musculoskeletal imaging guidelines

©2014 MedSolutions, Inc. Musculoskeletal Imaging Guidelines

MUSCULOSKELETAL IMAGING GUIDELINES Version 16.0; Effective 02-21-2014

MedSolutions, Inc. Clinical Decision Support Tool for Advanced Diagnostic Imaging

Common symptoms and symptom complexes are addressed by this tool. Imaging requests for patients with atypical symptoms or clinical presentations that are not specifically addressed will require physician review. Consultation with the referring physician may provide additional insight.

This version incorporates MSI accepted revisions prior to 12/31/13

CPT® (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT® five digit codes, nomenclature and other data are copyright 2014 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in the CPT® book. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein.

MedSolutions, Inc. This tool addresses common symptoms and symptom complexes. Imaging requests for patients with atypicalClinical Decision Support Tool symptoms or clinical presentations that are not specifically addressed will require physician review. Diagnostic Strategies Consultation with the referring physician, specialist and/or patient’s Primary Care Physician (PCP) may provide additional insight.

Version 16.0; Eff 02-21-2014 Musculoskeletal RETURN of 40

MUSCULOSKELETAL IMAGING GUIDELINES

Musculoskeletal Imaging Guidelines Abbreviations 3

MS-1~General Guidelines 4

MS-2~Imaging Techniques 6

MS-3~3D Rendering 8

DISEASE/ INJURY CATEGORY (Alphabetical Order)

MS-4~Avascular Necrosis (AVN) 9

MS-5~Fracture and Dislocation 9

MS-6~Foreign Body 10

MS-7~Ganglion Cysts 10

MS-8~Gout, Pseudogout and Crystal Deposition Disease 10

MS-9~Infection/Osteomyelitis 11

MS-10~Mass 12

MS-11~Muscle/Tendon Unit Injuries/Disease 13

MS-12~Osteoarthritis 13

MS-13~Osteochondritis 14

MS-14~OsteoPorosis 15

MS-15~Paget’s Disease 17

MS-16~Post-Operative Evaluation 17

MS-17~Rheumatoid Arthritis and Inflammatory Arthritis 18

MS-18~Tendonitis/Bursitis 19

MS-19~Total Joint Prosthesis 19

ANATOMICAL AREAS

MS-20~Shoulder 20

MS-21~Elbow 24

MS-22~Wrist 25

MS-23~Hand 26

MS-24~Pelvis 27

MS-25~Hip 28

MS-26~Knee 31

MS-27~Leg Length Discrepancy 34

MS-28~Leg Pain/Calf Tenderness 35

MS-29~Ankle 36

MS-30~Foot 38


ABBREVIATIONS for MUSCULOSKELETAL GUIDELINES

AP anteroposterior view

AVN avascular necrosis/aseptic necrosis

CMS Centers for Medicare and Medicaid Services

CPK creatinine phosphokinase

CT computed tomography

DEXA (DXA) dual energy x-ray absorptiometry

DMARDS disease modifying anti-rheumatic drugs

EMG electromyogram

ESR erythrocyte sedimentation rate

FROM full range of motion

MRI magnetic resonance imaging

NCV nerve conduction velocity

NSAIDS non steroidal anti-inflammatory drugs

OA osteoarthritis

OCD osteochondritis dissecans

RA rheumatoid arthritis

RCT rotator cuff tear

RICE rest, ice, compression, elevation

SI sacro-iliac

TFCC triangular fibrocartilage complex

TNF tumor necrosis factor

WBC white blood cell count



MS-1~GENERAL GUIDELINES

A current clinical evaluation (within 60 days) is required before advanced imaging can be considered.

The clinical evaluation should include a relevant history and physical examination, appropriate laboratory studies, and non-advanced imaging modalities such as x-ray. o Other meaningful contact (telephone call, electronic mail or messaging) by an

established patient can substitute for a face-to-face clinical evaluation. o A “clinical diagnosis” for many musculoskeletal bone, joint and soft tissue pain,

and injury disorders are based on examination and plain x-ray.

Many episodes of pain, particularly those involving the joints, should be evaluated with appropriate plain x-rays and then managed with at least 6 weeks of non-surgical care prior to considering advanced imaging.

Conservative treatment may include NSAIDS, oral steroids, injection; a physician directed home exercise program or physical therapy, or bracing/immobilization.

Orthopedic specialist evaluation can be helpful in determining the need for advanced imaging. o The need for repeat advanced imaging should be carefully considered and may not

be indicated if prior imaging has been performed. o Serial advanced imaging, whether CT or MRI, for surveillance of healing or

recovery from musculoskeletal disease is not supported in the majority of musculoskeletal conditions.

CODING NOTES

Ultrasound Coding for Examination of a Soft-Tissue Mass CPT® Extremity 76882

Axilla 76882

Chest wall 76604

Upper back 76604

Lower back 76705

Abdominal wall 76705

Other soft-tissue areas 76999


Computer-Assisted Musculoskeletal Surgical Navigation Procedures: The Category III code used to describe computer-assisted navigation in orthopedic

surgery with CT/MRI image guidance is: +0055T. o Computer-assisted navigation (CAN) in orthopedic procedures describes the use of

computer-enabled tracking systems to facilitate alignment in a variety of surgical procedures and verification of an intended implant placement.

o Code +0055T is intended to be used in addition to the code for the primary surgical procedure.

o CT/MRI imaging acquisition for preoperative planning, in the absence of written payor instructions, is not to be reported with a diagnostic CT or MRI code



MS-2~Imaging Techniques

Plain X-Ray

Should be done prior to advanced imaging in most musculoskeletal conditions to rule out those situations that do not require advanced imaging, such as osteoarthritis, acute/healing fracture, dislocation, osteomyelitis, acquired/congenital deformities, and tumors of bone amenable to biopsy or radiation therapy (in known metastatic disease), etc.

MRI or CT

MRI is often the preferred imaging modality in musculoskeletal conditions because it is superior in imaging the soft tissues and can also define physiological processes in some instances, e.g. edema, loss of circulation (AVN), and increased vascularity (tumors).

CT is better at imaging bone and joint anatomy; thus, it is useful for studying complex fractures (particularly of the joints and vertebra), dislocations, and assessing delayed union or non-union of fractures if plain x-rays are equivocal. CT may be the procedure of choice in patients who cannot have MRI, such as those with pacemakers.

Contrast Issues

Most musculoskeletal imaging (MRI or CT) is without contrast, except for the following: o Tumors and osteomyelitis (without and with contrast) o Post-MR arthrography (with contrast only) o MRI for rheumatoid arthritis (contrast as requested) o In postoperative MRIs of the joints, MRI arthrography can be approved if

requested, MRI without contrast is indeterminate.

PET At the present time there is inadequate evidence to support the medical necessity of

this study for the routine assessment of musculoskeletal disorders, other than for neoplastic disease. It should be considered experimental or investigational and will be forwarded to Medical Director Review.

See also: MS-16, MS-19, MS 30.7 and MS-30.8.


References

1. ACR Appropriateness Criteria, Musculoskeletal Imaging topics. 2. ACR—SPR—SSR Practice Guideline for the performance of radiography of the extremities in

adults and children, revised 2008. 3. Feller F. MR Arthrography Update. Advanced MRI. 2002. From Head to Toe. 4. Hsu, W. and T. M. Hearty (2012). Radionuclide Imaging in the Diagnosis and Management of

Orthopaedic Disease. Journal of the American Academy of Orthopaedic Surgeons 20(3): 151-159.



