Wake Radiology CPT Code Quick Reference MRI. CPT Code & Procedure Descriptions. Physician Hotlines. Exam Time

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1 CPT Code Quick Reference This document lists CPT codes associated with the most common procedures ordered at UNC REX Healthcare outpatient imaging offices. All of our radiologists are available to consult with you to determine the appropriate exam for your patient. If you re unsure about what to order, please call our. If a procedure you re looking for is not listed, please call our scheduling team for the CPT code. Please note that the exam times listed do not include patient registration, changing clothes or contrast administration Abdomen; Without Contrast Abdomen; Without & With Contrast Brain; Without Contrast Brain; Without & With Contrast Breast: Without Contrast (implant intregity) Breast: Without & With Contrast, Including CAD; Bilateral Breast Biopsy; -Guided Needle Placement (same code for both procedures) Breast Localization; -Guided Needle Placement Chest; Without Contrast Chest; Without & With Contrast Lower Extremity, Joint; Without Contrast Lower Extremity, Joint; With Contrast - for MR Arthrogram Lower Extremity, Joint; Without & With Contrast Lower Extremity, Other Than Joint; Without Contrast Lower Extremity, Other Than Joint; Without & With Contrast MRA, Abdomen; Without or With Contrast MRA, Chest; Without or With Contrast MRA, Head; Without Contrast MRA, Head; Without & With Contrast MRA, Lower Extremity; Without or With Contrast MRA, Neck; Without & With Contrast MRA, Upper Extremity; Without or With Contrast MR Enterography* Orbit Face and/or Neck; Without & With Contrast Pelvis; Without Contrast Pelvis; Without & With Contrast Spine, Cervical; Without Contrast Spine, Cervical; Without & With Contrast Spine, Lumbar; Without Contrast Spine, Lumbar; Without & With Contrast Spine, Thoracic; Without Contrast Spine, Thoracic; Without & With Contrast Tempromandibular Joint(s) Upper Extremity, Joint; Without Contrast Upper Extremity, Joint; With Contrast - for MR Arthrogram Upper Extremity, Joint; Without & With Contrast Upper Extremity, Other Than Joint; Without Contrast Upper Extremity, Other Than Joint; Without & With Contrast Note: MR Arthrograms do not require separate pre-authorization for the fluoro/joint injection. * MR Enterography is a dual study and pre-authorization is required for both CPT codes. Patients must arrive one hour prior to exam time for contrast preparation min Body Breast procedures require pre-authorization

2 G Abdomen & Pelvis; Without Contrast Abdomen & Pelvis; With Contrast Abdomen & Pelvis; Without Contrast 1 or Both, With Contrast 1 or Both Abdomen; Without Contrast Abdomen; With Contrast Abdomen; Without & With Contrast Angiography, Abdomen & Pelvis; With Contrast Angiography, Abdomen; Without & With Contrast Angiography, Abdominal Aorta & Bilateral Iliofemoral Lower Extremity Runoff; With Contrast Angiography, Head; Without & With Contrast Angiography, Lower Extremity; Without & With Contrast Angiography, Neck; Without & With Contrast Angiography, Chest; Without and/or With Contrast Cervical Spine; Without Contrast Cervical Spine; With Contrast Cervical Spine; Without & With Contrast Chest/Thorax; Without Contrast Chest/Thorax; With Contrast Chest/Thorax; Without & With Contrast Enterography; Abdomen & Pelvis; With Contrast* Head or Brain; Without Contrast Head or Brain; With Contrast Head or Brain; Without & With Contrast Heart; Coronary Calcium Scoring Lower Extremity; Without Contrast Lower Extremity; With Contrast Lower Extremity; Without & With Contrast Lumbar Spine; Without Contrast Lumbar Spine; With Contrast Lumbar Spine; Without & With Contrast Lung, Low Dose (LD) for Lung Cancer Screening** Maxillofacial Area; Without Contrast Maxillofacial Area; With Contrast Maxillofacial Area; Without & With Contrast Maxillofacial Area; Without Contrast (Limited Sinus Study) Orbit, Sella or Posterior Fossa or Outer, Middle or Inner Ear; Without Contrast Orbit, Sella or Posterior Fossa or Outer, Middle or Inner Ear; With Contrast Orbit, Sella or Posterior Fossa or Outer, Middle or Inner