CPT Code 70553: Magnetic Resonance Imaging of the Brain and Brain Stem, Without and With Contrast

What is CPT code 70553?

CPT code 70553 refers to a comprehensive magnetic resonance imaging (MRI) examination of the brain and brain stem, performed both without contrast (w/o contrast) and subsequently with contrast material. This specialized imaging technique provides healthcare providers with highly detailed images, essential for evaluating various neurological conditions such as brain tumors, infections, vascular abnormalities, degenerative joint diseases affecting the cervical spine, multiple sclerosis, seizures, and inflammatory processes. Typically performed by radiologists in collaboration with neurologists or neurosurgeons, the MRI scan, specifically focused on brain structures, helps to establish accurate diagnoses, monitor disease progression, and plan effective treatment strategies. The American Medical Association maintains this and other MRI CPT codes to ensure standardized reporting.

What is a brain MRI without and with contrast?

A brain MRI, both without and with contrast, is a specialized imaging technique that produces highly detailed images of the brain's structures. Initially, the MRI exam captures images without contrast, followed by the administration of contrast material to enhance the visibility of abnormalities or lesions. This comprehensive MRI scan is typically performed to detect tumors, multiple sclerosis lesions, infections, or vascular issues, providing crucial diagnostic insights.

CPT code 70553 documentation requirements

Proper documentation is essential for correct coding, reimbursement, and clinical accuracy. Required documentation includes:

Clinical indication

Clearly document the medical reason for the MRI brain exam, such as headache, seizure, suspicion of multiple sclerosis, or detection and characterization of brain tumors.

MRI sequences acquired

List all MRI sequences performed, such as T1, T2, FLAIR, diffusion-weighted imaging (DWI), and specifically confirm that both pre-contrast and post-contrast sequences were captured.

Contrast material details

Specify the type and exact volume of contrast material administered, documenting any patient reactions or tolerance issues clearly.

Radiologist’s findings and interpretation

Provide a detailed report of findings and the radiologist’s final impression, outlining abnormalities or significant clinical observations identified in the MRI examination.

Image storage

Confirm in the documentation that all MRI images are retained, stored, and linked to the patient's medical record in a secure Picture Archiving and Communication System (PACS).

CPT code 70553 billing guidelines

Following accurate billing practices ensures compliance and appropriate reimbursement:

Do not report separately with 70551 or 70552

CPT 70553 already includes both MRI procedures (without and with contrast), and separate reporting of codes 70551 (MRI brain without contrast) or 70552 (MRI brain with contrast only) is inappropriate.

Contrast administration included

Contrast material and its administration are inherently included in CPT 70553 and cannot be billed separately.

Frequency of billing

Generally, CPT 70553 is billable once per patient per day unless a separate medical necessity justifies a repeat or additional MRI exam.

Authorization verification

Always verify payer-specific authorization requirements, especially for repeat studies or conditions that require specialized care.

List of modifiers for CPT code 70553

• Modifier 26 – Professional component: Use when billing only the professional interpretation by a physician or radiologist.
• Modifier TC – Technical component: Apply when billing only the technical aspect, such as use of MRI equipment and technician services.
• Modifier 59 – Distinct procedural service: Indicate if the MRI is distinct from another procedure performed the same day, typically involving different anatomical areas.
• Modifier 76 – Repeat procedure by the same physician: Report when the same physician repeats the MRI exam on the same day.
• Modifier 77 – Repeat procedure by another physician: Use if a different physician repeats the MRI exam on the same day.
• Modifier 91 – Repeat clinical diagnostic test: Applicable for repeat MRIs performed for clinical reasons, excluding equipment issues.
• Modifier 52 – Reduced services: Apply if the MRI scan was intentionally limited or partially reduced.
• Modifier 53 – Discontinued procedure: Use when the MRI procedure started but was discontinued due to patient safety or other concerns.
• Modifier 22 – Increased procedural services: Report if the MRI required significantly more time or effort than typical, reflecting increased complexity.
• Modifier 99 – Multiple modifiers: Indicate multiple modifiers are necessary for accurate description.

Other relevant CPT codes

• 70551 – MRI brain without contrast
• 70552 – MRI brain with contrast only
• 77021 – MRI guidance for biopsy (separate procedure)
• 77046–77049 – Breast MRI for evaluating breast abnormalities
• 73221–73223 – MRI upper extremity (for shoulder, elbow, or wrist evaluations)