MS-3~3D RENDERING

Indications for musculoskeletal 3-D image post-processing: o Complex fractures (comminuted or displaced) of any joint or the pelvis/acetabulum o Spine fractures o Preoperative planning when conventional imaging is insufficient

The code assignment for 3-D rendering depends upon whether the 3-D post-processing is performed on the scanner workstation (CPT®76376) or on an independent workstation (CPT®76377). o 2-dimensional reconstruction (i.e., reformatting axial images into the coronal

plane) is considered part of the tomography procedure, is not separately reportable, and does not meet the definition of 3-D rendering.

o It is not appropriate to report 3-D rendering in conjunction with CTA and MRA because those procedure codes already include the postprocessing.

o In addition to the term “3-D”, the following terms may also be used to describe 3-D post-processing: maximum intensity projection (MIP) shaded surface rendering volume rendering

The 3-D rendering codes require concurrent supervision of image postprocessing 3-D

manipulation of volumetric data set and image rendering. Certain health plan payors do not reimburse separately for 3-D rendering while others may have differing indication/limitation criteria. In these cases, individual plan coverage policies may take precedence over MedSolutions guidelines.


DISEASE/ INJURY CATEGORY (ALPHABETICAL ORDER)

MS-4~Avascular Necrosis (AVN)

MS-4.1 AVN

MRI without contrast when suspected AVN, with negative plain X-ray(s)

Reference

1. ACR Appropriateness Criteria, Chronic Hip Pain, 2011.

MS-5~Fracture and Dislocation

MS-5.1 Acute

CT or MRI without contrast is appropriate, after plain x-ray, if one of the following is present; otherwise advanced imaging is not indicated: o Complex (comminuted or displaced) fracture on plain film

CT is preferred unless it is a pathologic fracture with tumor o 14 days of symptoms in the absence of trauma with suspected stress fracture. (See

below in MS-5.2. o Concern for delayed union or non-union of the bone o Suspected osteochondral fracture can also be considered for MR arthrogram, or CT

arthrogram (primarily seen in pediatric patients)

MS-5.2 Stress/Occult Fracture

Plain x-rays are usually negative initially and often become positive at 3 to 4 weeks in stress fractures and 10 to 14 days in occult fractures. Bone scan will often be positive within 72 hours of onset.

For suspected hip, femur, tibia, navicular (foot), or scaphoid (wrist) stress fractures, MRI or CT without contrast can be performed without waiting 3 to 4 weeks or obtaining follow-up plain x-rays if the initial evaluation of history, physical exam and either plain x-ray or bone scan fail to establish a definitive diagnosis of stress fracture.

MRI or CT without contrast can be performed for all other suspected stress fractures if plain x-rays are negative after 3 weeks of conservative therapy.

References

1. ACR Appropriateness Criteria®, Stress (fatigue/insufficiency) fracture, including sacrum, excluding other vertebrae, 2011.

2. ACR Appropriateness Criteria®, Chronic hip pain, 2011 3. ACR Appropriateness Criteria®, Acute hand and wrist trauma, 2008 4. ACR Appropriateness Criteria®, Chronic ankle pain, 2009. 5. Greene WB (Ed.). Essentials of Musculoskeletal Care. 3rd Ed. Rosemont,IL, American Academy of

Orthopaedic Surgeons, 2005, pp.697-698.



MS-6~FOREIGN BODY

MS-6.1 Foreign Body – General

MRI (contrast as requested) can be approved after plain x-rays rule out the presence of radiopaque foreign bodies.

Reference

1. Chan C, Salam GA. Splinter removal. Am Fam Physician 2003 June; 67(12):2557-2562.

MS-7~GANGLION CYSTS

MS-7.1 Ganglion Cysts – General

MRI without contrast is appropriate for occult ganglions (smaller cysts that remain hidden under the skin) or atypical cysts/masses. o Advanced imaging is not indicated for ganglions that can be diagnosed by

appearance and location.

References

1. Rubin DA, Weissman BN, Appel M, Arnold E. ACR Appropriateness Criteria®: Chronic Wrist Pain. Last review date 2012.

2. Freire V, Guerini H, Campagna R, Moutounet L et al. Imaging of hand and wrist cysts: a clinical approach. AJR, 2012; 199: W618-W628.

3. Vo P, Wright T, Hayden F, Dell P, et al. Evaluating dorsal wrist pain: MRI diagnosis of occult dorsal wrist ganglion. J Hand Surg Am, 1995; 20: 6670670.

MS-8~Gout/Pseudogout/Crystal Deposition Disease

MS-8.1 Gout/Pseudogout/Crystal Deposition Disease - General

Early stages of gout can be diagnosed clinically; radiographic findings are not present early in the disease course. Chondrocalcinosis (pseudogout) can often be diagnosed from plain x-rays alone.

MRI is indicated for gouty tophus, which can mimic an infectious or neoplastic process


References

1. Dore RK. Gout: What primary care physicians want to know. J Clin Rheumatol 2008;14(5 Suppl):S47-S54.

2. Eggebeen AT. Gout: an update. Am Fam Physician 2007;76(6):801-808. 3. Burns C, Wortmann RL. Chapter 44. Gout. In: Imboden JB, Hellmann DB, Stone JH, eds.

CURRENT Diagnosis & Treatment: Rheumatology. 3rd ed. New York: McGraw-Hill; 2013. http://www.accessmedicine.com/content.aspx?aID=57273972. Accessed October 9, 2013.

MS-9~Infection/Osteomyelitis

MS-9.1 Infection – General

MRI without and with contrast if: o Soft tissue or bone infection (osteomyelitis) not responding to surgical or non-

surgical care; or o Plain x-ray(s) are negative; or o Plain film(s) are positive for osteomyelitis, and the extent of infection into the soft

tissues and any skip lesions require evaluation

CT without contrast can replace an MRI: o To assess the extent of bony destruction from osteomyelitits; CT can guide

treatment decisions. o For pre-operative planning o If contraindicated by pacemaker insertion or other implanted devices sensitive to

radio waves, magnet fields, or ferromagnetic materials.

References

1. Green WB (Ed.). Essentials of Musculoskeletal Care. 3rd Ed. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, p.918.

2. Staheli LT. Fundamentals of Pediatric Orthopedics. 4th Ed. Philadelphia, Lippincott Williams & Wilkins, 2008, pp.110-111.



MS-10~MASS

MS-10.1 Mass – General

History and physical exam should include: location, size, duration, whether growing or stable, solid/cystic, fixed/not fixed to the bone. Plain x-ray initially Ultrasound (coding see MS-1) is appropriate for:

o Ill-defined and non-discrete soft tissue mass(es) o Hematomas o Differentiation between solid and cystic masses

MRI without and with contrast or without contrast is appropriate for:

o Bone or soft tissue mass o Mass with equivocal US or CT

MRI without and with contrast and ultrasound are both appropriate for the diagnosis

of pseudotumors surrounding metal-on-metal (MoM) hip prostheses. One of these two imaging modalities can be approved, but not both.

