National Imaging Associates, Inc. Clinical guidelines LOWER EXTREMTIY JOINT MRI UPPER EXTREMITY JOINT MRI TMJ CPT4 Codes: TMJ – 70336 Upper Extremity Joint MRI – 73221, 73222, 73223 Lower Extremity Joint MRI – 73721, 73722, 73723 LCD ID Number: L31750 J – 11 (NC, SC, VA, WV) Responsible Department: Clinical Operations

Original Date: March 2011 Page 1 of 16 “FOR CMS (MEDICARE) MEMBERS ONLY” Last Effective Date: October 2014

Last Revised Date: Implementation Date: February 2015

“FOR CMS (MEDICARE) MEMBERS ONLY” Coverage Indications, Limitations, and/or Medical Necessity Diagnostic examinations of joint(s) performed on Magnetic Resonance Imaging (MRI) units are covered if they are:  Reasonable and medically necessary for the individual patient.  Performed on a unit that has received Food and Drug Administration (FDA) approval. Such a unit(s) must be operated within the parameters specified by that approval.  Compliant with American College of Radiology (ACR) quality standards. Note: Refer to the guidelines listed below for office-based MRI. Office-Based MRI In order to maintain appropriate quality in office-based MRI, the ACR MRI Accreditation Program Requirements (http://www.acr.org/accreditation/mri/documents/mri_reqs.pdf) serve as a pertinent performance benchmark, and, using such as a reference document, it is intended that the following guidelines be followed with respect to: Staff Competency A provider who performs the interpretation and written report of an MRI of a joint (professional component) must possess the knowledge, skills, training and experience minimally necessary for this component of the service. Medicare coverage of these services is conditional on the competence of the individual who performs and interprets the service. Medicare expects that any provider who seeks and receives payment for the professional components of these radiographic services will be prepared to substantiate his training and/or experience if asked by Medicare to do so. Numerous pathways for achieving and maintaining competency for providing these services by physicians and technologists exist.

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The qualified physician’s continuing education should be in accordance with the ACR Practice Guideline for Continuing Medical Education (CME) OR should include CME in MRI as is appropriate to the physician’s practice needs. Technologists practicing MRI scanning should be licensed in the jurisdiction in which he practices, if state licensure for MRI technologists exists. The continuing education for a technologist should be 15 hours of Category A CME in MRI every three years. An MRI of a joint may be personally performed by a physician or a technologist. When performed by a technologist, one of the following standards must be met:  

Facility must be accredited for MRI by the American College of Radiology (ACR) For testing performed in non-ACR accredited office facilities, the technologist must have received credentials in MRI technology as a Certified Radiologic Technologist (CRT) from the American Registry of Radiologic Technologists (ARRT).

Quality Control and Quality Assurance There should be a well-documented office protocol for performing continuous quality control testing of instrumentation, in tandem with periodic preventive maintenance, which is also properly documented in service records maintained by the MRI site. In addition, appropriately documented physician peer-review activities should be an integral portion of the staff competency guidelines discussed above. The choice of the appropriate imaging modality should be determined at an individual level. In some cases, MRI may be an appropriate initial choice; in others, standard X-rays should be used for the initial evaluation. Generally, MRI of a joint is considered medically necessary when the following disorders are present or suspected and/or the necessary information is not available from standard X-rays. Joint MRIs are indicated for the following clinical conditions:              

Tumors/masses or swelling involving or contiguous to a joint. Rotator cuff tears or impingement. Joint instability, deformities or internal derangement. Intra-articular osteocartilaginous body(ies). Occult joint injury, e.g., osteochondral injury. Suspected nerve entrapment or mass close to a joint. Suspected ligament or tendon injury. Kienböck’s Disease of the wrist. Bone abnormalities of a joint related to soft tissue abnormalities. Occult Avascular Necrosis (AVN) or follow-up of this condition. Acute joint injuries. Actual or suspected infection or inflammation on joints or surrounding structures. Effect of other single or multiple system, non-joint disorders on joints and surrounding structures. Pain/other sensory disturbances in joints or surrounding structures.

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     

Weakness/other motor disturbances in joints or surrounding structures. Decreased range of motion; stiffness, popping/clicking, instability or discoordination related to joints and surrounding structures. Characterization of an abnormal finding in joints or surrounding structures detected on another test. Meniscal and/or ligamentous tears. Tendinopathy. Assessment of joints and surrounding structures in preparation for an interventional procedure.

Usually, an MRI of a joint is performed when standard X-rays are inconclusive and the patient may have failed a treatment regime for a disorder clinically diagnosed from medical history and examination. MRIs of a joint are generally not indicated when a surgical exploration of the joint (arthroscopic or open) will be performed regardless of the results of the MRI, unless the MRI results are to be used to provide information for planning the optimal surgical approach. The clinical necessity of performing a joint MRI must be noted in the medical record or easily inferred from the medical record. “Screening” imaging or unnecessary duplication of imaging is not considered medically necessary. There are relative contraindications to MRI scanning. These include cardiac pacemakers that do NOT meet CED criteria outlined in NCD 220.2.C.1, ferromagnetic clips, intraocular metal, and cochlear implants. MRI scanning under these circumstances is only covered when the medical situation is clearly explained. Documentation Requirements Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record, and made available to Medicare upon request. ICD-9 Codes that Support Medical Necessity Group 1 Paragraph: The CPT/HCPCS codes included in this LCD will be subjected to "procedure to diagnosis" editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary. Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

