Horizon NJ Health Pre-Authorization Codes Managed by NIA

Transcription

1 Horizon NJ Health Pre-Authorization Codes Managed by NIA Applicator Insertion Breast (breast surgeon) Applicator Insertion Breast (breast surgeon) Applicator Insertion Breast (breast surgeon) 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 Insertion of pacemaker pulse generator only, with existing single lead Insertion of pacemaker pulse generator only, with existing dual leads Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generation) 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 ) Insertion of pacing electrode, cardiac venous system, for left ventricular pacing at time of insertion of pacing cardioverter-defibrillator or pacemaker pulse generator (including ) Updated 6/ Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator, single lead system Updated 6/ Update

2 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 Updated 6/ Updated 6/ 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 cardioverter-defibrillator pulse generator, single lead system Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverter-defibrillator pulse generator, dual lead system Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverter-defibrillator pulse generator, multiple lead system CABG Vein, Single CABG Vein, Two CABG Vein, Three CABG Vein, Four CABG Vein, Five CABG Vein, Six or more CABG Artery-Vein, Single CABG Artery-Vein, Two CABG Artery-Vein, Three CABG Artery-Vein, Four CABG Artery-Vein, Five CABG Artery-Vein, Six or more CABG Arterial, Single Updated 6/ Updated 6/ Updated 9/ Update

3 33534 CABG Arterial, Two CABG Arterial, Three CABG Arterial, Four or more Ray Eye for Foreign Body Ray Exam of Jaw Ray Exam of Jaw Ray Exam of Mastoids Ray Exam of Mastoids Ray Exam of Middle Ear Ray Exam of Facial Bones Ray Exam of Facial Bones Ray Exam of Nasal Bones Ray Exam of Eye Sockets Ray Exam of Eye Sockets Ray Exam of Sinuses Ray Exam of Sinuses Ray Exam, Pituitary Saddle Ray Exam of Skull Ray Exam of Skull Ray Exam of Teeth Ray Exam of Teeth Full Mouth -Ray of Teeth Ray Exam of Jaw Joint Ray Exam of Jaw Joints MRI Temporomandibular joint(s) Ray Head for Orthodontia Panoramic -Ray of Jaws Ray Exam of Neck Throat -Ray and Fluoroscopy Speech Evaluation, complex Contrast -Ray of Larynx Ray Exam of Salivary Gland CT Brain, Head CT Head or Brain with Contrast CT Head or Brain without/with Contrast CT Orbit, eye socket, sella turcica, posterior fossa, ear, etc CT Orbit, eye socket, sella turcica, posterior fossa, ear with CT Orbit, eye socket, sella turcica, posterior fossa, ear, with/without CT Sinus, face, jaw, mandible, maxillofacial, no Update

4 70487 CT Face, jaw or mandible, maxillofacial, with CT Face, jaw or mandible, maxillofacial, without/with CT Neck soft tissues, larynx, thyroid, etc., no CT Neck soft tissues, larynx, thyroid, etc., with CT Neck soft tissues, larynx, thyroid, etc., without/with CT Angiography, head CT Angiography, Neck MRI Face, neck, orbit MRI Orbit, face, neck with dye MRI Orbit, face, neck without/with dye MR Angiography, head without dye MR Angiography, head with dye MR Angiography, head without/with dye MR Angiography, neck without dye MR Angiography, neck with dye MR Angiography, neck without/with dye MRI Brain, head, brainstem without MRI Head, brain, brainstem with MRI Head, brain, brainstem without/with FMRI Brain by tech FMRI Brain by phys/psych MRI Brain - during open intracranial procedure; w/o dye MRI Brain - during open intracranial procedure; w/ dye MRI Brain - during open intracranial procedure; w/o & w/ dye Chest -Ray Chest -Ray Chest -Ray Chest -Ray Chest -Ray Chest -Ray and Fluoroscopy Chest -Ray Chest -Ray and Fluoroscopy Chest -Ray Ray Exam of Ribs Update