Advanced imaging is not indicated for:

o Subcutaneous lipoma with no surgery planned o Ganglia o Sebaceous cyst o Mass that has been stable for >/= 1 year

References

1. ACR Appropriateness Criteria®, Soft tissue masses, 2009. 2. ACR Appropriateness Criteria®, Primary bone tumors, 2009.



MS-11~Muscle/Tendon Unit Injuries/Diseases

MS-11.1 Muscle/Tendon Unit Injuries/Diseases – General

MRI without contrast can be considered for a suspected partial tendon rupture of a specific (named) tendon

MRI is NOT needed for muscle belly strains/muscle tears MRI without contrast can be performed on complete tendon ruptures for pre-surgical

planning (for example, proximal hamstring ruptures)

References

1. ACR Appropriateness Criteria®, Chronic ankle pain, 2009. 2. Greene WB (Ed.). Essentials of Musculoskeletal Care. 3rd Ed. Rosemont, IL, Academy of

Orthopaedic Surgeons, 2005, p.452. 3. O’Kane JW. Anterior Hip Pain. Am Fam Physician 1999 Oct;60(6):1687-1696.

MS-12~OSTEOARTHRITIS

MS-12.1 Osteoarthritis – General

Plain x-rays are performed initially, which most often will reveal “characteristic joint space narrowing and osteophytic spurring.”

CT without contrast is appropriate for preoperative planning in joint replacement

MRI arthrogram or CT without contrast is appropriate for labral tear if: o Suspected concomitant labral tear of the shoulder (see MS-20.6) o Suspected concomitant labral tear of the hip (see MS-25.6) o Suspected concomitant internal derangement of the knee (see MS-26) o Suspected concomitant rotator cuff tear of the shoulder (see MS-20.5) o Preoperative planning for joint reconstruction

References

1. ACR Appropriateness Criteria®, Chronic hip pain,2008. 2. Manek NJ and Lane NE. Osteoarthritis: Current concepts in diagnosis and management. Am Fam

Physician 2000 March;61(6):1795-1804. 3. Greene WB (Ed.). Essentials of Musculoskeletal Care. 3rd Ed. Rosemont,IL, American Academy of

Orthopaedic Surgeons, 2005, p. 84.



MS-13~Osteochondritis

MS-13.1 Osteochondritis Dissecans – Imaging

MRI or CT without contrast: o If displaced o To evaluate healing if follow-up plain x-rays are equivocal after of 8 weeks of

failed conservative treatment

Reference

1. ACR Appropriateness Criteria®, Non traumatic knee pain, 2008.



MS-14~OSTEOPOROSIS

MS-14.1 Osteoporosis – General

Any of the following can be approved for bone mineral density testing:

Central or peripheral dual-energy x-ray absorptiometry (DXA or DEXA) Peripheral single-energy x-ray absorptiometry (SXA) Central quantitative computed tomography (QCT) Peripheral quantitative ultrasound densitometry (QUS)

For Screening Bone mineral density measurement is appropriate for ANY of the following indications:

woman age ≥65 years woman age <65 years whose 10-year fracture risk is equal to or greater than that of

a 65-year-old white woman without additional risk factors (a 9.3% 10-year risk for any osteoporotic fracture) as determined by FRAX* score (* Fracture Risk Assessment (FRAX®) tool, developed by the World Health Organization (Sheffield, United Kingdom) OR women age < 65 years

male age >50 years with at least one factor related to an increased risk of osteoporosis (i.e., age > 70, low body weight, weight loss >10%, physical inactivity, corticosteroid use, androgen deprivation therapy, hypogonadism and previous fragility fracture

Note: Repeat bone density measurement is medically necessary every two years.

For Monitoring Bone mineral density measurement is appropriate for EITHER of the following indications:

prior to and during pharmacologic treatment for osteoporosis child or adolescent with a disease process known to adversely effect the skeleton

Note: Repeat bone density measurement no earlier than one year following a change in treatment regimen, and only when the results will directly impact a treatment decision.

Other (not screening or monitoring) Bone mineral density measurement is appropriate for EITHER of the following indications:

known osteoporotic fracture individual with vertebral abnormalities as demonstrated by an x-ray to be

indicative of osteoporosis, osteopenia, or vertebral fracture


Practice Notes

Risk factors include: postmenopausal women; women over age 65; prolonged bed-rest; corticosteroid use; tobacco use; and excessive alcohol use; men with low testosterone levels; early surgical menopause is a significant risk factor of osteoporosis. Please note that this is not an exhaustive list of risk factors.

Reference:

1. American Association of Clinical Endocrinologists (AACE) Menopause Guidelines Revision Task Force. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the diagnosis and treatment of postmenopausal osteoporosis.

2. National Osteoporosis Foundation (NOF). Clinician’s guide to prevention and treatment of osteoporosis.

3. U.S. Preventive Services Task Force (USPSTF). Screening for osteoporosis. January 2011 4. Greene WB (Ed.). Essentials of Musculoskeletal Care. 3rd Ed. Rosemont, IL, American Academy of

Orthopaedic Surgeons, 2005, p.99.http://www.niams.nih.gov/Health_Info/Bone/Osteoporosis/overview.asp



MS-15~PAGET’S DISEASE

MS-15.1 Paget’s Disease

MRI without contrast can be considered if the diagnosis (based on plain x-rays and laboratory studies) is in doubt or if malignant degeneration is suspected (occurs in up to 10% of the cases).

References

1. Schneider D, Hofmann MR, Peterson JA. Diagnosis and treatment of Paget's Disease of Bone. Am Fam Physician 2002 May;65:2069-2072.

2. Theodorou DJ, Theodorou SJ, Kakitsubata Y. Imaging of Paget Disease of bone and its musculoskeletal complications: review. AJR, 20122; 196: S64-S75.

MS-16~Post-Operative Evaluation

MS-16.1 Post-Operative Evaluation

The imaging choices in evaluating symptomatic post-operative patients can be complicated. Orthopedic evaluation is extremely helpful in determining the appropriate imaging pathway and to interpret the significance of imaging findings in the postoperative setting. Requests will be forwarded to Medical Director review.



MS-17~Rheumatoid Arthritis and Inflammatory Arthritis

MS-17.1 Rheumatoid Arthritis - General

Prior to advanced imaging, a physical exam and appropriate laboratory studies (for example: RA factor, Sed Rate, CRP, and ANA) and plain x-rays should be performed. MRI without contrast is appropriate for the most symptomatic joint, or of the

dominant hand or wrist in the following situations: o When diagnosis is uncertain prior to institution of therapy o To study the effects of treatment with DMARD (disease modifying anti-rheumatic

drugs) therapy o To identify seronegative RA patients that might benefit from early DMARD

therapy o To determine change in treatment, such as:

Switch from standard DMARD therapy to tumor necrosis factor (TNF) therapy Change to a different TNF drug, then one MRI (contrast as requested) of a

single joint can be performed Add other treatments, including joint injections

o For complications such as suspected internal derangement in the knee, (see MS-26~Knee) or rotator cuff tear in the shoulder, (see MS-20~Shoulder).

MRI should NOT be considered for routine follow-up of treatment

References

1. Haller J, Hofmann J. Inflammatory Joint Diseases. In Bohndorf K, Pope TL,Jr., Imhof H. (Eds.). Musculoskeletal Imaging, New York, Thieme New York, 2001, pp.338-343.

2. Conaghan P, Edmonds J, Emery P, et al. Magnetic resonance imaging in rheumatoid arthritis: summary of OMERACT activities, current status, and plans. Journal of Rheumatology 2001; 28(5):1158-1161.

