PROVIDER PROCEDURE CODES - EVICORE

Transcription

1 CARDIOLOGY/RADIOLOGY PROVIDER PROCEDURE CODES - EVICORE CPT CODE CPT CODE DESCRIPTION Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); ventricular Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular Insertion of pacemaker pulse generator only; with existing single lead Insertion of pacemaker pulse generator only; with existing dual leads Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new generator) Insertion of pacemaker pulse generator only; with existing multiple leads Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of existing generator) Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter-defibrillator or pacemaker pulse generator (including upgrade to dual chamber system and pocket revision) (list separately in addition to code for primary procedure) Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; single lead system Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; dual lead system Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; multiple lead system Insertion of pacing cardioverter-defibrillator pulse generator only; with existing dual leads Insertion of pacing cardioverter-defibrillator pulse generator only; with existing multiple leads Insertion of pacing cardioverter-defibrillator pulse generator only; with existing single lead Insertion or replacement of permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverter-defibrillator pulse generator; single lead system Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverter-defibrillator pulse generator; dual lead system Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverter-defibrillator pulse generator; multiple lead system Implantation of heart valve (pulmonary) to lungs, accessed through the skin M R I T M J C T Head Without Contrast C T Head With Contrast C T Head Without & With Contrast C T Orbit Without Contrast C T Orbit With Contrast C T Orbit Without & With Contrast C T Maxillofacial Without Contrast C T Maxillofacial With Contrast C T Maxillofacial Without & With Contrast C T Soft Tissue Neck Without Contrast C T Soft Tissue Neck With Contrast C T Soft Tissue Neck Without & With Contrast C T Angiography Head C T Angiography Neck M R I Orbit, Face, Neck and/or Without Contrast Provider Procedure Codes Last Updated: FEB 2018 PAGE 1

2 70542 M R I Face, Orbit, Neck With Contrast M R I Face, Orbit, Neck With & Without Contrast M R A Head Without Contrast M R A Head With Contrast M R A Head With & Without Contrast M R A Neck Without Contrast M R A Neck With Contrast M R A Neck With & Without Contrast M R I Head Without Contrast M R I Head With Contrast M R I Head With & Without Contrast MRI Brain, functional MRI MRI Brain, functional MRI, requiring physician C T Thorax Without Contrast C T Thorax With Contrast C T Thorax Without & With Contrast C T Angiography Chest Without Contrast Material, Followed by Contrast Material and Further Sections, Including Image Post-processing M R I Chest Without Contrast M R I Chest With Contrast M R I Chest With & Without Contrast M R A Chest (Excluding Myocardium) With Or Without Contrast C T Cervical Spine Without Contrast C T Cervical Spine With Contrast C T Cervical Spine Without & With Contrast C T Thoracic Spine Without Contrast C T Thoracic Spine With Contrast C T Thoracic Spine Without & With Contrast C T Lumbar Spine Without Contrast C T Lumbar Spine With Contrast C T Lumbar Spine Without & With Contrast M R I Cervical Spine Without Contrast M R I Cervical Spine With Contrast M R I Thoracic Spine Without Contrast M R I Thoracic Spine With Contrast M R I Lumbar Spine Without Contrast M R I Lumbar Spine With Contrast M R I Cervical Spine With & Without Contrast M R I Thoracic Spine With & Without Contrast M R I Lumbar Spine With & Without Contrast M R A Spinal Canal With Or Without Contrast C T Angiography Pelvis C T Pelvis Without Contrast C T Pelvis With Contrast C T Pelvis Without & With Contrast M R I Pelvis Without Contrast M R I Pelvis With Contrast M R I Pelvis With & Without Contrast M R A Pelvis With Or Without Contrast C T Upper Extremity Without Contrast C T Upper Extremity With Contrast Provider Procedure Codes Last Updated: FEB 2018 PAGE 2

