HealthFirst - Prior Authorization Procedure List: Radiology and Radiation Therapy

Transcription

1 Platform: ImageOne HealthFirst - Prior Procedure List: Radiology and Radiation Therapy Solution Category CPT Code CPT Code Description Radiology MRI MRI TMJ Radiology CT CT Head Without Contrast Radiology CT CT Head With Contrast Radiology CT CT Head Without & With Contrast Radiology CT CT Orbit Without Contrast Radiology CT CT Orbit With Contrast Radiology CT CT Orbit Without & With Contrast Radiology CT CT Maxillofacial Without Contrast Radiology CT CT Maxillofacial With Contrast Radiology CT CT Maxillofacial Without & With Contrast Radiology CT CT Soft Tissue Neck Without Contrast Radiology CT CT Soft Tissue Neck With Contrast Radiology CT CT Soft Tissue Neck Without & With Contrast Radiology CT CT Angiography Head Radiology CT CT Angiography Neck Radiology MRI MRI Orbit, Face, Neck and/or Without Contrast Radiology MRI MRI Face, Orbit, Neck With Contrast Radiology MRI MRI Face, Orbit, Neck With & Without Contrast Radiology MRA MRA Head Without Contrast Radiology MRA MRA Head With Contrast Radiology MRA MRA Head With & Without Contrast Radiology MRA MRA Neck Without Contrast Radiology MRA MRA Neck With Contrast Radiology MRA MRA Neck With & Without Contrast Radiology MRI MRI Head Without Contrast Radiology MRI MRI Head With Contrast Radiology MRI MRI Head With & Without Contrast Radiology MRI MRI Brain, functional MRI Radiology MRI MRI Brain, functional MRI, requiring physician Radiology CT CT Thorax Without Contrast Radiology CT CT Thorax With Contrast Radiology CT CT Thorax Without & With Contrast Radiology CT CT Angiography Chest Without Contrast Material, Followed by Contrast Material and Further Sections, Including Image Post processing Radiology MRI MRI Chest Without Contrast Radiology MRI MRI Chest With Contrast Radiology MRI MRI Chest With & Without Contrast Radiology MRA MRA Chest (Excluding Myocardium) With Or Without Contrast Radiology CT CT Cervical Spine Without Contrast Radiology CT CT Cervical Spine With Contrast Radiology CT CT Cervical Spine Without & With Contrast Radiology CT CT Thoracic Spine Without Contrast Radiology CT CT Thoracic Spine With Contrast Radiology CT CT Thoracic Spine Without & With Contrast

2 Radiology CT CT Lumbar Spine Without Contrast Radiology CT CT Lumbar Spine With Contrast Radiology CT CT Lumbar Spine Without & With Contrast Radiology MRI MRI Cervical Spine Without Contrast Radiology MRI MRI Cervical Spine With Contrast Radiology MRI MRI Thoracic Spine Without Contrast Radiology MRI MRI Thoracic Spine With Contrast Radiology MRI MRI Lumbar Spine Without Contrast Radiology MRI MRI Lumbar Spine With Contrast Radiology MRI MRI Cervical Spine With & Without Contrast Radiology MRI MRI Thoracic Spine With & Without Contrast Radiology MRI MRI Lumbar Spine With & Without Contrast Radiology MRA MRA Spinal Canal With Or Without Contrast Radiology CT CT Angiography Pelvis Radiology CT CT Pelvis Without Contrast Radiology CT CT Pelvis With Contrast Radiology CT CT Pelvis Without & With Contrast Radiology MRI MRI Pelvis Without Contrast Radiology MRI MRI Pelvis With Contrast Radiology MRI MRI Pelvis With & Without Contrast Radiology MRA MRA Pelvis With Or Without Contrast Radiology CT CT Upper Extremity Without Contrast Radiology CT CT Upper Extremity With Contrast Radiology CT CT Upper Extremity Without & With Contrast Radiology CT CT Angiography Upper Extremity Radiology MRI MRI Upper Extremity Without Contrast Radiology MRI MRI Upper Extremity With Contrast Radiology MRI MRI Upper Extremity With & Without Contrast Radiology MRI MRI Upper Extremity Joint Without Contrast Radiology MRI MRI Upper Extremity Joint With Contrast Radiology MRI MRI Upper Extremity Joint With & Without Contrast Radiology MRA MRA Upper Extremity With Or Without Contrast Radiology CT CT Lower Extremity Without Contrast Radiology CT CT Lower Extremity With Contrast Radiology CT CT Lower Extremity Without & With Contrast Radiology CT CT Angiography Lower Extremity Radiology MRI MRI Lower Extremity Without Contrast Radiology MRI MRI Lower Extremity With Contrast Radiology MRI MRI Lower Extremity With & Without Contrast Radiology MRI MRI Lower Extremity Joint Without Contrast Radiology MRI MRI Lower Extremity Joint With Contrast Radiology MRI MRI Lower Extremity Joint With & Without Contrast Radiology MRA MRA Lower Extremity With Or Without Contrast Radiology CT CT Abdomen Without Contrast Radiology CT CT Abdomen With Contrast Radiology CT CT Abdomen Without & With Contrast Radiology CT CT angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image post processing Radiology CT CT Angiography Abdomen