3. Ostergaard M, McQueen FM, Bird P, et al. Magnetic resonance imaging in rheumatoid arthritis--advances and research priorities. Journal of Rheumatology 2005;32(12):2462-2464.

4. The use of MRI in early RA. Rheumatology 2008;47(11):1597-1599. 5. Gossec L, Fautrel B, Pham T, et al. Structural evaluation in the management of patients with

rheumatoid arthritis: development of recommendations for clinical practice based on published evidence and expert opinion. Joint Bone Spine 2005;72:229-234.

6. Cohen SB, Potter H, Deodhar A, et al. Extremity magnetic resonance imaging in rheumatoid arthritis: updated literature review. Arthritis Care & Research 2011 May;63(5):660-665.



MS-18~TENDONITIS/ BURSITIS

MS-18.1 Tendonitis/Bursitis – General

MRI without contrast can be considered after both: o Plain x-rays to rule out entities such as calcific tendonitis/bursitis o At least 6 weeks of conservative treatment, which might include NSAIDS, oral

steroids, injection, a physician directed home exercise program or physical therapy, or bracing/immobilization

References

1. Fongemie AE, Buss DD, Rolnick SJ. Management of shoulder impingement syndrome and rotator cuff tears. Am Fam Physician1998 Feb;57(4):667-674.

2. Beltran J. MR imaging of soft-tissue infection. Magn Reson Imaging Clin N Am, 1995; 3:743.

MS-19~TOTAL JOINT PROSTHESIS

MS-19.1 Total Joint Prosthesis - General

CT or MRI without contrast of the joint prosthesis is appropriate if continued pain with a low suspicion of infection and a negative plain x-ray.

MRI without and with contrast and ultrasound are both appropriate for the diagnosis of pseudotumors surrounding metal-on-metal (MoM) hip prostheses. One of these two imaging modalities can be approved, but not both.

PET is under investigation, but also has decreased specificity because it is positive in most cases of aseptic loosening. “F-FDG imaging is less accurate than, and is not a suitable replacement for, leukocyte/marrow imaging [bone scan with Indium labeled WBC’s] for diagnosing infection of the failed joint replacement.” (Love et al., 2006)

References 1. Toms AD, Davidson D, Masri BA, Duncan CP. Management of peri-prosthetic infection in total

joint arthroplasty. J Bone Joint Surg Br 2006 Feb; 88(2):149-155. 2. Love C, Marwin SE, Tomas MB, et al. Diagnosing infection in the failed joint replacement: A

comparison of coincidence detection 18F-FDG and 111In-labeled leukocyte/99mTc-sulfur colloid marrow imaging. J Nucl Med 2004;45(11):1864-1871. ACR Appropriateness Criteria, Imaging after total knee arthroplasty, 2011.

3. J Nucl Med 2004;45(11):1864-1871


ANATOMICAL AREAS

General Considerations

Areas are organized from head to toe. Plain x-ray should almost always be performed prior to advanced imaging (see MS-2~Imaging Techniques).

MS-20~SHOULDER

MS-20.1 General Shoulder Pain

MRI shoulder without contrast, is appropriate if: o Plain x-ray has been performed; and o Failure of 6 weeks conservative treatment, which might include NSAIDS, oral


Ultrasound (CPT®76881 or CPT®76882) is generally not a preferred study in the evaluation of shoulder problems except for suspected bursitis or long head of the biceps tenosynovitis, or for suspected rotator cuff tear/impingement (see: MS-20.5 Rotator Cuff Tear).

MS-20.2 Impingement

MRI without contrast of the shoulder (CPT®73221) can be performed to identify variants of the acromion process such as Type II or Type III acromion, which can contribute to impingement syndrome, if surgery is being considered.

Practice Notes

Definition: Pressure-induced tendonitis of the rotator cuff (chiefly the supraspinatus) caused by the acromion process during shoulder abduction and often demonstrating “impingement sign” (abduction and internal rotation of the shoulder).

MS-20.3 Tendonitis

MRI without contrast (CPT®73221) should be approved only after a minimum of six weeks of conservative treatment which might include NSAIDS, oral steroids, injections, a physician directed home exercise program or physical therapy, or bracing/immobilization, or if the physician expresses concern for malignancy.

Practice Notes Inflammation of tendons, generally the rotator cuff (subscapularis, supraspinatus, and infraspinatus), but also of the tendon of the long head of the biceps which traverses the shoulder joint.


MS-20.4 Tendon (Biceps Long Head) Rupture

MRI without contrast (CPT® 73218) can be performed in obese patients with suspected biceps long head rupture.

MS-20.5 Rotator Cuff Tear

Ultrasound (CPT®76881 or CPT®76882) is generally not a preferred study in the evaluation of shoulder problems except for suspected bursitis or long head of the biceps tenosynovitis, or for suspected rotator cuff tear/impingement

Shoulder MRI without contrast (CPT®73221) if: o Individual with suspected acute injury, which may require more immediate

surgery; or o Six weeks of failed conservative management which might include NSAIDS, oral

steroids, injections, a physician directed home exercise program or physical therapy, or bracing/immobilization.

MRI arthrogram is appropriate in a shoulder that has previously had surgery for a rotator cuff

Practice Notes

The rotator cuff is composed of four musculotendinous units: subscapularis (anteriorly), supraspinatus (superiorly), and the infraspinatus and teres minor (posteriorly) which function to assist in rotating and stabilizing the humeral head.

Pain on abduction, a positive drop arm test, and limited shoulder rotation are not reliable signs of rotator cuff tear and can be positive in other pain-producing shoulder conditions. Provocative testing of the shoulder often has low sensitivity and specificity.

Other muscles such as the deltoid and pectoralis major can also affect shoulder rotation, and provocative testing often has low sensitivity and specificity.

MS-20.6 Dislocation/Subluxation/Labral Tear

Physical exam findings which may indicate a possible torn labrum such as positive apprehension sign or popping/clicking

Shoulder MRI with contrast (MRI arthrogram CPT®73222) is appropriate when a labral tear is suspected o Ultrasound is inappropriate for the evaluation of possible labral tear.

CT of the shoulder without contrast (CPT®73200) to evaluate large Hill-Sachs lesions (impaction/indentation fractures of the humeral head caused by the edge of the glenoid in a dislocation) or posterior dislocations


Shoulder MRI without and with contrast (MRI arthrography) is appropriate following the first dislocation in younger patients (40 years of age or younger) and in patients with recurrent shoulder dislocations.

Practice Notes

The glenoid (shoulder socket) labrum is a fibrocartilagenous ring/rim that deepens the glenoid cavity.

The labrum is torn in acute twisting injuries of the shoulder joint that can also cause dislocation. Chronic tears occur often in throwing athletes.

Symptoms/signs can be pain, a popping or clicking with shoulder motion, and a positive apprehension sign (anxiety and pain with shoulder abduction and external rotation).

MS-20.7 Frozen Shoulder/Adhesive Capsulitis

Advanced imaging is rarely indicated.

Practice Notes

Definition: A condition of extremely limited shoulder motion caused by adhesions (fibrous bands) within the joint and a thickened contracted capsule. This condition can be precipitated by a shoulder injury but is often idiopathic.

