EviCore Pediatric Musculoskeletal Imaging Guidelines
CLINICAL GUIDELINESPediatric Musculoskeletal ImagingGuidelinesVersion 1.1Effective October 1, 2020eviCore healthcare Clinical Decision Support Tool Diagnostic Strategies:This tool addresses common symptoms and symptom complexes. Imaging requests for individualswith atypical symptoms or clinical presentations that are not specifically addressed will require physician review. Consultation with the referring physician, specialist and/orindividual’s Primary Care Physician (PCP) may provide additional insight.CPT (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT five digit codes, nomenclature and other data arecopyright 2020 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in the CPT book. AMA doesnot directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein. 2020 eviCore healthcare. All rights reserved.
Pediatric Musculoskeletal Imaging GuidelinesPediatric Musculoskeletal Imaging GuidelinesProcedure Codes Associated with Musculoskeletal ImagingPEDMS-1: General GuidelinesPEDMS-2: Fracture and DislocationPEDMS-3: Soft Tissue and Bone MassesPEDMS-4: Limping ChildPEDMS-5: Developmental Dysplasia of the HipPEDMS-6: Avascular Necrosis (AVN) / Legg-Calvé-PerthesDisease/Idiopathic OsteonecrosisPEDMS-7: Suspected Physical Child AbusePEDMS-8: Infection/OsteomyelitisPEDMS-9: Foreign BodyPEDMS-10: Inflammatory Musculoskeletal DiseasePEDMS-11: Muscle/Tendon Unit InjuriesPEDMS-12: Osgood-Schlatter DiseasePEDMS-13: Popliteal (Baker) CystPEDMS-14: Slipped Capital Femoral Epiphysis (SCFE)PEDMS-15: Limb Length DiscrepancyPEDMS-16: Congenital Anomalies of the FootV1.135101417202225272829333435363738 2020 eviCore healthcare. All Rights Reserved.Page 2 of 39400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924www.eviCore.com
Pediatric Musculoskeletal Imaging GuidelinesV1.1Procedure Codes Associated with MusculoskeletalImagingCPT Upper Extremity MRI non-joint without contrastUpper Extremity MRI non-joint with contrast (rarely used)Upper Extremity MRI non-joint without and with contrastUpper Extremity MRI joint without contrastUpper Extremity MRI joint with contrast (rarely used)Upper Extremity MRI joint without and with contrastLower Extremity MRI non-joint without contrastLower Extremity MRI non-joint with contrast (rarely used)Lower Extremity MRI non-joint without and with contrastLower Extremity MRI joint without contrastLower Extremity MRI joint with contrast (rarely used)Lower Extremity MRI joint without and with contrastUnlisted MRI procedure (for radiation planning or surgical 372073721737227372376498Upper Extremity MRALower Extremity MRA7322573725MRACTCPT CPT Upper Extremity CT without contrastUpper Extremity CT with contrastUpper Extremity CT without and with contrastLower Extremity CT without contrastLower Extremity CT with contrastLower Extremity CT without and with contrastBone Mineral Density CT, one or more sites, axial skeletonBone Mineral Density CT, one or more sites, appendicular skeletonCT Guidance for Placement of Radiation Therapy FieldsUnlisted CT procedure (for radiation planning or surgical 701476497Upper Extremity CTALower Extremity CTA7320673706CTANuclear MedicinePET Imaging; limited area (this code not used in pediatrics)PET Imaging: skull base to mid-thigh (this code not used in pediatrics)PET Imaging: whole body (this code not used in pediatrics)PET with concurrently acquired CT; limited area (this code rarely used inpediatrics)PET with concurrently acquired CT; skull base to mid-thighPET with concurrently acquired CT; whole bodyBone Marrow Imaging Limited AreasBone Marrow Imaging Multiple AreasBone Marrow Imaging Whole BodyNuclear Bone Scan LimitedNuclear Bone Scan Multiple AreasNuclear Bone Scan Whole BodyCPT CPT 7830578306 2020 eviCore healthcare. All Rights Reserved.Page 3 of 39400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924www.eviCore.comPediatric Musculoskeletal ImagingMRI
V1.1Bone Scan Three PhaseDEXA Bone Densitometry, axial skeletonDEXA Bone Densitometry, peripheral skeletonRadiopharmaceutical localization of tumor, inflammatory process or distribution ofradiopharmaceutical agent(s) (includes vascular flow and blood pool imaging,when performed); planar, single area (eg, head, neck, chest, pelvis), single dayimagingRadiopharmaceutical localization of tumor, inflammatory process or distribution ofradiopharmaceutical agent(s) (includes vascular flow and blood pool imaging,when performed); planar, 2 or more areas (eg, abdomen and pelvis, head andchest), 1 or more days imaging or single area imaging over 2 or more daysRadiopharmaceutical localization of tumor, inflammatory process or distribution ofradiopharmaceutical agent(s) (includes vascular flow and blood pool imaging,when performed); planar, whole body, single day imagingRadiopharmaceutical localization of tumor, inflammatory process or