High Tech Imaging Quick Reference Guide
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1 High Tech Imaging Quick Reference Guide 1
2 High Tech Imaging Authorizations may now be requested through our secure provider portal, BlueAccess. Getting Started Step 1: Log into BlueAccess from site as shown below by entering your User ID and Password.. Note: if you do not have a User ID and Password, contact your ebusiness Marketing Representative or Service Center for personal assistance with registration and/or training (see contact information on last page of quick reference guide) Step 1: Log In to BlueAccess Register Now Step 2: Click the Service Center link Step 2: Click Service Center 2
3 Step 3: Click the Outpatient Surgical Procedure / High Tech Imaging Authorization Form. Step 3: Click Authorization Form The authorization form displays. Step 4: Enter the requested date of service and the Patient ID number Step 5: Click Search button. Step 4: Enter Date of Service and Patient ID Step 5: Enter Search 3
4 The member information should display on the screen as shown below. Step 6: Click the Continue button Member Information Displays Step 6: Click Continue Step 7: Complete authorization form & then click the complete button NOTE: Please leave the Admitting Facility field blank if the procedure is performed in an office setting. We added Office as an option when the procedure is in an office setting. Step 7: Complete Authorization Form Step 7: Click Complete Button 4
5 The Review the Outpatient Surgical Procedure/High Tech Imaging Summary page displays. Step 8: If the summary page is correct, click the Continue button. If something needs to be edited, please click the Back button Step 8: Click Continue Button Back Button You will be re-directed to the Clinical Certification page. Step 9: Click the continue button if the fax and phone numbers are correct. Step 9: Click Continue 5
6 Step 10: Enter patient s phone number & click the Submit button Step 10: Enter Phone number & Click Submit Step 11: Click the Continue button Step 11: Click Continue 6
7 Step 12: Select answer from drop down list as shown below Step 13: Click the Submit button or you may check the Finish Later check box Step 13: Click Submit Step 12: Select Answer Step 14: Check Clinical Certification check boxes Step 15: Click the Submit Case button Step 14: Read & Click Check Box Step 15: Submit Case 7
8 Clinical Certification An example of the approved clinical certification is displayed below. 8
9 Authorization Inquiry / Lookup Step 1: Click on the BCBST High Tech Imaging Program link Note: The bullets underneath the BCBST High Tech Imaging Program include helpful resource documents including a list of codes that require prior-authorization and a training quick reference guide. You may also click the click here link to begin a new authorization. Step 1: Click Application Link Link to Authorization Forms Resource Documents 9
10 The evicore page displays Step 2: Enter Provider NPI number and click the Submit button Step 2: Enter Provider NPI number and click Submit Step 3: Enter the Patient ID number and date of birth Step 4: Click the Search button Step 3: Enter Patient ID and Date of Birth Step 4: Click the Search Button 10
11 The Authorization Lookup Information displays as shown below. Note: If you need to change a service code, you may do so my clicking on the Change Service Code button You may view correspondence by clicking the View Correspondence button Change Service Code Clicking the Change Service Code button will display the following screen where you may click the Continue button to change the service code. Continue 11
12 Clicking the View Correspondence button will display all correspondence regarding the authorization. Step 5: Click the view button to view correspondence documents. Step 5: Click View Button Resources: You can find the Radiology Prior Authorization Program CPT List below or on our website at: CPT is a registered trademark of the American Medical Association. 12
