2025 CPT code 3111F
Effective Date: N/A Revision Date: N/A Category II Codes - Diagnostic/Screening Processes or Results Feed
CT or MRI of the brain performed in the hospital within 24 hours of arrival or in an outpatient imaging center, to confirm initial diagnosis of stroke, TIA, or intracranial hemorrhage (STR).
Modifiers 1P, 2P, 3P (performance measure exclusion modifiers), and 8P (performance measure reporting modifier) may be applicable.
The medical necessity for this code is established by the presence of signs or symptoms suggestive of stroke, TIA, or intracranial hemorrhage requiring urgent imaging confirmation for appropriate management.
- Diagnostic/screening processes or results codes describe results of tests ordered (clinical laboratory tests, radiological or other procedural examinations, and conclusions of medical decision-making).
In simple words: A brain scan (CT or MRI) done within 24 hours of arriving at the hospital or at an outpatient center to confirm a suspected stroke, mini-stroke, or bleeding in the brain.
CT or MRI of the brain performed in the hospital within 24 hours of arrival or in an outpatient imaging center, to confirm the initial diagnosis of stroke, transient ischemic attack (TIA), or intracranial hemorrhage.
Example 1: A 65-year-old patient arrives at the emergency room with symptoms of stroke. A CT scan of the brain is performed within 24 hours to confirm the diagnosis and rule out intracranial hemorrhage., A 78-year-old patient presents to an outpatient imaging center with signs of a TIA. An MRI of the brain is performed to assess the extent of possible ischemia and confirm the diagnosis., A 50-year-old patient with a history of hypertension experiences sudden onset of severe headache. A CT scan is performed within 24 hours of arrival at the hospital to rule out intracranial hemorrhage.
Documentation should include the order for the imaging study, the indication (suspected stroke, TIA, or intracranial hemorrhage), the time of symptom onset, the time of arrival at the facility, and the imaging report documenting the findings.
- Specialties:Neurology, Emergency Medicine, Radiology
- Place of Service:Inpatient Hospital, On Campus-Outpatient Hospital, Off Campus-Outpatient Hospital, Emergency Room - Hospital, Independent Clinic, or Mobile Unit