distribution ofradiopharmaceutical agent(s) (includes vascular flow and blood pool imaging,when performed); tomographic (SPECT), single area (eg, head, neck, chest,pelvis), single day imaging783157708077081Ultrasound, extremity, nonvascular; complete jointUltrasound, extremity, nonvascular; limited, anatomic specific for focal abnormalityUltrasound, infant hips; dynamic (requiring physician manipulation)Ultrasound, infant hips; limited, static (not requiring physician manipulation)Ultrasound, axillaUltrasound, upper backUltrasound, lower backUltrasound, other soft tissue areas not otherwise specifiedLimited bilateral noninvasive physiologic studies of upper or lower extremityarteriesComplete bilateral noninvasive physiologic studies of upper or lower extremityarteriesDuplex scan of upper extremity arteries or arterial bypass grafts; complete bilateralDuplex scan of upper extremity arteries or arterial bypass grafts; unilateral orlimitedNon-invasive physiologic studies of extremity veins, complete bilateral studyDuplex scan of extremity veins including responses to compression and othermaneuvers; complete bilateral studyDuplex scan of extremity veins including responses to compression and othermaneuvers; unilateral or limited studyDuplex scan of hemodialysis access (including arterial inflow, body of access andvenous trasound78800788017880278803CPT 9392293923939309393193965939709397193990 2020 eviCore healthcare. All Rights Reserved.Page 4 of 39400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924www.eviCore.comPediatric Musculoskeletal ImagingPediatric Musculoskeletal Imaging Guidelines
Pediatric Musculoskeletal Imaging GuidelinesPEDMS-1: General GuidelinesPEDMS-1.0: General GuidelinesPEDMS-1.1: Age ConsiderationsPEDMS-1.2: Appropriate Clinical Evaluation and ConservativeTreatmentPEDMS-1.3: Modality General ConsiderationsV1.16667 2020 eviCore healthcare. All Rights Reserved.Page 5 of 39400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924www.eviCore.com
Pediatric Musculoskeletal Imaging GuidelinesV1.1PEDMS-1.0: General Guidelines A recent (within 60 days) face to face evaluation including a detailed history,physical examination, appropriate laboratory studies, and basic imaging such asplain radiography or ultrasound should be performed prior to considering advancedimaging (CT, MR, Nuclear Medicine), unless the patient is undergoing guidelinesupported scheduled imaging evaluation. Plain x-ray should be done prior to advanced imaging for musculoskeletal conditionsto rule out those situations that do not require advanced imaging, such asacute/healing fracture, osteomyelitis, and tumors of bone amenable to biopsy orradiation therapy (in known metastatic disease), etc. Even in soft tissue masses, plain x-rays are helpful in evaluating for calcium/bonydeposits, e.g. myositis ossificans and invasion of bone. Unless otherwise stated in a specific guideline section, repeat imaging studies of thesame body area are not necessary unless there is evidence for progression ofdisease, new onset of disease, and/or documentation of how repeat imaging willaffect patient management or treatment decisions. These guidelines are based upon using advanced imaging to answer specific clinicalquestions that will affect patient management. Imaging is not indicated if the resultswill not affect patient management decisions. Standard medical practice woulddictate continuing conservative therapy prior to advanced imaging in patients whoare improving on current treatment programs.PEDMS-1.1: Age Considerations Many conditions affecting the musculoskeletal system in the pediatric population aredifferent diagnoses than those occurring in the adult population. For those diseaseswhich occur in both pediatric and adult populations, differences may exist inmanagement due to patient age, comorbidities, and differences in disease naturalhistory between children and adults. Patients who are 18 years old should be imaged according to the PediatricMusculoskeletal Imaging Guidelines, and patients who are 18 years old should beimaged according to the adult Musculoskeletal Imaging Guidelines, except wheredirected otherwise by a specific guideline section.PEDMS-1.2: Appropriate Clinical Evaluation and ConservativeTreatment See: PEDMS-1.0: General Guidelines 2020 eviCore healthcare. All Rights Reserved.Page 6 of 39400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924www.eviCore.comPediatric Musculoskeletal Imaging Provider-directed conservative care may include any or all of the following: R.I.C.E(rest, ice, compression, and elevation), NSAIDs (non-steroidal anti-inflammatorydrugs), narcotic and non-narcotic analgesic medications, oral or injectablecorticosteroids, viscosupplementation injections, a provider-directed home exerciseprogram, cross-training, physical medicine, or immobilization bysplinting/casting/bracing.