13 BlueCross BlueShield of Tennessee RADIOLOGY PRIOR AUTHORIZATION PROGRAM CPT LIST VSHP West Grand Region members (effective 11/01/08) VSHP East Grand Region members (effective 1/1/09) CPT is a registered trademark of the American M edical Association CPT DESCRIPTION CODE HTI PRIOR AUTHORIZATION REQUIRED DATE REQUIRED AUTHORIZATION TERM ED MRI Temporomandibular Joint (s) {TMJ} CThead without contrast CThead with contrast CThead with & without contrast W&W/O CT Orbit, sella, or posterior fossa or outer, middle, or inner ear without contrast CT Orbit, sella, or posterior fossa or outer, middle, or inner ear with contrast CT Orbit, sella, or posterior fossa or outer, middle, or inner ear W&W/O CT Maxillofacial area, (sinus) without contrast CT Maxillofacial area, (sinus) with contrast CT Maxillofacial area, (sinus) with & without contrast W&W/O CT Soft-tissue Neck without contrast CT Soft-tissue Neck with contrast CT Soft-tissue Neck with & without contrast W&W/O CTA HEAD, with contrast material(s), including non-contrast images, if performed, and image post-processing (DESCRIPTION CHANGE) CTA NECK, with contrast material(s), including non-contrast images, if performed, and image post-processing (DESCRIPTION CHANGE) Magnetic resonance (e.g., proton) imaging, orbit, f ace, and/or neck; without contrast material(s) (DESCRIPTION CHANGE) Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; with contrast material(s) (DESCRIPTION CHANGE) Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and further sequences (DESCRIPTION CHANGE) MR Angiography (MRA) Head without contrast MR Angiography (MRA) Head with contrast MR Angiography (MRA) Head with and without contrast W&W/O MR Angiography (MRA) Neck without contrast MR Angiography (MRA) Neck with contrast MR Angiography (MRA) Neck with and without contrast W&W/O MRI Brain (Head) without contrast MRI Brain (Head) with contrast MRI Brain (Head) with and without contrast W&W/O Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration 1/1/2007 N/A Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing 1/1/2007 N/A CT Chest without contrast
14 71260 CT Chest with contrast CT Chest with and without contrast W&W/O CTA CHEST, (non-coronary), with contrast material(s), including non-contrast images, if performed, and image postprocessing (DESCRIPTION CHANGE) MRI Chest without contrast MRI Chest with contrast MRI Chest with and without contrast W&W/O MR Angiography (MRA) Chest (excluding myocardium)-with or w/o contrast CT Cervical Spine without contrast CT Cervical Spine with contrast CT Cervical Spine with and without contrast W&W/O CT Thoracic Spine without contrast CT Thoracic Spine with contrast CT Thoracic Spine with and without contrast W&W/O CT Lumbar Spine without contrast CT Lumbar Spine with contrast CT Lumbar Spine with and without contrast W&W/O MRI Cervical Spine without contrast MRI Cervical Spine with contrast MRI Thoracic Spine without contrast MRI Thoracic Spine with contrast MRI Lumbar Spine without contrast MRI Lumbar Spine with contrast MRI Cervical Spine with and without contrast W&W/O MRI Thoracic Spine with and without contrast W&W/O MRI Lumbar Spine with and without contrast W&W/O MR Angiography (MRA) Spinal Canal and contents-with or w/o contrast CTA PELVIS, with contrast material(s), including non-contrast images, if performed, and image post-processing (DESCRIPTION CHANGE) CT Pelvis without contrast CT Pelvis with contrast CT Pelvis with and without contrast W&W/O MRI Pelvis without contrast MRI Pelvis with contrast MRI Pelvis with and without contrast W&W/O MR Angiography (MRA) Pelvis -with or without contrast CT Upper Extremity without contrast CT Upper Extremity with contrast CT Upper Extremity with and without contrast W&W/O CTA Upper Extremity, with contrast material(s), including non-contrast images, if performed, and image postprocessing (DESCRIPTION CHANGE) MRI Upper Extremity-other than joint -without contrast MRI Upper Extremity-other than joint -with contrast MRI Upper Extremity-other than joint -with and without contrast MRI Any Joint of Upper Extremity--without contrast MRI Any Joint of Upper Extremity--with contrast
15 73223 MRI Any Joint of Upper Extremity with and without contrast MR & Angiography /O (MRA) Upper Extremity-with or without contrast CT Lower Extremity without contrast CT Lower Extremity with contrast CT Lower Extremity with and without contrast W&W/O CTA Lower Extremity, with contrast material(s), including noncontrast images, if performed, and image post-processing (DESCRIPTION CHANGE) MRI Lower Extremity-other than joint without contrast MRI Lower Extremity-other than joint with contrast MRI Lower Extremity-other than joint with and without contrast MRI Any Joint of Lower Extremity without contrast MRI Any Joint of Lower Extremity with contrast MRI Any Joint of Lower Extremity with and without contrast MR Angiography (MRA) Lower Extremity-with or without contrast CT Abdomen without contrast CT Abdomen with contrast CT Abdomen with and without contrast W&W/O CTA; abdomen and pelvis; with contrast material(s) including noncontrast images, if 1/1/2012 N/A CTA ABDOMEN, with contrast material(s), including noncontrast images, if performed, and image post-processing (DESCRIPTION CHANGE) Computed tomography, abdomen and pelvis; without contrast material 1/1/2011 N/A Computed tomography, abdomen and pelvis; with contrast material(s) 1/1/2011 N/A 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 1/1/2011 N/A MRI Abdomen without contrast MRI Abdomen with contrast MRI Abdomen with and without contrast W&W/O MR Angiography (MRA) 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 DELETED CODE 8/1/ /31/ DELETED CODE 8/1/ /31/ DELETED CODE 8/1/ /31/ DELETED CODE 8/1/ /31/ DELETED CODE 8/1/ /31/ 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)