MS-20.8 Osteoarthritis

Shoulder CT without contrast (CPT®73200) or MRI without contrast (CPT®73221) for preoperative planning

MS-20.9 Acromioclavicular (AC) Separation

In patients with disabling shoulder pain following an AC separation, an MRI can be considered to rule out a possible rotator cuff tear.

MS-20.10 Sternoclavicular (SC) Dislocation

Chest CT without contrast (CPT®71250) can be considered if a posterior sternoclavicular dislocation is suspected


References

1. Fongemie AE, Buss DD, Rolnick SJ. Management of shoulder impingement syndrome and rotator cuff tears. Am Fam Physician1998 Feb;57(4):667-674.

2. Woodward TW, Best TM. The painful shoulder: Part II. Acute and chronic disorders. Am Fam Physician 2000 June;61(11):3291-3300.

3. ACR Appropriateness Criteria, Acute shoulder pain, 2010. 4. Bradley M, Tung G, Green A. Overutilization of shoulder magnetic resonance imaging as a

diagnostic screening tool in patients with chronic shoulder pain. J Shoulder Elbow Surgery 2005 May/June;14(3):233-237.

5. Fongemie AE, Buss DD, Rolnick SJ. Management of shoulder impingement syndrome and rotator cuff tears. Am Fam Physician 1998 Feb;57(4):667-674.

6. Greene WB (Ed.). Essentials of Musculoskeletal Care. 3rd Ed. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, p.212.

7. ACR Appropriateness Criteria, Acute shoulder pain, 2010. 8. Fongemie AE, Buss DD, Rolnick SJ. Management of shoulder impingement syndrome and rotator

cuff tears. Am Fam Physician1998 Feb;57(4):667-674. 9. Woodward TW, Best TM. The painful shoulder: Part II. Acute and chronic disorders. Am Fam

Physician 2000 June;61(11):3291-3300. 10. ACR Appropriateness Criteria, Acute shoulder pain, 2010. 11. Woodward TW, Best TM. The painful shoulder: Part II. Acute and chronic disorders. Am Fam

Physician 2000 June;61(11):3291-3300. 12. Greene WB (Ed.). Essentials of Musculoskeletal Care. 3rd Ed. Rosemont, IL, American Academy of

Orthopaedic Surgeons 2005, p. 219. 13. Woodward TW, Best TM. The painful shoulder: Part II. Acute and chronic disorders. Am Fam

Physician 2000 June;61(11):3291-3300. 14. Greene WB (Ed.). Essentials of Musculoskeletal Care. 3rd Ed. Rosemont, IL, American Academy of

Orthopaedic Surgeons, 2005, pp.163-166. 15. Woodward TW, Best TM. The painful shoulder: Part II. Acute and chronic disorders. Am Fam

Physician 2000 June;61(11):3291-3300. 16. Wheeless CR. Sternoclavicular Joint Injury, Updated April 5, 2009,

http://www.wheelessonline.com/ortho/sternoclavicular_joint_injury. 17. Seade LE, Bartz RL, Josey R. Acromioclavicular Joint Injury. eMedicine-Medscape,

http://emedicine.medscape.com/article/92337-overview. Updated December 5, 2011. Accessed November 6, 2012.

18. Petersen SA, Murphy TP. The timing of rotator cuff repair for the restoration of function. Journal of Shoulder and Elbow Surgery, 2011; 20(1):62-8.

19. Hovelius L, Olofsson A, Sandstrom B, Augustini BG, et al. Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger: a prospective twenty-five year follow-up. Journal of Bone and Joint Surgery, 2008; 90: 945-52.


ANATOMICAL AREAS

MS-21~ELBOW

MS-21.1 General Elbow Pain

MRI without contrast is appropriate if: o Plain x-ray has been performed; and o Failure of 6 weeks conservative treatment which might include NSAIDS, oral

steroids, injections, a physician directed home exercise program or physical therapy, or bracing/immobilization

MS-21.2 Elbow – Lateral or Medial Epicondylitis /Tendonitis (Tennis Elbow)

Ultrasound (CPT®76881 or CPT®76882) is appropriate after plain x-rays are obtained.

MRI is appropriate if ultrasound examination is non-diagnostic and if symptoms persist for longer than six months following appropriate treatment.

MS-21.3 Elbow - Ruptured Biceps Insertion (at elbow)

Elbow MRI (CPT®73221) is appropriate when distal biceps rupture is suspected based on patient history and physical examination.

MS-21.4 Elbow - Trauma

CT without contrast (CPT®73200) or occasionally MRI without contrast (CPT®73221) is appropriate for preoperative planning

MS-21.5 Elbow – Ulnar Collateral Ligament (UCL) Tear

MRI Arthrogram is appropriate in elbow injuries when an ulnar collateral ligament injury is suspected

References

1. Torp-Pedersen TE, Torp-Pedersen ST, Qvistgaard E, et al. Effect of glucocorticosteroid injections in tennis elbow verified on colour Doppler ultrasonography: evidence of inflammation. Br J Sports Med 2008 Mar;42(12):978-982.

2. Johnson GW, Cadwallader K, Scheffel SB, Epperly TD.Treatment of lateral epicondylitis. Am Fam Physician 2007 Sept;76(6):843-848.

3. *Greene WB (Ed.). Essentials of Musculoskeletal Care. 3rd Ed. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp. 279-280.

4. ACR Appropriateness Criteria, Chronic elbow pain, 2011. 5. Griffith JF, Roebuck DJ, Cheng JCY, et al. Acute elbow trauma in children: Spectrum of injury

revealed by MR imaging not apparent on radiographs. AJR 2001;176:53-60.


ANATOMICAL AREAS

MS-22~WRIST

MS-22.1 Wrist – General

MRI without contrast, is appropriate if: o Plain x-ray has been performed; and o In the absence of trauma, failure 6 weeks conservative treatment which might

include NSAIDS, oral steroids, injections, a physician directed home exercise program or physical therapy, or bracing/immobilization; or

o If initial plain x-rays are negative for suspected navicular/scaphoid fracture based on patient history and physical examination.

CT without contrast can be considered to evaluate complex distal radius/ulna fractures

MS-22.2 Wrist - Carpal Tunnel Syndrome

Diagnosis is made clinically and with NCV/EMG.

Wrist MRI without contrast (CPT®73221) can be performed preoperatively when a mass is identified

See PN-2.1 Carpal Tunnel Syndrome in the Peripheral Nerve Disorders Imaging Guidelines.

MS-22.3 Wrist - Ligament/Triangular Fibrocartilage Complex Injuries

Wrist MRI arthrogram or wrist arthroscopy can be considered when suspected ligament and triangular fibrocartilage complex (TFCC) injuries after: o Equivocal plain x-ray; and o Failure of 6 weeks conservative treatment which might include NSAIDS, oral

steroids, injections, a physician directed home exercise program or physical therapy, or bracing/immobilization;

Reference

1. Bruno MA, Weissman BN, Kransdorf MJ, Adler R et al. ACR Appropriateness Criteria®: Acute Hand and Wrist Trauma. Last review date 2013.

2. Rubin DA, Weissman BN, Appel M, Arnold E. ACR Appropriateness Criteria®: Chronic Wrist Pain. Last review date 2012.

3. Hayter CL, Gold SL, Potter HG. Magnetic resonance imaging of the wrist: Bone and cartilage injury. J Magn Reson Imaging. May 2013;37(5):1005-19.


