CPT code 72141: MRI cervical spine without contrast

What is CPT code 72141?

CPT code 72141 is used to report a magnetic resonance imaging (MRI) scan of the cervical spinal canal and surrounding structures without the use of contrast material. This non-invasive imaging procedure provides detailed visualization of the vertebrae, spinal cord, discs, soft tissues, and nerve roots in the neck region.

A provider typically orders 72141 CPT code to evaluate conditions such as herniated discs, spinal stenosis, tumors, infections, or neurological symptoms like numbness, tingling, or weakness. The procedure may be performed at a hospital, an outpatient imaging center, or another facility setting.

Unlike other MRI codes that involve contrast, no contrast dye is injected when billing 72141. A different code (e.g., 72156) would apply if both non-contrast and contrast images are required.

Documentation requirements

Proper documentation is essential for billing CPT 72141 and supporting medical necessity:

• Clinical indication: Clearly document the patient's symptoms (e.g., neck pain, radiculopathy, suspected disc herniation) and why an MRI is needed.
• Order by a qualified provider: Ensure that a physician or other qualified healthcare professional has formally ordered the MRI.
• Specify without contrast: Confirm and document that the MRI is performed without contrast material.
• Procedure details: Record that the imaging covered the entire cervical spinal canal, and note any relevant findings.
• Patient information: Document the patient's name, date of service, referring provider, and imaging facility where the services were performed.

Billing guidelines

Follow these billing and coding guidelines to ensure proper reimbursement for CPT 72141:

• Contrast status: Bill 72141 only when no contrast dye is used. Use different codes if contrast is administered.
• Professional and technical components: Use modifier 26 if billing only for the professional component (interpretation). Use modifier TC if billing only for the technical component (equipment and facility). However, no modifier is needed if billing globally (both components).
• Place of service: Confirm that the correct place of service code is indicated (e.g., outpatient hospital, imaging center).
• Medical necessity: Link the MRI order to relevant ICD-10 diagnosis codes that support why imaging of the cervical spine was required.
• Authorization: Some payers, especially commercial plans, may require pre-authorization before performing MRI procedures.

Other relevant CPT codes

• 72142: MRI cervical spine with contrast material
• 72156: MRI cervical spine without and with contrast material
• 72146: MRI thoracic spine without contrast
• 72148: MRI lumbar spine without contrast