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Medicare is establishing the following limited coverage for CPT/HCPCS code 70336: Group 1 Codes: NEOPLASM OF UNCERTAIN BEHAVIOR OF BONE AND ARTICULAR 238.0 CARTILAGE 524.01 MAJOR ANOMALIES OF JAW SIZE MAXILLARY HYPERPLASIA 524.02 MAJOR ANOMALIES OF JAW SIZE MANDIBULAR HYPERPLASIA 524.03 MAJOR ANOMALIES OF JAW SIZE MAXILLARY HYPOPLASIA 524.04 MAJOR ANOMALIES OF JAW SIZE MANDIBULAR HYPOPLASIA 524.05 MAJOR ANOMALIES OF JAW SIZE MACROGENIA 524.06 MAJOR ANOMALIES OF JAW SIZE MICROGENIA TEMPOROMANDIBULAR JOINT DISORDERS ADHESIONS AND ANKYLOSIS 524.61 (BONY OR FIBROUS) TEMPOROMANDIBULAR JOINT DISORDERS ARTHRALGIA OF 524.62 TEMPOROMANDIBULAR JOINT TEMPOROMANDIBULAR JOINT DISORDERS ARTICULAR DISC DISORDER 524.63 (REDUCING OR NON-REDUCING) 682.0 CELLULITIS AND ABSCESS OF FACE 682.1 CELLULITIS AND ABSCESS OF NECK 695.9 UNSPECIFIED ERYTHEMATOUS CONDITION 714.0 RHEUMATOID ARTHRITIS CHRONIC OR UNSPECIFIED POLYARTICULAR JUVENILE RHEUMATOID 714.30 ARTHRITIS 714.9 UNSPECIFIED INFLAMMATORY POLYARTHROPATHY OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING OTHER SPECIFIED 715.18 SITES OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING OTHER 715.28 SPECIFIED SITES OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR 715.38 SECONDARY INVOLVING OTHER SPECIFIED SITES OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR 715.98 LOCALIZED INVOLVING OTHER SPECIFIED SITES 716.68 UNSPECIFIED MONOARTHRITIS INVOLVING OTHER SPECIFIED SITES 716.88 OTHER SPECIFIED ARTHROPATHY INVOLVING OTHER SPECIFIED SITES 716.98 UNSPECIFIED ARTHROPATHY INVOLVING OTHER SPECIFIED SITES 718.08 ARTICULAR CARTILAGE DISORDER INVOLVING OTHER SPECIFIED SITES 718.98 UNSPECIFIED DERANGEMENT OF JOINT OF OTHER SPECIFIED SITES 719.08 EFFUSION OF JOINT OF OTHER SPECIFIED SITES 730.08 ACUTE OSTEOMYELITIS INVOLVING OTHER SPECIFIED SITES 733.45 ASEPTIC NECROSIS OF BONE, JAW 782.3 EDEMA 784.0* HEADACHE 784.92 JAW PAIN 848.1 JAW SPRAIN Group 1 Medical Necessity ICD-9 Codes Asterisk Explanation: ** Note: 784.0 - Use this

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code when the headache is suspected to be caused by temporomandibular joint problems. Group 2 Paragraph: Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims. Medicare is establishing the following limited coverage for CPT/HCPCS codes 73221, 73222, 73223, 73721, 73722 and 73723: Group 2 Codes: 170.4 MALIGNANT NEOPLASM OF SCAPULA AND LONG BONES OF UPPER LIMB 170.5 MALIGNANT NEOPLASM OF SHORT BONES OF UPPER LIMB 170.7 MALIGNANT NEOPLASM OF LONG BONES OF LOWER LIMB 170.8 MALIGNANT NEOPLASM OF SHORT BONES OF LOWER LIMB MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF 171.2 UPPER LIMB INCLUDING SHOULDER MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF 171.3 LOWER LIMB INCLUDING HIP MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF 171.6 PELVIS 195.4 MALIGNANT NEOPLASM OF UPPER LIMB 195.5 MALIGNANT NEOPLASM OF LOWER LIMB SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH 196.3 NODES OF AXILLA AND UPPER LIMB SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH 196.5 NODES OF INGUINAL REGION AND LOWER LIMB 198.5 SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW 213.3 BENIGN NEOPLASM OF RIBS STERNUM AND CLAVICLE 213.4 BENIGN NEOPLASM OF SCAPULA AND LONG BONES OF UPPER LIMB 213.5 BENIGN NEOPLASM OF SHORT BONES OF UPPER LIMB 213.6 BENIGN NEOPLASM OF PELVIC BONES SACRUM AND COCCYX 213.7 BENIGN NEOPLASM OF LONG BONES OF LOWER LIMB 213.8 BENIGN NEOPLASM OF SHORT BONES OF LOWER LIMB BENIGN NEOPLASM OF BONE AND ARTICULAR CARTILAGE SITE 213.9 UNSPECIFIED 214.9 LIPOMA UNSPECIFIED SITE NEOPLASM OF UNCERTAIN BEHAVIOR OF BONE AND ARTICULAR 238.0 CARTILAGE 239.2 NEOPLASM OF UNSPECIFIED NATURE OF BONE SOFT TISSUE AND SKIN 274.00 GOUTY ARTHROPATHY, UNSPECIFIED 274.01 ACUTE GOUTY ARTHROPATHY 274.02 CHRONIC GOUTY ARTHROPATHY WITHOUT MENTION OF TOPHUS (TOPHI) 274.03 CHRONIC GOUTY ARTHROPATHY WITH TOPHUS (TOPHI) 681.00 UNSPECIFIED CELLULITIS AND ABSCESS OF FINGER 681.10 UNSPECIFIED CELLULITIS AND ABSCESS OF TOE 682.2 CELLULITIS AND ABSCESS OF TRUNK