16 75573 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 3 D image post processing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed) Cardiac MRI for morphology and function without contrast materials 1/1/2008 N/A DELETED CODE 1/1/ /31/ Cardiac MRI for morphology and function without contrast materials; with stress imaging 1/1/2008 N/A DELETED CODE 1/1/ /31/ Cardiac MRI for morphology and function without contrast materials, followed by contrast material(s) and further sequences 1/1/2008 N/A DELETED CODE 1/1/ /31/ Cardiac MRI for morphology and function without contrast materials, followed by contrast material(s) and further sequences; with stress imaging 1/1/2008 N/A DELETED CODE 1/1/ /31/ CTA ABDOMINAL AORTA and bilateral iliofemoral lower extremity runoff, with contrast material(s), including non-contrast images, if performed, and image post-processing (DESCRIPTION CHANGE) Cardiac MRI for velocity flow mapping DELETED CODE 8/1/ /31/ DELETED CODE 8/1/ /31/ DELETED CODE 8/1/ /31/ DELETED CODE 8/1/ /31/ D rendering with interpretation and reporting of Computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring post processing on an independent workstation D rendering requiring post processing on an independent workstation CT Limited or Localized follow-up MR Spectroscopy DELETED CODE 8/1/ /31/ Unlisted Computed Tomography procedure (e.g., diagnostic, interventional) Unlisted Magnetic Resonance procedure (e.g., diagnostic, interventional) Computed tomography guidance for stereotactic localization 1/1/2007 5/25/ Computed tomography guidance for needle placement, (e.g., 1/1/2007 5/25/2007 biopsy, aspiration, injection, localization device), RS&I* Computed tomography guidance for placement of radiation therapy fields Magnetic resonance guidance for needle placement, (e.g., biopsy, needle aspiration, injection, or placement of localization device), RS&I* Magnetic resonance imaging, breast, without and/or with contrast, unilateral 1/1/2007 5/25/2007 1/1/2007 5/25/2007 1/1/2007 N/A
17 77059 Magnetic resonance imaging, breast, without and/or with contrast, bilateral CT Bone Mineral Density Study, one or more sites; axial skeleton (e.g., hips, pelvis, spine) 1/1/2007 N/A 1/1/2007 N/A DELETED CODE 1/1/ /31/ Magnetic resonance imaging, bone marrow blood supply 1/1/2007 N/A Determination of central c-v hemodynamics (non-imaging) (e.g., 8/1/2006 4/1/2007 ejection fraction with probe technique) with or without pharmacologic intervention or exercise, single or multiple determinations 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 pharmocologic) and/or redistribution and/or rest reinjection Myocardial perfusion imaging, planar (including qualititative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise 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 pharmocologic) and/or redistribution and/or rest reinjection PET Cardiac (myocardial imaging) metabolic evaluation DELETED CODE 8/1/ /31/ DELETED CODE 8/1/ /31/ DELETED CODE 8/1/ /31/ DELETED CODE 8/1/ /31/ Myocardial Imaging, infarct avid, planar; qualitative or quantitative Myocardial Imaging, infarct avid, planar; w/ef by first pass technique Myocardial Imaging, infarct avid, planar; tomographic SPECT Cardiac Blood Pool imaging, gated equilibrium; planar, single study at rest or stress, wall motion study plus ejection fraction, with or without additional quantitative processing Cardiac Blood Pool imaging, gated equilibrium; multiple studies, wall motion plus ejection fraction, at rest and stress, with or without additional quantitative DELETED CODE 8/1/ /31/ DELETED CODE 8/1/ /31/ Cardiac Blood Pool imaging, (planar), first pass technique; single study, at rest or with stress, wall motion study plus ejection fraction Cardiac Blood Pool imaging, (planar), first pass technique; multiple studies at rest and with stress, wall motion study plus ejection fraction PET Cardiac (myocardial imaging) perfusion single study at rest or stress PET Cardiac (myocardial imaging) perfusion multiple studies rest and/or stress Cardiac Blood Pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction 8/1/2006 N/A
