AMA Clinical Examples in Radiology - 2026 Issue 1 (Winter)
Magnetic Resonance Neurography
Winter 2026 pages 9-13 DOCUMENTATION CHALLENGE Reports that fail to adequately support the coding for the procedure performed not only have serious implications for fraud and abuse but also may negatively affect how the physician can report the procedure. In each issue, you will be provided with a documentation challenge. This documentation challenge will serve as a learning tool for both coders and physicians. Magnetic Resonance Neurography CLINICAL INDICATION A 67-year-old male presents with left arm pain and a history of lymphoma. PROCEDURE Magnetic resonance neurography (MRN) of the left brachial plexus TECHNIQUE Magnetic resonance imaging (MRI) of the...
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Article Overview
This premium coding article uses a documentation challenge to review how magnetic resonance neurography should be supported in the medical record and why missing anatomic detail can make code assignment uncertain. It is aimed at coders, radiology staff, and physicians who document MRI studies involving the brachial plexus and related anatomy. The discussion also references CPT guidance, CPT Assistant, and Medicare MRI coverage policy as part of the coding context.
Why This Topic Matters
Accurate documentation determines whether the imaging service can be coded appropriately and whether the report supports the selected CPT code. The article explains why clarifying the scanned anatomy and study context matters for compliant reporting.
Article Sections
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Winter 2026 pages 9-13
Issue and page reference for the documentation challenge presented in the article.
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Documentation Challenge
Overview of the coding and documentation problem presented for review.
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Clinical Indication
Brief patient context and reason the examination was performed.
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Procedure
General description of the imaging study that was performed.
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Technique
Technical imaging approach and whether contrast was used.
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Findings
Summary of imaging observations across the brachial plexus and other imaged structures.
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Impression
Condensed interpretation of the study findings and differential considerations.
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How to Code
Discussion of documentation gaps, code selection considerations, and related guidance sources.
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Discussion
Expanded explanation of why an accurate code cannot be selected from the report as written and what documentation elements are relevant.
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Sources
Cited reference materials from professional and Medicare sources.
What You Will Learn
- How documentation quality affects MRI-related code selection
- What information is important when coding neurography studies
- How scan anatomy and study context influence reporting decisions
- Which sources are referenced for professional and Medicare guidance
Who Should Read This
- Medical coders
- Radiology coders
- Radiologists
- Physician documentation staff
- Compliance professionals
Codes Discussed
Code Ranges Discussed
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