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682.3 CELLULITIS AND ABSCESS OF UPPER ARM AND FOREARM 682.4 CELLULITIS AND ABSCESS OF HAND EXCEPT FINGERS AND THUMB 682.5 CELLULITIS AND ABSCESS OF BUTTOCK 682.6 CELLULITIS AND ABSCESS OF LEG EXCEPT FOOT 682.7 CELLULITIS AND ABSCESS OF FOOT EXCEPT TOES 695.9 UNSPECIFIED ERYTHEMATOUS CONDITION 696.0 PSORIATIC ARTHROPATHY 707.01 PRESSURE ULCER, ELBOW 707.02 PRESSURE ULCER, UPPER BACK 707.03 PRESSURE ULCER, LOWER BACK 707.04 PRESSURE ULCER, HIP 707.05 PRESSURE ULCER, BUTTOCK 707.06 PRESSURE ULCER, ANKLE 707.07 PRESSURE ULCER, HEEL 707.10 UNSPECIFIED ULCER OF LOWER LIMB 707.11 ULCER OF THIGH 707.12 ULCER OF CALF 707.13 ULCER OF ANKLE 707.14 ULCER OF HEEL AND MIDFOOT 707.15 ULCER OF OTHER PART OF FOOT 707.19 ULCER OF OTHER PART OF LOWER LIMB 711.01 PYOGENIC ARTHRITIS INVOLVING SHOULDER REGION 711.02 PYOGENIC ARTHRITIS INVOLVING UPPER ARM 711.03 PYOGENIC ARTHRITIS INVOLVING FOREARM 711.04 PYOGENIC ARTHRITIS INVOLVING HAND 711.05 PYOGENIC ARTHRITIS INVOLVING PELVIC REGION AND THIGH 711.06 PYOGENIC ARTHRITIS INVOLVING LOWER LEG 711.07 PYOGENIC ARTHRITIS INVOLVING ANKLE AND FOOT ARTHROPATHY INVOLVING SHOULDER REGION ASSOCIATED WITH 711.41 OTHER BACTERIAL DISEASES ARTHROPATHY INVOLVING UPPER ARM ASSOCIATED WITH OTHER 711.42 BACTERIAL DISEASES ARTHROPATHY INVOLVING FOREARM ASSOCIATED WITH OTHER 711.43 BACTERIAL DISEASES ARTHROPATHY INVOLVING HAND ASSOCIATED WITH OTHER BACTERIAL 711.44 DISEASES ARTHROPATHY INVOLVING PELVIC REGION AND THIGH ASSOCIATED 711.45 WITH OTHER BACTERIAL DISEASES ARTHROPATHY INVOLVING LOWER LEG ASSOCIATED WITH OTHER 711.46 BACTERIAL DISEASES ARTHROPATHY INVOLVING ANKLE AND FOOT ASSOCIATED WITH OTHER 711.47 BACTERIAL DISEASE ARTHROPATHY INVOLVING SHOULDER REGION ASSOCIATED WITH 711.61 MYCOSES

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711.62 ARTHROPATHY INVOLVING UPPER ARM ASSOCIATED WITH MYCOSES 711.63 ARTHROPATHY INVOLVING FOREARM ASSOCIATED WITH MYCOSES 711.64 ARTHROPATHY INVOLVING HAND ASSOCIATED WITH MYCOSES ARTHROPATHY INVOLVING PELVIC REGION AND THIGH ASSOCIATED 711.65 WITH MYCOSES 711.66 ARTHROPATHY INVOLVING LOWER LEG ASSOCIATED WITH MYCOSES ARTHROPATHY INVOLVING ANKLE AND FOOT ASSOCIATED WITH 711.67 MYCOSES 711.91 UNSPECIFIED INFECTIVE ARTHRITIS INVOLVING SHOULDER REGION 711.92 UNSPECIFIED INFECTIVE ARTHRITIS INVOLVING UPPER ARM 711.93 UNSPECIFIED INFECTIVE ARTHRITIS INVOLVING FOREARM 711.94 UNSPECIFIED INFECTIVE ARTHRITIS INVOLVING HAND UNSPECIFIED INFECTIVE ARTHRITIS INVOLVING PELVIC REGION AND 711.95 THIGH 711.96 UNSPECIFIED INFECTIVE ARTHRITIS INVOLVING LOWER LEG 711.97 UNSPECIFIED INFECTIVE ARTHRITIS INVOLVING ANKLE AND FOOT 713.5* ARTHROPATHY ASSOCIATED WITH NEUROLOGICAL DISORDERS 714.0 RHEUMATOID ARTHRITIS CHRONIC OR UNSPECIFIED POLYARTICULAR JUVENILE RHEUMATOID 714.30 ARTHRITIS 714.31 ACUTE POLYARTICULAR JUVENILE RHEUMATOID ARTHRITIS 714.9 UNSPECIFIED INFLAMMATORY POLYARTHROPATHY 715.11 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING SHOULDER REGION 715.12 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING UPPER ARM 715.13 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING FOREARM 715.14 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING HAND OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING PELVIC REGION AND 715.15 THIGH 715.16 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING LOWER LEG 715.17 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING ANKLE AND FOOT OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING SHOULDER 715.21 REGION 715.22 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING UPPER ARM 715.23 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING FOREARM 715.24 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING HAND OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING PELVIC REGION 715.25 AND THIGH 715.26 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING LOWER LEG 715.27 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING ANKLE AND FOOT OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR 715.31 SECONDARY INVOLVING SHOULDER REGION OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR 715.32 SECONDARY INVOLVING UPPER ARM OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR 715.33 SECONDARY INVOLVING FOREARM 7— LE_UE Joint MRI/TMJ – CMS

OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY INVOLVING HAND OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR 715.35 SECONDARY INVOLVING PELVIC REGION AND THIGH OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR 715.36 SECONDARY INVOLVING LOWER LEG OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR 715.37 SECONDARY INVOLVING ANKLE AND FOOT OSTEOARTHROSIS INVOLVING OR WITH MULTIPLE SITES BUT NOT 715.89 SPECIFIED AS GENERALIZED OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED 715.90 INVOLVING UNSPECIFIED SITE OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED 715.91 INVOLVING SHOULDER REGION OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED 715.92 INVOLVING UPPER ARM OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED 715.93 INVOLVING FOREARM OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED 715.94 INVOLVING HAND OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED 715.95 INVOLVING PELVIC REGION AND THIGH OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED 715.96 INVOLVING LOWER LEG OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED 715.97 INVOLVING ANKLE AND FOOT OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED 715.98 INVOLVING OTHER SPECIFIED SITES 716.11 TRAUMATIC ARTHROPATHY INVOLVING SHOULDER REGION 716.12 TRAUMATIC ARTHROPATHY INVOLVING UPPER ARM 716.13 TRAUMATIC ARTHROPATHY INVOLVING FOREARM 716.14 TRAUMATIC ARTHROPATHY INVOLVING HAND 716.15 TRAUMATIC ARTHROPATHY INVOLVING PELVIC REGION AND THIGH 716.16 TRAUMATIC ARTHROPATHY INVOLVING LOWER LEG 716.17 TRAUMATIC ARTHROPATHY INVOLVING ANKLE AND FOOT 716.81 OTHER SPECIFIED ARTHROPATHY INVOLVING SHOULDER REGION 716.82 OTHER SPECIFIED ARTHROPATHY INVOLVING UPPER ARM 716.83 OTHER SPECIFIED ARTHROPATHY INVOLVING FOREARM 716.84 OTHER SPECIFIED ARTHROPATHY INVOLVING HAND OTHER SPECIFIED ARTHROPATHY INVOLVING PELVIC REGION AND 716.85 THIGH 716.86 OTHER SPECIFIED ARTHROPATHY INVOLVING LOWER LEG 716.87 OTHER SPECIFIED ARTHROPATHY INVOLVING ANKLE AND FOOT 716.88 OTHER SPECIFIED ARTHROPATHY INVOLVING OTHER SPECIFIED SITES 716.89 OTHER SPECIFIED ARTHROPATHY INVOLVING MULTIPLE SITES 715.34

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716.91 UNSPECIFIED ARTHROPATHY INVOLVING SHOULDER REGION 716.92 UNSPECIFIED ARTHROPATHY INVOLVING UPPER ARM 716.93 UNSPECIFIED ARTHROPATHY INVOLVING FOREARM 716.94 UNSPECIFIED ARTHROPATHY INVOLVING HAND 716.95 UNSPECIFIED ARTHROPATHY INVOLVING PELVIC REGION AND THIGH 716.96 UNSPECIFIED ARTHROPATHY INVOLVING LOWER LEG 716.97 UNSPECIFIED ARTHROPATHY INVOLVING ANKLE AND FOOT 716.98 UNSPECIFIED ARTHROPATHY INVOLVING OTHER SPECIFIED SITES 716.99 UNSPECIFIED ARTHROPATHY INVOLVING MULTIPLE SITES 717.0 OLD BUCKET HANDLE TEAR OF MEDIAL MENISCUS 717.1 DERANGEMENT OF ANTERIOR HORN OF MEDIAL MENISCUS 717.2 DERANGEMENT OF POSTERIOR HORN OF MEDIAL MENISCUS 717.3 OTHER AND UNSPECIFIED DERANGEMENT OF MEDIAL MENISCUS 717.40 DERANGEMENT OF LATERAL MENISCUS UNSPECIFIED 717.41 BUCKET HANDLE TEAR OF LATERAL MENISCUS 717.42 DERANGEMENT OF ANTERIOR HORN OF LATERAL MENISCUS 717.43 DERANGEMENT OF POSTERIOR HORN OF LATERAL MENISCUS 717.5 DERANGEMENT OF MENISCUS NOT ELSEWHERE CLASSIFIED 717.6 LOOSE BODY IN KNEE 717.7 CHONDROMALACIA OF PATELLA 717.81 OLD DISRUPTION OF LATERAL COLLATERAL LIGAMENT 717.82 OLD DISRUPTION OF MEDIAL COLLATERAL LIGAMENT 717.83 OLD DISRUPTION OF ANTERIOR CRUCIATE LIGAMENT 717.84 OLD DISRUPTION OF POSTERIOR CRUCIATE LIGAMENT 717.85 OLD DISRUPTION OF OTHER LIGAMENTS OF KNEE 717.89 OTHER INTERNAL DERANGEMENT OF KNEE 718.01 ARTICULAR CARTILAGE DISORDER INVOLVING SHOULDER REGION 718.02 ARTICULAR CARTILAGE DISORDER INVOLVING UPPER ARM 718.03 ARTICULAR CARTILAGE DISORDER INVOLVING FOREARM 718.04 ARTICULAR CARTILAGE DISORDER INVOLVING HAND ARTICULAR CARTILAGE DISORDER INVOLVING PELVIC REGION AND 718.05 THIGH 718.07 ARTICULAR CARTILAGE DISORDER INVOLVING ANKLE AND FOOT 718.08 ARTICULAR CARTILAGE DISORDER INVOLVING OTHER SPECIFIED SITES 718.09 ARTICULAR CARTILAGE DISORDER INVOLVING MULTIPLE SITES 718.11 LOOSE BODY IN JOINT OF SHOULDER REGION 718.12 LOOSE BODY IN UPPER ARM JOINT 718.13 LOOSE BODY IN FOREARM JOINT 718.14 LOOSE BODY IN HAND JOINT 718.15 LOOSE BODY IN JOINT OF PELVIC REGION AND THIGH 718.17 LOOSE BODY IN ANKLE AND FOOT JOINT 718.18 LOOSE BODY IN JOINT OF OTHER SPECIFIED SITES 718.19 LOOSE BODY IN JOINT OF MULTIPLE SITES 718.21 PATHOLOGICAL DISLOCATION OF JOINT OF SHOULDER REGION 9— LE_UE Joint MRI/TMJ – CMS

