PROVIDER PROCEDURE CODES - EVICORE

Transcription

1 RADIOLOGY CPT CPT Description M R I T M J C T Head Without Contrast C T Head With Contrast C T Head Without & With Contrast C T Orbit Without Contrast 7048 C T Orbit With Contrast C T Orbit Without & With Contrast C T Maxillofacial Without Contrast C T Maxillofacial With Contrast C T Maxillofacial Without & With Contrast C T Soft Tissue Neck Without Contrast 7049 C T Soft Tissue Neck With Contrast C T Soft Tissue Neck Without & With Contrast C T Angiography Head C T Angiography Neck M R I Orbit, Face,Neck and/or Without Contrast M R I Face, Orbit, Neck With Contrast M R I Face, Orbit, Neck With & Without Contrast M R A Head Without Contrast M R A Head With Contrast M R A Head With & Without Contrast M R A Neck Without Contrast M R A Neck With Contrast M R A Neck With & Without Contrast 7055 M R I Head Without Contrast M R I Head With Contrast M R I Head With & Without Contrast MRI Brain, functional MRI MRI Brain, functional MRI, requiring physician 7250 C T Thorax Without Contrast 7260 C T Thorax With Contrast 7270 C T Thorax Without & With Contrast 7275 C T Angiography Chest Without Contrast Material, Followed by Contrast Material and Further Sections,Including Image Postprocessing 7550 M R I Chest Without Contrast 755 M R I Chest With Contrast 7552 M R I Chest With & Without Contrast 7555 M R A Chest (Excluding Myocardium) With Or Without Contrast 7225 C T Cervical Spine Without Contrast 7226 C T Cervical Spine With Contrast 7227 C T Cervical Spine Without & With Contrast 7228 C T Thoracic Spine Without Contrast Provider Procedure Codes Last Updated: NOV 206 PAGE

2 7229 C T Thoracic Spine With Contrast 7230 C T Thoracic Spine Without & With Contrast 723 C T Lumbar Spine Without Contrast 7232 C T Lumbar Spine With Contrast 7233 C T Lumbar Spine Without & With Contrast 724 M R I Cervical Spine Without Contrast 7242 M R I Cervical Spine With Contrast 7246 M R I Thoracic Spine Without Contrast 7247 M R I Thoracic Spine With Contrast 7248 M R I Lumbar Spine Without Contrast 7249 M R I Lumbar Spine With Contrast 7256 M R I Cervical Spine With & Without Contrast 7257 M R I Thoracic Spine With & Without Contrast 7258 M R I Lumbar Spine With & Without Contrast 7259 M R A Spinal Canal With Or Without Contrast 729 C T Angiography Pelvis 7292 C T Pelvis Without Contrast 7293 C T Pelvis With Contrast 7294 C T Pelvis Without & With Contrast 7295 M R I Pelvis Without Contrast 7296 M R I Pelvis With Contrast 7297 M R I Pelvis With & Without Contrast 7298 M R A Pelvis With Or Without Contrast C T Upper Extremity Without Contrast 7320 C T Upper Extremity With Contrast C T Upper Extremity Without & With Contrast C T Angiography Upper Extremity 7328 M R I Upper Extremity Without Contrast 7329 M R I Upper Extremity With Contrast M R I Upper Extremity With & Without Contrast 7322 M R I Upper Extremity Joint Without Contrast M R I Upper Extremity Joint With Contrast M R I Upper Extremity Joint With & Without Contrast M R A Upper Extremity With Or Without Contrast C T Lower Extremity Without Contrast 7370 C T Lower Extremity With Contrast C T Lower Extremity Without & With Contrast C T Angiography Lower Extremity 7378 M R I Lower Extremity Without Contrast 7379 M R I Lower Extremity With Contrast M R I Lower Extremity With & Without Contrast 7372 M R I Lower Extremity Joint Without Contrast M R I Lower Extremity Joint With Contrast M R I Lower Extremity Joint With & Without Contrast Provider Procedure Codes Last Updated: NOV 206 PAGE 2