Ear; Without & With Contrast Pelvis; Without Contrast Pelvis; With Contrast Pelvis; Without & With Contrast Renal Colic Study Soft Tissue Neck; Without Contrast Soft Tissue Neck; With Contrast Soft Tissue Neck; Without & With Contrast Thoracic Spine; Without Contrast Thoracic Spine; With Contrast Thoracic Spine; Without & With Contrast Upper Extremity; Without Contrast Upper Extremity; With Contrast Upper Extremity; Without & With Contrast Urogram - Abdomen & Pelvis; Without Contrast one or Both, With Contrast one or Both * Enterography patients must arrive one hour prior to exam time for contrast preparation. ** As of 2/1/2019 this procedure is not included on the NC Medicaid Fee Schedule procedures require pre-authorization

3 Surgical & Injections T Arthrocentesis, Aspiration and/or Injection; Major Joint/Bursa (Shoulder, Hip, Knee) Arthrocentesis, Aspiration and/or Injection; Major Joint/Bursa (Shoulder, Hip, Knee), Ultrasound Guidance Arthrocentesis, Aspiration and/or Injection; Medium Joint/Bursa (Wrist, Elbow, Ankle) Arthrocentesis, Aspiration and/or Injection; Small Joint/Bursa (Fingers, Toes) Aspiration and/or Injection of Ganglion Cyst(s) Aspiration of Cyst of Breast Aspiration of Cyst of Breast; Each Additional Biopsy of Lymph Node; by Needle, Superficial (Axillary) Biopsy, Breast, Percutaneous; First Lesion, Stereotactic Guidance Biopsy, Breast, Percutaneous; Each Additional Lesion, Stereotactic Guidance Biopsy, Breast, Percutaneous; First Lesion, Ultrasound Guidance Biopsy, Breast, Percutaneous; Each Additional Lesion, Ultrasound Guidance Biopsy, Breast, Percutaneous; First Lesion, Guidance Biopsy, Breast, Percutaneous; Each Additional Lesion, Guidance Biopsy, Breast; Percutaneous, Needle Core; Without Imaging Guidance Biopsy, Muscle; Percutaneous Needle Breast Localization Device (e.g. Clip/Wire) Placement, Perc; First Lesion, graphic Guidance Breast Localization Device (e.g. Clip/Wire) Placement, Perc; Each Add l Lesion, graphic Guidance Breast Localization Device (e.g. Clip/Wire) Placement, Perc; First Lesion, Stereotactic Guidance Breast Localization Device (e.g. Clip/Wire) Placement, Perc; Each Add l Lesion, Stereotactic Guidance Breast Localization Device (e.g. Clip/Wire) Placement, Perc; First Lesion, Ultrasound Guidance Breast Localization Device (e.g. Clip/Wire) Placement, Perc; Each Add l Lesion, Ultrasound Guidance Catheterization/Introduction for Saline Infusion Sonohysterography (SIS) or Hysterosalpingography (HSG) Fine Needle Aspiration; Ultrasound Guidance; First Lesion Fine Needle Aspiration; Ultrasound Guidance; Each Add l Lesion Incision or Drainage of Hematoma; Seroma or Fluid Injection for Ankle Arthrography Injection for Cystography or Voiding Urethrocystograpy Injection for Elbow Arthrography Injection for Hip Arthrography; Without Anesthesia Injection for Knee Arthrography Injection for Retrograde Urethrocystograpy Injection for Sacroiliac Joint, Anesthetic/Steroid; With Image Guidance ( or ) Injection for Shoulder Arthrography; Any Method Injection for Visualization of Ileal Conduit and/or Ureteropyelography Injection for Wrist Arthrography Injection of Corpora Cavernosa With Pharmacologic Agent(s) (Penile Injection) Injection of Sinus Tract; Diagnostic Injection(s); Anesthetic Agent/Steroid, Transforamenal Epidural, With Guidance; Lumbar/Sacral, 1 Level Injection(s); Diagnostic or Therapeutic Substance(s), With Needle/Catheter Placement; Lumbar/Sacral Injection(s); Diagnostic/Therapeutic Agent, Paravertebral Facet Joint, With Guidance; Lumbar/Sacral 1 Level Injection(s); Single Tendon Origin/Insertion Injection(s); Single Tendon Sheath or Ligament Injection; Mammary Ductogram/Galactogram Injection; Platelet Rich Plasma, Any Site (PRP Injection) Insertion of Temporary Indwelling Bladder Catheter; Simple Puncture Aspiration of Abscess; Hematoma, Bulla or Cyst (Popliteal, Baker s) Spinal Puncture; Lumbar, Diagnostic Body Breast Note: Most of the surgical and injection codes fall under the primary imaging study and do not require separate pre-authorization. You will be notified at the time of scheduling if pre-authorization is needed for any of the above codes.

