Guidelines and billing references
Clinical functional Magnetic Resonance Imaging (fMRI) requires expert knowledge in a series of different domains to be completed successfully, including neuroimaging, cognitive design and assessment, and the clinical care of patients with neurological disorders. The validity of fMRI will be critically determined (and potentially invalidated by) the neuroradiological and cognitive skills of the team completing imaging.
As such, clinical billing of fMRI in the US recognizes this varied input:
- 70554: MRI, brain, fMRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration.
- 70555: MRI, brain, fMRI; requiring physician or psychologist administration. Must also be billed with 96020.
- 96020: Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or psychologist, with review of test results and report.
Some discussion on the use of these codes is available in:
- Clinical Use of Functional Magnetic Resonance Imaging: Reflections on the New CPT Codes. Bobholz et al, 2014.
- Hart et al. (2007). Clinical Functional Magnetic Resonance Imaging. Cognitive & Behavioral Neurology: 2007, 20(3): 141.
Consistent with interdisciplinary nature of fMRI, a range of disciplines have put forth clinical guidelines in its use. There is not yet a clear model showing how these different professions can best collaborate to improve clinical care. When it develops, such a model may look like that used in the intracarotid amobarbital procedure (IAT or "Wada" test) which fMRI supplements.
Neuropsychology: Some of the earliest guidelines came from the Division of Neuropsychology, who emphasize the skills required for clinical fMRI and the roles that might be played by different disciplines (APA Division 40, 2004).
Radiology: The American College of Radiology (ACR), the American Society of Neuroradiology (ASNR), and the Society for Pediatric Radiology also provides technical guidelines (ACR-ASNR-SPR, 2014). These focus on technical guidelines on image acquisition. They also provide useful guidelines on reporting of diagnostic imaging (ACR, 2014).
Neurology: Perhaps the best review of evidence supporting and the use of language fMRI for pre-surgical planning is provided in the American Academy of Neurology practice guidelines published this year (Szaflarski et al. 2017).
There is currently a lack of clear guidance on cognitive task selection in language fMRI (see discussion here).
How should I store my data?
There are now multiple different codified data structures available that help you store your MRI data in a way that is clear, simple, and easily understood by others.
This is extremely beneficial in fMRI for many reasons of course; in the clinic it will allow you to easily share data with other groups in the future for research; encourage others working with you to fully document their tasks and analysis; and allow future (unknown) researchers at your institution to revisit and use your data.
A particularly useful standard is "BIDS:" The Brain Imaging Data Structure Specification. This is a quite simple specification that can be set up in a relatively short period of time. Full details are available in the group's brief and clear Nature Scientific Data paper, and in the full specifications on their website.