3 73725 M R A Lower Extremity With Or Without Contrast 7450 C T Abdomen Without Contrast 7460 C T Abdomen With Contrast 7470 C T Abdomen Without & With Contrast 7474 CT angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing 7475 C T Angiography Abdomen 7476 CT ABDOMEN AND PELVIS WITHOUT CONTRAST 7477 CT ABDOMEN AND PELVIS WITH CONTRAST COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL IN ONE OR BOTH 7478 BODY REGIONS, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS IN ONE OR BOTH BODY REGIONS 748 M R I Abdomen Without Contrast 7482 M R I Abdomen With Contrast 7483 M R I Abdomen With & Without Contrast 7485 M R A Abdomen With Or Without Contrast 7426 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including non-contrast images, if performed Computed tomographic (CT) colonography, screening, including image postprocessing 7472 Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; single or first gestation 7473 Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; each additional gestation (List separately in addition to code for primary procedure) C T Angiography Abdominal Aorta D Rendering W/O Postprocessing D Rendering W Postprocessing C T Limited Or Localized Follow-Up Study M R I Spectroscopy Unlisted computed tomography procedure Unlisted MRI Procedure 7702 Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation 7704 CT GUIDE PLCMNT RADIATION 7702 M R I Guidance For Needle Placement Magnetic resonance guidance for, and monitoring of, parenchymal tissue ablation M R I Breast With And/Or Without Contrast M R I Breast Bilateral Computed Tomography, bone mineral density study, or more sites; axial skeleton Magnetic resonance (eg, proton) imaging, bone marrow blood supply 7802 Thyroid uptake, single or multiple quantitative measurement(s) (including stimulation, suppression, or discharge, when performed) 7803 Thyroid imaging (including vascular flow, when performed) 7804 Thyroid imaging (including vascular flow, when performed); with single or multiple uptake(s) Provider Procedure Codes Last Updated: NOV 206 PAGE 3

4 quantitative measurement(s) (including stimulation, suppression, or discharge, when performed) 7805 Thyroid Met Imaging 7806 Thyroid Met Imaging With Additional Studies 7808 Thyroid Scan Whole Body Thyroid Carcinoma Metastases Uptake Parathyroid planar imaging (including subtraction, when performed) 7807 Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT) Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT), and concurrently acquired computed tomography (CT) for anatomical localization Adrenal Nuclear Imaging 7802 Bone Marrow Imaging, Limited 7803 Bone Marrow Imaging, Multiple 7804 Bone Marrow Imaging, Whole Body 7840 Labeled Red Cell Sequestration 7885 Spleen Imaging With & Without Vascular Flow 7895 Lymph System Imaging 7820 Liver Imaging Liver Imaging With Flow Liver Imaging SPECT (3D) Liver Imaging SPECT With Vasulcar Flow 7825 Liver & Spleen Imaging 7826 Liver & Spleen Imaging With Flow Hepatobiliary system imaging, including gallbladder when present; Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention, including quantitative measurement(s) when performed Salivary Gland Imaging 7823 Serial Salivary Gland Salivary Gland Function Exam Esophogus Motility Study 7826 Gastric Mucosa Imaging Gastroesophageal Reflux Exam Gastric Emptying Study Gastric emptying imaging study (eg, solid, liquid, or both); with small bowel transit Gastric emptying imaging study (eg, solid, liquid, or both); with small bowel and colon transit, multiple days GI Bleeder Scan Meckels Diverticulum Imaging 7829 Leveen Shunt Patency Exam Bone Or Joint Imaging Limited Bone Or Joint Imaging Multiple Bone Scan Whole Body 7835 Bone Scan 3 Phase Study Bone Joint Imaging Tomo Test SPECT 7844 Non-Imaging Heart Function Cardiac Shunt Imaging Provider Procedure Codes Last Updated: NOV 206 PAGE 4

5 78445 Radionuclide Venogram Non-Cardiac Venous Thrombosis Imaging Unilateral Venous Thrombosis Images, Bilateral Myocardial Infarction Scan Heart Infarct Image Ejection Fraction Heart Infarct Image 3D SPECT CARDIAC BLOODPOOL IMG, SINGLE CARDIAC BLOODPOOL IMG, MULTI 7848 Heart First Pass Single Cardiac Blood Pool Imaging -- Multiple Cardiac Blood Pool Imaging, SPECT Cardiac Blood Pool Imaging - Single Rest Unlisted Cardiovascular Procedure Pulmonary ventilation imaging (eg, aerosol or gas) Pulmonary perfusion imaging (eg, particulate) Pulmonary ventilation (eg, aerosol or gas) and perfusion imaging Pulmonary Perfusion With Washout With Or Without Single Breath Quantitative differential pulmonary perfusion, including imaging when performed Quantitative differential pulmonary perfusion and ventilation (eg, aerosol or gas), including imaging when performed Brain Imaging Limited Static 7860 Brain Limited Imaging And Flow Brain Imaging Complete Brain Imaging Complete With Flow Brain Imaging 3D Brain Imaging, Positron Emission Tomography (PET) Metabolic Evaluation Brain Imaging, Positron Emission Tomography (PET) Perfusion Evaluation 7860 Brain Flow Imaging Only Cisternogram (Cerebrospinal Fluid Flow) Cerebrospinal Ventriculography CSF Shunt Evaluation Cerebrospinal Fluid Scan (Tomographic) SPECT C S F Leakage Detection And Localization Radiopharmaceutical Dacryocystography Unlisted Nuclear Medicine Procedure Kidney Imaging Morphology 7870 Kidney Imaging With Vascular Flow Kidney Imaging With Vascular Flow & Function Single Study Without Pharmacological Intervention Kidney Imaging Single Study With Pharmacological Intervention Kidney Imaging - Multiple Studies Without & With Pharmacological Intervention 7870 Kidney Imaging - Tomographic (SPECT) Kidney Function Study - Non-Imaging Radioisotopic Urinary Bladder Residual Study Ureteral Reflux Study Provider Procedure Codes Last Updated: NOV 206 PAGE 5

