and/or implant components that may contraindicate MR examination.” If a device that lacks conditional labeling is researched and determined to be “MR Safe,” it poses no safety hazard in the MR environment and requires no modifications to the MR examination. Those safety findings are documented in the patient’s medical record. If the patient is later seen for a subsequent MR examination, repeat safety services (clinical staff research) are not required or reported as the previous safety service findings are accessible in the medical record. A device determined to be “MR Conditional” indicates that it is safe only under certain MR conditions and the MR examination may need to be modified to accommodate those conditions. If a device is determined to be “MR Unsafe,” it poses an unacceptable risk in the MR environment and should never be brought near an MR machine. Also important to understanding the new MR safety services code set is the concept of “technical component” and “professional component” as well as the difference in physicians and clinical staff. The “technical component” of a service represents any work completed by clinical staff (e.g. MR Safety Officer, MR Technologist, Medical Physicist, Nurse, etc.), while the “professional component” represents the work performed by the Physician or other Qualified Healthcare Professional (QHP).
Reporting Multiple MR Safety ServicesThere may be instances where more than one MR safety service is needed to ensure patient safety. These codes may each be reported independently for the same MR examination. Codes 76017 – 76019 are modifier 51 exempt, which means there is no multiple service payment reduction when reporting all three codes for the same MR examination. CPT® Code Series 76014 - 76019Following is a summary of the new codes, including recommended documentation requirements as stated in the CPT® and RBRVS 2025 Annual Symposium and clinical example summaries from CPT® Changes: An Insider’s View 2025. Safety Services on Date Prior to MR Exam
Analysis and Documentation by Clinical Staff (CPT® 76014 and 76015)The first two codes in the new code set, CPT® 76014 and 76015, represent the technical component for any preparatory research performed by clinical staff. These services are performed on a date prior to the MR exam, have no physician involvement or work, and do not require a modifier. After performing the necessary research for the medical device in question, the clinical staff need to document their findings in the medical record for review by the physician and identify whether the device is MR Safe, MR Conditional, or MR Unsafe and any applicable contraindications for the MR exam. These two codes are time-based; clinical staff should include the total time spent on research in their documentation. As time-based codes, staff must meet the midpoint threshold to support billing. For example, CPT® 76014 is billed for the initial 15 minutes spent performing the analysis; if the clinical staff member spends 8 minutes, they have exceeded the midpoint threshold of time and can bill the service. If the clinical staff only spends 7 minutes, it is not billable as they did not cross the midpoint threshold time requirement. Add-on CPT® code 76015 represents each additional 30 minutes of research; therefore, a minimum of 16 minutes of research must be performed in order to report the service in addition to CPT® 76014. CPT® 76015 can be reported a maximum of three times per encounter. The AMA provides the following clinical example: “Clinical Example Summary: An MRI of the lumbar spine is ordered for a patient with a neurostimulator. The medical record does not include model information for the implanted leads. Certain lead models have anatomical exclusion zones over the implant. MR conditions for the implant are dependent on the lead model; therefore, clinical staff must use appropriate sources, such as a patient screening form, surgical reports, or review of prior imaging and various databases, in order to determine MR conditional status of the implanted leads. This information is documented in the patient’s medical record to be accessed by the Radiologist and/or MRSO. Documentation should indicate the leads as either MR safe, MR conditional, or MR unsafe.” Analysis and Documentation by Physician or QHP (CPT® 76016)CPT® 76016 represents work on a date prior to the MR exam but is performed by the physician or other qualified health care professional (QHP). In emergent situations, this may be performed on the day of the MR exam. The physician or QHP must document the findings and analysis in a formal written report. This code is intended for situations where an implant and/or foreign body lacks MR conditional labeling, is contraindicated for MR, or may result in a limited MR examination based upon the performance of an MR safety determination by a physician or other QHP responsible for the safe performance of the MR procedure. If the device or implant is known to be MR safe or if the MR conditional labeling is clear or not relevant, a risk benefit analysis is not needed as they do not present a limitation to the performance of the MR exam. The physician should assess proximity of the implanted device/foreign body to sensitive tissues and evaluate the clinical risk to the patient if device malfunction, thermal injury, or displacement forces are induced by the MR exam procedure. The MR exam parameters are reviewed for conformance with implanted device safety instructions, and if not, decide whether informed consent should be obtained prior to the MR exam. Alternative diagnostic tests are considered for appropriateness and relative risk. The report should address the issues related to the implanted device and the MR exam. If the device is determined to be “MR Conditional”, a risk benefit analysis by a physician or other QHP responsible for the safe performance of the MR exam should be included. If it is determined that the MR exam can be conducted, additional documentation should address what needs to be scanned, the specific sequences, if the risks outweigh the benefits, and if there is any special MR equipment or expertise needed to carry out the exam. The AMA provides the following clinical example: “Clinical Example Summary: A pacemaker lacks MR conditional labeling and programming modes. A physician or other QHP performs a risk benefit analysis, including review of MR safety parameters for conformance with implanted-device safety instructions. If MR safety parameters do not conform with the implanted-device safety instructions, the physician or other QHP will consider alternative diagnostic tests for appropriateness and risk, and make recommendations for alternative tests, procedures, or MR requirements.” In the event the MR exam is cancelled based on the findings of the MR safety review and analysis, the services related to the analysis can be billed. Safety Services on Date of the MR Exam
