2016 CPT Code Reference Guide. T F imaginghealthcare.com

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1 2016 CPT Code Reference Guide T F imaginghealthcare.com

2 HEAD/NECK & NEURO MRI brain - post fossa w/ & w/o contrast (IAC w/ & w/o) MRI brain (pituitary protocol) w/ & w/o contrast MRI brain (seizure protocol) w/ & w/o contrast MRI brain and orbits w/ & w/o contrast MRI brain w/ & w/o contrast MRI brain w/o contrast Bell s Palsy Hearing loss Vertigo Hormone abnormalities Pituitary Seizures - multiple early onset Loss of vision Ocular mass or tumor 70553, Optic neuritis Visual disturbance Bell s Palsy Brain tumor Dizziness Headaches (depends on Meningitis associated clinical history) Metastatic brain disease Multiple sclerosis Seizures Vertigo Ataxia CVA Dementia Headaches (depends on Traumatic brain injury associated clinical history) (chronic) Magnetic Resonance Imaging (MRI) MRI brain w/o contrast and consider MRA head Personal or family history of aneurysm Severe headache Subarachnoid hemorrhage 70551, MRI face, orbit, neck w/ & w/o contrast Tumor, mass, swelling, or infection of the soft tissue neck 70543

3 ABDOMEN & PELVIS MRI abdomen w/ & w/o contrast MRA abdomen w/ or w/o contrast *If exam includes history of gall stones, gall bladder disease, bile duct dilation, cholangitis, biliary tumor or pancreatitis include MRCP. MRI abdomen w/ & w/o contrast w/ MRCP MRI abdomen and pelvis w/ & w/o contrast Abdominal pain Any complaint related to liver, spleen, pancreas or kidneys Hypertension Renal artery stenosis Common bile duct or gallbladder concerns Pancreatic duct Crohn s disease Inflammatory bowel disease Ischemic bowel disease , Abdomen w/ & w/o Pelvis w/ & w/o Magnetic Resonance Imaging (MRI) MRI pelvis w/o contrast Coccyx fracture Pubic arthralgia Sacroiliitis Stress fracture (Pelvis) Pelvic fracture Sacral fracture Sports hernia MRI pelvis and prostate gland w/ & w/o contrast Prostate cancer screening, staging or follow up 72197

4 PELVIS SPINE MRI pelvis female GYN w/ & w/o contrast MRI pelvis w/ & w/o contrast MRI cervical spine w/ & w/o contrast MRI cervical spine w/o contrast MRI lumbar spine w/ & w/o contrast *If prior lumbar surgery (within 10 years), r/o infection, or bone mets then MRI lumbar spine w/ & w/o contrast. Adenomyosis Cervical cancer Dermoid Family history of uterine Fibroid or ovarian malignant tumor Infection or tumor Ovarian disease Post menopausal bleeding UFE planning Uterine mass Vaginal cancer Non-gynecological tumor or infection Non-specific pelvic pain Demyelination MS Suspected tumor of cervical spinal cord Benign cervical spine Cervical neck pain Compression fracture (Cervical Spine) Degenerative disc disease Disk herniation radiculopathy Low back pain longer than 6 weeks Neuro impairment Magnetic Resonance Imaging (MRI) MRI lumbar spine w/ & w/o contrast Failed back syndrome Pathologic compression fracture (Lumbar Spine) 72158

5 SPINE OTHER MRI lumbar spine w/o contrast MRI thoracic spine w/o contrast MRI arthrogram (knee only) MRI arthrogram (shoulder only) Compression fracture Disk herniation Radiculopathy Degenerative disk disease Low back pain Sciatica Compression fracture benign (Thoracic Spine) Degenerative disk disease Disk herniation Thoracic back pain Ankle pain with concern for unstable osteochondral lesion Hip pain with concern for labral tear Knee pain with concern for unstable osteochondral Knee pain with prior arthroscopy Elbow pain with concern for ligament or intra articular injury including unstable osteochondral lesions Shoulder pain after dislocation or concern for labral tear Shoulder pain after rotator cuff or labral repair Wrist pain with concern for ligament or intra articular injury MRI joint LOWER extremity w/ contrast Arthro injection Fluoro guidance MRI joint UPPER extremity w/ contrast Arthro injection Fluoro guidance Magnetic Resonance Imaging (MRI) MRI extremity LOWER w/o contrast MRI extremity UPPER w/o contrast Fracture to non-joint extremity Lipoma Myositis Nonspecific pain Soft tissue injury Stress response Fracture to non-joint extremity Lipoma Myositis Nonspecific pain Soft tissue injury Stress response

6 OTHER MRI joint LOWER extremity w/o contrast MRI joint UPPER extremity w/o contrast MRI w/ & w/o contrast Evaluate for bony or soft tissue pathology Internal derangement occult Joint pain Evaluate for bony or soft tissue pathology Internal derangement occult Joint pain Tumor or infection of extremity UPPER extremity (non-joint) LOWER extremity (non-joint) Magnetic Resonance Imaging (MRI)