718.22 PATHOLOGICAL DISLOCATION OF UPPER ARM JOINT 718.23 PATHOLOGICAL DISLOCATION OF FOREARM JOINT 718.24 PATHOLOGICAL DISLOCATION OF HAND JOINT 718.25 PATHOLOGICAL DISLOCATION OF JOINT OF PELVIC REGION AND THIGH 718.26 PATHOLOGICAL DISLOCATION OF JOINT OF LOWER LEG 718.27 PATHOLOGICAL DISLOCATION OF ANKLE AND FOOT JOINT 718.29 PATHOLOGICAL DISLOCATION OF JOINT OF MULTIPLE SITES 718.31 RECURRENT DISLOCATION OF JOINT OF SHOULDER REGION 718.32 RECURRENT DISLOCATION OF UPPER ARM JOINT 718.33 RECURRENT DISLOCATION OF FOREARM JOINT 718.34 RECURRENT DISLOCATION OF HAND JOINT 718.35 RECURRENT DISLOCATION OF JOINT OF PELVIC REGION AND THIGH 718.36 RECURRENT DISLOCATION OF LOWER LEG JOINT 718.37 RECURRENT DISLOCATION OF ANKLE AND FOOT JOINT 718.39 RECURRENT DISLOCATION OF JOINT OF MULTIPLE SITES 718.41 CONTRACTURE OF JOINT OF SHOULDER REGION 718.42 CONTRACTURE OF UPPER ARM JOINT 718.43 CONTRACTURE OF FOREARM JOINT 718.44 CONTRACTURE OF HAND JOINT 718.45 CONTRACTURE OF JOINT OF PELVIC REGION AND THIGH 718.46 CONTRACTURE OF LOWER LEG JOINT 718.47 CONTRACTURE OF ANKLE AND FOOT JOINT 718.49 CONTRACTURE OF JOINT OF MULTIPLE SITES 718.51 ANKYLOSIS OF JOINT OF SHOULDER REGION 718.52 ANKYLOSIS OF UPPER ARM JOINT 718.53 ANKYLOSIS OF FOREARM JOINT 718.54 ANKYLOSIS OF HAND JOINT 718.55 ANKYLOSIS OF JOINT OF PELVIC REGION AND THIGH 718.56 ANKYLOSIS OF LOWER LEG JOINT 718.57 ANKYLOSIS OF ANKLE AND FOOT JOINT 718.59 ANKYLOSIS OF JOINT OF MULTIPLE SITES 718.77 DEVELOPMENTAL DISLOCATION OF JOINT ANKLE AND FOOT 718.98 UNSPECIFIED DERANGEMENT OF JOINT OF OTHER SPECIFIED SITES 719.01 EFFUSION OF JOINT OF SHOULDER REGION 719.02 EFFUSION OF UPPER ARM JOINT 719.03 EFFUSION OF FOREARM JOINT 719.04 EFFUSION OF HAND JOINT 719.05 EFFUSION OF JOINT OF PELVIC REGION AND THIGH 719.06 EFFUSION OF LOWER LEG JOINT 719.07 EFFUSION OF ANKLE AND FOOT JOINT 719.41 PAIN IN JOINT INVOLVING SHOULDER REGION 719.42 PAIN IN JOINT INVOLVING UPPER ARM 719.43 PAIN IN JOINT INVOLVING FOREARM 719.44 PAIN IN JOINT INVOLVING HAND 10— LE_UE Joint MRI/TMJ – CMS

719.45 PAIN IN JOINT INVOLVING PELVIC REGION AND THIGH 719.46 PAIN IN JOINT INVOLVING LOWER LEG 719.47 PAIN IN JOINT INVOLVING ANKLE AND FOOT STIFFNESS OF JOINT NOT ELSEWHERE CLASSIFIED INVOLVING 719.51 SHOULDER REGION STIFFNESS OF JOINT NOT ELSEWHERE CLASSIFIED INVOLVING UPPER 719.52 ARM 719.53 STIFFNESS OF JOINT NOT ELSEWHERE CLASSIFIED INVOLVING FOREARM 719.54 STIFFNESS OF JOINT NOT ELSEWHERE CLASSIFIED INVOLVING HAND STIFFNESS OF JOINT NOT ELSEWHERE CLASSIFIED INVOLVING PELVIC 719.55 REGION AND THIGH STIFFNESS OF JOINT NOT ELSEWHERE CLASSIFIED INVOLVING LOWER 719.56 LEG STIFFNESS OF JOINT NOT ELSEWHERE CLASSIFIED INVOLVING ANKLE 719.57 AND FOOT 719.61 OTHER SYMPTOMS REFERABLE TO JOINT OF SHOULDER REGION 719.62 OTHER SYMPTOMS REFERABLE TO UPPER ARM JOINT 719.63 OTHER SYMPTOMS REFERABLE TO FOREARM JOINT 719.64 OTHER SYMPTOMS REFERABLE TO HAND JOINT 719.65 OTHER SYMPTOMS REFERABLE TO JOINT OF PELVIC REGION AND THIGH 719.66 OTHER SYMPTOMS REFERABLE TO LOWER LEG JOINT 719.67 OTHER SYMPTOMS REFERABLE TO ANKLE AND FOOT JOINT 719.81 OTHER SPECIFIED DISORDERS OF JOINT OF SHOULDER REGION 719.82 OTHER SPECIFIED DISORDERS OF UPPER ARM JOINT 719.83 OTHER SPECIFIED DISORDERS OF FOREARM JOINT 719.84 OTHER SPECIFIED DISORDERS OF HAND JOINT 719.85 OTHER SPECIFIED DISORDERS OF JOINT OF PELVIC REGION AND THIGH 719.86 OTHER SPECIFIED DISORDERS OF LOWER LEG JOINT 719.87 OTHER SPECIFIED DISORDERS OF ANKLE AND FOOT JOINT 726.0 ADHESIVE CAPSULITIS OF SHOULDER DISORDERS OF BURSAE AND TENDONS IN SHOULDER REGION 726.10 UNSPECIFIED 726.11 CALCIFYING TENDINITIS OF SHOULDER 726.12 BICIPITAL TENOSYNOVITIS 726.13 PARTIAL TEAR OF ROTATOR CUFF OTHER SPECIFIED DISORDERS OF BURSAE AND TENDONS IN SHOULDER 726.19 REGION OTHER AFFECTIONS OF SHOULDER REGION NOT ELSEWHERE 726.2 CLASSIFIED 726.31 MEDIAL EPICONDYLITIS 726.32 LATERAL EPICONDYLITIS 726.33 OLECRANON BURSITIS 726.4 ENTHESOPATHY OF WRIST AND CARPUS 726.5 ENTHESOPATHY OF HIP REGION