6 7876 Testicular Imaging With Vascular Flow Radiopharm Localization Of Tumor, Limited Area 7880 Radiopharm Localization Of Tumor, Multiple Areas Radiopharm Localization Of Tumor, Whole Body Radiopharm Localization Of Tumor Tomographic (SPECT) Radiopharm Localization Of Tumor, Whole Body Radiopharm Localization Of Abscess, Limited Area Radiopharm Localization Of Abscess, Whole Body Radiopharm Localization Of Abscess, Tomographic SPECT 788 TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); LIMITED AREA (EG, CHEST, HEAD/NECK) 7882 TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); SKULL BASE TO MID-THIGH 7883 POSITRON EMISSION TOMOGRAPHY (PET); WHOLE BODY TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED 7884 COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION; LIMITED AREA (EG CHEST, HEAD/NECK) TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED 7885 COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION; SKULL BASE TO MID-THIGH TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED 7886 COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION; WHOLE BODY 0042T CT PERFUSION BRAIN Computer-aided detection, including computer algorithm analysis of MRI image data for lesion 059T detection/characterization, pharmacokinetic analysis, with further physician review for interpretation, breast MRI (List separately in addition to code for primary procedure) C8900 MRA Abdomen with contrast C890 MRA Abdomen without contrast C8902 MRA Abdomen with and w/o contrast C8903 MRI Breast w/ contrast, unilateral C8904 MRI Breast w/o contrast, unilateral C8905 MRI Breast w. and w/o contrast, unilateral C8906 MRI BREAST BILATERAL w/ CONTRAST C8907 MRI BREAST BILATERAL w/o CONTRAST C8908 MRI BREAST BILATERAL w/ and w/o CONTRAST C8909 MRA chest w/contrast (excluding myocardium) C890 MRA chest w/o contrast (excluding myocardium) C89 MRA chest (excluding myocardium) C892 MRA lower extremity w/ contrast C893 MRA lower extremity w/o contrast C894 MRA lower extremity w/ and w/o contrast C898 MRA pelvis w/ contrast C899 MRA pelvis w/o contrast C8920 MRA pelvis w/ and w/o contrast C893 MRA, W/DYE, SPINAL CANAL C8932 MRA, W/O DYE, SPINAL CANAL Provider Procedure Codes Last Updated: NOV 206 PAGE 6

7 C8933 C8934 C8935 C8936 G029 G0235 G0252 G0297 S8032 S8037 S8042 S8080 S8085 S8092 MRA, W/O&W/DYE, SPINAL CANAL MRA, W/DYE, UPPER EXTREMITY MRA, W/O DYE, UPPER EXTR MRA, W/O&W/DYE, UPPER EXTR PET IMAGING WHOLE BODY; MELANOMA FOR NON-COVERED INDICATIONS PET IMAGING, ANY SITE, NOT OTHERWISE SPECIFIED PET IMAGING, FULL AND PARTIAL-RING PET SCANNERS ONLY FOR INITIAL DIAGNOSIS OF BREAST CANCER AND/OR SURGICAL PLANNING FOR BREAST CANCER Low-dose Computed Tomography For Lung Cancer Screening Low-dose Computed Tomography For Lung Cancer Screening Magnetic resonance cholangiopancreato-graphy (MRCP) MAGNETIC RESONANCE IMAGING (MRI), LOW-FIELD SCINTIMAMMOGRAPHY (RADIOIMMUNOSCINTIGRAPHY OF THE BREAST), UNILATERAL, INCLUDING SUPPLY OF RADIOPHARMACEUTICAL FLUORINE-8 FLUORODEOXYGLUCOSE (F-8 FDG) IMAGING USING DUAL HEAD COINCIDENCE DETECTION SYSTEM. (Non-dedicated PET scan) ELECTRON BEAM COMPUTED TOMOGRAPHY (ALSO KNOWN AS ULTRAFAST CT, CINET) CARDIOLOGY CPT CPT Description 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), 7556 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 procedure) Computed tomography, heart, without contrast material, with quantitative evaluation of coronary 7557 calcium Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3d image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed) Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3d image postprocessing, 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 3d image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed) 7845 myocardial perfusion imaging, tomographic (spect) including attenuation correction, qualitative 7845 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, Provider Procedure Codes Last Updated: NOV 206 PAGE 7