5 Ray Exam of Ribs/Chest Ray Exam of Ribs Ray Exam of Ribs/Chest Ray Exam of Breastbone Ray Exam of Breastbone CT Thorax w/o CT Thorax w/ CT Thorax w/o, followed by & further sections CT angiography, Chest, w/ MRI Chest; w/o MRI Chest; w/ MRI Chest; w/o, w/o, followed by & further sections MRA, MRI Angiography chest [not myocardium] with/without Ray Exam of Spine Ray Exam of Spine Ray Exam of Neck Spine Ray Exam of Neck Spine Ray Exam of Neck Spine Ray Exam of Trunk Spine Ray Exam of Thoracic Spine Ray Exam of Thoracic Spine Ray Exam of Thoracic Spine Ray Exam of Trunk Spine Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); one view Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); 2 or 3 views Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); 4 or 5 views Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); minimum of 6 views Ray Exam of Trunk Spine Update

6 Ray Exam of Lower Spine Ray Exam of Lower Spine Ray Exam of Lower Spine Ray Exam of Lower Spine CT Cervical Spine, neck spine no CT Cervical Spine, neck spine with CT Cervical Spine, neck spine without and with CT Thoracic Spine, upper back no CT Thoracic Spine, upper back with CT Thoracic Spine, upper back without and with CT Lumbar Spine, low back CT Lumbar Spine, low back with CT Lumbar Spine, low back without and with MRI Cervical Spine or Neck Spine without MRI Cervical Spine or Neck Spine with MRI Thoracic Spine Chest Spine Upper Back without MRI Thoracic Spine or Chest Spine or Upper Back with MRI Lumbar Spine or Low Back without MRI Lumbar Spine or Low Back with MRI Cervical Spine Neck Spine without/with MRI Thoracic Spine or Chest Spine without/with MRI Lumbar Spine or Low Back without/with MRA, MRI Angiography Spinal Canal & Contents with/without Ray Exam of Pelvis Ray Exam of Pelvis CT Angiograph Pelvis without & with dye CT Pelvis no CT Pelvis with CT Pelvis without/with MRI Pelvis without dye Update

7 72196 MRI Pelvis MRI Pelvis without & with dye MRA, MRI Pelvis Angiography with/without Ray Exam Sacroiliac Joints Ray Exam Sacroiliac Joints Ray Exam of Tailbone Ray Exam of Collar Bone Ray Exam of Shoulder Blade Ray Exam of Shoulder Ray Exam of Shoulder Ray Exam of Shoulders Ray Exam of Humerus Ray Exam of Elbow Ray Exam of Elbow Ray Exam of Forearm Ray Exam of Arm, Infant Ray Exam of Wrist Ray Exam of Wrist Ray Exam of Hand Ray Exam of Hand Ray Exam of Finger(s) CT Arm or Upper Extremity CT Arm or Upper Extremity with CT Arm or Upper Extremity without and with CT Angio Upper Extremity without & with dye MRI Upper Extremity without dye MRI Upper Extremity with dye MRI Upper Extremity, Entire Extremity, not a joint MRI Joint of Upper Extremity MRI Joint Upper Extremity with dye MRI Joint Upper Extremity without & with dye MRA, MRI Angiography Upper Extremity with/without Ray Exam of Hip Radiologic examination, hip, unilateral, with pelvis when performed; 1 view Radiologic examination, hip, unilateral, with pelvis when performed; 2-3 views Update

8 Radiologic examination, hip, unilateral, with pelvis when performed; minimum of 4 views -Ray Exam of Hip -Ray Exam of Hips Radiologic examination, hips, bilateral, with pelvis when performed; 2 views Radiologic examination, hips, bilateral, with pelvis when performed; 3-4 views Radiologic examination, hips, bilateral, with pelvis when performed; minimum of 5 views Ray Exam of Hip Ray Exam of Pelvis and Hips Ray Exam of Thigh Radiologic examination, femur; 1 view Radiologic examination, femur; min. 2 views Ray Exam of Knee, 1 or Ray Exam of Knee, Ray Exam, Knee, 4 or more Ray Exam of Knees Ray Exam of Lower Leg Ray Exam of Leg, Infant Ray Exam of Ankle Ray Exam of Ankle Ray Exam of Foot Ray Exam of Foot Ray Exam of Heel Ray Exam of Toe(s) CT Leg or Lower Extremity CT Leg or Lower Extremity with CT Leg or Lower Extremity without/with CT Angio Lower Extremity without & with dye MRI Lower Extremity without dye MRI Lower Extremity with dye MRI Leg or Lower Extremity, other than joint Update