3 Radiology CT CT Abdomen And Pelvis Without Contrast Radiology CT CT Abdomen And Pelvis With Contrast Radiology CT 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 Radiology MRI MRI Abdomen Without Contrast Radiology MRI MRI Abdomen With Contrast Radiology MRI MRI Abdomen With & Without Contrast Radiology MRA MRA Abdomen With Or Without Contrast Radiology CT Computed tomographic (CT) colonography, diagnostic, including image post processing; without contrast material Radiology CT Radiology CT Radiology MRI Radiology MRI Radiology CMRI Radiology CMRI Radiology CMRI Radiology CMRI Radiology CMRI Radiology CCTA Radiology CCTA 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 ) 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 ) Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium 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) Radiology CCTA 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) Radiology CCTA 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) Radiology CT C T Angiography Abdominal Aorta

4 Radiology 3DI D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image post processing under concurrent supervision; not requiring image post processing on an independent workstation Radiology 3DI D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image post processing under concurrent supervision; requiring image post processing on an independent workstation Radiology CT CT Limited Or Localized Follow-Up Study Radiology MRI MRI Spectroscopy Radiology CT Unlisted computed tomography Radiology MRI Unlisted MRI Procedure Radiology MRI Unlisted Radiology Procedure Radiology DGUS Us Echoencephalography Radiology DGUS Us Soft Tissue Head And Neck Radiology DGUS Us Chest Real Time With Image Documentation Radiology DGUS Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete Radiology DGUS Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited Radiology DGUS Ultrasound Abdominal Real Time With Image Documentation Radiology DGUS U/S Single Organ Radiology DGUS Ultrasound,Retroperotonral,Real Time With Image Documentation; Complete Radiology DGUS Us Echo Limited Radiology DGUS Ultrasound, Transplanted Kidney, Real Time And Duplex Doppler With Image Documentation Radiology DGUS Us Echo Spinal Canal Radiology OB-US Ultrasound Obstetrical Pelvis, Pregnant Uterus, First Trimester less than 14 Weeks Single Or First Gestation Radiology OB-US Ultrasound Obstetrical Pelvis, Pregnant Uterus, First Trimester less than 14 Weeks Each Additional Gestation Radiology OB-US Ultrasound Obstetrical Pelvis, Pregnant Uterus, B-Scan Radiology OB-US Ultrasound Obstetrical Pelvis Complete, Multiple Gestation After 1st Trimester Radiology OB-US Ultrasound Pregnant Uterus Fetal & Maternal Evaluation Plus Fetal Anatomic Evaluation Transabdominal Single Or First Gestation Radiology OB-US Ultrasound Pregnant Uterus Fetal & Maternal Evaluation Plus Fetal Anatomic Evaluation Transabdominal Each Additional Gestation Radiology OB-US Ultrasound, pregnant uterus, real time with image documentation Radiology OB-US Ultrasound, pregnant uterus, real time with image documentation Radiology OB-US Ultrasound Obstetrical Pelvis Limited (Gestational Age, Heart Beat, Emergency) Radiology OB-US Ultrasound Obstetrical Pelvis Follow Up Or Repeat Radiology OB-US Ultrasound Pregnant Uterus Transvaginal Radiology OB-US Fetal Biophysical Profile Radiology OB-US Fetal Biophysical Profile Without Stress n Stress Radiology OB-US Doppler Velocimetry, Fetal; Umbilical Artery Radiology OB-US Doppler Velocimetry, Fetal; Middle Cerebral Artery Radiology OB-US Ultrasound Obstetrical Echocardiography, Fetal, Cardiovascular System

5 Radiology OB-US Follow Up Or Repeat Study Radiology OB-US Doppler Echocardiography Fetal Complete Radiology OB-US Follow Up Or Repeat Study Radiology DGUS U/S Transvaginal Radiology DGUS Hysterosonography W Or W/O Col Radiology DGUS Ultrasound Pelvic Real Time With Image Documentation; Complete Radiology DGUS Us Pel Lim Or F/U Radiology DGUS Us Echo Scrotum Radiology DGUS U/S Transrectal Radiology DGUS Ultrasound, Extremity, n-vascular, Real Time With Image Documentation; Complete Radiology DGUS Ultrasound, Extremity, n-vascular, Real Time With Image Documentation; Limited, Anatomic Specific Radiology DGUS Us Echo, Infant Hips Real-time Radiology DGUS Us, Infant Hips, Real Time; Limited, Static Radiology DGUS Us Study Follow Up Radiology DGUS Ultrasound Gastrointestinal, Endoscopic Radiology DGUS Echo Examination Procedure Radiology CT CT For Stereotactic Localization Radiology CT Computed tomography guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), radiological supervision and interpretation Radiology CT CT Guidance For Procedures For Ablation Radiology CT CT Guide Placement Radiation Radiology MRI M R I Guidance For Needle Placement Radiology MRI Magnetic resonance guidance for, and monitoring of, parenchymal tissue ablation Radiology BMRI M R I Breast With And/Or Without Contrast Radiology BMRI M R I Breast Bilateral Radiology CT Computed Tomography, bone mineral density study, 1 or more sites; axial skeleton Radiology MRI Magnetic resonance (e.g., proton) imaging, bone marrow blood supply Radiology NUC MED Thyroid uptake; single determination AMA Deleted 1/1/2013; AMA Deleted 1/1/2013; Request with Request with Radiology NUC MED Thyroid uptake; multiple determinations AMA Deleted 1/1/2013; AMA Deleted 1/1/2013; Request with Request with Radiology NUC MED Thyroid uptake stimulation, suppression or discharge (not including initial uptake AMA Deleted 1/1/2013; AMA Deleted 1/1/2013; studies) Request with Request with Radiology NUC MED Thyroid imaging, with uptake; single determination Radiology NUC MED Thyroid imaging, multiple determinations Radiology NUC MED Thyroid imaging; only Radiology NUC MED Thyroid imaging; with vascular flow Radiology NUC MED Thyroid uptake, single or multiple quantitative measurement(s) (including stimulation, suppression, or discharge, when performed) Radiology NUC MED Thyroid imaging (including vascular flow, when performed) Radiology NUC MED Thyroid imaging (including vascular flow, when performed); with single or multiple uptake(s) quantitative measurement(s) (including stimulation, suppression, or discharge, when performed) Radiology NUC MED Thyroid Met Imaging Radiology NUC MED Thyroid Met Imaging With Additional Studies

