Diagnostic Imaging Utilization Management and Consultation Management Programs Imaging Code Listing for Connecticut, Maine and New Hampshire

Transcription

1 Diagnostic Imaging Utilization Management and Consultation Management Programs Imaging Code Listing for Connecticut, Maine and New Hampshire The grid below contains the CPT * codes that are subject to the utilization management (UM) and consultation management (CM) programs through American Imaging Management (AIM). This list includes the echocardiography services added as a pre-notification program beginning August 24, If an order ID number is issued by AIM, the service is eligible for coverage subject to the provisions of the member s coverage document. Services rendered as part of emergency room services, inpatient hospitalization or rehabilitation or 23-hour observation are not subject to the UM or CM programs. The grid identifies the CPT codes included within specific groupers. Add-on or secondary codes do not require a separate prior authorization. Computerized Tomography (CT) CPT Description Abdomen CT abdomen; w/o CT abdomen; with CT abdomen; w/o followed by Chest CT thorax; w/o CT thorax; with CT thorax; w/o followed by Upper CT upper extremity; w/o Extremity CT upper extremity; with CT upper extremity; w/o followed by Lower CT lower extremity; w/o Extremity CT lower extremity; with CT lower extremity; w/o followed by Head CT head or brain; w/o CT head or brain; with CT head or brain; w/o followed by Orbit CT orbit, sella or posterior fossa; w/o CT orbit, sella or posterior fossa; with CT orbit, sella or posterior fossa; w/o followed by Sinus CT maxillofacial area; w/o CT maxillofacial area; with CT maxillofacial area; w/o followed by Neck CT soft tissue neck; w/o CT soft tissue neck; with CT soft tissue neck; w/o followed by Pelvis CT pelvis; w/o CT pelvis; with CT pelvis w/o followed by

2 Cervical CT cervical spine; w/o Spine CT cervical spine; with CT cervical spine; w/o followed by Thoracic CT thoracic spine; w/o Spine CT thoracic spine; with CT thoracic spine; w/o followed by Lumbar CT lumbar spine; w/o Spine CT lumbar spine; with CT lumbar spine; w/o followed by Computerized Tomography Angiography (CTA) CPT Description Abdomen CTA abdomen; w/o followed by and Abdominal Arteries CTA abdominal aorta & bilateral iliofemoral lower extremity runoff; w/o followed by and Chest CTA chest; w/o followed by and Upper Extremity CTA upper extremity; w/o followed by and Lower Extremity CTA lower extremity; w/o followed by and Head CTA head; w/o followed by and Neck CTA neck; w/o followed by and Pelvis CTA pelvis; w/o followed by and Magnetic Resonance Imaging (MRI) CPT Description Abdomen MRI abdomen; w/o MRI abdomen; with MRI abdomen; w/o followed by Bone Marrow MRI bone marrow blood supply Breast MRI breast; unilateral MRI breast; bilateral Chest MRI chest; w/o MRI chest; with MRI chest; w/o followed by Cardiac MRI cardiac for morphology and function w/o MRI cardiac for morphology and function w/o ; with flow/velocity quantification MRI cardiac for morphology and function w/o ; with stress imaging

3 75560 MRI cardiac for morphology and function w/o ; with flow/velocity quantification and stress MRI cardiac for morphology and function w/o, followed by and further sequences MRI cardiac for morphology and function w/o, followed by and further sequences; with flow/velocity quantification MRI cardiac for morphology and function w/o, followed by and further sequences; with stress imaging MRI cardiac for morphology and function w/o, followed by and further sequences; with flow/velocity quantification and stress Upper MRI upper extremity, other than joint w/o Extremity MRI upper extremity, other than joint with Non-joint MRI upper extremity, other than joint w/o followed by Upper MRI upper extremity, any joint w/o Extremity MRI upper extremity, any joint with Any Joint MRI upper extremity, any joint w/o followed by Lower MRI lower extremity, other than joint w/o Extremity MRI lower extremity, other than joint w MRI lower extremity, other than joint w/o followed by MRI lower extremity, any joint w/o MRI lower extremity, any joint w MRI lower extremity, any joint w/o followed by TMJ MRI temporomandibular joint(s) Orbit MRI orbit, face and neck; w/o MRI orbit, face and neck; with MRI orbit, face and neck; w/o followed by Brain MRI brain; w/o MRI brain; with MRI brain; w/o followed by Pelvis MRI pelvis; w/o MRI pelvis; with MRI pelvis; w/o followed by Cervical MRI cervical spine; w/o Spine MRI cervical spine; with MRI cervical spine; w/o followed by Thoracic MRI thoracic spine; w/o Spine MRI thoracic spine; with MRI thoracic spine; w/o followed by Lumbar MRI lumbar spine; w/o Spine MRI lumbar spine; with MRI lumbar spine; w/o followed by