9 73721 MRI Joint of Lower Extremity, Hip or Knee or Ankle or Foot Joint MRI Joint of Lower Extremity with dye MRI Joint of Lower Extremity without & with dye MRA, MRI Angiography Lower Extremity with/without Ray Exam of Abdomen Ray Exam of Abdomen Ray Exam of Abdomen Ray Exam Series, Abdomen CT Abdomen without CT Abdomen with CT Abdomen without and with CT Angio Abdomen & Pelvis without & with dye CT Angio Abdomen without & with dye CT Abdomen & Pelvis without CT Abdomen & Pelvis with CT Abdomen & Pelvis 1+ section/regns MRI Abdomen MRI Abdomen with dye MRI Abdomen without & with dye MRA, MRI Angiography Abdomen with/without Contrast -Ray Exam of Throat Contrast -Ray, Esophagus Cine/Vid -Ray, Throat/ Esophagus Remove Esophagus Obstruction Ray Exam, Upper GI Tract Ray Exam, Upper GI Tract Ray Exam, Upper GI Tract Contrast -Ray Upper GI Tract Contrast -Ray Upper GI Tract Contrast -Ray Upper GI Tract Ray Exam of Small Bowel Ray Exam of Small Bowel Computed tomographic (CT) Colonography, Diagnostic, Including Image Postprocessing; without Computed tomographic (CT) Colonography, Diagnostic, Including Image Postprocessing; with Update

10 74263 Computed tomographic (CT) Colonography, Screening, Including Image Postprocessing Contrast -Ray Exam of Colon Contrast -Ray Exam of Colon Contrast -Ray Exam of Colon Contrast -Ray, Gallbladder Rays at Surgery Add-On Contrast -Ray, Urinary Tract Contrast -Ray, Urinary Tract Contrast -Ray, Urinary Tract Contrast -Ray, Bladder Ray Control, Catheter Insert Ray Guide, GU Dilation Ray Measurement of Pelvis Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; single or first gestation 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) Ray Guide, GU Dilation Ray Measurement of Pelvis Cardiac MRI for Morph Cardiac MRI w/stress Img Cardiac MRI for Morph with dye Card MRI w/stress Img & dye Cardiac MRI for Velocity Flow Mapping (List separately in addition to code primary code.) CT, Heart, without material CT, Heart, with material CT, Heart, with and without material Computed Tomographic angiography, heart, coronary arteries and bypass grafts (when present) CT Angio Abdominal Arteries Rays, Transcatheter Therapy Remove CVA Device Obstruct Updated 9/ Update

11 75902 Remove CVA Lumen Obstruct Transcatheter IV Stent RS&I Repair Arterial Blockage Repair Artery Blockage, each Vascular Biopsy Repair Venous Blockage Fluoroscope Examination Fluoroscope Exam, extensive Ray, Nose to Rectum Ray Exam, Breast Specimen Ray Exam of Body Section Complex Body Section -Ray Complex Body Section -Rays Cine/Video -Rays Cine/Video -Rays Add-On Ray Consultation CT Multiplanar Reconstructions D Rendering without Postprocess D Rendering with Postprocess CT Follow-up or Limited Study any area MR Spectroscopy Fluoroscopic Procedure CT Procedure MRI Procedure Radiographic Procedure Echo Exam of Head US Exam of Head and Neck US Exam, Chest 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 US Exam, Abdomen, complete Echo Exam of Abdomen US Exam Abdomen Back Wall, complete US Exam Abdomen Back Wall, limited US Exam K Transpl with Doppler US Exam, Spinal Canal Echo Exam, Uterus Added 9/ Updated 9/ Update