6 Radiology NUC MED Thyroid Scan Whole Body Radiology NUC MED Thyroid Carcinoma Metastases Uptake Radiology NUC MED Parathyroid planar imaging (including subtraction, when performed) Radiology NUC MED Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT) Radiology NUC MED Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT), and concurrently acquired computed tomography (CT) for anatomical localization Radiology NUC MED Adrenal Nuclear Imaging Radiology NUC MED Unlisted endocrine Radiology NUC MED Bone Marrow Imaging, Limited Radiology NUC MED Bone Marrow Imaging, Multiple Radiology NUC MED Bone Marrow Imaging, Whole Body Radiology NUC MED Red Cell Survival Differential Radiology NUC MED Labeled Red Cell Sequestration Radiology NUC MED Spleen Imaging With & Without Vascular Flow Radiology NUC MED Platelet Survival W/ Or W/Out Differential Organ/Tissue Localization Radiology NUC MED Platelet Survival Study Only Radiology NUC MED Lymph System Imaging Radiology NUC MED Unlisted Hematopoetic Procedure Radiology NUC MED Liver Imaging Radiology NUC MED Liver Imaging With Flow Radiology NUC MED Liver Imaging SPECT (3D) Radiology NUC MED Liver Imaging SPECT With Vascular Flow Radiology NUC MED Liver & Spleen Imaging Radiology NUC MED Liver & Spleen Imaging With Flow Radiology NUC MED Liver function study with hepatobiliary agents, with serial images AMA Deleted 1/1/2012 AMA Deleted 1/1/2012 Radiology NUC MED Hepatobiliary ductal system imaging, including gallbladder, with or without pharmacologic intervention, with or without quantitative measurement of gallbladder function AMA Deleted 1/1/2012; Request with or AMA Deleted 1/1/2012; Request with or Radiology NUC MED Hepatobiliary system imaging, including gallbladder when present; Radiology NUC MED Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention, including quantitative measurement(s) when performed Radiology NUC MED Salivary Gland Imaging Radiology NUC MED Serial Salivary Gland Radiology NUC MED Salivary Gland Function Exam Radiology NUC MED Esophagus Motility Study Radiology NUC MED Gastric Mucosa Imaging Radiology NUC MED Gastroesophageal Reflux Exam Radiology NUC MED Gastric Emptying Study Radiology NUC MED Gastric emptying imaging study (e.g., solid, liquid, or both); with small bowel transit Radiology NUC MED Gastric emptying imaging study (e.g., solid, liquid, or both); with small bowel and colon transit, multiple days Radiology NUC MED B-12 Absorption With Out Intrinsic Factor Radiology NUC MED B-12 Absorption With Intrinsic Factor Radiology NUC MED GI Bleeder Scan Radiology NUC MED Gastronintestinal protein loss Radiology NUC MED Meckels Diverticulum Imaging

7 Radiology NUC MED Leveen Shunt Patency Exam Radiology NUC MED Unlisted Gastrointestinal Procedure Radiology NUC MED Bone Or Joint Imaging Limited Radiology NUC MED Bone Or Joint Imaging Multiple Radiology NUC MED Bone Scan Whole Body Radiology NUC MED Bone Scan 3 Phase Study Radiology NUC MED Bone Joint Imaging Tomo Test SPECT Radiology NUC MED Unlisted Musculoskeletal Procedure Radiology NUC MED n-imaging Heart Function Radiology NUC MED Cardiac Shunt Imaging Radiology NUC MED n-cardiac vascular flow imaging (i.e., angiography, venography) Radiology NUC CARD 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) Radiology NUC CARD 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 Radiology NUC CARD 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) Radiology NUC CARD 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 Radiology NUC MED Acute Venous Thrombosis Imaging Radiology NUC MED Venous Thrombosis Imaging Unilateral Radiology NUC MED Venous Thrombosis Images, Bilateral Radiology CPET Myocardial imaging, positron emission tomography (pet), metabolic evaluation Radiology NUC MED Myocardial perfusion imaging; (planar) single study, at rest or stress (exercise and/or pharmacologic), with or without quantification Radiology NUC MED Myocardial perfusion imaging; multiple studies (planar), at rest and/or stress (exercise and/or pharmacologic), and redistribution and/or rest injection, with or without quantification Radiology NUC MED Myocardial perfusion imaging; tomographic (SPECT), single study (including attenuation correction when performed), at rest or stress (exercise and/or pharmacologic), with or without quantification Radiology NUC MED Myocardial perfusion imaging; tomographic (SPECT), multiple studies (including attenuation correction when performed), at rest and/or stress (exercise and/or pharmacologic) and redistribution and/or rest injection, with or without quantification Radiology NUC MED Myocardial Infarction Scan Radiology NUC MED Heart Infarct Image Ejection Fraction Radiology NUC MED Heart Infarct Image 3D SPECT Radiology NUC MED Cardiac Bloodpool Img, Single