3 73202 C T Upper Extremity Without & With Contrast C T Angiography Upper Extremity M R I Upper Extremity Without Contrast M R I Upper Extremity With Contrast M R I Upper Extremity With & Without Contrast M R I Upper Extremity Joint Without Contrast M R I Upper Extremity Joint With Contrast M R I Upper Extremity Joint With & Without Contrast M R A Upper Extremity With Or Without Contrast C T Lower Extremity Without Contrast C T Lower Extremity With Contrast C T Lower Extremity Without & With Contrast C T Angiography Lower Extremity M R I Lower Extremity Without Contrast M R I Lower Extremity With Contrast M R I Lower Extremity With & Without Contrast M R I Lower Extremity Joint Without Contrast M R I Lower Extremity Joint With Contrast M R I Lower Extremity Joint With & Without Contrast M R A Lower Extremity With Or Without Contrast C T Abdomen Without Contrast C T Abdomen With Contrast C T Abdomen Without & With Contrast CT angiography, abdomen and pelvis, with contrast material(s), including non-contrast images, if performed, and image post-processing C T Angiography Abdomen C T Abdomen And Pelvis Without Contrast CT Abdomen And Pelvis With Contrast Computed Tomography, Abdomen And Pelvis; Without Contrast Material In One Or Both Body Regions, Followed By Contrast Material(S) And Further Sections In One Or Both Body Regions M R I Abdomen Without Contrast M R I Abdomen With Contrast M R I Abdomen With & Without Contrast M R A Abdomen With Or Without Contrast Computed tomographic (CT) colonography, diagnostic, including image post-processing; without contrast material Computed tomographic (CT) colonography, diagnostic, including image post-processing; with contrast material(s) including non-contrast images, if performed Computed tomographic (CT) colonography, screening, including image post-processing Magnetic resonance (e.g., proton) imaging, fetal, including placental and maternal pelvic imaging when performed; single or first gestation Magnetic resonance (e.g., proton) imaging, fetal, including placental and maternal pelvic imaging when performed; each additional gestation (List separately in addition to code for primary procedure) Cardiac magnetic resonance imaging for morphology and function without contrast material Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging Cardiac magnetic resonance imaging for velocity flow mapping (list separately in addition to code for primary procedure) Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium Provider Procedure Codes Last Updated: FEB 2018 PAGE 3

4 Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3d image post-processing, assessment of cardiac function, and evaluation of venous structures, if performed) Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3d image post-processing, assessment of lv cardiac function, rv structure and function and evaluation of venous structures, if performed) Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3d image post-processing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed) C T Angiography Abdominal Aorta D Rendering W/O post-processing D Rendering W post-processing C T Limited Or Localized Follow-Up Study M R I Spectroscopy Unlisted computed tomography procedure Unlisted MRI Procedure Us Echoencephalography Us Soft Tissue Head And Neck Us Chest Real Time With Image Documentation Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited Ultrasound Abdominal Real Time With Image Documentation U/S Single Organ ULTRASOUND, ABDOMINAL AORTA, REAL TIME WITH IMAGE DOCUMENTATION, SCREENING STUDY FOR ABDOMINAL AORTIC ANEURYSM (AAA) Ultrasound, Retroperotonral, Real Time With Image Documentation; Complete Us Echo Limited Ultrasound, Transplanted Kidney, Real Time And Duplex Doppler With Image Documentation Us Echo Spinal Canal Ultrasound Obstetrical Pelvis, Pregnant Uterus, First Trimester less than 14 Weeks Single Or First Gestation Ultrasound Obstetrical Pelvis, Pregnant Uterus, First Trimester less than 14 Weeks Each Additional Gestation Ultrasound Obstetrical Pelvis, Pregnant Uterus, B-Scan Ultrasound Obstetrical Pelvis Complete, Multiple Gestation After 1st Trimester Ultrasound Pregnant Uterus Fetal & Maternal Evaluation Plus Fetal Anatomic Evaluation Transabdominal Single Or First Gestation Ultrasound Pregnant Uterus Fetal & Maternal Evaluation Plus Fetal Anatomic Evaluation Transabdominal Each Additional Gestation Ultrasound, pregnant uterus, real time with image documentation Ultrasound, pregnant uterus, real time with image documentation Ultrasound Obstetrical Pelvis Limited (Gestational Age, Heart Beat, Emergency) Ultrasound Obstetrical Pelvis Follow Up Or Repeat Ultrasound Pregnant Uterus Transvaginal Fetal Biophysical Profile Fetal Biophysical Profile Without Stress Non Stress Doppler Velocimetry, Fetal; Umbilical Artery Doppler Velocimetry, Fetal; Middle Cerebral Artery Ultrasound Obstetrical Echocardiography, Fetal, Cardiovascular System Follow Up Or Repeat Study Doppler Echocardiography Fetal Complete Follow Up Or Repeat Study U/S Transvaginal Provider Procedure Codes Last Updated: FEB 2018 PAGE 4