7 HEAD/NECK & NEURO CT head, brain w/ & w/o contrast CT head, brain w/o contrast Ataxia Brain tumor CVA Dementia Headaches (Contrast - depends on associated clinical history) Ataxia CVA Dementia Headaches Normal pressure Traumatic brain injury hydrocephalus (NPH) (acute) (Contrast - depends on associated clinical history) CT maxillofacial w/o contrast Possible fracture Trauma CT orbit w/o contrast Fracture Trauma Swelling CT sinus w/o contrast Facial pain Sinusitis CT soft tissue neck w/ contrast Lymphadenopathy Mass Swelling Computed Tomography (CT) CT soft tissue neck w/o contrast Contraindication to iodine (consider MRI) Salivary gland stone CT temporal bones w/o contrast Earache Hearing loss Cholesteatoma 70480

8 CHEST ABDOMEN CT angiography chest CT chest interstitial disease evaluation, high-resolution chest w/o contrast Aneurysm Chest pain Dyspnea Pulmonary embolism Ascending aorta or aortic arch dissection Elevated D-Dimer Interstitial lung disease CT chest low dose screening w/o contrast Low dose lung cancer screening CT chest w/ contrast Preferred Abnormal chest x-ray Adenopathy Chest pain Cough Dyspnea Follow up for known neoplasm Lung cancer Pleural effusion Pneumonia Pulmonary nodule or mass CT chest w/o contrast Nodule follow-up when contrast is contraindicated Contraindication to iodine CT abdomen w/ & w/o contrast (w/ oral contrast, unless specified) CT abdomen w/ contrast (w/ oral contrast, unless specified) Adrenal mass Pancreatic mass Renal mass Preferred Adenopathy Pancreatitis Hepatic mass (dedicated liver study) Upper abdominal pain Mass Upper abdominal pain Computed Tomography (CT) CT abdomen w/o contrast (w/ oral contrast, unless specified) Contraindication to iodine (consider MRI) 74150

9 ABDOMEN & PELVIS CT abdomen/pelvis w/ & w/o contrast* (w/ oral contrast, unless specified) CT abdomen/pelvis w/ contrast (w/ oral contrast, unless specified) CT abdomen/pelvis w/o contrast (w/ oral contrast, unless specified) CT abdomen/pelvis w/o contrast (w/o oral contrast) - renal stone study CT colonography diagnostic Abdominal pain Constipation Lymph node enlargement Preferred Abdominal distension Adenopathy Bowel obstruction or perforation Diverticulitis Mass Cancer Diverticulitis Pelvis pain Abdominal or pelvic pain Contraindication to iodine (consider MRI) Flank pain Suspected renal stones or follow-up Abdominal pain Appendicitis Cancer Constipation Lymph node enlargement Pelvic pain Failed or contraindication to traditional colonoscopy due to: - Rectal bleeding, tortuous colon, or inability to tolerate sedation CT colonography screening Colon cancer screening Family history of colon cancer CT small bowel w/ contrast (w/ oral contrast) CT urogram w/ & w/o contrast Anemia Chronic GI bleed Small bowel mass Dysuria Hematuria Bowel obstruction Crohn s disease Flank pain UTIs Computed Tomography (CT) *Performing CT Abdomen/Pelvis w/ & w/o contrast is not our recommended study, except for some dedicated oncology cases.

10 SPINE OTHER CT cervical spine w/o contrast CT lumbar spine w/o contrast CT extremity LOWER w/o contrast CT extremity UPPER w/o contrast Compression fracture Trauma (Cervical Spine) Neck pain Compression fracture (Lumbar Spine) Low back pain Trauma (Lumbar Spine) Fracture Swelling Fracture Swelling Pain Pain Computed Tomography (CT)

11 NECK CHEST ABDOMEN US neck soft tissue Palpable head, face or neck mass (describe area) US thyroid or neck US chest US abdominal complete US abdominal LTD Goiter Palpable neck mass (describe on head, face, or neck) Parotid, abnormal thyroid tests Thyroidmegaly Mediastinum Palpable mass, chest wall and upper back (describe location) Pleura Abnormal liver tests Epigastric pain Hepatitis Nausea Ascites Fatty liver Jaundice Pain Test includes the liver, pancreas, gallbladder, kidneys, aorta, and spleen. If abdominal and kidney (renal) are ordered together use abdomen and pelvic LTD (76857) to include bladder images. Inguinal hernia Quadrant pain Single organ evaluation such as liver or gallbladder Palpable mass lower abdominal and lower back (describe location) Ultrasound