8 Radiology NUC MED Cardiac Bloodpool Img, Multi Radiology NUC MED Myocardial perfusion study with wall motion, qualitative or quantitative study (List separately in addition to code for primary ) Radiology NUC MED Myocardial perfusion study with ejection fraction (List separately in addition to code for primary ) Radiology NUC MED Heart First Pass Single Radiology NUC MED Cardiac Blood Pool Imaging -- Multiple Radiology CPET Myocardial imaging, positron emission tomography (pet), perfusion; single study at rest or stress Radiology CPET Myocardial imaging, positron emission tomography (pet), perfusion; multiple studies at rest and/or stress Radiology NUC MED Cardiac Blood Pool Imaging, SPECT Radiology NUC MED Cardiac Blood Pool Imaging - Single Rest Radiology NUC MED Unlisted Cardiovascular Procedure Radiology NUC MED Pulmonary ventilation imaging (e.g., aerosol or gas) Radiology NUC MED Pulmonary perfusion imaging (e.g., particulate) Radiology NUC MED Pulmonary ventilation (e.g., aerosol or gas) and perfusion imaging Radiology NUC MED Pulmonary perfusion imaging, particulate, with ventilation; single breath AMA Deleted 1/1/2012 AMA Deleted 1/1/2012 Radiology NUC MED Pulmonary Perfusion With Washout With Or Without Single Breath AMA Deleted 1/1/2012 AMA Deleted 1/1/2012 Radiology NUC MED Pulmonary ventilation imaging, aerosol; single projection AMA Deleted 1/1/2012 AMA Deleted 1/1/2012 Radiology NUC MED Pulmonary ventilation imaging, aerosol; multiple projections (e.g., anterior, posterior, lateral views) AMA Deleted 1/1/2012 AMA Deleted 1/1/2012 Radiology NUC MED Pulmonary perfusion imaging, particulate, with ventilation imaging, aerosol, 1 or multiple projections AMA Deleted 1/1/2012 AMA Deleted 1/1/2012 Radiology NUC MED Pulmonary ventilation imaging, gaseous, single breath, single projection AMA Deleted 1/1/2012 AMA Deleted 1/1/2012 Radiology NUC MED Pulmonary ventilation imaging, gaseous, with rebreathing and washout with or without single breath; single projection AMA Deleted 1/1/2012 AMA Deleted 1/1/2012 Radiology NUC MED Pulmonary ventilation imaging, gaseous, with rebreathing and washout with or without single breath; multiple projections (e.g., anterior, posterior, lateral views) AMA Deleted 1/1/2012 AMA Deleted 1/1/2012 Radiology NUC MED Pulmonary quantitative differential function (ventilation/perfusion) study AMA Deleted 1/1/2012 AMA Deleted 1/1/2012 Radiology NUC MED Quantitative differential pulmonary perfusion, including imaging when performed Radiology NUC MED Quantitative differential pulmonary perfusion and ventilation (e.g., aerosol or gas), including imaging when performed Radiology NUC MED Unlisted Respiratory Procedure Radiology NUC MED Brain Imaging Limited Static Radiology NUC MED Brain Limited Imaging And Flow Radiology NUC MED Brain Imaging Complete Radiology NUC MED Brain Imaging Complete With Flow Radiology NUC MED Brain Imaging 3D Radiology PET Brain Imaging, Positron Emission Tomography (PET) Metabolic Evaluation Radiology PET Brain Imaging, Positron Emission Tomography (PET) Perfusion Evaluation Radiology NUC MED Brain Flow Imaging Only Radiology NUC MED Cisternogram (Cerebrospinal Fluid Flow) Radiology NUC MED Cerebrospinal Ventriculography

