CPT® Code 76015

Official Description

MR safety implant and/or foreign body assessment by trained clinical staff, including identification and verification of implant components from appropriate sources (eg, surgical reports, imaging reports, medical device databases, device vendors, review of prior imaging), analyzing current MR conditional status of individual components and systems, and consulting published professional guidance with written report; each additional 30 minutes (List separately in addition to code for primary procedure)

Common Language Description

The CPT® Code 76015 refers to the process of conducting a magnetic resonance (MR) safety assessment for implanted medical devices or foreign bodies by trained clinical staff, such as MRI technologists or medical physicists. This assessment is crucial prior to performing a planned MRI procedure, especially when the patient has an implanted device like a pacemaker or neurostimulator, or when the device is malfunctioning or incompletely implanted. The assessment involves a thorough review of various sources, including surgical reports, imaging reports, and medical device databases, to identify and verify the components of the implant. The clinical staff analyzes the current MR conditional status of these components and systems, ensuring that any potential contraindications are identified. This information is vital for the physician responsible for the MRI, as it may necessitate modifications to the exam or even exclude certain areas from imaging. The assessment culminates in a written report that captures the current MRI status labeling, detailing any restrictions or contraindications associated with the entire system and its individual components. Additionally, the report includes references to published professional guidelines relevant to the specific device being assessed for MRI compatibility. For billing purposes, CPT® Code 76014 is used for the initial 15 minutes of the assessment, while CPT® Code 76015 is applied for each additional 30 minutes of prolonged assessment, particularly in cases involving complex or multiple implants or those that are inadequately documented.

1. Indications

The MR safety implant and/or foreign body assessment is indicated in the following scenarios:

Implanted Medical Devices Assessment is necessary for patients with implanted devices such as pacemakers or neurostimulators prior to undergoing an MRI.
Malfunctioning Devices The procedure is indicated when a device is no longer functioning properly, requiring evaluation before MRI imaging.
Incompletely Implanted Devices If a device is incompletely implanted, an assessment is crucial to determine the safety of proceeding with an MRI.
Complex Cases The assessment is warranted in cases involving multiple implants or complex medical histories that may affect MRI safety.

2. Procedure

The procedure for conducting an MR safety implant and/or foreign body assessment involves several critical steps:

Step 1: Identification and Verification Trained clinical staff begin by identifying and verifying the components of the implanted device. This is done by reviewing appropriate sources such as surgical reports, imaging reports, and medical device databases. The staff may also consult with device vendors or manufacturers to gather comprehensive information about the device.
Step 2: Analysis of Current MR Conditional Status After gathering the necessary information, the staff analyzes the current MR conditional status of the individual components and the overall system. This analysis is essential to determine if the device is safe for MRI and to identify any restrictions or contraindications that may apply.
Step 3: Consultation of Published Guidelines The clinical staff consults published professional guidance related to the specific device and its compatibility with MRI procedures. This step ensures that the assessment aligns with the latest safety standards and recommendations.
Step 4: Documentation and Reporting Finally, the findings from the assessment are compiled into a written report. This report includes the current MRI status labeling, any identified restrictions or contraindications, and references to the consulted guidelines. The report serves as a critical document for the physician to ensure safe MRI practices.

3. Post-Procedure

Post-procedure care following the MR safety implant and/or foreign body assessment involves reviewing the written report with the physician responsible for the MRI. The physician will use the information provided to make informed decisions regarding the MRI procedure, including any necessary modifications to the imaging plan based on the assessment findings. It is essential to ensure that all safety protocols are followed, and any contraindications are addressed before proceeding with the MRI. Additionally, the clinical staff may need to communicate with the patient regarding the implications of the assessment results and any precautions that should be taken during the MRI process.

Short Descr	MR SFTY MPLT&/FB ASMT STF EA
Medium Descr	MR SAFETY IMPLANT&/FB ASSMT CLIN STAFF EA ADD 30
Long Descr	MR safety implant and/or foreign body assessment by trained clinical staff, including identification and verification of implant components from appropriate sources (eg, surgical reports, imaging reports, medical device databases, device vendors, review of prior imaging), analyzing current MR conditional status of individual components and systems, and consulting published professional guidance with written report; each additional 30 minutes (List separately in addition to code for primary procedure)
Status Code	Active Code
Global Days	ZZZ - Code Related to Another Service
PC/TC Indicator (26, TC)	3 - Technical Component Only Code
Multiple Procedures (51)	0 - No payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50)	0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions	09 - Concept does not apply.
Assistant Surgeon (80, 82)	0 - Payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62)	0 - Co-surgeons not permitted for this procedure.
Team Surgery (66)	0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family	99 - Concept Does Not Apply
APC Status Indicator	Items and Services Packaged into APC Rates
ASC Payment Indicator	Packaged service/item; no separate payment made.
Type of Service (TOS)	4 - Diagnostic Radiology
Berenson-Eggers TOS (BETOS)	none
MUE	Not applicable/unspecified.