Pediatric Musculoskeletal Imaging GuidelinesV1.1 MRI MRI without contrast is the preferred modality for pediatric musculoskeletalimaging unless otherwise stated in a specific guideline section, as it is superior inimaging the soft tissues and can also define physiological processes in someinstances, e.g. edema, loss of circulation (AVN), and increased vascularity(tumors). MRI without and with contrast is frequently recommended for evaluation oftumors, infection, post-operative evaluation, arthrography, and juvenile idiopathicarthritis, as described in the disease-specific guideline sections. Due to the length of time required for MRI acquisition and the need to minimizepatient movement, anesthesia is usually required for almost all infants (exceptneonates) and young children (age 7 years), as well as older children withdelays in development or maturity. This anesthesia may be administered via oralor intravenous route. In this patient population, MRI sessions should be plannedwith a goal of minimizing anesthesia exposure by adhering to the followingconsiderations: MRI procedures can be performed without and/or with contrast use assupported by these condition based guidelines. If intravenous access willalready be present for anesthesia administration and there is nocontraindication for using contrast, imaging without and with contrast may beappropriate if requested. By doing so, the requesting provider may avoidrepetitive anesthesia administration to perform an MRI with contrast if theinitial study without contrast is inconclusive. Recent evidence based literature demonstrates the potential forgadolinium deposition in various organs including the brain, after the useof MRI contrast. The U.S. Food and Drug Administration (FDA) has noted that there iscurrently no evidence to suggest that gadolinium retention in the brain isharmful and restricting gadolinium-based contrast agents (GBCAs) use isnot warranted at this time. It has been recommended that GBCA useshould be limited to circumstances in which additional informationprovided by the contrast agent is necessary and the necessity of repetitiveMRIs with GBCAs should be assessed. If multiple body areas are supported by eviCore guidelines for the clinicalcondition being evaluated, MRI of all necessary body areas should beobtained concurrently in the same imaging session. The presence of surgical hardware or implanted devices may preclude MRI, asmagnetic field distortion may limit detail in adjacent structures. CT may be theprocedure of choice in these cases. The selection of best examination may require coordination between the providerand the imaging service. 2020 eviCore healthcare. All Rights Reserved.Page 7 of 39400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924www.eviCore.comPediatric Musculoskeletal ImagingPEDMS-1.3: Modality General Considerations
Pediatric Musculoskeletal Imaging GuidelinesV1.1 CT CT without contrast is generally superior to MRI for imaging bone and jointanatomy; thus it is useful for studying complex fractures (particularly of the joints,dislocations, and assessing delayed union or non-union of fractures, integrationof bone graft material, if plain x-rays are equivocal. CT should not be used to replace MRI in an attempt to avoid sedation unlesslisted as a recommended study in a specific guideline section. CT beam attenuation can result in streak artifact which can obscure adjacentdetails. This can occur with radiopaque material such as metal objects or densebones. The selection of best examination may require coordination between therequesting provider and the rendering imaging facility. Nuclear Medicine Nuclear medicine studies are commonly used in evaluation of the peripheralmusculoskeletal system, and other rare indications exist as well: Bone scan (CPT 78315) or Distribution Of Radiopharmaceutical AgentSPECT (CPT 78803) is indicated for evaluation of suspected loosening oforthopedic prostheses when recent plain x-ray is nondiagnostic. Nuclear medicine bone marrow imaging (CPT codes: CPT 78102, CPT 78103, or CPT 78104) is indicated for detection of ischemic or infarctedregions in sickle cell disease. Triple phase bone scan (CPT 78315) is indicated for evaluation of complexregional pain syndrome or reflex sympathetic dystrophy. 3D Rendering 3D Rendering indications in pediatric musculoskeletal imaging are identical tothose for adult patients. See MS-3: 3D Rendering for imaging guidelines.The guidelines listed in this section for certain specific indications are not intended to beall-inclusive; clinical judgment remains paramount and variance from these guidelinesmay be appropriate and warranted for specific clinical situations. 2020 eviCore healthcare. All Rights Reserved.Page 8 of 39400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924www.eviCore.comPediatric Musculoskeletal Imaging Ultrasound Ultrasound is frequently used to evaluate infants for hip dysplasia, to detectand/or aspirate joint effusion, and as an initial evaluation of extremity soft tissuemasses. CPT codes vary by body area and the use of Doppler imaging. These CPT codes are included in the table at the beginning of this guideline.
