ACRIN 6651/Economic Forms CPT Code Listing
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1 ACRIN 6651/Economic Forms CPT Code Listing 1 EX Form 1. Pelvic Exam (unsure of how to capture, only pelvic exam with anesthesia available). 2. Intravenous Pyelogram Urography (pyelography), intravenous, with or without KUB, with or without tomography Urography (pyelography), intravenous, with or without KUB, with or without tomography; with special hypersensitive contrast concentration and/or clearance studies. 3. Barium Enema Exam 4. Cystoscopy 5. Proctoscopy Radiologic examination, colon; barium enema, with or without KUB Radiologic examination, colon; air contrast with specific high density barium, with or without glucagon Cystourethroscopy (separate procedure) Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with brush biopsy of ureter and/or renal pelvis Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) Proctosigmoidoscopy, rigid; with dilation, any method Proctosigmoidoscopy, rigid; with biopsy, single or multiple 6. Lymphangiogram Lymphangiography, pelvic/abdominal, unilateral, radiological supervision and interpretation Lymphangiography, pelvic/abdominal, bilateral, radiological supervision and interpretation 7. Pelvic Exam With Anesthesia 8. Colposcopy Pelvic exam with anesthesia Colposcopy (vaginoscopy); (separate procedure) Colposcopy (vaginoscopy); with biopsy(s) of the cervix and/or endocervical curettage Colposcopy (vaginoscopy); with loop electrode excision procedure of the cervix 9. Chest Imaging Radiologic examination, chest, two views, frontal and lateral; Radiologic examination, chest, complete, minimum of four views; Computerized axial tomography, thorax; without contrast material Computerized axial tomography, thorax; with contrast material
2 2 EX Form (con t) 10. Pelvic CT Computerized axial tomography, thorax; without contrast material Computerized axial tomography, thorax; with contrast material Computerized axial tomography, thorax; without contrast material, followed by contrast material(s)and further sections 11. Pelvic MRI Magnetic resonance (eg, proton) imaging, pelvis , 14: Other, specify 15. CT see number MRI see number PAP Cytopathology, smears, cervical or vaginal, up to three smears; screening by technician under physician supervision Cytopathology, smears, cervical or vaginal, up to three smears; requiring interpretation by physician Cytopathology, smears, cervical or vaginal, up to three smears; with definitive hormonal evaluation (eg, maturation index, karyopyknotic index, estrogenic index) Consultations: 17, 18, 19, 20, Office consultation for a new or established patient, which requires these three key components: a) problem focused history; b) a problem focused examination; c) straightforward medical decision making Office consultation for a new or established patient, which requires these three key components: a) an expanded problem focused history; b) an expanded problem focused examination; c) straightforward medical decision making Office consultation for a new or established patient, which requires these three key components: a) detailed history; b) a detailed examination; c) medical decision making of low complexity Office consultation for a new or established patient, which requires these three key components: a) a comprehensive history; b) a comprehensive examination; c) medical decision making of moderate complexity Office consultation for a new or established patient, which requires these three key components: a) a comprehensive history; b) a comprehensive examination; c) medical decision making of high complexity Follow Up: 17, 18, 19, 20, Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a) a problem focused history; b) a problem focused examination; c) straightforward medical decision making Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a) an expanded problem focused history; b) an expanded problem focused examination; c) medical decision making of low complexity.
3 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a) a detailed history; b) a detailed examination; c) medical decision making of moderate complexity Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a) a comprehensive history; b) a comprehensive examination; c) medical decision making of high complexity. EX Form (con t) 22. Pelvic Lymph Node Sampling Biopsy or excision of lymph nodes(s); superficial (separate procedure) Biopsy or excision of lymph node(s); by needle, superficial (eg, cervical, inguinal, axillary) Limited lymphadenectomy for staging (separate procedure); pelvic and para-aortic Limited lymphadenectomy for staging (separate procedure); retroperitoneal (aortic and/or splenic) 23. Other, specify
4 4 WX Form 1. Hysterectomy Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with or without removal of tube(s), with or without removal of ovary(s) Pelvic exenteration for gynecologic malignancy, with total abdominal hysterectomy or cervicectomy, with or without removal of tube(s), with or without removal of ovary(s), with removal of bladder and ureteral transplantations, and/or abdominoperineal resection of rectum and colon and colostomy, or any combination thereof 2. Pelvic Lymphadenectomy Pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes (separate procedure) Limited lymphadenectomy for staging (separate procedure); pelvic and para-aortic Limited lymphadenectomy for staging (separate procedure); retroperitoneal (aortic and/or splenic) 3. Hospital stay (I am not sure if these codes are needed, but the following are CPT codes for hospital stay) Initial Hospital Care/New or Established Patient Initial hospital care, per day, for the evaluation and management of a patient which requires these three key components: a) a detailed or comprehensive history; b) detailed or comprehensive examination; c) medical decision making that is straightforward or of low complexity Initial hospital care, per day, for the evaluation and management of a patient which requires these three key components: a) a comprehensive history; b) a comprehensive examination; c) medical decision making of moderate complexity Initial hospital care, per day, for the evaluation and management of a patient which requires these three key components: a) a comprehensive history; b) a comprehensive examination; c) medical decision making of high complexity Subsequent Hospital Care Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a) a problem focused interval history; b) a problem focused examination; c) medical decision making that is straightforward or of low complexity Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a) an expanded problem focused interval history; b) an expanded problem focused examination; c) medical decision making of moderate complexity Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a) a detailed interval history; b) a detailed examination; c) medical decision making of high complexity Hospital Discharge Services Hospital discharge day management; 30 minutes or less Hospital discharge day management; more than 30 minutes