9 Radiology NUC MED CSF Shunt Evaluation Radiology NUC MED Cerebrospinal Fluid Scan (Tomographic) SPECT Radiology NUC MED C S F Leakage Detection And Localization Radiology NUC MED Radiopharmaceutical Dacryocystography Radiology Unlisted Unlisted Nuclear Medicine Procedure Radiology NUC MED Kidney Imaging Morphology Radiology NUC MED Kidney Imaging With Vascular Flow Radiology NUC MED Kidney Imaging With Function Study (Imaging Renogram) Radiology NUC MED Kidney Imaging With Vascular Flow & Function Single Study Without Pharmacological Intervention Radiology NUC MED Kidney Imaging Single Study With Pharmacological Intervention Radiology NUC MED Kidney Imaging - Multiple Studies Without & With Pharmacological Intervention Radiology NUC MED Kidney Imaging - Tomographic (SPECT) Radiology NUC MED Kidney Function Study - n-imaging Radioisotopic Radiology NUC MED Urinary Bladder Residual Study Radiology NUC MED Ureteral Reflux Study Radiology NUC MED Testicular Imaging With Vascular Flow Radiology NUC MED Unlisted Genitourinary Procedure Radiology NUC MED Radiopharm Localization Of Tumor, Limited Area Radiology NUC MED Radiopharm Localization Of Tumor, Multiple Areas Radiology NUC MED Radiopharm Localization Of Tumor, Whole Body Radiology NUC MED Radiopharm Localization Of Tumor Tomographic (SPECT) Radiology NUC MED Radiopharm Localization Of Tumor, Whole Body Radiology NUC MED Radiopharm Localization Of Abscess, Limited Area Radiology NUC MED Radiopharm Localization Of Abscess, Whole Body Radiology NUC MED Radiopharm Localization Of Abscess, Tomographic SPECT Radiology PET Tumor Imaging, Positron Emission Tomography (Pet); Limited Area (E.g., Chest, Head/Neck) Radiology PET Tumor Imaging, Positron Emission Tomography (Pet); Skull Base To Mid-Thigh Radiology PET Positron Emission Tomography (Pet); Whole Body Radiology PET CT 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) Radiology PET CT Tumor Imaging, Positron Emission Tomography (Pet) With Concurrently Acquired Computer Tomography (Ct) For Attenuation Correction And Anatomical Localization; Skull Base To Mid-Thigh Radiology PET CT Tumor Imaging, Positron Emission Tomography (Pet) With Concurrently Acquired Computer Tomography (Ct) For Attenuation Correction And Anatomical Localization; Whole Body Radiology NUC MED Unlisted Misc. Procedure Diagnostic Nuclear Med Radiology DGUS Duplex scan of extracranial arteries; complete bilateral study Radiology DGUS Duplex scan of extracranial arteries; unilateral or limited study Radiology DGUS Transcranial Doppler study of the intracranial arteries; complete study Radiology DGUS Transcranial Doppler study of the intracranial arteries; limited study Radiology DGUS Transcranial Doppler vasoreactivity study Radiology DGUS Transcranial Doppler study of the intracranial arteries; emboli detection without intravenous microbubble injection

10 Radiology DGUS Transcranial Doppler study of the intracranial arteries; emboli detection with intravenous microbubble injection Radiology DGUS Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries, (e.g., for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus bidirectional, Doppler waveform recording and analysis at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus volume plethysmography at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries with, transcutaneous oxygen tension measurement at 1-2 levels) Radiology DGUS Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels (e.g., for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental blood pressure measurements with bidirectional Doppler waveform recording and analysis, at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental volume plethysmography at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental transcutaneous oxygen tension measurements at 3 or more levels), or single level study with provocative functional maneuvers (e.g., measurements with postural provocative tests, or measurements with reactive hyperemia) Radiology DGUS Radiology DGUS Radiology DGUS Radiology DGUS Radiology DGUS Radiology DGUS Radiology DGUS Radiology DGUS Radiology DGUS Radiology DGUS ninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, (i.e., bidirectional Doppler waveform or volume plethysmography recording and analysis at rest with ankle/brachial indices immediately after and at timed intervals following performance of a standardized protocol on a motorized treadmill plus recording of time of onset of claudication or other symptoms, maximal walking time, and time to recovery) complete bilateral study Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited study ninvasive physiologic studies of extremity veins, complete bilateral study (e.g., Doppler waveform analysis with responses to compression and other maneuvers, phleborheography, impedance plethysmography) Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited stud 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

11 Radiology DGUS Radiology DGUS 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 Radiology DGUS Duplex scan of arterial inflow and venous outflow of penile vessels; complete study Radiology DGUS Duplex scan of arterial inflow and venous outflow of penile vessels; follow-up or limited study Radiology DGUS Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow) Radiology DGUS Unlisted ninvasive Vascular Diagnostic Study Radiology CT 0042T CT Perfusion Brain Radiology CT 0066T Computed tomographic (CT) colonography (i.e., virtual colonoscopy); screening Radiology CT 0067T Computed tomographic (CT) colonography (i.e., virtual colonoscopy); diagnostic Radiology CT 0144T Radiology CT 0145T Radiology CT 0146T Radiology CT 0147T Radiology CT 0148T Computed tomography, heart, without contrast material, including image post processing and quantitative evaluation of coronary calcium Computed tomography, heart, with contrast material(s), including noncontrast images, if performed, cardiac gating and 3D image post processing; cardiac structure and morphology Computed tomography, heart, with contrast material(s), including noncontrast images, if performed, cardiac gating and 3D image post processing; computed tomographic angiography of coronary arteries (including native and anomalous coronary arteries, coronary bypass grafts), without quantitative evaluation of coronary calcium Computed tomography, heart, with contrast material(s), including noncontrast images, if performed, cardiac gating and 3D image post processing; computed tomographic angiography of coronary arteries (including native and anomalous coronary arteries, coronary bypass grafts), with quantitative evaluation of coronary calcium Computed tomography, heart, with contrast material(s), including noncontrast images, if performed, cardiac gating and 3D image post processing; cardiac structure and morphology and computed tomographic angiography of coronary arteries (including native and anomalous coronary arteries, coronary bypass grafts), without quantitative evaluation of coronary calcium Radiology CT 0159T Computer-aided detection, including computer algorithm analysis of MRI image data for lesion detection/characterization, pharmacokinetic analysis, with further physician review for interpretation, breast MRI (List separately in addition to code for primary ) Radiology MRA C8900 MRA Abdomen with contrast Radiology MRA C8901 MRA Abdomen without contrast Radiology MRA C8902 MRA Abdomen with and w/o contrast Radiology MRI C8903 MRI Breast w/ contrast, unilateral Radiology MRI C8904 MRI Breast w/o contrast, unilateral Radiology MRI C8905 MRI Breast w. and w/o contrast, unilateral Radiology MRI C8906 MRI Breast Bilateral W/ Contrast Radiology MRI C8907 MRI Breast Bilateral W/O Contrast Radiology MRI C8908 MRI Breast Bilateral W/ And W/O Contrast

