Anthem Blue Cross and Blue Shield Virginia Advanced Imaging Procedures Requiring Precertification Revised 02/13/2013 Modality and CT Head CTA Head: Cerebrovascular MRI Head MRA Head: Cerebrovascular Functional MRI (fmri) Code Code Description Head and Neck Imaging 70450 CT head, without contrast 70460 CT head, with contrast 70470 CT head, without contrast followed by re-imaging with contrast 0042T Cerebral perfusion analysis using computed tomography with contrast administration. Including post-processing of parametric maps with determination of cerbral blood flow, cerebral blood volume, and mean transit time 70496 CTA head, with contrast material(s), including noncontrast images, if performed, and image postprocessing 70551 MRI head, without contrast 70552 MRI head, with contrast 70553 MRI head, without contrast, followed by re-imaging with contrast 70544 MRA head, without contrast 70545 MRA head, with contrast 70546 MRA head, without contrast followed by re-imaging with contrast 70554 MRI brain, functional MRI; including test selection and admin of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration 70555 MRI brain, functional MRI; including test selection and admin of repetitive body part movement and/or visual stimulation, requiring physician or psychologist administration of entire neurofunctional testing PET Brain Imaging 78608 PET brain, metabolic evaluation 78609 PET brain, perfusion evaluation Magnetic Source 95965 MEG recording and analysis; for spontaneous brain magnetic activity Imaging and 95966 MEG recording and analysis; for evoked magnetic fields, single modality Magnetoencephal- 95967 MEG recording and analysis; for evoked magnetic fields, each additional modality ography -- S8035 Magnetic Source Imaging MEG CT Orbit, Sella Turcica, Posterior Fossa, Temporal Bone, including MRI Orbit, Face and Neck (Soft Tissues) CT Paranasal Sinus and Maxillofacial Area MRI TMJ 70336 MRI temporomandibular joint(s) 70490 CT soft tissue neck, without contrast CT Neck for Soft 70491 CT soft tissue neck, with contrast Tissue Evaluation 70492 CT soft tissue neck, without contrast followed by re-imaging with contrast 70480 CT orbit, sella or posterior fossa and outer, middle or inner ear, without contrast 70481 CT orbit, sella or posterior fossa and outer, middle or inner ear, with contrast 70482 CT orbit, sella or posterior fossa and outer, middle or inner ear, without contrast, followed by reimaging with contrast 70540 MRI orbit, face and neck, without contrast 70542 MRI orbit, face and neck, with contrast 70543 MRI orbit, face and neck, without contrast followed by re-imaging with contrast 70486 CT maxillofacial areak, without contrast 70487 CT maxillofacial area, with contrast 70488 CT maxillofacial area, without contrast followed by re-imaging with contrast CTA Neck 70498 CTA neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing 70547 MRA neck, without contrast MRA Neck 70548 MRA neck, with contrast 70549 MRA neck, without contrast followed by re-imaging with contrast SPECT 78071 Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT) 78072 Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT) and concurrently acquired computed tomography (CT) for anatomical localization Chest Imaging 71250 CT chest, without contrast CT Chest 71260 CT chest, with contrast Page 1 of 6
CT Chest CTA Chest MRI Chest Code Code Description 71270 CT chest, without contrast followed by re-imaging with contrast S8092 Electron beam CT (also known as ultrafast CT, cine CT) 71275 CTA chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image post-processing 71550 MRI chest, without contrast 71551 MRI chest, with contrast 71552 MRI chest, without contrast followed by re-imaging with contrast MRA Chest 71555 MRA chest (excluding myocardium), without contrast, followed by re-imaing with contrast 77058 MRI breast, without and/or with contrast material(s); unilateral 77059 MRI breast, without and/or with contrast material(s); bilateral C8903 MRI breast, unilateral with contrast MRI Breast C8904 MRI breast, unilateral without contrast C8905 MRI breast, unilateral without contrast followed by with contrast C8906 MRI breast, bilateral with contrast C8907 MRI breast, bilateral without contrast C8908 MRI breast, bilateral without contrast followed by with contrast Other S8080 Scintimammography, unilateral (including supply of radiopharmaceutical) Cardiac Imaging Nuclear Cardiology Myocardial Perfusion Imaging 78451 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed; single study at rest or stress (exercise or pharmacologic). 78452 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection. 78453 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). 78454 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. 