11— LE_UE Joint MRI/TMJ – CMS

726.60 ENTHESOPATHY OF KNEE UNSPECIFIED 726.61 PES ANSERINUS TENDINITIS OR BURSITIS 726.62 TIBIAL COLLATERAL LIGAMENT BURSITIS 726.63 FIBULAR COLLATERAL LIGAMENT BURSITIS 726.64 PATELLAR TENDINITIS 726.65 PREPATELLAR BURSITIS 726.69 OTHER ENTHESOPATHY OF KNEE 726.70 ENTHESOPATHY OF ANKLE AND TARSUS UNSPECIFIED 726.71 ACHILLES BURSITIS OR TENDINITIS 726.72 TIBIALIS TENDINITIS 726.73 CALCANEAL SPUR 726.79 OTHER ENTHESOPATHY OF ANKLE AND TARSUS 727.00 SYNOVITIS AND TENOSYNOVITIS UNSPECIFIED 727.03 TRIGGER FINGER (ACQUIRED) 727.05 OTHER TENOSYNOVITIS OF HAND AND WRIST 727.06 TENOSYNOVITIS OF FOOT AND ANKLE 727.41 GANGLION OF JOINT 727.51 SYNOVIAL CYST OF POPLITEAL SPACE 727.61 COMPLETE RUPTURE OF ROTATOR CUFF 727.63 NONTRAUMATIC RUPTURE OF EXTENSOR TENDONS OF HAND AND WRIST 727.64 NONTRAUMATIC RUPTURE OF FLEXOR TENDONS OF HAND AND WRIST 727.66 NONTRAUMATIC RUPTURE OF PATELLAR TENDON 727.67 NONTRAUMATIC RUPTURE OF ACHILLES TENDON 727.68 NONTRAUMATIC RUPTURE OF OTHER TENDONS OF FOOT AND ANKLE 729.81 SWELLING OF LIMB 730.01 ACUTE OSTEOMYELITIS INVOLVING SHOULDER REGION 730.02 ACUTE OSTEOMYELITIS INVOLVING UPPER ARM 730.03 ACUTE OSTEOMYELITIS INVOLVING FOREARM 730.04 ACUTE OSTEOMYELITIS INVOLVING HAND 730.05 ACUTE OSTEOMYELITIS INVOLVING PELVIC REGION AND THIGH 730.06 ACUTE OSTEOMYELITIS INVOLVING LOWER LEG 730.07 ACUTE OSTEOMYELITIS INVOLVING ANKLE AND FOOT 730.08 ACUTE OSTEOMYELITIS INVOLVING OTHER SPECIFIED SITES 730.11 CHRONIC OSTEOMYELITIS INVOLVING SHOULDER REGION 730.12 CHRONIC OSTEOMYELITIS INVOLVING UPPER ARM 730.13 CHRONIC OSTEOMYELITIS INVOLVING FOREARM 730.14 CHRONIC OSTEOMYELITIS INVOLVING HAND 730.15 CHRONIC OSTEOMYELITIS INVOLVING PELVIC REGION AND THIGH 730.16 CHRONIC OSTEOMYELITIS INVOLVING LOWER LEG 730.17 CHRONIC OSTEOMYELITIS INVOLVING ANKLE AND FOOT 730.18 CHRONIC OSTEOMYELITIS INVOLVING OTHER SPECIFIED SITES 730.19 CHRONIC OSTEOMYELITIS INVOLVING MULTIPLE SITES 730.21 UNSPECIFIED OSTEOMYELITIS INVOLVING SHOULDER REGION 730.22 UNSPECIFIED OSTEOMYELITIS INVOLVING UPPER ARM 12— LE_UE Joint MRI/TMJ – CMS