12 Radiology MRA C8909 MRA chest w/contrast (excluding myocardium) Radiology MRA C8910 MRA chest w/o contrast (excluding myocardium) Radiology MRA C8911 MRA chest (excluding myocardium) Radiology MRA C8912 MRA lower extremity w/ contrast Radiology MRA C8913 MRA lower extremity w/o contrast Radiology MRA C8914 MRA lower extremity w/ and w/o contrast Radiology MRA C8918 MRA pelvis w/ contrast Radiology MRA C8919 MRA pelvis w/o contrast Radiology MRA C8920 MRA pelvis w/ and w/o contrast Radiology MRA C8931 MRA, W/Dye, Spinal Canal Radiology MRA C8932 MRA, W/O Dye, Spinal Canal Radiology MRA C8933 MRA, W/O & W/Dye, Spinal Canal Radiology MRA C8934 MRA, W/Dye, Upper Extremity Radiology MRA C8935 MRA, W/O Dye, Upper Extr Radiology MRA C8936 MRA, W/O & W/Dye, Upper Extr Radiology DGUS C9744 Ultrasound, abdominal, with contrast Radiology PET G0219 Pet Imaging Whole Body; Melanoma For n-covered Indications Radiology PET G0235 Pet Imaging, Any Site, t Otherwise Specified Radiology PET G0252 Pet Imaging, Full And Partial-Ring Pet Scanners Only For Initial Diagnosis Of Breast Cancer And/Or Surgical Planning For Breast Cancer Radiology CT G0297 Low-dose Computed Tomography For Lung Cancer Screening Radiology DGUS G0389 Ultrasound B-Scan And/Or Real Time With Image Documentation; For Abdominal Aortic Aneurysm (Aaa) Screening Radiology CT S8032 Low-dose Computed Tomography For Lung Cancer Screening AMA Deleted 10/1/2016 AMA Deleted 10/1/2016 Radiology MRI S8037 Magnetic resonance cholangiopancreato-graphy (MRCP) Radiology MRI S8042 Magnetic Resonance Imaging (Mri), Low-Field Radiology CT S8080 Radiology PET S8085 Scintimammography (Radioimmunoscintigraphy Of The Breast), Unilateral, Including Supply Of Radiopharmaceutical Fluorine-18 Fluorodeoxyglucose (F-18 Fdg) Imaging Using Dual Head Coincidence Detection System. (n-dedicated Pet Scan) Radiology CT S8092 Electron Beam Computed Tomography (Also Known As Ultrafast CT, Cinet) Radiation Therapy Rev Code 333 Radiology/Therapeutic- Radiation Therapy Radiation Therapy N/A Placement Of Radiation Therapy Afterloading Expandable Catheter Into The Breast For Interstitial Radioelement Application Following Partial Mastectomy On Date Separate From Partial Mastectomy

13 Radiation Therapy N/A Placement Of Radiation Therapy Afterloading Expandable Catheter Into The Breast For Interstitial Radioelement Application Following Partial Mastectomy, Concurrent With Partial Mastectomy) Radiation Therapy N/A Placement Of Radiation Therapy Afterloading Brachytherapy Catheters (Multiple Tube And Button Type) Into The Breast For Interstitial Radioelement Application Following (At The Time Of Or Subsequent To) Partial Mastectomy, Includes Imaging Guidance. Radiation Therapy N/A Bronchoscopy (Rigid Or Flexible), With Placement Of Catheter For Intracavitary Radioelement Application Radiation Therapy N/A Placement Of Interstitial Device For Radiation Therapy Guidance, Percutaneous, Intra-Thoracic, Single Or Multiple Radiation Therapy N/A Placement Of Needles, Catheters, And Other Devices Into The Head And/Or Neck Radiation Therapy N/A Placement Of Interstitial Device(s) For Radiation Therapy Guidance, Open, Intra- Abdominal, Intra-Pelvic And/Or Retroperitoneum, Including Image Guidance, Single Or Multiple Radiation Therapy N/A Placement Of Interstitial Device(s) For Radiation Therapy Guidance (e.g., Fiducial Markers, Dosimeter), Open, Intra-Abdominal, Intrapelvic, And/Or Retroperitoneum, Including Image Guidance, If Performed, Single Or Multiple (List Separately In Addition To Code For Primary Procedure) Radiation Therapy N/A Transperineal Placement Of Needles Or Catheters Into Prostate For Interstitial Radioelement Application, With Or Out Cystoscopy Radiation Therapy N/A Fiducial Marker Placement In The Prostate Radiation Therapy N/A Placement Of Needles, Catheters, Or Other Device(s) Into The Head And/Or Neck Region (Percutaneous, Transoral, Or Transnasal) For Subsequent Interstitial Radioelement Application Radiation Therapy N/A Insertion Of Uterine Tandem And/Or Vaginal Ovoids For Clinical Brachytherapy Radiation Therapy N/A Insertion Of A Vaginal Radiation After Loading Apparatus For Clinical Brachytherapy Radiation Therapy N/A Insertion Of Heyman Capsules for Clinical Brachytherapy Radiation Therapy N/A US Transrectal Prostate Volume Study For Brachytherapy Radiation Therapy N/A Ultrasound Guidance For Interstitial Radioelement Application Radiation Therapy Radiologic Guidance Computed tomography guidance for placement of radiation therapy fields Radiation Therapy N/A Therapeutic Radiology Treatment Planning; Simple Radiation Therapy N/A Therapeutic Radiology Treatment Planning; Intermediate Radiation Therapy N/A Therapeutic Radiology Treatment Planning; Complex Radiation Therapy N/A Therapeutic Radiology Simulation; Simple Radiation Therapy N/A Therapeutic Radiology Simulation; Intermediate Radiation Therapy N/A Therapeutic Radiology Simulation; Complex Radiation Therapy N/A Respiratory Motion Management Simulation (List Separately In Addition To Code For Primary Procedure) Radiation Therapy N/A Dimensional Radiotherapy Plan, Including Dose-Volume Histograms Radiation Therapy N/A Unlisted Procedure; Therapeutic Radiology Treatment Planning Radiation Therapy N/A Basic Radiation Dosimetry Radiation Therapy N/A IMRT Planning Radiation Therapy N/A Electron Beam Computed Tomography (Also Known As Ultrafast CT, Cinet)