ANATOMICAL AREAS

MS-23~HAND

MS-23.1 Hand – General

Hand MRI without contrast is appropriate if: o Plain x-ray has been performed; and o If occult fracture suspected; or o Failure of 6 weeks conservative treatment if condition other than fracture

suspected.

Conservative management might include NSAIDS, oral steroids, injections, a physician directed home exercise program or physical therapy, or bracing/immobilization

CT without contrast (CPT®73200) can be considered any time when plain x-rays show a complex fracture

References

1. Bruno MA, Weissman BN, Kransdorf MJ, Adler R et al. ACR Appropriateness Criteria®: Acute Hand and Wrist Trauma. Last review date 2013.

2. Hayter CL, Gold SL, Potter HG. Magnetic resonance imaging of the wrist: Bone and cartilage injury. J Magn Reson Imaging. May 2013;37(5):1005-19.


ANATOMICAL AREAS

MS-24~PELVIS

MS-24.1 Pelvis – General

Advanced imaging, can be considered for any indication below, after: o Plain x-ray has been performed; and o Failure 6 weeks conservative treatment which might include NSAIDS, oral

steroids, injections, a physician directed home exercise program or physical therapy, or bracing/immobilization; or

o Clinical suspicion of a low energy/insufficiency fracture of the sacrum and/or sacral ala

MS-24.2 Pelvis - Complex Fracture

Pelvic CT without contrast (CPT®72192) can be considered to evaluate complex pelvic ring/acetabular fractures.

Pelvic CT without or with 3D rendering is appropriate for preoperative planning.

MS-24.3 Pelvis - Sacro-iliac Joints (SI Joints)

See SP-6 Sacroiliac (SI) Joint Pain and Coccydynia in the Spine Imaging Guidelines.


ANATOMICAL AREAS

MS-25~HIP

MS-25.1 Hip - General

For all hip pain conditions, hip MRI without contrast is appropriate if: o Plain x-ray has been performed; and o Failure 6 weeks conservative treatment which might include NSAIDS, oral

steroids, injection, a physician directed home exercise program or physical therapy

MRI without and with contrast and ultrasound are both appropriate for the diagnosis of pseudotumors surrounding metal-on-metal (MoM) hip prostheses. One of these two imaging modalities can be approved, but not both.

Practice Notes

True hip pain is usually anterior and often accompanied by a painful and or limited range of motion of the hip. Pain located posterior to the greater trochanter is most often spine or nerve related

MS-25.2 Hip - Suspected Occult Hip Fracture

CT without contrast (CPT®73700) or hip MRI without contrast (CPT®73721) is appropriate if plain x-ray is negative for fracture, but occult hip fracture is suspected

MS-25.3 Hip - Osteoarthritis

Hip CT without contrast (CPT®73700) for preoperative planning in patients undergoing total hip replacement.

MS-25.4 Avascular Necrosis (AVN)

See MS-4 Avascular Necrosis (AVN)

Positive plain x-rays do not require further advanced imaging since symptoms are treated only.

Hip MRI without contrast (CPT®73721) can be considered for: o Suspected AVN with negative or equivocal x-rays.

Coding Notes

o Unilateral hip MRI is reported as CPT®73721. o Bilateral hip MRI can be identified in several different ways on the claim.

MedSolutions will approve two separate codes (CPT®73721 x 2). However, providers are urged to check for individual payor preferences

regarding bilateral modifier use.


MS-25.5 Hip - Labral Tear

Hip MRI or Hip arthrography, contrast as requested, in order to diagnose labral tear or for preoperative planning

Practice Notes

The acetabular (hip socket) labrum is similar to the glenoid labrum, but is less frequently torn.

MS-25.6 Hip – Impingement (Femoroacetabular Impingement)

Hip MRI without or with arthrography is appropriate as a preoperative study

Practice Notes

The two types of types of femoral/acetabular impingement can be determined by plain x-ray. The cam type is caused by the loss of the normal “waist” (indention) at the head/neck junction (usually superior) causing incongruity with abduction. The pincer type is caused by an overcoverage/protrusion of the acetabulum causing incongruity with motion.

MS-25.7 Hip - Piriformis Syndrome

See PN-2.4 Sciatic Neuropathy in the Peripheral Nerve Disorders Imaging Guidelines

EMG/NCV may confirm the diagnosis.

Pelvis MRI without contrast (CPT®72195) or pelvis CT without contrast (CPT®72192) is appropriate as a preoperative study

Practice Notes

Piriformis Syndrome is characterized by buttock, thigh, and sometimes calf pain due to entrapment of the sciatic nerve at the sciatic notch in the pelvis by a tight piriformis muscle band and exacerbated by prolonged sitting. There is tenderness in the sciatic notch and pain with flexion, adduction, and internal rotation of the hip (FAIR test).


References

1. ACR Appropriateness Criteria®, Chronic hip pain, 2011. 2. ACR Appropriateness Criteria®, Avascular necrosis of the hip, 2009. 3. Greene WB (Ed.). Essentials of Musculoskeletal Care. 2nd Ed. Rosemont, IL, American Academy of

Orthopaedic Surgeons, 2001,p. 295. 4. Greene WB (Ed.). Essentials of Musculoskeletal Care. 3rd Ed. Rosemont, IL, American Academy of

Orthopaedic Surgeons, 2005, pp.433-436; 438-440. 5. Manek NJ and Lane NE. Osteoarthritis: Current concepts in diagnosis and management. Am Fam

Physician 2000 March;61(6):1795-1804. 6. Papadoupoulos EC and Kahn SN. Piriformis syndrome and low back pain: a new classification and

review of the literature. Orthop Clin North Am 2004 Jan; 35(1): 65-71.Reurink G, Sebastian, et al. Reliability and Validity of Diagnostic Acetabular Labral Lesions with Magnetic Resonance Arthrography. J Bone Joint Surg Am, 2012 Sep 19;94(181): 1643-1648.. pp 1643-1648.

7. Steinbach LS, Palmer WE, Schweitzer ME. MR Arthrography. RadioGraphics 2002;22:1223-1246.


ANATOMICAL AREAS

MS-26~KNEE

MS-26.1 Knee – General

Knee MRI without contrast is appropriate if: o Plain x-ray has been performed; and o Failure 6 weeks conservative treatment which might include NSAIDS, oral


Knee ultrasound (CPT®76881 or CPT®76882) is only useful for the evaluation of Baker’s cyst (see MS-26.7 Baker’s Cyst)

MS-26.2 Knee - Meniscus Tear

Knee MRI without contrast (CPT®73721) is appropriate when at least 2 of the following criteria are met: 1. McMurray’s test positive(rotating the foot while flexing/extending the knee

demonstrates a deep clunk or shift, not a snap or click as noted with crepitus) 2. Twisting or acute injury of the knee 3. Locked knee/inability to fully extend the knee 4. Knee effusion

MRI arthrogram is appropriate for a knee that has had a prior surgery for a meniscus tear

Practice Notes Most meniscal and ligament tears are sustained due to twisting type injuries. Meniscal tears can also be caused by squatting—particularly in the degenerated meniscus. Nearly all are associated with swelling

MS-26.3 Knee - Ligament Tear

MRI without contrast (CPT® 73721) can be considered if any of the following positive signs/tests are present: o Anterior drawer (pulling tibia forward with knee flexed 90 degrees); o Posterior drawer (pushing tibia backward with the knee flexed 90 degrees); o Lachman, (modified anterior drawer with knee at 20 degrees of flexion); o Medial (valgus); or o Lateral (varus)