5 WX Form (con t) 4. Radiation Therapy Therapeutic radiology treatment planning; simple Therapeutic radiology treatment planning; intermediate Therapeutic radiology treatment planning; complex Therapeutic radiology simulation-aided field setting; simple Therapeutic radiology simulation-aided field setting; intermediate Therapeutic radiology simulation-aided field setting; complex Therapeutic radiology simulation-aided field setting; by three-dimensional reconstruction of tumor volume in preparation for treatment with non-coplanar therapy beams Basic radiation dosimetry calculation, central axis depth dose, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, as required during course of treatment, only when prescribed by the treating physician Teletherapy, isodose plan (whether hand or computer calculated); simple (one or two parallel opposed unmodified ports directed to a single area of interest Teletherapy, isodose plan (whether hand or computer calculated); intermediate (three or more treatment ports directed to a single area of interest) Teletherapy, isodose plan (whether hand or computer calculated); complex (mantle or inverted Y, tangential ports, the use of wedges, compensators, complex blocking, rotational beam, or special beam considerations) Brachytherapy isodose calculation; simple (calculation made from single plane, one to four sources/ribbon application, remote afterloading brachytherapy, 1 to 8 sources) Brachytherapy isodose calculation; intermediate (multiplane dosage calculations, application involving five to ten sources/ribbons, remote afterloading brachytherapy, 9-12 sources) Brachytherapy isodose calculation; complex (multiplane isodose plan, volume implant calculations, over ten sources/ribbons used, special spatial reconstruction, remote afterloading brachytherapy, over 12 sources) Special Dosimetry (eg, TLD, microdosimetry) (specify), only when prescribed by the treating MD Treatment devices, design and construction; simple (simple block, simple bolus) Treatment devices, design and construction; intermediate (multiple blocks, stents, bite blocks, special bolus) Treatment devices, design and construction; complex (irregular blocks, special shields, compensators, wedges, molds or casts) Continuing medical radiation physics consultation in support of therapeutic radiologist including continuing quality assurance reported per week of therapy Special medical radiation physics consultation Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; up to 5 MeV Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; 6-10 MeV Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; MeV Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; 20 MeV or greater Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks; up to 5 MeV Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks; 6-10 MeV Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks; MeV Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks; 20 MeV or greater
6 WX Form (con t) Radiation treatment delivery, three or more separate treatment areas, three or more ports on a single custom blocking, tangential ports, wedges, rotational beam, compensators, special particle beam (eg, electron or neutrons); up to 5 MeV Radiation treatment delivery, three or more separate treatment areas, three or more ports on a single custom blocking, tangential ports, wedges, rotational beam, compensators, special particle beam (eg, electron or neutrons); 6-10 MeV Radiation treatment delivery, three or more separate treatment areas, three or more ports on a single custom blocking, tangential ports, wedges, rotational beam, compensators, special particle beam (eg, electron or neutrons); MeV Radiation treatment delivery, three or more separate treatment areas, three or more ports on a single custom blocking, tangential ports, wedges, rotational beam, compensators, special particle beam (eg, electron or neutrons); 20 MeV or greater Therapeutic radiology port film(s) Weekly radiation therapy management; conformal Weekly radiation therapy management; simple Weekly radiation therapy management; intermediate Weekly radiation therapy management; complex Intracavitary radioelement application; simple Intracavitary radioelement application; intermediate Intracavitary radioelement application; complex Remote afterloading high intensity brachytherapy; 1-4 source positions or catheters Remote afterloading high intensity brachytherapy; 5-8 source positions or catheters Remote afterloading high intensity brachytherapy; 9-12 source positions or catheters Remote afterloading high intensity brachytherapy; over 12 source positions or catheters Supervision, handling, loading of radioelement 5. Medications (Are we collecting all medication in hospital,? chemotherapy) 6. Other, specify
7 RX Form 7 1. Cystoscopy see EX #4 2. Proctoscopy see EX #5 3. Pelvic Exam with Anesthesia see EX #7 4. Intravenous Urograph Urography, retrograde, with or without KUB 5. Barium Enema Examination see EX #3 6. Chest Imaging see EX #9 7. Bone Scan Bone and/or joint imaging; whole body Unlisted musculoskeletal procedure, diagnostic nuclear medicine Bone and/or joint imaging; multiple areas Bone and/or joint imaging; limited areas 8. MRI see EX #11 9. CT see EX # PAP Cytopathology, smears, cervical or vaginal, up to three smears; screening by technician under physician supervision Cytopathology, smears, cervical or vaginal, up to three smears; requiring interpretation by physician Cytopathology, smears, cervical or vaginal, up to three smears; with definitive hormonal evaluation (eg, maturation index, karyopyknotic index, estrogenic index) 11. Other, specify 12. Other, specify Consultations: 13, 14, 15, 16, and 17 see EX #17-21 Follow Up: 13,14,15,16,17 see EX #17-21
8 DX Form 8 1. Hysterectomy see WX # 1 2. Pelvic Lymphadenectomy see WX # 2 3. Hospital Stay see WX # 3 4. Radiation Therapy see WX # 4 5. Medication see WX # 5 6. Other, specify
9 FX Form 9 1. Pelvic Exam see EX # 1 2. Intravenous Pyelogram see EX # 2 3. Barium Enema Examination see EX # 3 4. Cystoscopy see EX # 4 5. Proctoscopy see EX # 5 6. Chest Imaging see EX # 9 7. Bone Scan see RX # 7 8. Pelvic MRI Scan see EX # Pelvic CT Scan see EX # Other, specify 11. Other, specify Consultations: 12, 13, 14, 15, 16, and 17 see EX #17-21 Follow Up: 12, 13,14,15,16,17 see EX #17-21
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