Download Musculoskeletal Imaging Guidelines Medsolutions

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 patient’s 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
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
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ABBREVIATIONS for MUSCULOSKELETAL GUIDELINES
AP
anteroposterior view
AVN
avascular necrosis/aseptic necrosis
CMS
Centers for Medicare and Medicaid Services
CPK
creatinine phosphokinase
CT
DEXA (DXA)
DMARDS
computed tomography
dual energy x-ray absorptiometry
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
OA
OCD
RA
non steroidal anti-inflammatory drugs
osteoarthritis
osteochondritis dissecans
rheumatoid arthritis
RCT
rotator cuff tear
RICE
rest, ice, compression, elevation
SI
TFCC
sacro-iliac
triangular fibrocartilage complex
TNF
tumor necrosis factor
WBC
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
CPT®
Extremity
76882
Axilla
76882
Chest wall
76604
Upper back
76604
Lower back
76705
Abdominal wall
76705
Other soft-tissue areas
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. 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.
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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 (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 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. 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.
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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). 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
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DISEASE/ INJURY CATEGORY (ALPHABETICAL ORDER)
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.
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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
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
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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 (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.
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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 (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
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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 (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
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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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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.
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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: “Carpal Tunnel Syndrome”, PN-2~Focal Neuropathy 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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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.
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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.
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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.
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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: “Piriformis Syndrome”, PN-2~Focal 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).
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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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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
steroids, injection, a physician directed home exercise program or physical therapy,
or bracing/immobilization
 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)
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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 xrays 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-7.5 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 (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.
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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 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.
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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 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 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.
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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
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 (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.
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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.
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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
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 (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
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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 xrays are also negative
Practice Notes
Definition: inflammation 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.
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MS-30.10 Chronic Lateral Ankle/Foot Pain
See MS-29.3 Ankle Impingement in the Ankle guidelines
See MS-29.6 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.155156.
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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