Contrast Guidelines for Common CT/CTA & MRI/MRA
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1 Contrast Guidelines for Common /A & /MRA Body Imaging Gastrointestinal CLINICAL GUIDELINES EXAM DESCRIPTION /A CPT CODES EXAM DESCRIPTION /MRA CPT CODES Abdominal mass Abdomen & Pelvis w Abdomen w & wo Abdominal pain Abdomen & Pelvis w Abdomen w & wo Abscess Abdomen & Pelvis w Abdomen w & wo Appendicitis Abdomen & Pelvis w Abdomen and Pelvis w & wo & Biliary ductal dilatation Abdomen & Pelvis w Abdomen w & wo MRCP & Cancer staging Abdomen w Abdomen w & wo Cirrhosis Abdomen w & wo Abdomen w & wo (attn liver) Common bile duct stone Abdomen w & wo Abdomen w & wo MRCP & Constipation Abdomen & Pelvis w Crohn's disease, inflammatory bowel disease Enterography/Small Bowel & Diarrhea Abdomen & Pelvis w Diverticulitis, LLQ pain Abdomen & Pelvis w Hemochromatosis Abdomen w & wo (attn liver) Hepatitis Abdomen w & wo Abdomen w & wo (attn liver) Liver function test elevation Abdomen w & wo Abdomen w & wo (attn liver) Liver hemangioma, cyst Abdomen w & wo Abdomen w & wo (attn liver) Lymphoma Abdomen & Pelvis w Lymphadenopathy Abdomen & Pelvis w Pancreatic mass Abdomen w & wo Abdomen w & wo Pancreatitis Abdomen w & wo Abdomen w & wo Small bowel obstruction Abdomen & Pelvis w Weight loss Abdomen & Pelvis w Genitourinary CLINICAL GUIDELINES EXAM DESCRIPTION /A CPT CODES EXAM DESCRIPTION /MRA CPT CODES Adrenal adenoma /mass/cyst Abdomen w & wo Abdomen w & wo Bladder cancer, suspected Abdomen & Pelvis w Cancer staging Abdomen & Pelvis w Abdomen w & wo Flank pain, renal colic Abdomen & Pelvis wo Hematuria ( Urogram, IVP) Hematuria Protocol /IVP w & wo Abdomen and Pelvis w & wo & Hematuria (suspect mass) Hematuria Protocol /IVP w & wo Abdomen w & wo (attn kidney) Hematuria (suspect stone) Hematuria Protocol /IVP w & wo Hydronephrosis, work up Abdomen & Pelvis w and/or wo Renal calculus Abdomen & Pelvis wo Renal cyst Abdomen w & wo Abdomen w & wo (attn kidney) Renal mass or complex cyst Abdomen w & wo Abdomen w & wo (attn kidney) 74183
2 Contrast Guidelines for Common /A & /MRA Pelvis CLINICAL GUIDELINES EXAM DESCRIPTION /A CPT CODES EXAM DESCRIPTION /MRA CPT CODES Adenomyosis Pelvis w & wo Cancer staging Abdomen & Pelvis w Pelvis w & wo Complex adnexal cysts Pelvis w & wo Cysts Pelvis w & wo Dermoid Pelvis w Pelvis w & wo Endometriosis Pelvis w & wo Pelvic mass, origin uncertain Pelvis w & wo Uterine fibroid Pelvis w & wo Pulmonary CLINICAL GUIDELINES EXAM DESCRIPTION /A CPT CODES EXAM DESCRIPTION /MRA CPT CODES Asbestosis Chest wo Bronchiectasis Chest for Interstitial Lung Disease, High resolution ( Chest wo) Cancer staging Chest w Chest wall mass Chest w Chest w & wo Compex pleural effusion Chest w COPD Chest for Interstitial Lung Disease, High resolution ( Chest wo) Hilar fullness Chest w Intersitial lung disease Chest for Interstitial Lung Disease, High resolution ( Chest wo) Lung mass, suspected Chest w Lung nodules Chest wo Mediastinal adenopathy Chest w Mediastinal