14 Radiation Therapy N/A Teletherapy Isodose Plan; Complex (Multiple Treatment Areas, Tangential Ports, The Use Of Wedges, Blocking, Rotational Beam, Or Special Beam Considerations), Includes Basic Dosimetry Calculation(s) Radiation Therapy N/A Brachytherapy Isodose Plan; Simple (Calculation(s) Made From 1 To 4 Sources, Or Remote Afterloading Brachytherapy, 1 Channel), Includes Basic Dosimetry Calculation(s) Radiation Therapy N/A Brachytherapy Isodose Plan; Intermediate (Calculation(s) Made From 5 To 10 Sources, Or Remote Afterloading Brachytherapy, 2-12 Channels), Includes Basic Dosimetry Calculation(s) Radiation Therapy N/A Brachytherapy Isodose Plan; Complex (Calculation(s) Made From Over 10 Sources, Or Remote Afterloading Brachytherapy, 12 Channels), Includes Basic Dosimetry Calculation(s) Radiation Therapy N/A Special Teletherapy Port Plan, Particles, Hemibody, Total Body Radiation Therapy N/A Special Radiation Dosimetry Radiation Therapy N/A Treatment Devices; Simple Radiation Therapy N/A Treatment Devices; Intermediate Radiation Therapy N/A Treatment Devices; Complex Radiation Therapy N/A Continuing Medical Physics Consultation Radiation Therapy N/A Multi-Leaf Collimator (MLC) Device(s) For IMRT, Design And Construction Per IMRT Plan Radiation Therapy N/A Special Medical Physics Consultation Radiation Therapy Stereotactic Radiation Therapy Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based Radiation Therapy Stereotactic Radiation Therapy Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; linear accelerator based Radiation Therapy Stereotactic Radiation Therapy Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions Radiation Therapy Intensity Modulated Radiation Intensity modulated radiation treatment delivery (IMRT), includes guidance and Therapy (IMRT) tracking, when performed; simple Radiation Therapy Intensity Modulated Radiation Intensity modulated radiation treatment delivery (IMRT), includes guidance and Therapy (IMRT) tracking, when performed; complex Radiation Therapy Radiologic Guidance Guidance for localization of target volume for delivery of radiation treatment delivery, includes intrafraction tracking, when performed Radiation Therapy N/A Unlisted Procedure, Medical Radiation Physics Radiation Therapy Radiation Treatment Delivery Radiation treatment delivery, superficial and/or ortho voltage, per day Radiation Therapy Radiation Treatment Delivery Radiation treatment delivery, >1 MeV; simple Radiation Therapy Radiation Treatment Delivery Radiation treatment delivery; two separate treatment areas; three or more ports on a single treatment area; or three or more simple blocks;>=1 MeV; intermediate Radiation Therapy Radiation Treatment Delivery Radiation treatment delivery; three or more separate treatment areas; custom blocking; tangential ports; wedges; rotational beam; field-in-field or other tissue compensation that does not meet IMRT guidelines; or electron beam; >=1 MeV; complex Radiation Therapy Radiation Treatment Delivery Therapeutic Radiology Port Image(s) Radiation Therapy Neutron Beam Radiation Therapy High energy neutron radiation treatment delivery; single treatment area using a single port or parallel-opposed ports with no blocks or simple blocking Delete Delete