12 76856 Ultrasound Pelvic Non-Obstetric, complete Ultrasound Pelvic, Non-Obstetric, limited or follow-up US Exam, Scrotum US, Transrectal Echograp Trans R, Pros Study Ultrasound, Extremity, Nonvascular, real-time with image documentation, complete Ultrasound, Extremity, Nonvascular, real-time with image documentation, limited US Exam Infant Hips, dynamic US Exam Infant Hips, Static Ultrasonic Guidance for aspiration of Ova Ultrasound Exam Follow-Up GI Endoscopic Ultrasound Ultrasound Bone Density Measurement and Interpretation, peripheral site(s) Echo Examination Procedure Fluoroguide for Vein Device Needle Localization by -Ray Fluoroguide for Spine Inject Computed Tomography Guidance Computer D Mammogram Add-On Comp Screen Mammogram Add-On Ray of Mammary Duct Ray of Mammary Ducts Mammogram, one breast Mammogram, both breasts Mammogram, screening MRI, One Breast MRI, Both Breasts Ray Stress View Rays for Bone Age Rays, Bone Length Studies Rays, Bone Survey, limited Rays, Bone Survey, complete Rays, Bone Survey, infant Joint Survey, single view CT Bone Density, Axial DA Bone Density, Axial Magnetic Image, Bone Marrow Update

13 77085 Dual-energy -ray absorptiometry (DA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine), including vertebral fracture assessment Vertebral fracture assessment via dual-energy ray absorptionmetry (DA) Clinical Treatment Planning - simple Clinical Treatment Planning - intermediate Clinical Treatment Planning - complex Simulation simple Simulation - intermediate Simulation - complex Respiratory motion mgmt. simulation (List in addition to primary procedure code) D - Isodose Plan Dosimetry - Basic Radiation Calculation LMRT - Isodose Plan Teletherapy Isodose Plan simple Teletherapy Isodose Plan complex Brachytherapy Isodose Plan - simple Brachytherapy Isodose Plan intermediate Brachytherapy Isodose Plan - complex Isodose Plan - special Dosimetry - special Treatment Devices - simple Treatment Devices - intermediate Treatment Devices - complex Weekly Physics Consultation MLC Devices for LMRT Special Medical Radiation Physics Consultation Radiation Treatment Delivery SRS Radiation Treatment Delivery SRS Stereotactic Body Radiation Therapy Delivery IMRT simple IMRT complex Guidance for localization of target volume radiation treatment delivery Unlisted Procedure for Physics Dosimetry & Devices Radiation treatment delivery, superficial and/or ortho voltage, per day Update

14 77402 Radiation treatment delivery,=>1 MeV; simple Port Films High Energy Neutron Radiation Treatment Delivery High Energy Neutron Radiation Treatment Delivery Intra-Operative Radiation Treatment Delivery, -ray or electron single treatment session Intra-Operative Radiation Treatment Delivery, -ray or electron single treatment session Radiation Therapy Management, 5 treatments Radiation Therapy Management, 1 or 2 sessions for complete treatment Stereotactic Radiation Treatment Management Stereotactic Body Radiation Therapy Management Intra-Operative Radiation Treatment Management Special Treatment Procedure Management Radiation Therapy Management, unlisted Proton Treatment Delivery Proton Treatment Delivery Proton Treatment Delivery Proton Treatment Delivery Hyperthermia, externally generated Hyperthermia, externally generated Hyperthermia, generated by interstitial probe Hyperthermia, generated by interstitial probe Hyperthermia, generated by intracavitary probe Intracavitary Radiation - simple Intracavitary Radiation - intermediate Intracavitary Radiation - complex Remote afterloading high dose rate radionuclide skin surface brachytherapy; lesion up to 2.0 cm or 1 channel Update