8 when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection 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) 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 Myocardial imaging, positron emission tomography (pet), metabolic evaluation 7849 Myocardial imaging, positron emission tomography (pet), perfusion; single study at rest or stress Myocardial imaging, positron emission tomography (pet), perfusion; multiple studies at rest and/or stress Transthoracic echocardiography for congenital cardiac anomalies; complete Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study Echocardiography, transthoracic, real-time with image documentation (2d), includes m-mode recording, when performed, complete, with spectral doppler echocardiography, and with color flow doppler echocardiography Echocardiography, transthoracic, real-time with image documentation (2d) with or without m-mode recording; complete Echocardiography, transthoracic, real-time with image documentation (2d) with or without m-mode recording; follow-up or limited study 9332 TEE 2D;Incl Probe Placement, Imaging/Interp/Report 9333 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M- mode recording); placement of transesophageal probe only 9334 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M- mode recording); image acquisition, interpretation and report only 9335 Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report 9336 Transesophageal echocardiography for congenital cardiac anomalies; placement of transesophageal probe only 9337 Transesophageal echocardiography for congenital cardiac anomalies; image acquisition, interpretation and report only 9338 Echo transesophageal intraop Doppler echocardiography, pulsed wave and/or continuous wave with spectral display; complete 9332 Doppler echocardiography, pulsed wave and/or continuous wave with spectral display; follow-up or limited study Doppler echocardiography color flow velocity mapping Echocardiography, transthoracic, real-time with image documentation (2d), with or without m-mode recording, during rest and cardiovascular stress test, with interpretation and report Echocardiography, transthoracic, real-time with image documentation (2d), includes m-mode 9335 recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation Use of echocardiographic contrast agent during stress echocardiography (list separately in addition to code for primary procedure) 9345 RIGHT HEART CATHETERIZATION INCLUDING MEASUREMENT(S) OF OXYGEN SATURATION AND CARDIAC OUTPUT, WHEN PERFORMED Provider Procedure Codes Last Updated: NOV 206 PAGE 8

9 Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial venous grafts) including intraprocedural injection(s) for bypass graft angiography Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart 9346 catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography Left heart catheterization by transseptal puncture through intact septum or by transapical puncture (list separately in addition to code for primary procedure) RIGHT HEART CATHETERIZATION (CHD) 9353 RIGHT/LEFT HEART CATHETERIZATION (CHD) RIGHT/LEFT HEART CATHETERIZATION (CHD-TS) RIGHT/LEFT HEART CATHETERIZATION (CAD-ASD) Myocardial strain imaging (quantitative assessment of myocardial mechanics using image-based 0399T analysis of local myocardial dynamics) (List separately in addition to code for primary procedure) 0439T Myocardial Perfusion Echo C892 Transthoracic echocardiography w/contrast for congenital cardiac anomalies; complete C8922 Transthoracic echocardiography w/contrast for congenital cardiac anomalies; f/u or limited study Transthoracic echocardiography w/contrast, real-time w/image documentation (2d), w/wo m-mode C8923 recording; complete Provider Procedure Codes Last Updated: NOV 206 PAGE 9

10 C8924 C8928 C8929 C8930 Transthoracic echocardiography w/contrast, real-time w/image documentation (2d), w/wo m-mode recording; f/u or limited study Transthoracic echocardiography w/contrast, real-time w/image documentation (2d), w/wo m-mode recording, during rest and cardiovascular stress test, w/interpretation and report Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2d), includes m-mode recording, when performed, complete, with spectral doppler echocardiography, and with color flow doppler echocardiography Transthoracic echocardiography, with contrast, or without contrast followed by with contrast, realtime with image documentation (2d), includes m-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with physician supervision ULTRASOUND CPT CPT Description US ECHOENCEPHALOGRAPHY US SOFT TISSUE HEAD AND NECK US CHEST REAL TIME WITH IMAGE DOCUMENTATION 7664 Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited ULTRASOUND ABDOMINAL REAL TIME WITH IMAGE DOCUMENTATION U/S SINGLE ORGAN ULTRASOUND,RETROPEROTONRAL,REAL TIME WITH IMAGE DOCUMENTATION;COMPLETE US ECHO LIMITED Ultrasound, transplanted kidney, real time and duplex Doppler with image documentation US ECHO SPINAL CANAL U/S TRANSVAGINAL 7683 HYSTEROSONOGRAPHY W OR W/O COL ULTRASOUND PELCIC REAL TIME WITH IMAGE DOCUMENTATION;COMPLETE US PEL LIM OR F/U US ECHO SCROTUM U/S TRANSRECTAL 7688 Ultrasound, extremity, non-vascular, real time with image documentation; complete Ultrasound, extremity, non-vascular, real time with image documentation; limited, anatomic specific US ECHO, INFANT HIPS REALTIME US,Infant Hips,Real Time;Limited, Static US STUDY FOLLOW UP Ultrasound Gastrointestinal, Endoscopic Echo examination procedure DUPLEX SCAN EXTRACRANIAL ARTER DUPLEX SCAN EXTRACRANIAL ARTER TRANSCRANIAL DOPPLER STUDY INT TRANSCRANIAL DOPPLER STUDY INT Provider Procedure Codes Last Updated: NOV 206 PAGE 0