MS-26.4 Knee - Osteoarthritis

Knee MRI without contrast (CPT®73721) can be considered if: o History and physical exam consistent with internal derangement

(See MS 26.2, MS 26.3) o Concern for malignancy o Unicompartmental knee replacement (medial or lateral) considered when plain x-

rays do not show significant arthritis in the other side of the joint

Knee CT without contrast (CPT®73700) with 3-D rendering (CPT®76377) can be considered for preoperative planning of total knee replacement

MS-26.5 Knee - Patellar Dislocation/Subluxation

Knee MRI without contrast (CPT®73721) can be considered for: o Preoperative study (lateral release or formal extensor realignment if continued

dislocation/subluxation) o Chondral fracture and/or chondral loose body concern

Dynamic MRI and CT imaging for assessment of patellar tracking is considered experimental and investigational at this time

MS-26.6 Knee - Anterior Knee Pain Syndrome

MRI without contrast can be considered after 6 weeks of unsuccessful conservative treatment

Practice Notes

Crepitus is usually caused by chondromalacia (softening of the articular cartilage) which causes a momentary catch or failure of the joint surfaces to slide smoothly.

MS-26.7 Knee – Baker’s Cyst

Ultrasound (CPT®76881 or CPT®76882) is the initial imaging study.

Knee MRI without contrast (CPT®73721) can be considered if preoperative

See also PVD-7.3 Lower Extremity Edema in the Peripheral Vascular Disease Imaging Guidelines

Practice Notes

Cyst posterior to the knee is almost always associated, in adults, with intra-articular knee pathology.


MS-26.8 Knee - Plica (Symptomatic Synovial Plica/Medial Synovial Shelf)

MRI without contrast is appropriate after 6 weeks of unsuccessful conservative treatment which might include NSAIDS, oral steroids, injection, a physician directed home exercise program or physical therapy, or bracing/immobilization.

Practice Notes

Symptomatic Synovial Plica is a clinical diagnosis with symptoms of anterior knee pain, a painful snap or pop with knee flexion, and a palpable and tender cord (usually medially but occasionally laterally or above the patella).

MS-26.9 Knee - Swelling/Effusion

MRI without contrast is appropriate if no definite etiology has been determined after the following sequence: o Plain x-ray is performed initially to evaluate for arthritis or other bony pathology o Ultrasound (CPT®76881 or CPT®76882) may help detect joint effusion and

synovial hypertrophy o 6 weeks of unsuccessful concomitant trial of conservative treatment o Knee aspiration with examination of the knee fluid to rule out crystalline

deposition diseases

Practice Notes

Effusion is a very nonspecific finding. Knee swelling and effusion occurs in many knee conditions. Chondromalacia is one of the most frequent causes of ongoing knee effusion. Effusion can also be a sign of inflammation in the knee which has many causes (arthritis, crystalline deposit diseases, loose body, degenerative meniscal disease, and infectious causes). Effusion can also be due to blood in the knee from an acute fracture or ligament tear.

References

1. Landewé RBM, Günther KP, Lukas C, et al. EULAR/EFFORT recommendations for the diagnosis and initial management of patients with acute or recent onset swelling of the knee. Ann Rheum Dis 2010;69:12-19.

2. Johnson MW. Acute knee effusions: a systematic approach to diagnosis. Am Fam Physician 2000 April;61(8):2391-2400.

3. ACR Appropriateness Criteria, Nontraumatic knee pain, 2008. 4. Sung-Jae Kim, Byoung-Yoon Hwang, Duck-Hyun Choi, Yu-Mei. J Bone Joint Surg Am, 2012 Aug

15;94(16):e118 1-7. 5. Kannus P, Järvinen M. Nonoperative treatment of acute knee ligament injuries. A review with

special reference to indications and methods. Sports Med 1990 April;9(4):244-260. 6. Manek NJ and Lane NE. Osteoarthritis: Current concepts in diagnosis and management. Am Fam

Physician 2000 March;61(6):1795-1804. 7. Greene WB (Ed.). Essentials of Musculoskeletal Care. 3rd Ed. Rosemont, IL, American Academy of

Orthopaedic Surgeons, 2005, p.84; 541-545.


8. Lee IS, Choi JA, Kim TK, et al. Reliability analysis of 16-MDCT in preoperative evaluation of total knee arthroplasty and comparison with intraoperative measurements. AJR 2006 June;186(6):1778-1782.

9. Morrissey RT and Weinstein SL (Eds.). Lovell and Winter’s Pediatric Orthopaedics. 6th Ed. Philadelphia, Uppinortt Williams and Wilkins, p.1413.

MS-27~LEG LENGTH DISCREPANCY

MS-27.1 Leg Length Discrepancy

Either plain radiographic or “CT scanogram”, both reported with CPT®77073, is appropriate to evaluate leg length discrepancy.

References 1. Leitzes A, Potter HG, Amaral T, et. al. Reliability and accuracy of MRI scanogram in the evaluation

of limb length discrepancy. Journal of Pediatric Orthopaedics 2005 Nov/Dec;25(6):747-749. http://www.pedorthopaedics.com.


ANATOMICAL AREAS

MS-28~LEG PAIN/CALF TENDERNESS

MS-28.1 Leg Pain/Calf Tenderness – General

Diagnostic studies such as plain x-ray, ultrasound (CPT®76881 or CPT®76882), venous and/or arterial Doppler (CPT®93970 or CPT®93971 or CPT®93965 and/or CPT®93922 or CPT®93923 or CPT®93924), ankle/brachial index, compartment pressure, and NCV/EMG should be considered initially and can help determine the need for advanced imaging.

MS-28.2 Leg Pain/Calf Tenderness - Stress Fracture of the Tibia

MRI of the tibia without contrast (CPT®73718) is appropriate if suspected, AND if plain x-rays are negative

CT of the tibia without contrast (CPT®73700) is appropriate if concerned about non-union of the stress fracture

MS-28.3 Leg Pain/Calf Tenderness - Shin Splints

MRI of the lower leg without contrast (CPT® 73718) is appropriate if failure of a 4 week trial of conservative treatment, in order to rule out stress fracture of the tibia.

References

1. Harris GD and Hughes BC. Deciphering your patient’s leg pain. Emerg Med 2006;38(6):24-30. 2. Daffner RH, Weissman BN, Appel M, Bancroft L. et al. ACR Appropriateness Criteria®,

Stress(fatigue/insufficiency) fracture, including sacrum, excluding other vertebrae. 2011. 3. Greene WB (Ed.). Essentials of Musculoskeletal Care. 3rd Ed. Rosemont, IL, American Academy of

Orthopaedic Surgeons, 2005, pp.568-570.


ANATOMICAL AREAS

MS-29~ANKLE

MS-29.1 Ankle – General

MRI without contrast is appropriate if: o Plain x-ray has been performed; and o Failure of 6 weeks conservative treatment which might include NSAIDS, oral


One Study/Area Only o In foot and ankle imaging, studies are frequently ordered of both areas. This is

unnecessary since ankle MRI will image from above the ankle to the mid- metatarsal area. Only one CPT® code should be reported.