5 76831 Hysterosonography W Or W/O Col Ultrasound Pelcic Real Time With Image Documentation; Complete Us Pel Lim Or F/U Us Echo Scrotum U/S Transrectal Ultrasound, complete joint (i.e., joint space and peri-articular soft tissue structures) real-time with image documentation Ultrasound, limited, joint or other nonvascular extremity structure(s) (e.g., joint space, peri-articular tendon[s], muscle[s], nerve[s], other soft tissue structure[s], or soft tissue mass[es]), real-time with image documentation Us Echo, Infant Hips Realtime Us, Infant Hips, Real Time; Limited, Static Us Study Follow Up Ultrasound Gastrointestinal, Endoscopic Echo Examination Procedure Computed tomography guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), radiological supervision and interpretation Ct Guide Plcmnt Radiation M R I Guidance For Needle Placement Magnetic resonance guidance for, and monitoring of, parenchymal tissue ablation M R I Breast With And/Or Without Contrast M R I Breast Bilateral Computed Tomography, bone mineral density study, 1 or more sites; axial skeleton Magnetic resonance (e.g., proton) imaging, bone marrow blood supply Thyroid uptake, single or multiple quantitative measurement(s) (including stimulation, suppression, or discharge, when performed) Thyroid imaging (including vascular flow, when performed) Thyroid imaging (including vascular flow, when performed); with single or multiple uptake(s) quantitative measurement(s) (including stimulation, suppression, or discharge, when performed) Thyroid Met Imaging Thyroid Met Imaging With Additional Studies Thyroid Scan Whole Body Thyroid Carcinoma Metastases Uptake Parathyroid planar imaging (including subtraction, when performed) Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT) Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT), and concurrently acquired computed tomography (CT) for anatomical localization Adrenal Nuclear Imaging Bone Marrow Imaging, Limited Bone Marrow Imaging, Multiple Bone Marrow Imaging, Whole Body Labeled Red Cell Sequestration Spleen Imaging With & Without Vascular Flow Lymph System Imaging Liver Imaging Liver Imaging With Flow Liver Imaging SPECT (3D) Liver Imaging SPECT With Vasulcar Flow Liver & Spleen Imaging Liver & Spleen Imaging With Flow Hepatobiliary system imaging, including gallbladder when present; Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention, including Provider Procedure Codes Last Updated: FEB 2018 PAGE 5

6 quantitative measurement(s) when performed Salivary Gland Imaging Serial Salivary Gland Salivary Gland Function Exam Esophogus Motility Study Gastric Mucosa Imaging Gastroesophageal Reflux Exam Gastric Emptying Study Gastric emptying imaging study (e.g., solid, liquid, or both); with small bowel transit Gastric emptying imaging study (e.g., solid, liquid, or both); with small bowel and colon transit, multiple days GI Bleeder Scan Meckels Diverticulum Imaging Leveen Shunt Patency Exam Bone Or Joint Imaging Limited Bone Or Joint Imaging Multiple Bone Scan Whole Body Bone Scan 3 Phase Study Bone Joint Imaging Tomo Test SPECT Non-Imaging Heart Function Cardiac Shunt Imaging Radionuclide Venogram Non-Cardiac myocardial perfusion imaging, tomographic (spect) including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) Myocardial perfusion imaging, tomographic (spect) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection Venous Thrombosis Imaging Unilateral Venous Thrombosis Images, Bilateral Myocardial imaging, positron emission tomography (pet), metabolic evaluation Myocardial Infarction Scan Heart Infarct Image Ejection Fraction Heart Infarct Image 3D SPECT Cardiac Bloodpool Img, Single Cardiac Bloodpool Img, Multi Heart First Pass Single Cardiac Blood Pool Imaging -- Multiple Myocardial imaging, positron emission tomography (pet), perfusion; single study at rest or stress Myocardial imaging, positron emission tomography (pet), perfusion; multiple studies at rest and/or stress Cardiac Blood Pool Imaging, SPECT Cardiac Blood Pool Imaging - Single Rest Unlisted Cardiovascular Procedure Pulmonary ventilation imaging (e.g., aerosol or gas) Pulmonary perfusion imaging (e.g., particulate) Pulmonary ventilation (e.g., aerosol or gas) and perfusion imaging Provider Procedure Codes Last Updated: FEB 2018 PAGE 6