11 93890 Transcranial Doppler vasoreactivity study Transcranial Doppler study of the intracranial arteries; emboli detection without intravenous microbubble injection Transcranial Doppler study of the intracranial arteries; emboli detection with intravenous microbubble injection NON-INVASIVE PHYSIOLOGIC STUDI NON-INVASIVE PHYSIOLOGIC STUDI NON-INVASIVE PHYSIOLOGIC STUDI DUPLEX SCAN LOW EXT. ART. OR A DUPLEX SCAN LOW EXT. ART. OR A DUPLEX SCAN UP EXT. ART. OR AR 9393 DUPLEX SCAN UP EXT. ART. OR AR NON-INVASIVE PHYSIOLOGIC STUDI DUPLEX SCAN EXT. VEINS, COMPLE 9397 DUPLEX SCAN EXT. VEINS, UNILAT 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 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 Duplex scan of arterial inflow and venous outflow of penile vessels; complete study 9398 Duplex scan of arterial inflow and venous outflow of penile vessels; follow-up or limited study Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow) UNLISTED NONINVASIVE VASCULAR DIAGNOSTIC STUDY G0389 Ultrasound B-Scan And/Or Real Time With Image Documentation; For Abdominal Aortic Aneurysm (Aaa) Screening 7680 Ultrasound Obstetrical Pelvis, Pregnant Uterus, First Trimester less than 4 Weeks Single Or First Gestation Ultrasound Obstetrical Pelvis, Pregnant Uterus, First Trimester less than 4 Weeks Each Additional Gestation Ultrasound Obstetrical Pelvis, Pregnant Uterus, B-Scan 7680 Ultrasound Obstetrical Pelvis Complete, Multiple Gestation After st Trimester 768 Ultrasound Pregnant Uterus Fetal & Maternal Evaluation Plus Fetal Anatomic Evaluation Transabdominal Single Or First Gestation 7682 Ultrasound Pregnant Uterus Fetal & Maternal Evaluation Plus Fetal Anatomic Evaluation Transabdominal Each Additional Gestation 7683 Ultrasound, pregnant uterus, real time with image documentation 7684 Ultrasound, pregnant uterus, real time with image documentation 7685 Ultrasound Obstetrical Pelvis Limited (Gestational Age, Heart Beat, Emergency) 7686 Ultrasound Obstetrical Pelvis Follow Up Or Repeat 7687 Ultrasound Pregnant Uterus Transvaginal 7688 Fetal Biophysical Profile 7689 Fetal Biophysical Profile Without Stress Non Stress DOPPLER VELOCIMETRY, FETAL; UMBILICAL ARTERY Provider Procedure Codes Last Updated: NOV 206 PAGE

12 7682 DOPPLER VELOCIMETRY, FETAL; MIDDLE CEREBRAL ARTERY Ultrasound Obstetrical Echocardiography, Fetal, Cardiovascular System Follow Up Or Repeat Study Doppler Echocardiography Fetal Complete Follow Up Or Repeat Study RT Code Description 7704 Computed tomography guidance for placement of radiation therapy fields 7737 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of session; multi-source Cobalt 60 based Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of session; linear accelerator based Stereotactic body radiation therapy, treatment delivery, per fraction to or more lesions, including image guidance, entire course not to exceed 5 fractions Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; simple Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex Guidance for localization of target volume for delivery of radiation treatment delivery, includes intrafraction tracking, when performed 7740 Radiation treatment delivery, superficial and/or ortho voltage, per day Radiation treatment delivery, > MeV; simple Radiation treatment delivery, > MeV; intermediate 7742 Radiation treatment delivery, > MeV; complex High energy neutron radiation treatment delivery; single treatment area using a single port or parallelopposed ports with no blocks or simple blocking High energy neutron radiation treatment delivery; or more isocenter(s) with coplanar or noncoplanar geometry with blocking and/or wedge, and/or compensator(s) Intraoperative radiation treatment delivery, x-ray, single treatment session Intraoperative radiation treatment delivery, electrons, single treatment session Proton treatment delivery; simple, without compensation Proton treatment delivery; simple, with compensation Proton treatment delivery; intermediate Proton treatment delivery; complex Hyperthermia, externally generated; superficial (ie, heating to a depth of 4 cm or less) Hyperthermia, externally generated; deep (ie, heating to depths greater than 4 cm) 7760 Hyperthermia generated by interstitial probe(s); 5 or fewer interstitial applicators 7765 Hyperthermia generated by interstitial probe(s); more than 5 interstitial applicators Hyperthermia generated by intracavitary probe(s) Infusion or instillation of radioelement solution (includes 3-month follow-up care) 7776 Intracavitary radiation source application; simple Intracavitary radiation source application; intermediate Intracavitary radiation source application; complex Provider Procedure Codes Last Updated: NOV 206 PAGE 2