12 PELVIS US aorta LTD US renal retroperitoneal US pelvic (female) and transvaginal *Patient or doctor may specifically request no transvaginal due to patient age (under 18 years old), pregnancy or comfort. US pelvic (female and male) (No transvaginal included) US pelvic LTD Aorta screening Abdominal aortic aneurysm (AAA) Abnormal kidney labs Calculus of kidney stones Dysuria includes bladder and Flank pain pre & post void measurements Hematuria Hydronephrosis Mass or cyst CKB UTI If clinical history suggests urinary tract pathology, then a complete evaluation of the kidneys and urinary bladder will be included in the exam. Bleeding Bloating Endometriosis Excessive or frequent Female pelvis to view menstruation uterus and ovaries Fibroids Leiomyoma Mass Lower abdominal and pelvic pain Pelvic pain Mass Irregular bleeding Bloating Fibroids Abscess Free fluid Male pelvis bladder Bladder Urinary tract problems Soft palpable mass, To evaluate bladder in pelvic wall and buttocks addition to abdominal US (describe location) , US scrotal Mass Pain Swelling and tenderness 76870, Ultrasound

13 VASCULAR OTHER US arterial - lower extremity only *Always includes bilateral extremity unless amputation. US carotid duplex arteries bilateral US extremity venous studies duplex scan of veins, UNILATERAL upper and lower US extremity venous study duplex scan of veins, BILATERAL upper and lower US noninvasive extremity artery bilateral US breast, unilateral, complete US breast, unilateral, limited US non-vascular extremity LTD Cellulitis Claudication Edema Extremity pain PVD or PAD (Peripheral vascular/arterial disease) Bruit Diplopia Hypercholestremia Hyperlipidemia Trauma Vertigo Edema Numbness Swelling in extremity Warm limb Pain in extremity Thrombosis Please indicate upper/lower extremity and right/left. Pain Redness Swelling Tenderness in both legs Please indicate upper/lower extremity and right/left , Claudication Pain Palpable mass to INCLUDE side and location on breast (i.e. right breast palpable 10:00) Lumps Soft tissue masses on extremities and axilla (document specific area of concern) Ultrasound US spinal canal and contents Tethered cord (pediatric exam) 76800

14 BONE MINERAL DENSITOMETRY PREGNANCY DXA, Bone Density, one or more sites (hips, pelvis, spine) DXA, Peripheral Bone Mineral Density (wrist, forearm) US Obstetrical < 14 weeks US Transvaginal US Obstetrical > 14 weeks US Obstetrical w/ imaging of additional fetus Evaluate bone loss Osteoporosis Osteopenia Pregnancy LESS than 14 weeks Fetal demise Please include last menstrual period or established estimated date of delivery on all exams (less than 14 weeks). *Preferred exam to include EV for early OB. Pregnancy GREATER than 14 weeks Evaluation of fetal growth Please include last menstrual period or established estimated date of delivery for OB ultrasound (more than 14 weeks or for multiple fetus). Multiple fetus US obstetrical less than 14 weeks Evaluate FX Risk CT, Bone Density, QCT Osteoporosis Osteopenia , , (first) (additional) Bone Mineral Densitometry Pregnancy

15 MAMMOGRAPHY & BREAST ULTRASOUND Annual bilateral diagnostic mammogram Personal history breast cancer - asymptomatic women G0204 Annual screening mammogram All asymptomatic women age 40 and older G0202 Breast ultrasound Diagnostic bilateral mammogram (male) Palpable mass Complete breast US* - Complete examination of all four quadrants of the breast and the retroareolar region Limited breast US* - Focused exam of the breast that is limited to one or more of the elements included in Palpable mass woman age 29 and younger complete limited G0204 Breast tomosynthesis, unilateral Breast tomosynthesis, bilateral Screening breast tomosynthesis, bilateral Diagnostic bilateral mammogram Breast ultrasound (female) Symptomatic patients age 30 and older G complete limited Mammography & Breast Ultrasound *Both code definitions include an examination of the axilla, if performed.

16 MAMMOGRAPHY Unilateral diagnostic mammogram Personal history breast cancer - mastectomy G0206 Consider high-risk screening MRI of breasts in addition to (not as a replacement for) annual screening mammography High Risk Patients: - BRCA 1 or 2 carrier - History of chest radiation from ages Lifetime risk of breast cancer 20-25% or greater - Untested patient w/ 1st degree relative positive for BRCA 1 or Mammography

17 Our Locations TEMECULA VALLEY Hancock Avenue, Ste 105 Murrieta, CA TRI-CITY 3601 Vista Way, Bldg A, Ste 101 Oceanside, CA ENCINITAS 477 N. El Camino Real, Ste A 102 Encinitas, CA POWAY Monte Vista Road, Ste A Poway, CA GOLDEN TRIANGLE 4150 Regents Park Row, Ste 195 La Jolla, CA HILLCREST 150 W. Washington Street San Diego, CA ALVARADO 6386 Alvarado Court, Ste 121 San Diego, CA SOUTH BAY 333 H Street, Ste 1095 Chula Vista, CA CPT is a registered trademark of the American Medical Association and are subject to change. V 02.16