15 Remote afterloading high dose rate radionuclide skin surface brachytherapy; lesion over 2.0 cm and 2 or more channels Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy; 1 channel Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy; 2-12 channels Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy; over 12 channels Interstitial Radiation - simple Interstitial Radiation - intermediate Interstitial Radiation- complex High Dose Rate Brachytherapy Delivery High Dose Rate Brachytherapy Delivery High Dose Rate Brachytherapy Delivery Brachytherapy Surface Application Delivery Supervision Handling Loading Rad Source Unlisted Procedure Clinical Brachytherapy Thyroid Uptake, single or multiple quantitative measurement(s) Thyroid Imaging, including vascular flow, when performed Thyroid Imaging, with single or multi uptake measurement Thyroid Carcinoma/Neoplasm Imaging, neck and chest Thyroid Neoplasm Imaging, with additional studies Thyroid Neoplasm Imaging, multiple areas Thyroid Neoplasm Imaging, whole body Thyroid Carcinoma Metastases Uptake (list separately in addition to code for initial procedure) Parathyroid Scan Update

16 Parathyroid Planar Imaging, with tomographic (SPECT) Parathyroid Planar Imaging, with tomographic (SPECT) and concurrently acquired CT Adrenal Scan or Isotope Imaging Endocrine Nuclear Procedure Bone Marrow, limited area Bone Marrow, multiple areas Bone Marrow, whole body Plasma Volume Nuclear Exam, Plasma Volume RBC or Red Blood Cell Mass or Volume or Survival Study Red Cell Volume Determination, multiple samplings Whole Blood Volume or Plasma, RBC or red blood cell volume Red Cell Survival Exam Differential Organ/Tissue Kinetics (EG, splenic and/or hepatic sequestration) RBC or Red Blood Cell Sequestration Study Plasma Radioiron Disappearance (Turnover) Rate Spleen Imaging Only, with or without vascular flow Kinetics, study of platelet survival, with or without differential organ/tissue Platelet Survival Study White Blood Cell or WBC localization, limited area White Blood Cell or WBC localization, whole body Lymphatics and lymph glands or lymph or lymphatic system Blood/Lymph Nuclear Exam Hepatic or Liver Scan, static only Hepatic or Liver Scan, with vascular flow Hepatic or Liver Scan, SPECT Liver Imaging (SPECT), with vascular flow Hepatic or Liver and Spleen Imaging or Scan, static only Hepatic or Liver and Spleen Imaging or Scan, with vascular flow Update

17 78220 Liver Function with hepatobiliary agents Hepatobiliary, TC HIDA scan - biliary tract, gall bladder Hepatobiliary System Imaging Hepatobiliary System Imaging with drug Salivary Gland Imaging Salivary Gland Imaging, with multiple images Salivary Gland Function Study Esophageal Motility or Esophageal Scan Stomach or Gastric Mucosa or Lining Study Gastro-esophageal Reflux Study Stomach or Gastric Emptying Study Vitamin B-12 Absorption Study or Schilling Test, no intrinsic factor Vitamin B-12 Absorption Study or Schilling Test, with intrinsic factor Vitamin B-12 Absorption Study or Schilling Test, combined without and with Nuclear Exam, GI Blood Loss Nuclear Scan, GI Blood Loss GI Blood Loss Exam GI Protein Loss Exam Nuclear Scan of Bowel Test Venous Drain, abdomen GI Nuclear Procedure Bone Scan and/or Joint Limited Area Bone Scan and/or Joint Multiple Areas Bone or Skeleton Scan, whole body Nuclear Scan of Bone Bone and/or Joint Multiple Areas, tomographic or SPECT Bone Mineral, single photon Bone Density Dual Photon, osteoporosis study Musculoskeletal Nuclear Exam Nuclear Exam of Heart Flow Nuclear Exam, Heart Shunt Vascular Flow Imaging or Isotope Angiography or Isotope Venography Myocardial or Heart Muscle SPECT, Single Thallium SPECT, Myocardial/Heart Update

