Knowledge Base Article

In a fit of spring-cleaning this week (well, I guess that would be fall-cleaning technically since it is October), I cleaned out my grandchildren’s toy closet. Those toys beyond repair were trashed and those in good shape but no longer played with I donated. I kept their favorite toys, including those toys that seem timeless even in our current electronic world such as water color paints, building blocks, and magnets. Even as an adult, I am fascinated by the pull of a magnetic field on metal objects. One really big magnet is a Magnetic Resonance Imaging (MRI) machine which has an enormous magnetic pull. This is a cause for concern and extreme caution when a patient is put into an MRI machine. Medicare recently released transmittals expanding coverage of MRI services to patients who have cardiac pacemakers or defibrillators, but only under specific conditions.

MLN Matters Article MM10877 explains that for dates of service on and after April 10, 2018, Medicare will allow for MRI coverage for beneficiaries with an Implanted Pacemaker (PM), Implantable Cardioverter Defibrillator (ICD), Cardiac Resynchronization Therapy Pacemaker (CRT-P), or Cardiac Resynchronization Therapy Defibrillator (CRT-D) according to changes to National Coverage Determination (NCD) 220.2. The MRI must be used according to FDA labeling. For devices that do not have FDA labeling specific to use in an MRI environment, the following conditions must be met:

• MRI field strength is 1.5 Tesla using Normal Operating Mode;
• The implanted pacemaker, ICD, CRT-P, or CRT-D system has no fractured, epicardial, or abandoned leads;
• The facility has implemented a checklist which includes the following:
• patient assessment is performed to identify the presence of an implanted pacemaker, ICD, CRT-P, or CRT-D;
• before the scan benefits and harms of the MRI scan are communicated with the patient or the patient’s delegated decision-maker;
• prior to the MRI scan, the implanted pacemaker, ICD, CRT-P, or CRT-D is interrogated and programmed into the appropriate MRI scanning mode;
• a qualified physician, nurse practitioner, or physician assistant with expertise with implanted pacemakers, ICDs, CRT-Ps, or CRT-Ds must directly supervise the MRI scan as defined in 42 CFR § §410.28 and 410.32;
• patients are observed throughout the MRI scan via visual and voice contact and monitored with equipment to assess vital signs and cardiac rhythm;
• an advanced cardiac life support provider must be present for the duration of the MRI scan;
• a discharge plan that includes before being discharged from the hospital/facility, the patient is evaluated and the implanted pacemaker, ICD, CRT-P, or CRT-D is reinterrogated immediately after the MRI scan to detect and correct any abnormalities that might have developed.

For Medicare patients with implanted PMs, ICDs, CRT-Ps, or CRT-Ds undergoing MRIs both on and off FDA label, providers should report the appropriate MRI code and ICD-10 diagnosis code Z95.0 for cardiac pacemakers and CRT-Ps or code Z95.810 for ICDs and CRT-Ds.

Since the changes to the NCD also include removal of the Coverage with Evidence Development (CED) requirement, the -Q0 and -KX modifiers on claims for MRIs for patients with an implanted pacemaker are no longer required effective April 10, 2018.

These NCD changes expand the benefits of diagnostic MRI studies to Medicare patients with certain cardiac devices. Radiology personnel must still be mindful of potential complications from metallic objects and MRIs. For example, the NCD lists a contraindication for patients with metallic clips on vascular aneurysms. Toy magnets are fun to play with and big magnets have many valuable uses – as long as we remain aware of the dangers.