7 78585 Pulmonary Perfusion With Washout With Or Without Single Breath Quantitative differential pulmonary perfusion, including imaging when performed Quantitative differential pulmonary perfusion and ventilation (eg, aerosol or gas), including imaging when performed Brain Imaging Limited Static Brain Limited Imaging And Flow Brain Imaging Complete Brain Imaging Complete With Flow Brain Imaging 3D Brain Imaging, Positron Emission Tomography (PET) Metabolic Evaluation Brain Imaging, Positron Emission Tomography (PET) Perfusion Evaluation Brain Flow Imaging Only Cisternogram (Cerebrospinal Fluid Flow) Cerebrospinal Ventriculography CSF Shunt Evaluation Cerebrospinal Fluid Scan (Tomographic) SPECT C S F Leakage Detection And Localization Radiopharmaceutical Dacryocystography Unlisted Nuclear Medicine Procedure Kidney Imaging Morphology Kidney Imaging With Vascular Flow Kidney Imaging With Vascular Flow & Function Single Study Without Pharmacological Intervention Kidney Imaging Single Study With Pharmacological Intervention Kidney Imaging - Multiple Studies Without & With Pharmacological Intervention Kidney Imaging - Tomographic (SPECT) Kidney Function Study - Non-Imaging Radioisotopic Urinary Bladder Residual Study Ureteral Reflux Study Testicular Imaging With Vascular Flow Radiopharm Localization Of Tumor, Limited Area Radiopharm Localization Of Tumor, Multiple Areas Radiopharm Localization Of Tumor, Whole Body Radiopharm Localization Of Tumor Tomographic (SPECT) Radiopharm Localization Of Tumor, Whole Body Radiopharm Localization Of Abscess, Limited Area Radiopharm Localization Of Abscess, Whole Body Radiopharm Localization Of Abscess, Tomographic SPECT Tumor Imaging, Positron Emission Tomography (Pet); Limited Area (e.g. Chest, Head/Neck) Tumor Imaging, Positron Emission Tomography (Pet); Skull Base To Mid-Thigh Positron Emission Tomography (Pet); Whole Body Tumor Imaging, Positron Emission Tomography (Pet) With Concurrently Acquired Computer Tomography (Ct) For Attenuation Correction And Anatomical Localization; Limited Area (e.g. Chest, Head/Neck) Tumor Imaging, Positron Emission Tomography (Pet) With Concurrently Acquired Computer Tomography (Ct) For Attenuation Correction And Anatomical Localization; Skull Base To Mid-Thigh Tumor Imaging, Positron Emission Tomography (Pet) With Concurrently Acquired Computer Tomography (Ct) For Attenuation Correction And Anatomical Localization; Whole Body Transthoracic echocardiography for congenital cardiac anomalies; complete Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study Echocardiography, transthoracic, real-time with image documentation (2d), includes m-mode recording, when performed, complete, with spectral doppler echocardiography, and with color flow doppler echocardiography Echocardiography, transthoracic, real-time with image documentation (2d) with or without m-mode recording; Provider Procedure Codes Last Updated: FEB 2018 PAGE 7

8 complete Echocardiography, transthoracic, real-time with image documentation (2d) with or without m-mode recording; follow-up or limited study TEE 2D;Incl Probe Placement, Imaging/Interp/Report Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); placement of transesophageal probe only Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); image acquisition, interpretation and report only Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report Transesophageal echocardiography for congenital cardiac anomalies; placement of transesophageal probe only Transesophageal echocardiography for congenital cardiac anomalies; image acquisition, interpretation and report only Echo transesophageal intraop Doppler echocardiography, pulsed wave and/or continuous wave with spectral display; complete Doppler echocardiography, pulsed wave and/or continuous wave with spectral display; follow-up or limited study Doppler echocardiography color flow velocity mapping Echocardiography, transthoracic, real-time with image documentation (2d), with or without m-mode recording, during rest and cardiovascular stress test, with interpretation and report Echocardiography, transthoracic, real-time with image documentation (2d), includes m-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation Use of echocardiographic contrast agent during stress echocardiography (list separately in addition to code for primary procedure) RIGHT HEART CATHETERIZATION INCLUDING MEASUREMENT(S) OF OXYGEN SATURATION AND CARDIAC OUTPUT, WHEN PERFORMED Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial venous grafts) including intraprocedural injection(s) for bypass graft angiography Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for Provider Procedure Codes Last Updated: FEB 2018 PAGE 8