18 78453 Myocardial or Heart Thallium Perfusion, single study Myocardial or Heart Muscle Perfusion, multiple studies Acute Venous Thrombus Image Venous Thrombosis or Blood Clot Imaging, unilateral Venous Thrombosis or Blood Clot Imaging, bilateral Myocardial Imaging, PET Myocardial or Heart Muscle Imaging Infarct Myocardial or Heart Muscle Ejection Fraction Tomographic SPECT with/without quantitation Cardiac or Heart Blood Pool Imaging MUGA Heart Scan Heart First Pass, single Heart First Pass, multiple Heart Image (PET), single Heart Image (PET), multiple Cardiac Blood Pool Imaging, gated equilibrium, SPECT, at rest, wall motion Cardiac Blood Pool Imaging, gated equilibrium, single study, at rest (List in addition to primary procedure code) Cardiovascular Nuclear Exam Lung Ventilation Imaging Lung Lung Ventilation and Perfusion Imaging Lung Perfusion Lung Perfusion Imaging, rebreathing and washout, with/without single breath Lung Lung Pulmonary Perfusion Imaging, particulate, with ventilation imaging, aerosol Lung Lung Ventilation Imaging, gaseous, with rebreathing and washout, single pro Lung Ventilation Imaging, gaseous, with rebreathing and washout, multiple pro Update

19 78596 Lung Scan Differential Function (Ventilation/Perfusion) Study Lung Perfusion Differential Lung Perfusion and Ventilation Differential Unlisted Respiratory Procedure Nervous System, Brain Nervous System, Brain Nervous System, Brain Brain Scan or Imaging, with vascular flow Brain Scan or Imaging SPECT or tomographic Brain PET [Positron Emission Tomography] Brain PET [Positron Emission Tomography] Perfusion Brain Cerebrospinal Fluid Cerebrospinal Fluid Cerebrospinal Fluid Cerebrospinal Fluid Cerebrospinal Fluid Leakage Detection And Localization Nuclear Exam of eye lesion Tear Flow, 1 Not Nervous System Nuclear Exam Renal or Kidney Imaging, static Renal or Kidney Imaging, with vascular flow Renal or Kidney Imaging, with vascular flow and function study Kidney Flow and Function Image Kidney Flow and Function Image Renal or Kidney Imaging, SPECT Kidney, no pharmaceuticals Kidney, with pharmaceuticals Renal or Kidney Transplant Evaluation Urinary Bladder Residual Study Ureteral Reflux Study Scan of Testes/Blood Flow Genitourinary Nuclear Exam Nuclear Tumor Localization, limited Nuclear Tumor Localization, multiple Nuclear Tumor Localization, whole body Tomographic (SPECT) Update

20 78804 Tumor Imaging, whole body Abscess Localization or Gallium Scan, limited area Abscess Localization or Gallium Scan, whole body Tomographic (SPECT) Tumor Imaging (PET), limited Tumor Image (PET), skull-thigh Tumor Image (PET), full body Tumor Image PET/CT, limited Tumor Image PET/CT, skull-thigh Tumor Image PET/CT, full body Provide Radioisotope(s) Nuclear, Unlisted Exam Initial Hyperthyroid Therapy Nuclear Rx, Oral Admin Nuclear Rx, IV Admin Intracavitary Nuclear Treatment Nuclear Joint Therapy Nuclear Rx, Intra-Arterial Nuclear Medicine Therapy Prq Cardiac Angioplasty, 1 Art Prq Cardiac Angio, Add Art Prq Card Angio/Athrect, 1 Art Prq Card/Angio/Athrect, Add Prq Card Stent with Angio, 1 Vsl Prq Card Stent with Angio, Add Prq Card Stent/Ath/Angio Prq Card Stent/Ath/Angio Prq Revasc Byp Graft, 1 Vsl Prq Revasc Byp Graft, Add Prq Card Revasc Mi, 1 Vsl Prq Card Revasc Chronic, 1 Vsl Prq Card Revasc Chronic, Add Percut Coronary Thrombectomy Echo Transthoracic Echo Transthoracic Echo Transthoracic Echo Exam of Heart Echo Exam of Heart Echo Transesophageal Echo Transesophageal Echo Transesophageal Update