4 Magnetic Resonance Angiography (MRA) CPT Description Abdomen MRA abdomen; with or w/o Chest MRA chest; with or w/o Upper Extremity MRA upper extremity; with or w/o Lower Extremity MRA lower extremity; with or w/o Head MRA head; w/o MRA head; with MRA head; w/o followed by Neck MRA neck; w/o MRA neck; with MRA neck; w/o followed by Pelvis MRA pelvis; with or w/o Spinal Canal MRA spinal canal and contents with or w/o Magnetic Resonance Spectroscopy (MRS) CPT Description MR Spectroscopy QCT Bone Densitometry CPT Description CT bone mineral density study; axial skeleton Nuclear Cardiology CPT Description Myocardial Planar, single study at rest or stress Perfusion Planar, multiple studies at rest and/or stress Imaging SPECT, single study at rest or stress SPECT, multiple studies at rest and/or stress Infarct Planar, infarct avid; qualitative or quantitative Imaging Planar, infarct avid; with ejection fraction by first pass technique SPECT, infarct avid; with or w/o quantification Cardiac Blood Pool Imaging Gated equilibrium; planar, single study, wall motion plus ejection fraction Gated equilibrium; planar, multiple studies, wall motion study plus ejection fraction First pass tech; single study, wall motion study plus ejection fraction First pass tech; multiple studies, wall motion study plus ejection fraction Gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction

5 Positron Emission Tomography (PET) CPT Description Brain PET brain, metabolic evaluation Imaging PET brain, perfusion evaluation Myocardial PET myocardial, metabolic evaluation Imaging PET myocardial, perfusion, single study PET myocardial, perfusion, multiple studies PET & CT/PET Fusion CPT Description Tumor Imaging PET tumor imaging, limited PET tumor imaging, skull to mid-thigh PET tumor imaging, whole body PET tumor imaging with concurrent CT, limited PET tumor imaging with concurrent CT, skull to midthigh PET tumor imaging with concurrent CT, whole body Screening CT Colonoscopy CPT Description 0066T Screening CT Colonoscopy (Virtual colonoscopy) Diagnostic CT Colonoscopy CPT Description 0067T Diagnostic CT Colonoscopy (Virtual colonoscopy) Coronary CT & CTA CPT Description 0144T CT heart wo ; calcium scoring 0145T CT heart w/wo structure/morphology 0146T Coronary CTA wo eval of coronary calcium 0147T Coronary CTA w eval of coronary calcium 0148T Coronary CTA, structure and morphology 0149T Coronary CTA, structure and morpho w quan calc 0150T Coronary CTA congenital heart disease Functional MRI (fmri) CPT Description fmr not requiring physician administration fmri requiring physician administration

6 Add-On Codes CPT Description CT and MRI Groups CT Groups Limited follow-up CT 3D interpretation and reporting of CT, MRI, ULS or other Tomographic modality; not requiring image post processing on an independent workstation 3D interpretation and reporting of CT, MRI, ULS or other Tomographic modality; requiring image post processing on an independent workstation Nuclear Cardiology Group Coronary CT/CTA T Myocardial perfusion study w wall motion, qualitative or quantitative study (Add-on code to 78460, 78461, 78464, or only) Myocardial perfusion study with ejection fraction (Add-on code to 78460, 78461, or only) Add-on code to 0145T, 0146T, 0147T, 0148T, 0149T, 0150T Echocardiography (Effective 8/24/2009, Pre-Notification Only) Echocardiogram CPT Description Stress Echo (SE) Transthoracic Stress Echo, complete Transthoracic Stress Echo, complete w cont EKG Resting Trans Echo (TTE) Transesophageal Echo (TEE) Transthoracic Echo cardiac anomalies Transthoracic Echo cardiac anomalies, limited Transthoracic Echo complete w color & spectral Transthoracic Echo complete wo color & spectral Transthoracic Echo limited Transesophageal Echo Transesophageal Echo probe only Transesophageal Echo interpretation Transesophageal Echo congenital Transesophageal Echo congenital, probe only Transesophageal Echo congenital interpretation Echo Add-On Codes CPT Description Doppler Echo complete Doppler Echo limited Doppler Echo flow velocity Echo agent (SE only)