9 coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography Left heart catheterization by transseptal puncture through intact septum or by transapical puncture (list separately in addition to code for primary procedure) RIGHT HEART CATHETERIZATION (CHD) RIGHT/LEFT HEART CATHETERIZATION (CHD) RIGHT/LEFT HEART CATHETERIZATION (CHD-TS) RIGHT/LEFT HEART CATHETERIZATION (CAD-ASD) Duplex Scan Extracranial Arter Duplex Scan Extracranial Arter Transcranial Doppler Study Int Transcranial Doppler Study Int Transcranial Doppler Vasoreactivity Study Transcranial Doppler Study Of The Intracranial Arteries; Emboli Detection Without Intravenous Microbubble Injection Transcranial Doppler Study Of The Intracranial Arteries; Emboli Detection With Intravenous Microbubble Injection Non-Invasive Physiologic Studi Non-Invasive Physiologic Studi Non-Invasive Physiologic Studi Duplex Scan Low Ext. Art. Or A Duplex Scan Low Ext. Art. Or A Duplex Scan Up Ext. Art. Or Ar Duplex Scan Up Ext. Art. Or Ar Duplex Scan Ext. Veins, Comple Duplex Scan Ext. Veins, Unilat Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; cunilateral or limited study Duplex scan of arterial inflow and venous outflow of penile vessels; complete study Duplex scan of arterial inflow and venous outflow of penile vessels; follow-up or limited study Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow) Unlisted Noninvasive Vascular Diagnostic Study 0042T CT Perfusion Brain Computer-aided detection, including computer algorithm analysis of MRI image data for lesion 0159T detection/characterization, pharmacokinetic analysis, with further physician review for interpretation, breast MRI (List separately in addition to code for primary procedure) 0319T Insertion or replacement of subcutaneous implantable defibrillator system with subcutaneous electrode 0387T Implantation or replacement of permanent ventricular pacemaker 0388T Removal of permanent ventricular pacemaker 0399T Myocardial strain imaging (quantitative assessment of myocardial mechanics using image-based analysis of local myocardial dynamics) (List separately in addition to code for primary procedure) 0482T Absolute quantitation of myocardial blood flow, positron emission tomography (PET), rest and stress (List separately in addition to code for primary procedure) Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography 0501T angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; data preparation and transmission, analysis of fluid dynamics and simulated maximal coronary hyperemia, generation of estimated FFR model, with anatomical data review in Provider Procedure Codes Last Updated: FEB 2018 PAGE 9

10 0502T 0503T 0504T C8900 C8901 C8902 C8903 C8904 C8905 C8906 C8907 C8908 C8909 C8910 C8911 C8912 C8913 C8914 C8918 C8919 C8920 C8921 C8922 C8923 C8924 C8928 C8929 C8930 C8931 C8932 C8933 C8934 C8935 C8936 comparison with estimated FFR model to reconcile discordantdata, interpretation and report Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; data preparation and transmission Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; analysis of fluid dynamics and simulated maximal coronary hyperemia, and generation of estimated FFR model Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation and report MRA Abdomen with contrast MRA Abdomen without contrast MRA Abdomen with and w/o contrast MRI Breast w/ contrast, unilateral MRI Breast w/o contrast, unilateral MRI Breast w. and w/o contrast, unilateral MRI Breast Bilateral W/ Contrast MRI Breast Bilateral W/O Contrast MRI Breast Bilateral W/ And W/O Contrast MRA chest w/contrast (excluding myocardium) MRA chest w/o contrast (excluding myocardium) MRA chest (excluding myocardium) MRA lower extremity w/ contrast MRA lower extremity w/o contrast MRA lower extremity w/ and w/o contrast MRA pelvis w/ contrast MRA pelvis w/o contrast MRA pelvis w/ and w/o contrast Transthoracic echocardiography w/contrast for congenital cardiac anomalies; complete Transthoracic echocardiography w/contrast for congenital cardiac anomalies; f/u or limited study Transthoracic echocardiography w/contrast, real-time w/image documentation (2d), w/wo m-mode recording; complete Transthoracic echocardiography w/contrast, real-time w/image documentation (2d), w/wo m-mode recording; f/u or limited study Transthoracic echocardiography w/contrast, real-time w/image documentation (2d), w/wo m-mode recording, during rest and cardiovascular stress test, w/interpretation and report Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2d), includes m-mode recording, when performed, complete, with spectral doppler echocardiography, and with color flow doppler echocardiography Transthoracic echocardiography, with contrast, or without contrast followed by with contrast, real-time with image documentation (2d), includes m-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with physician supervision MRA, W/Dye, Spinal Canal MRA, W/O Dye, Spinal Canal MRA, W/O&W/Dye, Spinal Canal MRA, W/Dye, Upper Extremity MRA, W/O Dye, Upper Extr MRA, W/O&W/Dye, Upper Extr Provider Procedure Codes Last Updated: FEB 2018 PAGE 10