MS-29.2 Ankle - Sprain (including Avulsion Fracture)

Failure of 6 weeks conservative treatment which might include NSAIDS, oral steroids, injection, a physician directed home exercise program or physical therapy.

Ankle MRI without contrast (CPT®73721) or CT without contrast (CPT®73700) can be considered if suspected: o Osteochondral fracture of the talar dome, o Occult fracture (see MS-5) o Posterior tibial tendon dysfunction o “High ankle sprain,” (injury to the ligaments of the tibiofibular syndesmosis which

attach the distal ends of the tibia and fibula to each other).

Ultrasound (CPT®76881 or CPT®76882) is generally not a preferred study in the evaluation of ankle problems except for suspected tendon abnormality or suspected ankle impingement*

MS-29.3 Ankle - Impingement

Anterior impingement - ultrasound (CPT®76881 or CPT®76882) ultrasound (CPT®76881 r CPT®76882), or Ankle MRI without contrast (CPT®73721)

Anterior-lateral impingement - MR or CT arthrography (CPT®73722 or CPT®73701)

Posterior impingement - Ankle MRI without contrast (CPT®73721)

MS-29.4 Ankle - Tendonitis

Ultrasound (CPT®76881 or CPT®76882) is appropriate if expertise is available, otherwise MRI ankle without contrast (CPT®73721) for indications stated above.


MS-29.5 Ankle - Ruptured Achilles Tendon (Partial/Complete)

MRI without contrast (CPT®73721) or ultrasound (CPT®76881 or CPT®76882) if expertise is available can be considered for pre-operative evaluation for either complete or partial Achilles Tendon rupture/tear.

MS-29.6: Ankle - Lateral Instability

Ankle MRI without contrast (CPT®73721) or MR arthrography (CPT®73722) is appropriate for preoperative evaluation.

References

1. ACR Appropriateness Criteria, Chronic ankle pain, 2009. 2. Wolfe MW, Uhl TL, McClusky LC. Management of ankle sprains. Am Fam Physician 2001

Jan;63(1):93-104. 3. Greene WB (Ed.). Essentials of Musculoskeletal Care. 3rd Ed. Rosemont, IL, American Academy of

Orthopedic Surgeons, 2005, pp.593-596; 606-609; 683. 4. Bergkvist D, Astrom I, Josefsson PO, Dahlberg LE. Acute Achilles Tendon Rupture: A

Questionnaire Follow-up of 487 Patients. J Bone Joint Surg Am, 2012 Jul 03;94(13): 1229-1233. 5. Hartgerink P, Fessell DP, Jacobson JA, et al. Full- versus partial-thickness Achilles tendon tears:

sonographic accuracy and characterization in 26 cases with surgical correlation. Radiology 2001;220:406-412.

6. Jones MP, Riaz JK, Smith RLC. Surgical Interventions for Treating Acute Achlles Tendon Rupture: Key Findings from a Recent Cochrane Review. J Bone Joint Surg Am, 2012 Jun 20;94(12):e88 1-6.


ANATOMICAL AREAS

MS-30~FOOT

MS-30.1 Foot - General

Foot MRI without contrast is appropriate if: o Plain x-ray has been performed; and o Failure of 6 weeks conservative treatment which might include NSAIDS, oral


MS-30.2 Sprain/Fracture/Dislocation/Subluxation (Lisfranc tarsometatarsal fracture)

CT without contrast (CPT®73700) or MRI (CPT®73718) if: o Tarsometatarsal dislocation of the foot (Lisfranc fracture) suspected o Stress fracture suspected after repeat x-ray and failure of 3 weeks conservative

treatment

MS-30.3 Tendonitis

Prior to advanced imaging: o Plain x-rays should be performed to rule out entities such as calcific

tendonitis/bursitis; and o Six weeks of unsuccessful conservative treatment must be completed (for example,

NSAIDS, oral steroids, injection, a physician directed home exercise program or physical therapy).

MRI without contrast (CPT®73718) is the appropriate study if the plain x-rays are nondiagnostic

MS-30.4 Tendon Rupture

MRI without contrast (CPT®73721) is appropriate if unilateral and accompanied by medial foot and/or ankle pain

Practice Notes

Posterior tibial and peroneal tendon ruptures are the most commonly ruptured foot/ankle tendons after the Achilles tendon.

MS-30.5 Morton’s Neuroma

Foot MRI without and with contrast (CPT®73720) is appropriate as a preoperative test


MS-30.6 Plantar Fasciitis

MRI without contrast (CPT®73718) is appropriate: o As a preoperative study for cases unresponsive to non-surgical care for six months

or more o To confirm a calcaneal insufficiency/stress fracture if initial x-rays are negative,

and following two weeks of physician directed presumptive treatment, repeat x-rays are also negative

Practice Notes

Definition: nflammation of plantar fascia at its insertion into the calcaneus (at bottom of heel).

MS-30.7 Diabetic Foot Infection

Foot MRI without and with contrast (CPT®73720) is appropriate with suspected osteomyelitis or deep infection when plain x-ray is negative

MS-30.8 Tarsal Tunnel Syndrome

Ankle MRI without contrast (CPT®73721) or CT without contrast (CPT®73700) is appropriate for: o Preoperative study if mass/lesion is suspected as etiology of the entrapment or to

evaluate for associated tarsal coalition

Practice Notes

Definition: Nerve entrapment of the posterior tibial nerve in the area of the medial malleolus analogous to carpal tunnel syndrome in the wrist.

MS-30.9 Sinus Tarsi Syndrome

Ankle MRI without contrast (CPT®73721) can be considered if: o Diagnosis is unclear; or o Pre-operative evaluation

Practice Notes

Etiology is strain/sprain of the intertarsal ligaments of the subtalar joint.


MS-30.10 Chronic Lateral Ankle/Foot Pain

See MS-29.4 Ankle Impingement in the Ankle guidelines

See MS-29.7 Lateral Instability in the Ankle guidelines

See MS-30.9 Sinus Tarsi Syndrome in the Foot guidelines.

References

1. Greene WB (Ed.). Essentials of Musculoskeletal Care 3rd Ed. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp.619-622; 667-671; 681-684; 697-699; 700-702

2. ACR Appropriateness Criteria, Chronic foot pain, 2008. 3. ACR Appropriateness Criteria, Stress (fatigue/insufficiency) fracture, including sacrum, excluding

other vertebrae, 2011. 4. Fongemie AE, Buss DD, Rolnick SJ. Management of shoulder impingement syndrome and rotator

cuff tears. Am Fam Physician 1998 Feb;57(4):667-674. 5. Needell S and Cutler J. Morton neuroma imaging. eMedicine, April 11, 2011,

http://emedicine.medscape.com/article/401417-overview. Accessed November 7, 2012. 6. Morton’s Neuroma. MDGuidelines™. http://www.mdguidelines.com/mortons-neuroma. Accessed

November 7, 2012. 7. Berquist TH (Ed.). Radiology of the Foot and Ankle. 2nd Ed. Philadelphia, Lippincott, 2000, pp.155-

156. 8. Bouché R. Sinus Tarsi syndrome. American Academy of Podiatric Sports Medicine.

http://www.aapsm.org/sinus_tarsi_syndrome.html. Accessed May 9, 2011 November 7, 2012. 9. D Resnick, Internal Derangements of Joints 2006: Imaging-Arthroscopic Correlation. Washington,

DC, Oct.31- Nov. 4, 2006

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