4 Ultrasound Abdominal; Complete Abdominal; Limited (i.e., Single Organ, Quadrant, Followup) Aorta/Abdominal Aortic Aneurysm (AAA) Screening for Medicare Initial Preventive Physical Exam (IPPE) Bladder Only - Pelvic; Limited Breast, Unilateral; Complete (Medicaid requires pre-authorization) Breast, Unilateral; Limited-Routine (Medicaid requires pre-authorization) Carotid Doppler Endovaginal/Transvaginal Extremity; Upper or Lower Head Ultrasound Hips; Dynamic OB Ultrasound (1st Trimester) Pelvic; Complete Pelvic; Complete with Endovaginal/Transvaginal Penile Doppler Renal Complete Saline Infused Hysterogram/Sonohysterogram Shoulder Complete Spinal Canal and Contents Thyroid and/or Neck scopy Venous Doppler; Bilateral Venous Doppler; Right or Left 45 Min Abscess, Fistula or Sinus Tract Study; Radiologist Supervision & Interpretation Arthrogram - Ankle Arthrogram - Elbow Arthrogram - Hip Arthrogram - Knee Arthrogram - Shoulder Arthrogram - Wrist Barium Swallow Chest, With scopy (combo code Chest 2 view) Colon, Barium Enema; With Air Contrast Colon, Barium Enema; Without Air Contrast Cystography; Minimum 3 Views, Rad Supervision & Interpretation scopy; Up to 1 Hour Guidance for Percutaneous Drainage with Catheter Radiologist Supervision & Interpretation IVP (Intravenous Pyelogram) Modified Barium Swallow (West Raleigh Office Only) Small Bowel Follow Through Upper GI; With Air, With Barium Upper GI; With Air, With Barium, With Small Bowel Follow Through Urethrocystography; Retrograde, Rad Supervision & Interpretation VCUG (Voiding Cystourethrogram) up to 4 hours up to 4 hours

5 graphy Physician Hotline: G Digital Breast Tomosynthesis; Unilateral (3D graphy) Digital Breast Tomosynthesis; Bilateral (3D graphy) Screening Digital Breast Tomosynthesis; Bilateral (3D graphy) Diagnostic Digital Breast Tomosynthesis; Unilateral or Bilateral (3D graphy) - Medicare and Medicaid Only Diagnostic graphy; Digital, Bilateral, All Views w/ CAD Diagnostic graphy; Digital, Unilateral, All Views w/ CAD Screening graphy, Digital, Bilateral, All Views w/ CAD Bone Density Physician Hotline DXA Bone Density Screening; Axial Skeleton (Hips and Spine) Abdominal Paracentesis (Diagnostic or Therapeutic); With Imaging Guidance Biopsy or Excision of Lymph Node(s); by Needle, Superficial (e.g. Cervical, Inguinal, Axillary) Biopsy Thyroid; Percutaneous Core Needle Endovenous Laser Ablation Therapy, Extremity; 1st Veins Endovenous Laser Ablation Therapy, Extremity; 2nd & Subsequent Veins Evaluation of CVAD Using Contrast Injection, Including scopy Incision or Drainage; Hematoma, Seroma or Fluid Injection of Sclerosing Solution, Single or Multiple Spider Veins; Face Sclerotherapy Injection of Sclerosing Solution, for Spider Veins; Limb or Trunk (Teleangiectasia) Sclerotherapy Injection of Sclerosing Solution; Single Incompetent Vein (other than Teleangiectasia) Sclerotherapy Injection of Sclerosing Solution; Multiple Incompetent Veins, Same Leg (other than Teleangiectasia) Insertion of Tunneled CVAD; With Subcutaneous Port Puncture Aspiration of Abscess; Hematoma, Bulla or Cyst Removal of Tunneled CVAD; With