11 C9744 G0219 G0235 G0252 G0297 G0389 S8032 S8037 S8042 S8080 S8085 S8092 ULTRASOUND, ABDOMINAL, WITH CONTRAST Pet Imaging Whole Body; Melanoma For Non-Covered Indications Pet Imaging, Any Site, Not Otherwise Specified Pet Imaging, Full And Partial-Ring Pet Scanners Only For Initial Diagnosis Of Breast Cancer And/Or Surgical Planning For Breast Cancer Low-dose Computed Tomography For Lung Cancer Screening Ultrasound B-Scan And/Or Real Time With Image Documentation; For Abdominal Aortic Aneurysm (Aaa) Screening Low-dose Computed Tomography For Lung Cancer Screening Magnetic resonance cholangiopancreato-graphy (MRCP) Magnetic Resonance Imaging (Mri), Low-Field Scintimammography (Radioimmunoscintigraphy Of The Breast), Unilateral, Including Supply Of Radiopharmaceutical Fluorine-18 Fluorodeoxyglucose (F-18 Fdg) Imaging Using Dual Head Coincidence Detection System. (Non- Dedicated Pet Scan) Electron Beam Computed Tomography (Also Known As Ultrafast Ct, Cinet) LAB CPT CODE CPT CODE DESCRIPTION BRCA1, BRCA2 (breast cancer 1 and 2) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis and full duplication/deletion analysis APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; full gene sequence APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; duplication/deletion variants BRCA1, BRCA2 (breast cancer 1 and 2) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common duplication/deletion variants in BRCA1 (ie, exon 13 del 3.835kb, exon 13 dup 6kb, exon del 26kb, exon 22 del 510bp, exon 8-9 del 7.1kb) BRCA1, BRCA2 (breast cancer 1 and 2) (e.g., hereditary breast and ovarian cancer) gene analysis; 185delAG, 5385insC, 6174delT variants BRCA1, BRCA2 (breast cancer 1 and 2) (e.g., hereditary breast and ovarian cancer) gene analysis; uncommon duplication/deletion variants BRCA1 (breast cancer 1) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common duplication/deletion variants (ie, exon 13 del 3.835kb, exon 13 dup 6kb, exon del 26kb, exon 22 del 510bp, exon 8-9 del 7.1kb) BRCA1 (breast cancer 1) (e.g., hereditary breast and ovarian cancer) gene analysis; known familial variant BRCA2 (breast cancer 2) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis BRCA2 (breast cancer 2) (e.g., hereditary breast and ovarian cancer) gene analysis; known familial variant CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic fibrosis) gene analysis; duplication/deletion variants CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic fibrosis) gene analysis; full gene sequence CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *4, *8, *17) CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN) CYP2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *5, *6) Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number variants (e.g., bacterial artificial chromosome [BAC] or oligo-based comparative genomic hybridization [CGH] microarray analysis) Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy Provider Procedure Codes Last Updated: FEB 2018 PAGE 11

12 number and single nucleotide polymorphism (SNP) variants for chromosomal abnormalities CYP3A4 (cytochrome P450 family 3 subfamily A member 4) (eg, drug metabolism), gene analysis, common variant(s) (e.g., *2, *22) CYP3A5 (cytochrome P450 family 3 subfamily A member 5) (eg, drug metabolism), gene analysis, common variants (e.g., *2, *3, *4, *5, *6, *7) DPYD (dihydropyrimidine dehydrogenase) (eg, 5-fluorouracil/5-FU and capecitabine drug metabolism), gene analysis, common variant(s) (e.g., *2A, *4, *5, *6) F9 (coagulation factor IX) (e.g., hemophilia B), full gene sequence G6PD (glucose-6-phosphate dehydrogenase) (e.g., hemolytic anemia, jaundice), gene analysis; full gene sequence HBA1/HBA2 (alpha globin 1 and alpha globin 2) (e.g., alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis common deletions or variant (e.g., Southeast Asian, Thai, Filipino, Mediterranean, alpha3.7, alpha4.2, alpha20.5, and Constant Spring) HBA1/HBA2 (alpha globin 1 and alpha globin 2) (e.g., alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; full gene sequence HBA1/HBA2 (alpha globin 1 and alpha globin 2) (e.g., alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; duplication/deletion variants IFNL3 (interferon, lambda 3) (e.g., drug response), gene analysis, rs variant MGMT (O-6-methylguanine-DNA methyltransferase) (e.g., glioblastoma multiforme), methylation analysis MTHFR (5,10-methylenetetrahydrofolate reductase) (e.g., hereditary hypercoagulability) gene analysis, common variants (e.g., 677T, 1298C) MLH1 (mutl homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis MLH1 (mutl homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants MSH2 (muts homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis MSH2 (muts homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants MSH6 (muts homolog 6 [E. coli]) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis MSH6 (muts homolog 6 [E. coli]) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants PCA3/KLK3 (prostate cancer antigen 3 [non-protein coding]/kallikrein-related peptidase 3 [prostate specific antigen]) ratio (e.g., prostate cancer) PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants PTEN (phosphatase and tensin homolog) (e.g., Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; full sequence analysis PTEN (phosphatase and tensin homolog) (e.g., Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; duplication/deletion variant PMP22 (peripheral myelin protein 22) (e.g., Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; full sequence analysis SEPT9 (Septin9) (e.g., colorectal cancer) methylation analysis SLCO1B1 (solute carrier organic anion transporter family, member 1B1) (eg, adverse drug reaction), gene analysis, common variant(s) (e.g., *5) TPMT (thiopurine S-methyltransferase) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3) TYMS (thymidylate synthetase) (e.g., 5-fluorouracil/5-FU drug metabolism), gene analysis, common variant(s) (e.g., tandem repeat variant) VKORC1 (vitamin K epoxide reductase complex, subunit 1) (e.g., warfarin metabolism), gene analysis, common variant(s) (e.g., -1639G>A, c c>t) Provider Procedure Codes Last Updated: FEB 2018 PAGE 12