15 Radiation Therapy Neutron Beam Radiation Therapy High energy neutron radiation treatment delivery; 1 or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s) Radiation Therapy Intraoperative Radiation Therapy (IORT) Intraoperative radiation treatment delivery, x-ray, single treatment session Radiation Therapy Intraoperative Radiation Therapy (IORT) Intraoperative radiation treatment delivery, electrons, single treatment session Radiation Therapy N/A Radiation Treatment Management, Five Treatments Radiation Therapy N/A Radiation Treatment Management, With Complete Course Of Therapy Consisting Of 1-2 Fractions Radiation Therapy N/A Stereotactic Radiation Treatment Management Cerebral Lesion(s) Complete Course Of Treatment Consisting Of 1 Session Radiation Therapy N/A Stereotactic Body Radiation Treatment Management Per Treatment Course; 1 Or More Lesions, Including Image Guidance Entire Course t To Exceed 5 Fractions Radiation Therapy N/A Intraoperative Radiation Treatment Management Radiation Therapy N/A Special Treatment Procedure (e.g.. Total Body Radiation, Hemibody Radiation Or Per Oral Endocavity) Radiation Therapy N/A Unlisted Procedure, Therapeutic Radiology Treatment Management Radiation Therapy Proton Beam Radiation Therapy Proton treatment delivery; simple, without compensation Radiation Therapy Proton Beam Radiation Therapy Proton treatment delivery; simple, with compensation Radiation Therapy Proton Beam Radiation Therapy Proton treatment delivery; intermediate Radiation Therapy Proton Beam Radiation Therapy Proton treatment delivery; complex Radiation Therapy Hyperthermia Treatment Hyperthermia, externally generated; superficial (i.e., heating to a depth of 4 cm or less) Radiation Therapy Hyperthermia Treatment Hyperthermia, externally generated; deep (i.e., heating to depths greater than 4 cm) Radiation Therapy Hyperthermia Treatment Hyperthermia generated by interstitial probe(s); 5 or fewer interstitial applicators Radiation Therapy Hyperthermia Treatment Hyperthermia generated by interstitial probe(s); more than 5 interstitial applicators Radiation Therapy Hyperthermia Treatment Hyperthermia generated by intracavitary probe(s) Radiation Therapy Brachytherapy Infusion or instillation of radioelement solution (includes 3-month follow-up care) Radiation Therapy Brachytherapy Intracavitary radiation source application; simple Radiation Therapy Brachytherapy Intracavitary radiation source application; intermediate Radiation Therapy Brachytherapy Intracavitary radiation source application; complex Radiation Therapy Brachytherapy HDR radionuclide skin surface brachytherapy; lesion diameter up to 2.0 cm or 1 channel Radiation Therapy Brachytherapy HDR radionuclide skin surface brachytherapy; lesion diameter over 2.0 cm and 2 or more channels, or multiple lesions Radiation Therapy Brachytherapy HDR radionuclide interstitial or intracavitary brachytherapy; 1 channel Radiation Therapy Brachytherapy HDR radionuclide rate interstitial or intracavitary brachytherapy; 2 to 12 channels Radiation Therapy Brachytherapy HDR radionuclide interstitial or intracavitary brachytherapy; over 12 channels Radiation Therapy Brachytherapy Interstitial radiation source application, complex, includes supervision, handling, loading of radiation source when performed Radiation Therapy Brachytherapy Surface application of low dose rate radionuclide source Radiation Therapy Brachytherapy Supervision, handling, loading of radiation source

16 Radiation Therapy N/A Unlisted Procedure, Clinical Brachytherapy Radiation Therapy Associated Services with Radiation Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous Therapy infusion Radiation Therapy N/A 0190T Placement Of Intraocular Radiation Source Applicator Radiation Therapy Brachytherapy 0394T HDR electronic brachytherapy, skin surface application, per fraction Radiation Therapy Brachytherapy 0395T HDR electronic brachytherapy, interstitial or intracavitary treatment, per fraction Radiation Therapy Therapeutic Radiopharmaceuticals A9543 Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 millicuries Radiation Therapy N/A A9545 Iodine I-131 Tositumomab, Therapeutic, Per Treatment Dose Radiation Therapy N/A A9563 Sodium Phosphate P-32, Therapeutic, Per Millicurie Radiation Therapy N/A A9564 Chromic Phosphate P-32 Suspension, Therapeutic, Per Millicurie Radiation Therapy N/A A9600 Strontium SR-89 Chloride, Therapeutic, Per Millicurie Radiation Therapy N/A A9604 Samarium SM-153 Lexidronam, Therapeutic, Per Treatment Dose, Up To 150 Millicuries Radiation Therapy Therapeutic Radiopharmaceuticals A9606 Radium RA-223 Dichloride, Therapeutic, Per Microcurie Radiation Therapy N/A A9699 Radiopharmaceutical, therapeutic, not otherwise classified Radiation Therapy Stereotactic Radiation Therapy G0339 Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session or first session of fractionated treatment Radiation Therapy Stereotactic Radiation Therapy G0340 Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment Radiation Therapy N/A G0458 Low Dose Rate (LDR) Prostate Brachytherapy Services, Composite Rate Radiation Therapy Radiologic Guidance G6001 Ultrasonic guidance for placement of radiation therapy fields Radiation Therapy Radiologic Guidance G6002 Stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy Radiation Therapy Radiation Treatment Delivery G6003 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: up to 5mev Radiation Therapy Radiation Treatment Delivery G6004 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 6-10mev Radiation Therapy Radiation Treatment Delivery G6005 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 11-19mev Radiation Therapy Radiation Treatment Delivery G6006 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 20mev or greater Radiation Therapy Radiation Treatment Delivery G6007 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: up to 5mev Radiation Therapy Radiation Treatment Delivery G6008 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 6-10mev Radiation Therapy Radiation Treatment Delivery G6009 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 11-19mev Radiation Therapy Radiation Treatment Delivery G6010 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 20 mev or greater Radiation Therapy Radiation Treatment Delivery G6011 Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5mev