18 78496 Cardiac Blood Pool imaging, gated equilibrium, single study, at rest, with right ventricular EF by first pass technique Unlisted cardiovascular procedure, diagnostic nuclear medicine 10/1/2008 N/A PET Brain metabolic evaluation PET Brain perfusion evaluation Positron emission tomography (PET) imaging; limited area (DESCRIPTION CHANGE) Positron emission tomography (PET) imaging; skull base to mid-thigh (DESCRIPTION CHANGE) Positron emission tomography (PET) imaging; whole body (DESCRIPTION CHANGE) Positron emission tomography (PET) imaging with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; limited area (DESCRIPTION CHANGE) Positron emission tomography (PET) imaging with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; skull base to mid- thigh (DESCRIPTION CHANGE) Positron emission tomography (PET) imaging with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; whole body (DESCRIPTION CHANGE) 0144T DELETED CODE 8/1/ /31/ T DELETED CODE 8/1/ /31/ T DELETED CODE 8/1/ /31/ T DELETED CODE 8/1/ /31/ T DELETED CODE 12/31/ T DELETED CODE 8/1/ /31/ T DELETED CODE 8/1/ /31/ T DELETED CODE 8/1/ /31/ T Computer-aided detection, including computer algorithm analysis of 1/1/2007 N/A MI image data for lesion detection/characterization, pharmacokinetic analysis, with further physician review for interpretation, breast MRI. 0066T DELETED CODE 8/1 / /31/ T DELETED CODE 8/1 / /31/2009 C8900 Magnetic resonance angiography with contrast, abdomen C8901 Magnetic resonance angiography without contrast, abdomen C8902 Magnetic resonance angiography without contrast followed by with contrast C8903 Magnetic resonance imaging with contrast, breast ; unilateral C8904 Magnetic resonance imaging without contrast, breast; unilateral C8905 Magnetic resonance imaging without contrast followed by with contrast b t C8906 Magnetic resonance imaging with contrast, breast; bilateral C8907 Magnetic resonance imaging without contrast, breast; bilateral C8908 Magnetic resonance imaging without contrast followed by with contrast b t C8909 Magnetic resonance angiography with contrast, chest (excluding myocardium) C8910 Magnetic resonance angiography without contrast, chest (excluding myocardium) C8911 Magnetic resonance angiography without contrast followed by with contrast, chest (excluding myocardium) C8912 Magnetic resonance angiography with contrast, lower extremity C8913 Magnetic resonance angiography without contrast, lower extremity C8914 Magnetic resonance angiography without contrast followed by with contrast, lower C8918 Magnetic resonance angiography with contrast, pelvis
19 C8919 Magnetic resonance angiography without contrast, pelvis C8920 Magnetic resonance angiography without contrast followed by with contrast, pelvis C8931 MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, SPINAL CANAL AND CONTENTS C8932 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, SPINAL CANAL AND CONTENTS C8933 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, SPINAL CANAL AND CONTENTS C8934 MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, UPPER EXTREMITY C8935 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, UPPER EXTREMITY C8936 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, UPPER EXTREMITY G0219 PET imaging whole body; melanoma for non-covered indications 1/1/2011 1/1/2011 1/1/2011 1/1/2011 N/A N/A N/A N/A 1/1/2011 N/A 1/1/2011 N/A 10/1/2008 N/A G0235 PET imaging, any site, not otherwise specified 10/1/2008 N/A G0252 PET imaging, full and partial-ring PET scanners only, for initial 10/1/2008 N/A diagnosis of breast cancer and/or surgical planning f or breast cancer (e.g., initial staging of axillary lymph nodes) S8032 Low-dose computed tomography for lung cancer screening 10/1/2014 N/A S8035 Magnetic source imaging S8037 Magnetic Resonance Cholangiopancreatography (MRCP) S8042 Magnetic Resonance Imaging (MRI), Low-field S8085 Fluorine-1 8 Fluorodeoxyglucose (F-1 8 FDG) Imaging using dualhead coincidence detection system (non-dedicated PET scan) S8092 Electron Beam Computed Tomography (also known as Ultrafast CT, Cine CT) Covered Services specifically exclude mammography, inpatient radiology services, radiology services rendered in an Emergency Department of a hospital, radiation therapy services, interventional radiology procedures, services provided outside the BlueCross BlueShield of Tennessee Service Area for fully insured (non-aso) commercial M embers, and all other outpatient diagnostic services other than the MRI, MRA, MRS, CT or PET services.
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