13 81361 HBB (hemoglobin, subunit beta) (e.g., sickle cell anemia, beta thalassemia, hemoglobinopathy); common variant(s) (e.g., HbS, HbC, HbE) HBB (hemoglobin, subunit beta) (e.g., sickle cell anemia, beta thalassemia, hemoglobinopathy); duplication/deletion variant(s) HBB (hemoglobin, subunit beta) (e.g., sickle cell anemia, beta thalassemia, hemoglobinopathy); full gene sequence Molecular pathology procedure, Level 1 (e.g., identification of single germline variant [eg, SNP] by techniques such as restriction enzyme digestion or melt curve analysis) Molecular pathology procedure, Level 2 (e.g., 2-10 SNPs, 1 methylated variant, or 1 somatic variant [typically using nonsequencing target variant analysis], or detection of a dynamic mutation disorder/triplet repeat) Molecular pathology procedure, Level 3 Molecular pathology procedure, Level 4 (e.g., analysis of single exon by DNA sequence analysis, analysis of > amplicons using multiplex PCR in 2 or more independent reactions, mutation scanning or duplication/deletion variants of 2-5 exons) Molecular pathology procedure, Level 5 (e.g., analysis of 2-5 exons by DNA sequence analysis, mutation scanning or duplication/ deletion variants of 6-10 exons, or characterization of a dynamic mutation disorder/triplet repeat by Southern blot analysis) Molecular pathology procedure, Level 6 (e.g., analysis of 6-10 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of exons, regionally targeted cytogenomic array analysis) Molecular pathology procedure, Level 7 (e.g., analysis of exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of exons, cytogenomic array analysis for neoplasia) Molecular pathology procedure, Level Molecular pathology procedure, Level 9 Aortic dysfunction or dilation (e.g., Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); genomic sequence analysis panel, must include sequencing of at least 9 genes, including FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, and MYLK Aortic dysfunction or dilation (e.g., Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); duplication/deletion analysis panel, must include analyses for TGFBR1, TGFBR2, MYH11, and COL3A1 Ashkenazi Jewish associated disorders (e.g., Bloom syndrome, Canavan disease, cystic fibrosis, familial dysautonomia, Fanconi anemia group C, Gaucher disease, Tay-Sachs disease), genomic sequence analysis panel, must include sequencing of at least 9 genes, including ASPA, BLM, CFTR, FANCC, GBA, HEXA, IKBKAP, MCOLN1, and SMPD1 Cardiac ion channelopathies (e.g., Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); genomic sequence analysis panel, must include sequencing of at least 10 genes, including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, and SCN5A Cardiac ion channelopathies (e.g., Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); duplication/deletion gene analysis panel, must include analysis of at least 2 genes, including KCNH2 and KCNQ Exome (e.g., unexplained constitutional or heritable disorder or syndrome); sequence analysis Exome (e.g., unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator exome (e.g., parents, siblings) (List separately in addition to code for primary procedure) Exome (e.g., unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously obtained exome sequence (e.g., updated knowledge or unrelated condition/syndrome) Fetal chromosomal aneuploidy (e.g., trisomy 21, monosomy X) genomic sequence analysis panel, circulating cellfree fetal DNA in maternal blood, must include analysis of chromosomes 13, 18, and Fetal chromosomal microdeletion(s) genomic sequence analysis (e.g., DiGeorge syndrome, Cri-du-chat syndrome), cirulating cell-free fetal DNA in maternal blood Genome (e.g., unexplained constitutional or heritable disorder or syndrome); sequence analysis Genome (e.g., unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator genome (e.g., parents, siblings) (List separately in addition to code for primary procedure) Genome (e.g., unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously Provider Procedure Codes Last Updated: FEB 2018 PAGE 13

