MedSolutions, Inc. This tool addresses common symptoms and symptom complexes.

Imaging requests for patients with atypical Clinical 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 patients Primary Care Physician (PCP) may provide additional insight.

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.

2014 MedSolutions, Inc.

Musculoskeletal Imaging Guidelines

MUSCULOSKELETAL IMAGING GUIDELINES

Musculoskeletal Imaging Guidelines

Abbreviations MS-1~General Guidelines MS-2~Imaging Techniques MS-3~3D Rendering DISEASE/ INJURY CATEGORY (Alphabetical Order) MS-4~Avascular Necrosis (AVN) MS-5~Fracture and Dislocation MS-6~Foreign Body MS-7~Ganglion Cysts MS-8~Gout, Pseudogout and Crystal Deposition Disease MS-9~Infection/Osteomyelitis MS-10~Mass MS-11~Muscle/Tendon Unit Injuries/Disease MS-12~Osteoarthritis MS-13~Osteochondritis MS-14~OsteoPorosis MS-15~Pagets Disease MS-16~Post-Operative Evaluation MS-17~Rheumatoid Arthritis and Inflammatory Arthritis MS-18~Tendonitis/Bursitis MS-19~Total Joint Prosthesis ANATOMICAL AREAS MS-20~Shoulder MS-21~Elbow MS-22~Wrist MS-23~Hand MS-24~Pelvis MS-25~Hip MS-26~Knee MS-27~Leg Length Discrepancy MS-28~Leg Pain/Calf Tenderness MS-29~Ankle MS-30~Foot
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3 4 6 8 9 9 10 10 10 11 12 13 13 14 15 17 17 18 19 19 20 24 25 26 27 28 31 34 35 36 38 RETURN
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ABBREVIATIONS for MUSCULOSKELETAL GUIDELINES AP AVN CMS CPK CT DEXA (DXA) DMARDS EMG ESR FROM MRI NCV NSAIDS OA OCD RA RCT RICE SI TFCC TNF WBC anteroposterior view avascular necrosis/aseptic necrosis Centers for Medicare and Medicaid Services creatinine phosphokinase computed tomography dual energy x-ray absorptiometry disease modifying anti-rheumatic drugs electromyogram erythrocyte sedimentation rate full range of motion magnetic resonance imaging nerve conduction velocity non steroidal anti-inflammatory drugs osteoarthritis osteochondritis dissecans rheumatoid arthritis rotator cuff tear rest, ice, compression, elevation sacro-iliac triangular fibrocartilage complex tumor necrosis factor white blood cell count

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MUSCULOSKELETAL IMAGING GUIDELINES

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
Extremity Axilla Chest wall Upper back Lower back Abdominal wall Other soft-tissue areas

CPT
76882 76882 76604 76604 76705 76705 76999

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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

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MUSCULOSKELETAL IMAGING GUIDELINES

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.

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References
1. ACR Appropriateness Criteria, Musculoskeletal Imaging topics. 2. ACRSPRSSR 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.

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MUSCULOSKELETAL IMAGING GUIDELINES

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 postprocessing is performed on the scanner workstation (CPT76376) or on an independent workstation (CPT76377). 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 3D 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.

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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.
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DISEASE/ INJURY CATEGORY (ALPHABETICAL ORDER)

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

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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 nonsurgical 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.

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DISEASE/ INJURY CATEGORY (ALPHABETICAL ORDER)

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.

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DISEASE/ INJURY CATEGORY (ALPHABETICAL ORDER)

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. OKane 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.
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DISEASE/ INJURY CATEGORY (ALPHABETICAL ORDER)

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.

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DISEASE/ INJURY CATEGORY (ALPHABETICAL ORDER)

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

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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). Clinicians 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

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DISEASE/ INJURY CATEGORY (ALPHABETICAL ORDER)

MS-15~PAGETS DISEASE
MS-15.1 Pagets 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.

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DISEASE/ INJURY CATEGORY (ALPHABETICAL ORDER)

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.

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DISEASE/ INJURY CATEGORY (ALPHABETICAL ORDER)

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 WBCs] 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

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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 steroids, injection, a physician directed home exercise program or physical therapy, or bracing/immobilization Ultrasound (CPT76881 or CPT76882) 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 (CPT73221) 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 (CPT73221) 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.

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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 (CPT76881 or CPT76882) 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 (CPT73221) 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 CPT73222) 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 (CPT73200) 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

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 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 (CPT73200) or MRI without contrast (CPT73221) 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 (CPT71250) can be considered if a posterior sternoclavicular dislocation is suspected

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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.