mass Chest w & wo Chest w & wo Sarcoidosis Chest for Interstitial Lung Disease with contrast, High resolution ( Chest w) Cardiac CLINICAL GUIDELINES EXAM DESCRIPTION /A CPT CODES EXAM DESCRIPTION /MRA CPT CODES Aortic dissection Chest w & wo Chest w & wo Cardiac anomalies Chest wo Coronary artery anomalies A Coronary w & wo Include 3 D Coronary artery disease A Coronary w & wo Include 3 D Coronary artery disease + LV/RV cardiac function A Coronary w & wo Include 3 D Pericardial disease Chest w Chest w & wo Pulmonary vein mapping, pre ablation A Heart Morphology 75572
3 Contrast Guidelines for Common /A & /MRA Vascular CLINICAL GUIDELINES EXAM DESCRIPTION /A CPT CODES EXAM DESCRIPTION /MRA CPT CODES Abdominal aortic aneurysm (AAA), suspected Angiography Abdomen & Pelvis MRA Abdomen w or wo Abdominal aortic aneurysm (AAA), known Angiography Abdomen & Pelvis MRA Abdomen w or wo Aortic dissection, Thoracic Angiography Chest MRA Chest w or wo Carotid bruit Angiography Carotid/Neck MRA Neck w & wo 70549* Carotid stenosis/occlusion Angiography Carotid/Neck MRA Neck w & wo 70549* Claudication Angiography Abdomen, Pelvis, Lower Ext w runoff MRA Abdomen w & wo and MRA Lower Ext w & wo & * Cold feet Angiography Abdomen, Pelvis, Lower Ext w runoff MRA Abdomen w & wo and MRA Lower Ext w & wo & * Foot ulcer Angiography Abdomen, Pelvis, Lower Ext w runoff MRA Abdomen w & wo and MRA Lower Ext w & wo & * Hypertension, malignant Angiography Renal (Abdomen) w & wo Contrast MRA Abdomen w or wo Leg edema Angiography Abdomen & Pelvis Peripheral vascular disease legs Angiography Abdomen, Pelvis, Lower Ext w runoff MRA Abdomen w & wo and MRA Lower Ext w & wo & * Pre op or post op stent graft AAA/Endograft Renal artery stenosis Angiography Renal (Abdomen) w & wo Contrast MRA Abdomen w or wo Coronary Artery Disease Angiography Coronary Thoracic aortic aneurysm Angiography Chest MRA Chest w or wo 71555
4 Contrast Guidelines for Common /A & /MRA Neurological Imaging Head and Neck CLINICAL GUIDELINES EXAM DESCRIPTION /A CPT CODES EXAM DESCRIPTION /MRA CPT CODES Abscess Brain w & wo AVM, vascular malformation Brain w & wo and MRA Head w & Breast discharge Brain w & wo (Attention to Pituitary) Cancer staging, Brain Brain w & wo Cancer staging, Neck Soft tissue neck w Orbit, Face, & Neck w & wo Carotid stenosis/occlusion Angiography Carotid/Neck MRA Neck w & wo Sinus congestion/drainage Limited sinus wo Chronic sinusitis Complete sinus wo Change in mental status Brain wo Brain w & wo Brain w & wo and Orbit, Face, Neck w & wo Cranial neuropathy & Dementia Brain wo Dizziness, syncope Brain wo Dizziness, syncope with cancer history Brain w & wo Headache, acute onset Brain wo Brain wo Headache, acute onset with cancer history Brain w & wo Brain w & wo Migraines Brain wo Migraines with cancer history Brain w & wo Headaches, subacute or chronic Brain wo Diplopia Brain w & wo and Orbit, Face, Neck w & wo & Family history intracranial aneurysm Angiography Brain/Head Brain w & wo Fracture