21 93315 Echo Transesophageal Echo Transesophageal Echo Transesophageal Echo Transesophageal Intra-op Doppler Echo Exam, Heart (List in addition to primary procedure code) Doppler Echo Exam, Heart (List in addition to primary procedure code) Doppler Color Flow (List in addition to primary procedure code) Echo Transthoracic Stress Echocardiography including stress ECG Echo Transthoracic (List in addition to primary procedure code) Left Heart Cath with Ventrclgrphy R&L Heart Cath with Ventriclgrphy Coronary Artery Angio S&I Coronary Art/Grft Angio S&I Coronary Art/Grft Angio S&I Coronary Art/Grft Angio S&I L Heart Artery/Ventricle Angio L Heart Art/Grft Angio R&L Heart Art/Ventricle Angio R&L Heart Art/Ventricle Angio L Heart Cath trnsptl puncture Drug Admin and Hemodynmic Meas Exercise with Hemodynamic Meas Inject L Ventr/Atrial Angio Inject R Ventr/Atrial Angio Inject Suprvlv Aortography Inject Pulm Art Heart Cath Carotid Duplex Sonogram Bilateral Unilateral or Limited Study Transcranial Doppler Study of the Intracranial Arteries, complete study Limited study Duplex Scan of Lower Extremity Arteries or Arterial Bypass Grafts, complete bilateral study Limited study Updated 9/ Update

22 93930 Duplex Scan of upper extremity arteries or arterial bypass grafts, complete bilateral study Limited study Duplex Scan of extremity veins, complete bilateral study Unilateral or limited study Duplex Scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal or retroperitoneal organs, complete Limited study Duplex Scan of aorta, IVC, iliac vasculature or bypass grafts, complete study Unilateral or limited Duplex Scan of arterial inflow and venous outflow or penile vessels, complete study Follow-up or limited study Duplex scan of hemodialysis access 0042T CT with Contrast, Cerebral Perfusion Analysis 0159T CAD Breast MRI 0182T High Dose Rate Electronic Brachytherapy 0394T High dose rate electronic brachytherapy, skin surface application, per fraction 0395T High dose rate electronic brachytherapy, interstitial or intracavitary treatment, per fraction 3111F CT/MRI Brain done within 24 hrs 3112F CT/MRI Brain done greater than 24 hrs 3269F Bone Scan B/4 Treatment/After D 3322F Melanoma > AJCC Stage 0 or IA (ML) A9500 Tc99m Sestamibi A9502 Tc99m Tetrofosmin A9503 Tc99m Medronate A9505 TL201 Thallium A9510 Technetium Tc99m Disofenin A9516 Iodine I-123 Sodium Iodide, diagnostic, per 100 microcuries, up to 999 microcuries A9521 Technetiumtc-99m Exametazine A9537 Tc99m Mebrofenin A9540 Tc99m MAA A9547 Indium In-111 Oxyquinoline, diagnostic, per 0.5 millicurie Update

23 A9548 In111 Pentetate A9551 Tc99m Succimer A9552 F18 FDG A9555 RB82 Rubidium A9558 enon e-133 Gas, diagnostic, per 10 millicuries A9561 Tc99m Oxidronate A9562 Tc99m Mertiatide A9567 Technetium TC-99m Aerosol A9584 Iodine I-123 Ioflupane C2613 Lung biopsy plug with delivery system C2616 Brachytherapy source, Nonstranded, Yttrium- 90, per source C8900 MRA with, abdomen C8901 MRA without, abdomen C8902 MRA without/with, abdomen C8903 MRI with, breast, unilateral C8904 MRI without, breast, unilateral C8905 MRI without/with, breast, unilateral C8906 MRI with, breast, bilateral C8907 MRI without, breast, bilateral C8908 MRI without/with, breast, bilateral C8909 MRA with, chest C8910 MRA without, chest C8911 MRA without/with, chest excl myocardium C8912 MRA with, lower extremity C8913 MRA without, lower extremity C8914 MRA without/with, lower extremity C8918 MRA with, pelvis C8919 MRA with, pelvis C8920 MRA without/with, pelvis C8921 TTE with/without fol with cont, com C8922 TTE with/without fol with cont, f/u C8923 2D TTE with/without fol with con, com C8924 2D TTE with/without fol with con, f/u C8925 2D TEE with/without fol with con, in C8926 TEE with/without fol with cont, cong C8927 TEE with/without fol with cont, mon C8928 TTE with/without fol with con stres C8929 TTE with/without fol with con, Doppler C8930 TTE with/without contr, cont ECG Update