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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 (CPT76881 or CPT76882) 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 (CPT73221) is appropriate when distal biceps rupture is suspected based on patient history and physical examination. MS-21.4 Elbow - Trauma CT without contrast (CPT73200) or occasionally MRI without contrast (CPT73221) 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.

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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 (CPT73221) 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.

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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 (CPT73200) 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.

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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 (CPT72192) 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.

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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 (CPT73700) or hip MRI without contrast (CPT73721) 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 (CPT73700) 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 (CPT73721) can be considered for: o Suspected AVN with negative or equivocal x-rays. Coding Notes o Unilateral hip MRI is reported as CPT73721. o Bilateral hip MRI can be identified in several different ways on the claim. MedSolutions will approve two separate codes (CPT73721 x 2). However, providers are urged to check for individual payor preferences regarding bilateral modifier use.
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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 (CPT72195) or pelvis CT without contrast (CPT72192) 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).

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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.

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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 steroids, injection, a physician directed home exercise program or physical therapy, or bracing/immobilization Knee ultrasound (CPT76881 or CPT76882) is only useful for the evaluation of Bakers cyst (see MS-26.7 Bakers Cyst) MS-26.2 Knee - Meniscus Tear Knee MRI without contrast (CPT73721) is appropriate when at least 2 of the following criteria are met: 1. McMurrays 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 squattingparticularly 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)

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MS-26.4 Knee - Osteoarthritis Knee MRI without contrast (CPT73721) 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 xrays do not show significant arthritis in the other side of the joint Knee CT without contrast (CPT73700) with 3-D rendering (CPT76377) can be considered for preoperative planning of total knee replacement MS-26.5 Knee - Patellar Dislocation/Subluxation Knee MRI without contrast (CPT73721) 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 Bakers Cyst Ultrasound (CPT76881 or CPT76882) is the initial imaging study. Knee MRI without contrast (CPT73721) 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.

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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 (CPT76881 or CPT76882) 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. Landew RBM, Gnther 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, Jrvinen 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.
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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):17781782. 9. Morrissey RT and Weinstein SL (Eds.). Lovell and Winters 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 CPT77073, 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.

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MS-28~LEG PAIN/CALF TENDERNESS

MS-28.1 Leg Pain/Calf Tenderness General Diagnostic studies such as plain x-ray, ultrasound (CPT76881 or CPT76882), venous and/or arterial Doppler (CPT93970 or CPT93971 or CPT93965 and/or CPT93922 or CPT93923 or CPT93924), 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 (CPT73718) is appropriate if suspected, AND if plain x-rays are negative CT of the tibia without contrast (CPT73700) is appropriate if concerned about nonunion 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 patients 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.

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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 steroids, injection, a physician directed home exercise program or physical therapy, or bracing/immobilization 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 midmetatarsal 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 (CPT73721) or CT without contrast (CPT73700) 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 (CPT76881 or CPT76882) 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 (CPT76881 or CPT76882) ultrasound (CPT76881 r CPT76882), or Ankle MRI without contrast (CPT73721) Anterior-lateral impingement - MR or CT arthrography (CPT73722 or CPT73701) Posterior impingement - Ankle MRI without contrast (CPT73721) MS-29.4 Ankle - Tendonitis Ultrasound (CPT76881 or CPT76882) is appropriate if expertise is available, otherwise MRI ankle without contrast (CPT73721) for indications stated above.
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MS-29.5 Ankle - Ruptured Achilles Tendon (Partial/Complete) MRI without contrast (CPT73721) or ultrasound (CPT76881 or CPT76882) 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 (CPT73721) or MR arthrography (CPT73722) 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.

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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 steroids, injection, a physician directed home exercise program or physical therapy, or bracing/immobilization MS-30.2 Sprain/Fracture/Dislocation/Subluxation (Lisfranc tarsometatarsal fracture) CT without contrast (CPT73700) or MRI (CPT73718) 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 (CPT73718) is the appropriate study if the plain x-rays are nondiagnostic MS-30.4 Tendon Rupture MRI without contrast (CPT73721) 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 Mortons Neuroma Foot MRI without and with contrast (CPT73720) is appropriate as a preoperative test

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MS-30.6 Plantar Fasciitis MRI without contrast (CPT73718) 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 xrays 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 (CPT73720) is appropriate with suspected osteomyelitis or deep infection when plain x-ray is negative MS-30.8 Tarsal Tunnel Syndrome Ankle MRI without contrast (CPT73721) or CT without contrast (CPT73700) 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 (CPT73721) 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.

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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. Mortons 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.155156. 8. Bouch 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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