facial, orbital Maxillofacial Bones wo Glioma Brain w & wo Hearing loss, conductive Temporal Bones wo Brain w & wo (Attn to Internal Auditory Canal) Hearing loss, sensorineural Hoarseness Soft tissue neck w Intracerebral artery stenosis/occlusion Angiography Brain/Head MRA Brain w Intracranial hemorrhage, acute Brain wo Lyme disease Brain w & wo Mastoiditis Temporal Bones w Meningeal disease Brain w & wo Meningioma Brain w & wo Metastasis Brain w & wo Multiinfarct state Brain w & wo Multiple sclerosis, diagnosed Brain w & wo Multiple sclerosis, suspected Brain w & wo 70553
5 Contrast Guidelines for Common /A & /MRA Head and Neck CLINICAL GUIDELINES EXAM DESCRIPTION /A CPT CODES EXAM DESCRIPTION /MRA CPT CODES Neck lymphadenopathy Soft tissue neck w Orbit, Face, & Neck w & wo Neck mass or cyst Soft tissue neck w Orbit, Face, & Neck w & wo Optic neuritis Brain w & wo and Orbit, Face, Neck w & wo & Parkinson's disease Brain w & wo Pituitary adenoma/microadenoma Pituitary (Brain w & wo) Prolactin, increased Pituitary (Brain w & wo) Salivary gland stone or mass Soft tissue neck w & wo Seizures Brain w & wo Stroke, acute Brain wo Brain w & wo Subarachnoid hemorrhage Brain wo Subdural hematoma Brain wo Brain w & wo TIA Brain wo Brain w & wo Tinnitus (ringing in ears) Temporal bones wo IACs (Brain w & wo) Trauma, acute Brain wo Trauma, subacute or chronic Brain wo Brain w & wo Vertigo IACs (Brain w & wo) Visual disturbance Brain w & wo and Orbit, Face, Neck w & wo & Visual field defect Brain w & wo and Orbit, Face, Neck w & wo & 70543
6 Contrast Guidelines for Common /A & /MRA Spine CLINICAL GUIDELINES EXAM DESCRIPTION /A CPT CODES EXAM DESCRIPTION /MRA CPT CODES Cauda equina lesion Lumbar spine w & wo Cervical rotation, decreased Cervical spine wo Cervical wo Chiari malformation Cervical wo Disc vs scar (epidural fibrosis) Lumbar spine w & wo Discitis, lumbar Lumbar spine w & wo Epidural abscess Lumbar spine w & wo Fracture Cervical, Thoracic or Lumbar spine wo 72125,72128 or Cervical wo, Thoracic wo or Lumbar wo 72141, or Fracture, sacrum or coccyx Pelvis wo Herniated disc Lumbar spine wo Cervical wo, Thoracic wo or Lumbar wo 72141, or Intradural extramedullary lesion Cervical w & wo, Thoracic w & wo or Lumbar w & wo 72156, 72157, or Leg weakness Cervical wo, Thoracic wo or Lumbar wo 72141, or Low back pain Lumbar spine wo Lumbar spine wo Metastasis Cervical w & wo, Thoracic w & wo or Lumbar w & wo 72156, 72157, or Mid back pain *If contraindicated; Thoracic spine and Bone Scan Thoracic spine wo Multiple sclerosis, diagnosed Cervical w & wo, Thoracic w & wo or Lumbar w & wo 72156, 72157, or Multiple sclerosis, suspected Cervical w & wo, Thoracic w & wo or Lumbar w & wo 72156, 72157, or Myelopathy Cervical wo, Thoracic wo or Lumbar wo 72141, or Neck pain Cervical spine wo Cervical spine wo Numbness, leg Lumbar spine wo Lumbar spine wo Numbness, shoulder or arm Cervical spine wo Pain, leg Lumbar spine wo Lumbar spine wo Pain, shoulder or arm Cervical