730.23 UNSPECIFIED OSTEOMYELITIS INVOLVING FOREARM 730.24 UNSPECIFIED OSTEOMYELITIS INVOLVING HAND 730.25 UNSPECIFIED OSTEOMYELITIS INVOLVING PELVIC REGION AND THIGH 730.26 UNSPECIFIED OSTEOMYELITIS INVOLVING LOWER LEG 730.27 UNSPECIFIED OSTEOMYELITIS INVOLVING ANKLE AND FOOT 730.28 UNSPECIFIED OSTEOMYELITIS INVOLVING OTHER SPECIFIED SITES 730.29 UNSPECIFIED OSTEOMYELITIS INVOLVING MULTIPLE SITES 730.91 UNSPECIFIED INFECTION OF BONE OF SHOULDER REGION 730.92 UNSPECIFIED INFECTION OF UPPER ARM BONE 730.93 UNSPECIFIED INFECTION OF FOREARM BONE 730.94 UNSPECIFIED INFECTION OF HAND BONE 730.95 UNSPECIFIED INFECTION OF BONE OF PELVIC REGION AND THIGH 730.96 UNSPECIFIED INFECTION OF LOWER LEG BONE 730.97 UNSPECIFIED INFECTION OF ANKLE AND FOOT BONE 731.0 OSTEITIS DEFORMANS WITHOUT BONE TUMOR 731.3 MAJOR OSSEOUS DEFECTS 732.1 JUVENILE OSTEOCHONDROSIS OF HIP AND PELVIS 732.3 JUVENILE OSTEOCHONDROSIS OF UPPER EXTREMITY 732.4 JUVENILE OSTEOCHONDROSIS OF LOWER EXTREMITY EXCLUDING FOOT 732.5 JUVENILE OSTEOCHONDROSIS OF FOOT 732.9 UNSPECIFIED OSTEOCHONDROPATHY 733.41 ASEPTIC NECROSIS OF HEAD OF HUMERUS 733.42 ASEPTIC NECROSIS OF HEAD AND NECK OF FEMUR 733.43 ASEPTIC NECROSIS OF MEDIAL FEMORAL CONDYLE 733.44 ASEPTIC NECROSIS OF TALUS 733.49 ASEPTIC NECROSIS OF OTHER BONE SITES 782.2 LOCALIZED SUPERFICIAL SWELLING MASS OR LUMP 782.3 EDEMA 831.00 CLOSED DISLOCATION OF SHOULDER UNSPECIFIED SITE 831.01 CLOSED ANTERIOR DISLOCATION OF HUMERUS 831.02 CLOSED POSTERIOR DISLOCATION OF HUMERUS 831.03 CLOSED INFERIOR DISLOCATION OF HUMERUS 831.04 CLOSED DISLOCATION OF ACROMIOCLAVICULAR (JOINT) 831.09 CLOSED DISLOCATION OF OTHER SITE OF SHOULDER 831.10 OPEN DISLOCATION OF SHOULDER UNSPECIFIED 831.11 OPEN ANTERIOR DISLOCATION OF HUMERUS 831.12 OPEN POSTERIOR DISLOCATION OF HUMERUS 831.13 OPEN INFERIOR DISLOCATION OF HUMERUS 831.14 OPEN DISLOCATION OF ACROMIOCLAVICULAR (JOINT) 831.19 OPEN DISLOCATION OF OTHER SITE OF SHOULDER 832.00 CLOSED DISLOCATION OF ELBOW UNSPECIFIED SITE 832.01 CLOSED ANTERIOR DISLOCATION OF ELBOW 832.02 CLOSED POSTERIOR DISLOCATION OF ELBOW 832.03 CLOSED MEDIAL DISLOCATION OF ELBOW 13— LE_UE Joint MRI/TMJ – CMS

832.04 CLOSED LATERAL DISLOCATION OF ELBOW 832.10 OPEN DISLOCATION OF ELBOW UNSPECIFIED SITE 832.11 OPEN ANTERIOR DISLOCATION OF ELBOW 832.12 OPEN POSTERIOR DISLOCATION OF ELBOW 832.13 OPEN MEDIAL DISLOCATION OF ELBOW 832.14 OPEN LATERAL DISLOCATION OF ELBOW 833.00 CLOSED DISLOCATION OF WRIST UNSPECIFIED PART 833.01 CLOSED DISLOCATION OF RADIOULNAR (JOINT) DISTAL 833.02 CLOSED DISLOCATION OF RADIOCARPAL (JOINT) 833.03 CLOSED DISLOCATION OF MIDCARPAL (JOINT) 833.04 CLOSED DISLOCATION OF CARPOMETACARPAL (JOINT) 833.05 CLOSED DISLOCATION OF METACARPAL (BONE) PROXIMAL END 833.09 CLOSED DISLOCATION OF OTHER PART OF WRIST 833.10 OPEN DISLOCATION OF WRIST UNSPECIFIED PART 833.11 OPEN DISLOCATION OF RADIOULNAR (JOINT) DISTAL 833.12 OPEN DISLOCATION OF RADIOCARPAL (JOINT) 833.13 OPEN DISLOCATION OF MIDCARPAL (JOINT) 833.14 OPEN DISLOCATION OF CARPOMETACARPAL (JOINT) 833.15 OPEN DISLOCATION OF METACARPAL (BONE) PROXIMAL END 833.19 OPEN DISLOCATION OF OTHER PART OF WRIST 834.00 CLOSED DISLOCATION OF FINGER UNSPECIFIED PART 834.01 CLOSED DISLOCATION OF METACARPOPHALANGEAL (JOINT) 834.02 CLOSED DISLOCATION OF INTERPHALANGEAL (JOINT) HAND 834.10 OPEN DISLOCATION OF FINGER UNSPECIFIED PART 834.11 OPEN DISLOCATION OF METACARPOPHALANGEAL (JOINT) 834.12 OPEN DISLOCATION INTERPHALANGEAL (JOINT) HAND 835.00 CLOSED DISLOCATION OF HIP UNSPECIFIED SITE 835.01 CLOSED POSTERIOR DISLOCATION OF HIP 835.02 CLOSED OBTURATOR DISLOCATION OF HIP 835.03 OTHER CLOSED ANTERIOR DISLOCATION OF HIP 835.10 OPEN DISLOCATION OF HIP UNSPECIFIED SITE 835.11 OPEN POSTERIOR DISLOCATION OF HIP 835.12 OPEN OBTURATOR DISLOCATION OF HIP 835.13 OTHER OPEN ANTERIOR DISLOCATION OF HIP 836.0 TEAR OF MEDIAL CARTILAGE OR MENISCUS OF KNEE CURRENT 836.1 TEAR OF LATERAL CARTILAGE OR MENISCUS OF KNEE CURRENT 836.2 OTHER TEAR OF CARTILAGE OR MENISCUS OF KNEE CURRENT 836.3 DISLOCATION OF PATELLA CLOSED 836.4 DISLOCATION OF PATELLA OPEN 836.50 CLOSED DISLOCATION OF KNEE UNSPECIFIED PART 836.51 ANTERIOR DISLOCATION OF TIBIA PROXIMAL END CLOSED 836.52 POSTERIOR DISLOCATION OF TIBIA PROXIMAL END CLOSED 836.53 MEDIAL DISLOCATION OF TIBIA PROXIMAL END CLOSED 836.54 LATERAL DISLOCATION OF TIBIA PROXIMAL END CLOSED 14— LE_UE Joint MRI/TMJ – CMS