Subcutaneous Port or Pump, Central or Peripheral Insertion Removal of Tunneled CVAD; Without Subcutaneous Port or Pump Replacement, Complete, of Tunneled CVAD; With Subcutaneous Port Stab Phlebectomy of Varicose Veins; 1 Extremity, 10 to 20 Incisions Stab Phlebectomy of Varicose Veins; 1 Extremity, More than 20 Incisions Stab Phlebectomy of Varicose Veins; 1 Extremity, Less than 10 Incisions Thoracentesis, Needle or Catheter; Aspiration of Pleural Space; Without Imaging Guidance Thoracentesis, Needle or Catheter; Aspiration of Pleural Space; With Imaging Guidance

6 The Right Dose: We Go Beyond Low-Dose Imaging Reducing radiation exposure during medical imaging has always been at the forefront of patient care at REX UNC Healthcare. For years, we ve adopted and held to rigorous Computed Tomography () dose compliance and quality control protocols that exceed the standards set by the American College of Radiology. Minimizing radiation exposure while maintaining diagnostic quality imaging is at the core of what we do. is one of the most powerful diagnostic tools that offers referring providers and their patients. It involves small amounts of ionizing radiation and combines special x-ray equipment with sophisticated computers to produce high-quality diagnostic images. is known for having one of the region s most responsible programs. Driven by radiologist oversight and a formal quality assurance program, we internally track radiation dose and include it on our reports. Thomas Presson, MD, is the Director of Radiation Safety Programs at. An interventional radiologist, Dr. Presson also serves as the radiation safety officer at UNC REX Healthcare and for our other hospital partners. If you have any questions about radiation safety at, please contact Dr. Presson at rightdose@wakerad.com. PET- Not part of the UNC REX Healthcare Partnership. Physician Hotline PET- PET- PET- PET- Brain With Amyvid for Alzheimer s Disease Skull Base to Mid-Thigh Whole Body Brain Imaging; Metabolic Evaluation 1.75 hours 2 hours PET- hotline PET- studies require pre-authorization Nuclear Medicine Bone Scan; Three-Phase Bone Scan; Limited Bone Scans; Multiple SPE Bone Scan Total Body Bone Scan MUGA Scan Gastric Emptying Scan HIDA Without CCK (Hepatobiliary) HIDA With CCK (Hepatobiliary) Meckels Scan Renal With Diuretic (Lasix) Renal Without Diuretic (Lasix) Liver/Spleen Scan Parathyroid Scan Parathyroid Planar and SPE Imaging WBC Indium Study Limited Area Thyroid Carcinoma Metastases Scan Thyroid Image Only Thyroid Scan With Iodine RAIU Thyroid Uptake Voiding Cystogram - VCG - 1 hr - 1 hr 1.25 hours 4.5 hours 1-4 hours hours 2 hours 2.5 hours 3.5 hours Day One 1.5 hrs; Day Two 1.5 hrs Day One 2 hrs; Day Two 2 hrs Day One ; Day Two 1.5 hrs 2.5 hours Note: The amount of time needed for a nuclear medicine exam varies greatly depending on the type of exam. It can take several seconds, hours or days for the radiotracer to travel through the body and accumulate in the organ or area being studied. Actual scan times for nuclear medicine exams can take from utes to a few hours and may be conducted over multiple days.