spine wo Prior surgery, cervical Cervical spine wo Prior surgery, lumbar (less than 10 years) Lumbar spine w & wo Prior surgery, lumbar (greater than 10 years) Lumbar spine wo Prior surgery, thoracic (less than 10 years) Thoracic spine w & wo Prior surgery, thoracic (greater than 10 years) Thoracic spine wo Radiculopathy Cervical wo, Thoracic wo or Lumbar wo 72141, or Spinal cord ischemia Cervical w & wo or Thoracic spine w & wo or Spinal cord lesion Cervical w & wo, Thoracic w & wo or Lumbar w & wo 72156, 72157, or Spinal stenosis Cervical wo, Thoracic wo or Lumbar wo 72141, or Syrinx Cervical w & wo, Thoracic w & wo or Lumbar w & wo 72156, 72157, or Transverse myelitis Cervical w & wo, Thoracic w & wo or Lumbar w & wo 72156, 72157, or 72158
7 Contrast Guidelines for Common /A & /MRA Musculoskeletal CLINICAL GUIDELINES EXAM DESCRIPTION /A CPT CODES EXAM DESCRIPTION /MRA CPT CODES Bone contusion, joint Lower Ext JT wo or Upper Ext JT wo (L)73721 or (U)73221 Bone contusion, non joint Lower or Upper Ext other than JT wo (L)73718 or (U)73218 Bursitis Lower Ext JT wo or Upper Ext JT wo (L)73721 or (U)73221 DJD Lower Ext JT wo or Upper Ext JT wo (L)73721 or (U)73221 Fracture, joint Lower or Upper Extremity wo (L)73700 (U)73200 Lower Ext JT wo or Upper Ext JT wo (L)73721 or (U)73221 Fracture, non joint Lower or Upper Extremity wo (L)73700 (U)73200 Lower or Upper Ext other than JT wo (L)73718 or (U)73218 Joint effusion Lower Ext JT wo or Upper Ext JT wo (L)73721 or (U)73221 Labral tear, hip Lower Ext JT wo Labral tear, hip, consider arthrogram if post surgery Lower Ext JT w Labral tear, shoulder Upper Ext JT wo Labral tear, shoulder, consider arthrogram if post Upper Ext JT w surgery Ligamentous tear, wrist, consider arthrogram Upper Ext JT w Meniscal, ligamentous tear knee Lower Ext JT wo Muscle injury, joint Lower Ext JT wo or Upper Ext JT wo (L)73721 or (U)73221 Muscle injury, non joint Lower or Upper Ext other than JT wo (L)73718 or (U)73218 Osteoarthritis Lower Ext JT wo or Upper Ext JT wo (L)73721 or (U)73221 Osteochondral defect, joint Lower Ext JT wo or Upper Ext JT wo (L)73721 or (U)73221 Osteomyelitis, joint Lower or Upper Ext JT w & wo (L)73723 or (U)73223 Osteomyelitis, non joint Lower or Upper Ext other than JT w & wo (L)73720 or (U)73220 Rheumatoid arthritis, Inflammatory arthritis, Lower or Upper Ext JT w & wo (L)73723 or (U)73223 Inflammatory arthropathy, Synovitis Rotator cuff tear Upper Ext JT wo Rotator cuff tear, consider arthrogram if post surgery Upper Ext JT w Soft tissue mass or bony lesion, joint Lower or Upper Extremity w & wo (L)73702 (U)73202 Lower or Upper Ext JT w & wo (L)73723 or (U)73223 Soft tissue mass or bony lesion, non joint Lower or Upper Extremity w & wo (L)73702 (U)73202 Lower or Upper Ext other than JT w & wo (L)73720 or (U)73220 Tendon tear or injury Lower Ext JT wo or Upper Ext JT wo (L)73721 or (U)73221 Triangular fibrocartilage tear (wrist) Upper Ext JT wo 73221
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