13 77767 HDR radionuclide skin surface brachytherapy; lesion diameter up to 2.0 cm or channel HDR radionuclide skin surface brachytherapy; lesion diameter over 2.0 cm and 2 or more channels, or multiple lesions HDR radionuclide interstitial or intracavitary brachytherapy; channel 7777 HDR radionuclide rate interstitial or intracavitary brachytherapy; 2 to 2 channels HDR radionuclide interstitial or intracavitary brachytherapy; over 2 channels Interstitial radiation source application, complex, includes supervision, handling, loading of radiation source when performed Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion 0394T HDR electronic brachytherapy, skin surface application, per fraction 0395T HDR electronic brachytherapy, interstitial or intracavitary treatment, per fraction A9543 Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 millicuries A9606 Radiopharmaceutical, therapeutic, not otherwise classified G0339 Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session or first session of fractionated treatment Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator G0340 changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment G600 Ultrasonic guidance for placement of radiation therapy fields G6002 Stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy G6003 Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple blocks or no blocks: up to 5mev G6004 Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple blocks or no blocks: 6-0mev G6005 Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple blocks or no blocks: -9mev G6006 Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple blocks or no blocks: 20mev or greater G6007 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: up to 5mev G6008 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 6-0mev G6009 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: -9mev G600 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 20 mev or greater G60 Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5mev G602 Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 6-0mev G603 Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; -9mev G604 Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 20mev or greater G605 Intensity modulated treatment delivery, single or multiple fields/arcs,via narrow spatially and temporally modulated beams, binary, dynamic mlc, per treatment session Provider Procedure Codes Last Updated: NOV 206 PAGE 3

14 G606 Compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or more high resolution (milled or cast) compensator, convergent beam modulated fields, per treatment session CRID CPT CPT Description Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); ventricular Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular 3322 Insertion of pacemaker pulse generator only; with existing single lead 3323 Insertion of pacemaker pulse generator only; with existing dual leads Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber 3324 system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new generator) 3322 Insertion of pacemaker pulse generator only; with existing multiple leads Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of existing generator) Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter-defibrillator or pacemaker pulse generator (including upgrade to dual chamber system and pocket revision) (list separately in addition to code for primary procedure) Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; single lead system Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; dual lead system Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; multiple lead system Insertion of pacing cardioverter-defibrillator pulse generator only; with existing dual leads 3323 Insertion of pacing cardioverter-defibrillator pulse generator only; with existing multiple leads Insertion of pacing cardioverter-defibrillator pulse generator only; with existing single lead Insertion or replacement of permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverterdefibrillator pulse generator; single lead system Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverterdefibrillator pulse generator; dual lead system Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverterdefibrillator pulse generator; multiple lead system 039T Insertion or replacement of subcutaneous implantable defibrillator system with subcutaneous electrode 0387T Implantation or replacement of permanent ventricular pacemaker 0388T Removal of permanent ventricular pacemaker Implantation of heart valve (pulmonary) to lungs, accessed through the skin Provider Procedure Codes Last Updated: NOV 206 PAGE 4