Pediatric Musculoskeletal Imaging GuidelinesV1.1ReferencesPediatric Musculoskeletal Imaging1. ACR–ASER–SCBT-MR–SPR Practice Parameter for the performance of pediatric computedtomography (CT) Revised 2014 (Resolution 3), meters/CT-Ped.pdf?la en2. ACR–SPR–SSR PRACTICE PARAMETER FOR THE PERFORMANCE OFRADIOGRAPHY OF THE EXTREMITIES Revised 2018 (Resolution 6) meters/Rad-Extremity.pdf?la en3. ACR Practice Parameter for performing and interpreting magnetic resonance imaging (MRI) Revised2017 (Resolution 10). ameters/MR-PerfInterpret.pdf4. Biassoni L, Easty M, Paediatric nuclear medicine imaging. Br Med Bull 2017; 123:127-48.5. Ing C, DiMaggio C, Whitehouse A, et al. Long-term differences in language and cognitive functionafter childhood exposure to anesthesia. Pediatrics. 2012 Sep;130(3):e476-e485. doi:10.1542/peds.2011-3822d6. Monteleone M, Khandji A, Cappell J, et al. Anesthesia in children: perspectives from nonsurgicalpediatric specialists. J Neurosurg Anesthesiol. 2014 Oct; 26(4):396-398. doi:10.1097/ana.00000000000001247. DiMaggio C, Sun LS, and Li G. Early Childhood exposure to anesthesia and risk of developmentaland behavioral disorders in a sibling birth cohort. Anesth Analg. 2011 Nov;113(5):1143-1151. doi:10.1213/ane.0b013e3182147f428. Hindorf C, Glatting G, Chiesa C, et al. EANM Dosimetry committee guidelines for bone marrow andwhole body dosimetry. Eur J Nucl Med Mol Imaging. 2010 Jun;37(6):1238-1250. doi:10.1007/s00259-010-1422-49. Hryhorczuk AL, Restropo R, Pediatric musculoskeletal ultrasound: practical imaging approach. AJR2016; 206:62-W72.10. Fraum TJ, Ludwig DR, Bashir MR, et al. Gadolinium-based contrast agents: a comprehensive riskassessment. J. Magn. Reson. Imaging. 2017 Aug; 46(2):338–353.doi: 10.1002/jmri.2562511. FDA Medical Imaging Drug Advisory Committee meeting 9/8/17 Minutes available rugsAdvisoryCommittee/UCM574746.pdf.12. Siegel MJ. Musculoskeletal system and vascular imaging. Chapter 15 In: Pediatric sonography. 5thed. Philadelphia. Wolters Kluwer. 2018:601-11. 2020 eviCore healthcare. All Rights Reserved.Page 9 of 39400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924www.eviCore.com
Pediatric Musculoskeletal Imaging GuidelinesPEDMS-2: Fracture and DislocationPEDMS-2.1: Acute FracturePEDMS-2.2: Joint FracturePEDMS-2.3: Growth Plate Injuries (Salter-Harris Fractures)PEDMS-2.4: Osteochondral or Chondral Fractures, IncludingOsteochondritis DissecansPEDMS-2.5: Stress/Occult FracturePEDMS-2.6: Compartment SyndromePEDMS-2.7: Physical Child AbuseV1.111111112121213 2020 eviCore healthcare. All Rights Reserved.Page 10 of 39400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924www.eviCore.com
Pediatric Musculoskeletal Imaging GuidelinesV1.1 A recent (within 60 days) evaluation including a detailed history, physicalexamination, and plain radiography should be performed prior to consideringadvanced imaging.PEDMS-2.1: Acute Fracture Plain x-rays should be performed initially in any obvious or suspected acute fractureor dislocation. If plain x-rays are positive, no further imaging is generally indicated except incomplex (comminuted or displaced) joint fractures where MRI or CT withoutcontrast can be approved for preoperative planning. 