14 obtained genome sequence (e.g., updated knowledge or unrelated condition/syndrome) Hearing loss (e.g., nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); genomic sequence analysis panel, must include sequencing of at least 60 genes, including CDH23, CLRN1, GJB2, GPR98, MTRNR1, MYO7A, MYO15A, PCDH15, OTOF, SLC26A4, TMC1, TMPRSS3, USH1C, USH1G, USH2A, and WFS1 Hearing loss (e.g., nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); duplication/deletion analysis panel, must include copy number analyses for STRC and DFNB1 deletions in GJB2 and GJB6 genes Hereditary breast cancer-related disorders (e.g., hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); genomic sequence analysis panel, must include sequencing of at least 10 genes, always including BRCA1, BRCA2, CDH1, MLH1, MSH2, MSH6, PALB2, PTEN, STK11, and TP53 Hereditary breast cancer-related disorders (e.g., hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); duplication/deletion analysis panel, must include analyses for BRCA1, BRCA2, MLH1, MSH2, and STK11 Hereditary retinal disorders (e.g., retinitis pigmentosa, Leber congenital amaurosis, cone-rod dystrophy), genomic sequence analysis panel, must include sequencing of at least 15 genes, including ABCA4, CNGA1, CRB1, EYS, PDE6A, PDE6B, PRPF31, PRPH2, RDH12, RHO, RP1, RP2, RPE65, RPGR, and USH2A Hereditary colon cancer disorders (e.g., Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis); genomic sequence analysis panel, must include sequencing of at least 10 genes, including APC, BMPR1A, CDH1, MLH1, MSH2, MSH6, MUTYH, PTEN, SMAD4, and STK11 Hereditary colon cancer disorders (e.g., Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis); duplication/deletion analysis panel, must include analysis of at least 5 genes, including MLH1, MSH2, EPCAM, SMAD4, and STK11 Hereditary neuroendocrine tumor disorders (e.g., medullary thyroid carcinoma, parathyroid carcinoma, malignant pheochromocytoma or paraganglioma); genomic sequence analysis panel, must include sequencing of at least 6 genes, including MAX, SDHB, SDHC, SDHD, TMEM127, and VHL Hereditary neuroendocrine tumor disorders (e.g., medullary thyroid carcinoma, parathyroid carcinoma, malignant pheochromocytoma or paraganglioma); duplication/deletion analysis panel, must include analyses for SDHB, SDHC, SDHD, and VHL Hereditary cardiomyopathy (e.g., hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy) genomic sequence analysis panel, must include sequencing of at least 5 cardiomyopathy-related genes, (e.g., DSG2, MYBPC3, MYH7, PKP2, and TTN) Nuclear encoded mitochondrial genes (e.g., neurologic or myopathic phenotypes), genomic sequence panel, must include analysis of at least 100 genes, including BCS1L, C10orf2, COQ2, COX10, DGUOK, MPV17, OPA1, PDSS2, POLG, POLG2, RRM2B, SCO1, SCO2, SLC25A4, SUCLA2, SUCLG1, TAZ, TK2, and TYMP Noonan spectrum disorders (e.g., Noonan syndrome, cardio-facio-cutaneous syndrome, Costello syndrome, LEOPARD syndrome, Noonan-like syndrome), genomic sequence analysis panel, must include sequencing of at least 12 genes, including BRAF, CBL, HRAS, KRAS, MAP2K1, MAP2K2, NRAS, PTPN11, RAF1, RIT1, SHOC2, and SOS1 Targeted genomic sequence analysis panel, solid organ neoplasm, DNA analysis, and RNA analysis when performed, 5-50 genes (e.g., ALK, BRAF, CDKN2A, EGFR, ERBB2, KIT, KRAS, NRAS, MET, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed Hereditary peripheral neuropathies (e.g., Charcot-Marie-Tooth, spastic paraplegia), genomic sequence analysis panel, must include sequencing of at least 5 peripheral neuropathy-related genes (eg, BSCL2, GJB1, MFN2, MPZ, REEP1, SPAST, SPG11, SPTLC1) Targeted genomic sequence analysis panel, hematolymphoid neoplasm or disorder, DNA analysis, and RNA analysis when performed, 5-50 genes (e.g., BRAF, CEBPA, DNMT3A, EZH2, FLT3, IDH1, IDH2, JAK2, KRAS, KIT, MLL, NRAS, NPM1, NOTCH1), interrogation for sequence variants, and copy number variants or rearrangements, or isoform expression or mrna expression levels, if performed Targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (e.g., ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed Whole mitochondrial genome (e.g., Leigh syndrome, mitochondrial encephalomyopathy, lactic acidosis, and Provider Procedure Codes Last Updated: FEB 2018 PAGE 14