15 SLEEP Code Description POLYSOMNOGRAPHY; YOUNGER THAN 6 YEARS, SLEEP STAGING WITH 4 OR MORE ADDITIONAL PARAMETERS OF SLEEP, ATTENDED BY A TECHNOLOGIST POLYSOMNOGRAPHY; YOUNGER THAN 6 YEARS, SLEEP STAGING WITH 4 OR MORE ADDITIONAL PARAMETERS OF SLEEP, WITH INITIATION OF CONTINUOUS POSITIVE AIRWAY PRESSURE THERAPY OR BI-LEVEL VENTILATION, ATTENDED BY A TECHNOLOGIST Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (e.g., by airflow or peripheral arterial tone), and sleep time 9580 Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, respiratory analysis (e.g., by airflow or peripheral arterial tone), and sleep time Multiple Sleep Latency Test or Maintenance of Wakefulness Test Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort (e.g. Thoracoabdominal movement) Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist Polysomnography, Sleep staging with -3 Additional Parameters of Sleep, Attended by a Technologist 9580 Polysomnography, Sleep staging with 4 or more Additional Parameters of Sleep, Attended by a Technologist Polysomnography, Sleep staging with 4 or more additional Parameters of Sleep for PAP titration, with 958 initiation of continuous positive airway pressure therapy or bilevel ventilation, Attended by a Technologist HOME SLEEP STUDY TEST (HST) WITH TYPE II PORTABLE MONITOR, UNATTENDED; MINIMUM OF 7 G0398 CHANNELS including: EEG, EOG, EMG, RESPIRATORY MOVEMENT, AIRFLOW, ECG/HEART RATE AND OXYGEN SATURATION G0399 HOME SLEEP STUDY TEST (HST) WITH TYPE III PORTABLE MONITOR, UNATTENDED; MINIMUM OF 4 CHANNELS: 2 RESPIRATORY MOVEMENT/AIRFLOW, ECG/HEART RATE AND OXYGEN SATURATION G0400 HOME SLEEP STUDY TEST (HST) WITH TYPE IV PORTABLE MONITOR, UNATTENDED; MINIMUM OF 3 CHANNELS A4604 TUBING WITH INTEGRATED HEATING ELEMENT FOR USE WITH POSITIVE AIRWAY PRESSURE DEVICE A7027 COMBINATION ORAL/NASAL MASK, USED WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE, EACH A7028 ORAL CUSHION FOR COMBINATION ORAL/NASAL MASK, REPLACEMENT ONLY, EACH A7029 NASAL PILLOWS FOR COMBINATION ORAL/NASAL MASK, REPLACEMENT ONLY, PAIR A7030 FULL FACE MASK USED WITH POSITIVE AIRWAY PRESSURE DEVICE, EACH A703 FACE MASK INTERFACE, REPLACEMENT FOR FULL FACE MASK, EACH A7032 CUSHION FOR USE ON NASAL MASK INTERFACE, REPLACEMENT ONLY, EACH A7033 PILLOW FOR USE ON NASAL CANNULA TYPE INTERFACE, REPLACEMENT ONLY, PAIR A7034 NASAL INTERFACE (MASK OR CANNULA TYPE) USED WITH POSITIVE AIRWAY PRESSURE A7035 HEADGEAR USED WITH POSITIVE AIRWAY PRESSURE DEVICE A7036 CHINSTRAP USED WITH POSITIVE AIRWAY PRESSURE DEVICE A7037 TUBING USED WITH POSITIVE AIRWAY PRESSURE DEVICE A7038 FILTER, DISPOSABLE, USED WITH POSITIVE AIRWAY PRESSURE DEVICE A7039 FILTER, NON DISPOSABLE, USED WITH POSITIVE AIRWAY PRESSURE DEVICE A7044 ORAL INTERFACE USED WITH POSITIVE AIRWAY PRESSURE DEVICE, EACH Provider Procedure Codes Last Updated: NOV 206 PAGE 5

16 PT/OT A7045 EXHALATION PORT WITH OR WITHOUT SWIVEL USED WITH ACCESSORIES FOR POSITIVE A7046 WATER CHAMBER FOR HUMIDIFIER, USED WITH POSITIVE AIRWAY PRESSURE DEVICE, E0470 RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITHOUT BACKUP RATE E047 RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITH BACK-UP RATE E060 CONTINUOUS AIRWAY PRESSURE (CPAP) DEVICE E056 HUMIDIFIER, NON-HEATED, USED WITH POSITIVE AIRWAY PRESSURE DEVICE E0562 HUMIDIFIER, HEATED, USED WITH POSITIVE AIRWAY PRESSURE DEVICE CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP), INITIATION AND MANAGEMENT Code AMA Long Description 420 PHYSICAL THERAPY 42 PHYSICAL THERAPY: VISIT CHARGE 422 PHYSICAL THERAPY: HOURLY CHARGE 423 PHYSICAL THERAPY: GROUP RATE 424 PHYSICAL THERAPY: EVALUATION/RE-EVALUATION 429 PHYSICAL THERAPY: OTHER PHYSICAL THERAPY 430 OT General 43 OT Visit Code 432 OCCUPATIONAL THERAPY: HOURLY CHARGE 433 OCCUPATIONAL THERAPY: GROUP RATE 434 OCCUPATIONAL THERAPY: EVALUATION/RE-EVALUATION 439 OCCUPATIONAL THERAPY: OTHER OCCUPATIONAL THERAPY Strapping, hip 2905 Application of long arm splint(shoulder to hand) 2925 Application of short arm splint (forearm to hand), static 2926 Application of short arm splint (forearm to hand), dynamic 2930 Application of finger splint, static 293 Application of finger splint, dynamic Strapping; thorax Strapping, thorax Strapping; shoulder (eg, Velpeau) Strapping; elbow or wrist Strapping; hand or finger Strapping; hip Strapping; knee Strapping; ankle and/or foot Strapping; toes 909 Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry 9583 Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk Muscle testing, manual (separate procedure) with report; hand, with or without comparison with normal side Muscle testing, manual (separate procedure) with report; total evaluation of body, excluding hands Muscle testing, manual (separate procedure) with report; total evaluation of body, including hands 9585 Range of motion measurements and report (separate procedure); each extremity (excluding hand) or each Provider Procedure Codes Last Updated: NOV 206 PAGE 6