24 C8931 MRA with, spinal canal and contents C8932 MRA without, spinal canal and contents C8933 MRA, without followed by with, spinal canal and contents C8934 MRA, with, upper extremity C8935 MRA, without, upper extremity C8936 MRA, without followed by with, upper extremity C9453 Injection, nivolumab, 1 mg C9454 Injection, pasireotide long acting, 1 mg C9455 Injection, siltuximab, 10 mg Percutaneous Transcatheter Placement of C9600 drug-eluting intracoronary stent(s), with coronary angioplasty when performed, single major coronary artery or branch C9601 Percutaneous Transcatheter Placement of drug-eluting intracoronary stent(s), with coronary angioplasty when performed, each additional branch of a major coronary artery (list separately, in addition to code for primary procedure) C9602 Percutaneous Transluminal Coronary Atherectomy, with drug-eluting intracoronary stent, with coronary angioplasty when performed, single major coronary artery or branch C9603 Percutaneous Transluminal Coronary Atherectomy, with drug-eluting intracoronary stent, with coronary angioplasty when performed, each additional branch of a major coronary artery (list separately in addition to code for primary procedure) C9604 Percutaneous Transluminal Revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed, single vessel Update

25 C9605 Percutaneous Transluminal Revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed, each additional branch subtended by the bypass graft (list separately in addition to code for primary procedure) C9606 Percutaneous Transluminal Revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, C9607 single vessel Percutaneous Transluminal Revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty; single vessel C9608 Percutaneous Transluminal Revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft (list separately in addition to code for primary procedure) G0062 G0063 Peripheral Bone Densitometry Central Bone Densitometry G0202 Diagnostic Mammography, producing direct digital image, bilateral, all views Update

26 G0204 Diagnostic Mammography, producing direct digital image, bilateral, all views G0206 Diagnostic Mammography, producing direct digital image, unilateral, all views G0219 PET Imaging Whole Body, melanoma for noncovered indications G0235 PET, not otherwise specified G0252 PET Imaging, initial D G0288 Reconstruction, CTA of aorta for surgical planning for vascular surgery G0290 Drug-eluting Stents, single G0297 Low dose CT scan (LDCT) for lung cancer screening G0339 Stereotactic Body Radiation Therapy Delivery Updated 1/ G0340 G6001 G6002 G6003 G6004 G6005 G6006 G6007 Stereotactic Body Radiation Therapy Delivery Ultrasonic guidance for placement of radiation therapy Stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: up to 5MeV Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 6-10MeV Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 11-19MeV Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 20 MeV or greater Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks; up to 5MeV Update

27 G6008 G6009 G6010 G6011 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks; 6-10MeV Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks; 11-19MeV Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks; 20 MeV or greater Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5MeV G6012 Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 6-10MeV G6013 Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 11-19MeV G6014 G6015 Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 20MeV or greater Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session G6016 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 Update

28 G6017 Q5101 Q9976 Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy(eg,3d positional tracking, gating, 3D surface tracking), each fraction of treatment Injection, filgrastim (G-CSF), biosimilar, 1 microgram Injection, ferric pyrophosphate citrate solution, 0.1 mg of iron Q9977 Compounded drug, not otherwise classified Q9978 Netupitant 300 mg and palonosetron 0.5 mg, oral S8032 Low-dose computed tomography for lung cancer screening S8035 Magnetic Source Imaging S8037 MRCP S8040 Topographic Brain Mapping S8042 MRI Low Field S8085 Fluorine-18 Fluorodeoxyglucose S8092 Electron Beam Computed Tomography Update