3D Rendering may sometime be indicated for complex fracture repairs. See MS3: 3D Rendering for imaging guidelines. If plain x-rays are negative or equivocal for fracture, and fracture or bone marrowedema is still clinically suspected, CT or MRI without contrast is indicated if theresults will determine immediate treatment decisions as documented by the treatingphysician. Bone scan may be approved for evaluation of suspected fracture when two x-raysare negative at least 10 days apart, using any of the following CPT codecombinations: CPT 78300, CPT 78305, or CPT 78306 as a single study See PEDMS-2.5: Stress/Occult Fracture for bone scan indicationsPEDMS-2.2: Joint Fracture CT can be approved when there is clinical concern for delayed union or non-union offracture or joint fusions on follow-up plain x-ray.PEDMS-2.3: Growth Plate Injuries (Salter-Harris Fractures) These fractures can generally be diagnosed and managed adequately with plain xray. In case of severe injury with displacement of bone fractures, CT may be indicatedprior to surgical intervention.
Pediatric Musculoskeletal Imaging CT CT without contrast is generally superior to MRI for imaging bone and joint anatomy; thus it is useful for studying complex fractures (particularly of the joints,
Musculoskeletal Imaging Guidelines Procedure Codes associated with Musculoskeletal Imaging 3 MS-1: General Guidelines 5 MS-2: Imaging Techniques 7 MS-3: 3D Rendering 12 MS-4: Avascular Necrosis (AVN)/Osteonecrosis 13 MS-5: Fractures 16 MS-6: Foreign Body 20 MS-7: Ganglion Cysts 22
Musculoskeletal Imaging Guidelines Procedure Codes associated with Musculoskeletal Imaging 3 MS-1: General Guidelines 5 MS-2: Imaging Techniques 7 MS-3: 3D Rendering 11 MS-4: Avascular Necrosis (AVN)/Osteonecrosis 12 MS-5: Fractures 15 MS-6: Foreign Body 19 MS-7: Ganglion Cysts 21 MS-8: Gout/Calcium Pyrophosphate Deposition Disease
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Head to Toe Imaging Conference 34th Annual Morton A. Bosniak The Department of Radiology Presents: New York Hilton Midtown December 14–18, 2015 Monday, Dec. 14 Abdominal Imaging & Emergency Imaging Tuesday, Dec. 15 Thoracic Imaging & Cardiac Imaging Wednesday, Dec. 16 Neuroradiology & Pediatric Imaging Thursday, Dec. 17 Musculoskeletal Imaging & Interventional
Communication Skills Learning Tools for the Pediatric Clerkship 37 Pediatric History Taking Approach to the Pediatric Patient 38-39 Explanation of Pediatric H&Ps/Pediatric Database 40-43 Example H&Ps (older child and infant) 44-52 Pediatric Physical Examination Benchmarks for Pediatric Physical Examination 53 54-65
The need for repeat advanced imaging should be carefully considered and may not be indicated if prior imaging has been performed. Serial advanced imaging, whether CT or MRI, for surveillance of healing or recovery from musculoskeletal disease is not supported by the medical evidence in the majority of musculoskeletal conditions.
titles in Radiology. Radiology Books Journals Electronic Resources 2016. 3 Contents 3 Neurologic Imaging 6 Abdominal Imaging 7 Breast Imaging 8 Diagnostic Imaging 9 Pediatric Imaging 10 Thieme eRadiology 11 General Radiology 13 Musculoskeletal Imaging 14 Interventional Radiology 16 RadCases
This book is meant to provide a thorough introduction to Description Logics, equently,thebookisdividedintothreeparts: Part I introduces the theoretical foundations of Description Logics, addressing some of