7 X-Ray Abdomen Series With PA Chest Abdomen; 2 Views Abdomen; 3 Views or more KUB Abdomen; 1 View Acromioclavicular (AC) Joints; Bilateral, With or Without Weight Ankle; Complete, Minimum 3 Views Bone Age Studies Bone Length Studies Calcaneus; Minimum 2 Views Chest; 1 View, PA Chest; 2 View, PA & Lateral Chest; 3 Views Chest; 4 or more Views Clavicle; Complete Elbow; Complete, Minimum 3 Views Facial Bones; Complete, Minimum 3 Views Femur; 2 Views Finger(s); Minimum 2 Views Foot; Complete, Minimum 3 Views Forearm; 2 Views Hand; Minimum 3 Views Hip, Unilateral; with Pelvis if Preferred; 2-3 Views Hips, Bilateral; with Pelvis if Preferred; 2-3 Views Humerus; Minimum 2 Views Knee; Complete, 4 or More Views Lower Extremity, Infant; Minimum 2 Views (less than one year old) Mandible; Complete, Minimum 4 Views Neck; Soft Tissue (Lateral view) Nose to Rectum for Foreign Body; 1 View, Child Orbits, Complete; Minimum 4 Views Osseous Survey; Complete (Metastatic Bone Survey) scheduled exam, not walk-in Osseous Survey; Complete (Pediatric Child Abuse) scheduled exam, not walk-in Ribs, Bilateral; Including PA Chest, Minimum 4 Views Ribs, Unilateral; Including PA Chest, Minimum 3 Views Sacroiliac Joints; 3 or More Views Sacrum & Coccyx; Minimum 2 Views Shoulder; Complete, Minimum 2 Views Sinuses, Paranasal; Fewer Than 3 Views (Waters & Lateral) Sinuses, Paranasal; Minimum 3 Views Skull; Complete, Minimum 4 Views Spine, Cervical; 3 Views or Less Spine, Cervical; 4 or 5 Views Spine, Lumbosacral; 2 or 3 Views Spine, Lumbosacral; Complete Including Bending Views, Minimum 6 Views Spine, Lumbosacral; Minimum 4 Views Spine, Scoliosis - Entire Thoracic and Lumbar; 1 View* Spine; Thoracic; 2 Views Spine; Thoracolumbar Junction; 2 Views Sternoclavicular Joint(s); Minimum 3 Views Sternum; Minimum 2 Views Tibia & Fibula; 2 Views Toe(s); Minimum 2 Views Upper Extremity, Infant; Minimum 2 Views (less than one year old) Wrist; Complete, Minimum 3 Views 10 min 10 min 10 min Note: Many EMRs provide multiple imaging options. The CPT codes listed above are s routine exams. The physicians at have created protocols and standards that adjust for the patient s specific needs and are consistent with ACR guidelines. * Long-length spine imaging is available at our West Raleigh office and North Hills Office.

8 Accreditations UNC REX Healthcare is proud to have earned the highest accreditations possible for imaging in the United States as awarded by the American College of Radiology (ACR). Earning these designations signifies that our practice is among the best in the specialty and demonstrates the quality and range of radiology exams we perform. All UNC REX facilities are accredited by the ACR, the leading accrediting body for medical imaging providers. is the first outpatient provider in the Triangle to earn the ACR s prestigious Breast Imaging Center of Excellence (BICOE) designation. is the first outpatient provider in North Carolina to earn distinction as a Lung Cancer Screening Center by the ACR. has earned certification by the ACR for: Ultrasound Nuclear medicine PET- is also the only provider in the Triangle to be certified by the International Society for Clinical Densitometry (ISCD) for bone density screenings. Locations graphy Breast Breast ultrasound Ultrasound-guided breast biopsy Stereotactic breast biopsy Breast Care Center 3100 Duraleigh Rd., #204 Raleigh, NC Fuquay-Varina 7636 Purfoy Rd., #200 Fuquay-Varina, NC Knightdale 6602 Knightdale Blvd Knightdale, NC Raleigh 3811 Merton Drive Raleigh, NC Wake Forest 3150 Rogers Rd., #115 Wake Forest, NC Cary 300 Ashville Avenue Cary, NC Garner 300 Health Park Dr., #100 Garner, NC Morrisville Women s Imaging 1101 Grace Park Drive Morrisville, NC Smithfield 218 Venture Drive Smithfield, NC West Raleigh 4301 Lake Boone Trail Raleigh, NC Chapel Hill 110 S. Estes Drive Chapel Hill, NC Holly Springs 781 Avent Ferry Road Holly Springs, NC North Hills 3821 Merton Drive Raleigh, NC Wakefield Governor Manly Way Raleigh, NC Panther Creek Coming in 2019! Main Chapel Hill WakeRad.com