836.59 OTHER DISLOCATION OF KNEE CLOSED 836.60 DISLOCATION OF KNEE UNSPECIFIED PART OPEN 836.61 ANTERIOR DISLOCATION OF TIBIA PROXIMAL END OPEN 836.62 POSTERIOR DISLOCATION OF TIBIA PROXIMAL END OPEN 836.63 MEDIAL DISLOCATION OF TIBIA PROXIMAL END OPEN 836.64 LATERAL DISLOCATION OF TIBIA PROXIMAL END OPEN 836.69 OTHER DISLOCATION OF KNEE OPEN 837.0 CLOSED DISLOCATION OF ANKLE 837.1 OPEN DISLOCATION OF ANKLE 840.0 ACROMIOCLAVICULAR (JOINT) (LIGAMENT) SPRAIN 840.3 INFRASPINATUS (MUSCLE) (TENDON) SPRAIN 840.4 ROTATOR CUFF (CAPSULE) SPRAIN 840.5 SUBSCAPULARIS (MUSCLE) SPRAIN 840.6 SUPRASPINATUS (MUSCLE) (TENDON) SPRAIN 840.8 SPRAIN OF OTHER SPECIFIED SITES OF SHOULDER AND UPPER ARM 840.9 SPRAIN OF UNSPECIFIED SITE OF SHOULDER AND UPPER ARM 841.0 RADIAL COLLATERAL LIGAMENT SPRAIN 841.1 ULNAR COLLATERAL LIGAMENT SPRAIN 841.2 RADIOHUMERAL (JOINT) SPRAIN 841.3 ULNOHUMERAL (JOINT) SPRAIN 841.8 SPRAIN OF OTHER SPECIFIED SITES OF ELBOW AND FOREARM 841.9 SPRAIN OF UNSPECIFIED SITE OF ELBOW AND FOREARM 842.00 SPRAIN OF UNSPECIFIED SITE OF WRIST 842.01 SPRAIN OF CARPAL (JOINT) OF WRIST 842.02 SPRAIN OF RADIOCARPAL (JOINT) (LIGAMENT) OF WRIST 842.09 OTHER WRIST SPRAIN 842.11 SPRAIN OF CARPOMETACARPAL (JOINT) OF HAND 842.19 OTHER HAND SPRAIN 843.8 SPRAIN OF OTHER SPECIFIED SITES OF HIP AND THIGH 843.9 SPRAIN OF UNSPECIFIED SITE OF HIP AND THIGH 844.0 SPRAIN OF LATERAL COLLATERAL LIGAMENT OF KNEE 844.1 SPRAIN OF MEDIAL COLLATERAL LIGAMENT OF KNEE 844.2 SPRAIN OF CRUCIATE LIGAMENT OF KNEE 844.3 SPRAIN OF TIBIOFIBULAR (JOINT) (LIGAMENT) SUPERIOR OF KNEE 844.8 SPRAIN OF OTHER SPECIFIED SITES OF KNEE AND LEG 844.9 SPRAIN OF UNSPECIFIED SITE OF KNEE AND LEG 845.00 UNSPECIFIED SITE OF ANKLE SPRAIN 845.01 DELTOID (LIGAMENT) ANKLE SPRAIN 845.02 CALCANEOFIBULAR (LIGAMENT) ANKLE SPRAIN 845.03 TIBIOFIBULAR (LIGAMENT) SPRAIN DISTAL 845.09 OTHER ANKLE SPRAIN 845.10 UNSPECIFIED SITE OF FOOT SPRAIN 845.11 TARSOMETATARSAL (JOINT) (LIGAMENT) SPRAIN 845.12 METATARSAOPHALANGEAL (JOINT) SPRAIN 15— LE_UE Joint MRI/TMJ – CMS

845.13 INTERPHALANGEAL (JOINT) TOE SPRAIN 845.19 OTHER FOOT SPRAIN 848.1 JAW SPRAIN 848.41 STERNOCLAVICULAR (JOINT) (LIGAMENT) SPRAIN 848.42 CHONDROSTERNAL (JOINT) SPRAIN 848.5 PELVIC SPRAIN PERSONAL HISTORY OF OTHER LYMPHATIC AND HEMATOPOIETIC V10.79 NEOPLASMS Group 2 Medical Necessity ICD-9 Codes Asterisk Explanation: **Note: Use 713.5 for Charcot’s joints Associated Information Documentation Requirements Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record, and made available to Medicare upon request.

16— LE_UE Joint MRI/TMJ – CMS