Analysis and Documentation by Physician or QHP (CPT® 76017 - 76019)Some devices may require MR safety exam customization in real-time as the MR examination is performed. The staff performing this work would likely be the medical physicist or MR safety expert, (under supervision of the physician or other QHP for CPT® 76017 or qualified clinical staff for CPT® 76018 and 76019). Physician supervision and physician work should be evident in the documentation pertaining to each of these codes. The reports for CPT® 76017 and 76018 should address any MR safety exam customization or changes made in real-time on the date of the MR exam. Report documentation on how the examination was customized and modified for specific patient circumstances should include a review of exam indications, analysis and any adjustment of the MR scanning protocols based on specific patient parameters and imaging requirements, and monitoring of the performance of the MR exam itself in real time. Additionally, the documentation for CPT® code 76018 should address the programming performed to put the device into safe mode, or other appropriate programming, while the patient is in the MR suite and prior to the examination. If the device was put in safe mode in a separate office, i.e., outside of the MR suite in the neurologist or cardiologist's office, CPT® 76018 is not separately billable. Documentation should also address that the device was returned to normal mode following the scan, as appropriate, and signed. The AMA provides the following clinical example for CPT® code 76017: “Clinical Example Summary: An MRI is ordered for a patient presenting with new seizures and weakness. The patient has a deep brain stimulator (DBS) for Parkinson disease. The DBS has MR conditions restricting scan time and energy deposition. MR conditions of the DBS, including scanner idle times to allow for device cooling, are met by a Medical Physicist who customizes and monitors the performance of the MR exam interactively. The Medical Physicist performs these services under the supervision of a Radiologist who reviews MR images and provides feedback to the Medical Physicist in real time to determine if any scan parameter adjustments or additional views are needed. The Radiologist considers cutting additional views from protocol in order to avoid exceeding any total scan time restrictions of the DBS. Any limitations to the MR examination that are related to the DBS system affecting the diagnostic quality and interpretation of the MR examination should be documented in a written report.” The AMA provides the following clinical example for CPT® code 76018: “Clinical Example Summary: A patient with a DBS has their device modified into an MR safe mode in the MR suite prior to the exam. The device programming is performed in a safe area away from the scanner, where the patient also gets their IV started before the MR examination begins. After the MR examination is completed, the device is turned back on in a safe area, where the patient also changes their clothes.” Some devices or implants may have the potential to migrate when exposed to the MR environment. There are manufacturer instructions on properly immobilizing the patient to keep the device from moving. For example, a patient with a cochlear implant, which uses an internal magnet that can only be removed with surgical intervention, may require a compression headwrap to mitigate the risk of the implant moving during the MR examination. Because there is a risk to the patient by exposing them to the MR environment, this service requires an informed consent discussion with the patient prior to the MR examination. CPT® 76019 represents the immobilization or positioning of a device for a safer MR exam. Report documentation should include the specific device and potential to migrate, any manufacturer instructions to immobilize the device, risk to the patient and device by placing them in the MR field, and informed consent discussion with the patient before the exam. The AMA provides the following clinical example for CPT® code 76019: “Clinical Example Summary: An MRI of the brain is ordered for a patient with an auditory brainstem implant (ABI). The ABI has MR conditions for an internal magnet, which require the application of a head wrap to immobilize and secure the device. Because there is a risk to the patient and to the ABI when entering the MR field, this service requires a discussion with the patient prior to the start of the MR examination. Informed consent must be obtained from the patient before proceeding with the MR examination. Ensure Compliance & Optimize MR Workflows in 2025
With these updates, ensuring compliance and accurate documentation is more important than ever. At RCCS, we’re here to help with: - Educational Resources 🠮 Equip your team with our 2025 Navigator® Coding Guides designed to simplify the integration of new codes and ensure accuracy. - Training and Consulting Services 🠮 Let us review your current coding and documentation practices, identify gaps, and train your providers to use these codes confidently and effectively. Don’t let these changes overwhelm your team—partner with RCCS to navigate 2025 with ease. Explore Our Resources and contact us to learn more about our customized training solutions. Disclaimer: CPT® codes and descriptions are copyrighted 1995-2004 by the American Medical Association (AMA). All rights reserved.
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