Ask Dr. Z

We are performing the following MRI for a cervicomedullary imaging protocol. Based on the order, instructions to the tech, and findings, would CPT 70553 be the only code we would report? We can image all the way to C7/T1 depending on the tumor.

Order: MR Brain w & wo

Instructions for tech: Precontrast Cervicomedullary - 3 PLANE LOC, SAG 3D T1 MPRAGE, TRAN rDWI, SAG T2 TSE. Cervicomedullary Coverage- All transverse imaging (including rDWI) have the same placement, If tumor extends past C7, tech will increase slices and/or FoV to include entire tumor. Postcontrast Cervicomedullary- TRAN T2 TSE, TRAN T2 FLAIR, SAG 3D T1 MPRAGE, SAG T1 SPACE

Findings: Persistent T2 & T2 FLAIR hyperintense non-enhancing expansile intra-axial mass centered upon the R paracentral medulla. The superior margin of the mass is at the R pontomedullary junction, with inferior extension into the cervical cord to the level of C3-C4. Stable mass effect upon the R lat aspect of 4th ventricle.

Impression: Stable intra-axial lesion of the brainstem & upper cervical cord, asymmetric to the R.