17 trunk section (spine) Range of motion measurements and report (separate procedure); hand, with or without comparison with normal side 9700 Physical therapy evaluation Physical therapy re-evaluation Occupational therapy evaluation Occupational therapy re-evaluation 9700 Application of a modality to or more areas; hot or cold packs 9702 Application of a modality to or more areas; traction, mechanical 9704 Application of a modality to or more areas; electrical stimulation (unattended) 9706 Application of a modality to or more areas; vasopneumatic devices 9708 Application of a modality to or more areas; paraffin bath Microwave Application of a modality to or more areas; whirlpool Application of a modality to or more areas; diathermy (eg, microwave) Application of a modality to or more areas; infrared Application of a modality to or more areas; ultraviolet Application of a modality to or more areas; electrical stimulation (manual), each 5 minutes Application of a modality to or more areas; iontophoresis, each 5 minutes Application of a modality to or more areas; contrast baths, each 5 minutes Application of a modality to or more areas; ultrasound, each 5 minutes Application of a modality to or more areas; Hubbard tank, each 5 minutes Unlisted modality (specify type and time if constant attendance) 970 Therapeutic procedure, or more areas, each 5 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility 972 Therapeutic procedure, or more areas, each 5 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities 973 Therapeutic procedure, or more areas, each 5 minutes; aquatic therapy with therapeutic exercises 976 Therapeutic procedure, or more areas, each 5 minutes; gait training (includes stair climbing) 9724 Therapeutic procedure, or more areas, each 5 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) 9739 Unlisted therapeutic procedure (specify) 9740 Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), or more regions, each 5 minutes 9750 Therapeutic procedure(s), group (2 or more individuals) Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 5 minutes Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 5 minutes Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 5 minutes Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 5 minutes Community/work reintegration training (eg, shopping, transportation, money management, avocational Provider Procedure Codes Last Updated: NOV 206 PAGE 7

18 activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact, each 5 minutes Wheelchair management (eg, assessment, fitting, training), each 5 minutes Work hardening /conditioning; initial 2 hours Work hardening /conditioning; each additional hour (list separately in addition to code for primary procedure) Physical performance test or measurement (eg, musculoskeletal, functional capacity), with written report, each 5 minutes Assistive technology assessment (eg, to restore, augment or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility), direct one-on-one contact, with written report, each 5 minutes Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 5 minutes 9776 Prosthetic training, upper and/or lower extremity(s), each 5 minutes Checkout for orthotic/prosthetic use, established patient, each 5 minutes Unlisted physical medicine/rehabilitation service or procedure G05 Services of physical therapist in home health setting, each 5 minutes G052 Services of occupational therapist in home health setting, each 5 minutes G057 Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 5 minutes G058 Services performed by a qualified occupational therapist assistant in the home health or hospice setting, each 5 minutes G059 Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program, each 5 minutes G060 Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and effective occupational therapy maintenance program, each 5 minutes G028 Electrical stimulation, (unattended), to one or more areas, for chronic stage iii and stage iv pressure ulcers, etc. G0282 Electrical stimulation, (unattended), to one or more areas, for wound care other than described in G028 G0283 Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care ST Code AMA Long Description 440 SPEECH-LANGUAGE PATHOLOGY 44 SPEECH-LANGUAGE PATHOLOGY: VISIT CHARGE 442 SPEECH-LANGUAGE PATHOLOGY: HOURLY CHARGE 443 SPEECH-LANGUAGE PATHOLOGY: GROUP RATE 444 SPEECH-LANGUAGE PATHOLOGY: EVALUATION/ RE-EVALUATION 3575 Laryngoscopy, flexible fiberoptic; diagnostic 3579 Laryngoscopy, flexible or rigid fiberoptic, with stroboscopy Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals 925 Nasopharyngoscopy with endoscope (separate procedure) Laryngeal function studies (ie, aerodynamic testing and acoustic testing) 9252 Evaluation of speech fluency (eg, stuttering, cluttering) Provider Procedure Codes Last Updated: NOV 206 PAGE 8