78472 Gated equilibrium; planar, single study, at rest or stress, wall motion plus ejection fraction 78473 Gated equilibrium; planar, multiple studies, wall motion study plus ejection fraction, at rest and stress Nuclear Cardiology Cardiac Blood Pool Imaging Includes MUGA (Multi-Gated Acquisition) and First Pass Radionuclide Ventriculography Nuclear Cardiology Infarct Imaging Stress Echocardiography (SE) 78481 First pass technique; single study, wall motion study plus ejection fraction, at rest or with stress 78483 First pass technique; multiple studies, at rest and with stress, wall motion study plus ejection fraction 78494 Gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction 78496 This code is an add-on code to be used in conjunction with 78472. As such, this code does not require separate review. Gated equilibrium, single study, at rest, with right ventricular ejection fraction by first pass technique. 78466 Planar, infarct avid; qualitative or quantitative 78468 Planar, infarct avid; with ejection fraction by first pass technique 78469 SPECT, infarct avid; with or without quantification 93350 Echocardiography, transthoracic during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report 93351 Echocardiography, transthoracic 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 93320 This code is an add-on code to be used in conjunction with 93350 and 93351. As such, this code 93321 This code is an add-on code to be used in conjunction with 93350 and 93351. As such, this code 93325 This code is an add-on code to be used in conjunction with 93350 and 93351. As such, this code 93352 This code is an add-on code to be used in conjunction with 93350 and 93351. As such, this code 93312 TEE real-time with image documentation (2-D) (with or without M-mode recording) 93313 Placement of transesophageal probe only 93314 Image acquisition, interpretation and report only Page 2 of 6
Transesophageal Echocardiography (TEE) Transthoracic Echocardiography (TTE) CT Cardiac (Structure) CT Angiography Coronary Arteries (CCTA) Cardiac CT for Quantitative Evaluation of Cornoary Calcification MRI Cardiac PET Myocardial Imaging Other Cardiac CT Abdomen MRI Abdomen Code Code Description 93315 TEE for congenital cardiac anomalies 93316 Placement of transesophageal probe only 93317 Image acquisition, interpretation and report only 93320 This code is an add-on code to be used in conjunction with 93350 and 93351. As such, this code 93321 This code is an add-on code to be used in conjunction with 93350 and 93351. As such, this code 93325 This code is an add-on code to be used in conjunction with 93350 and 93351. As such, this code 93303 Transthoracic echocardiography for congenital cardiac anomalies; complete 93304 Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study 93306 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 93307 Transthoracic echocardiography; complete, without spectral Doppler echocardiography, or color flow Doppler echocardiography 93308 Transthoracic echocardiography; complete, without spectral Doppler echocardiography, or color flow Doppler echocardiography follow-up or limited study 93320 This code is an add-on code to be used in conjunction with 93350 and 93351. As such, this code 93321 This code is an add-on code to be used in conjunction with 93350 and 93351. As such, this code 93325 This code is an add-on code to be used in conjunction with 93350 and 93351. As such, this code CT, heart, with contrast material, for evaulation of cardiac structure and morphology (including 3-D 75572 post processing, assessment of cardiac function, and evaluation of venous structures if performed) 75573 CT, heart, with contrast material, for evaulation of cardiac structure and morphology in the setting of congenital heart disease (including 3-D post processing, assessment of left ventricular cardiac function, right ventricular structure and function and evaluation of venous structures, if performed) 75574 CT angiography, heart, coronary arteries and any coronary bypass grafts (where present), with contrast material, including 3-D image post processing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed) 75571 CT, heart, without contrast material, with quantitative evaluation of coronary artery calcium 75557 Cardiac MRI for morphology and function, without contrast material 75559 Cardiac MRI for morphology and function, without contrast material, with stress imaging 75561 Cardiac MRI for morphology and function, without contrast material, followed by contrast material 75563 Cardiac MRI for morphology and function, without contrast material, followed by contrast material with stress imaging 75565 This is an add-on code to be used in conjunction with 75557, 75559, 75561 and 75563. As such, this code 78491 PET myocardial perfusion, single study 78492 PET myocardial perfusion, multiple studies 78459 PET myocardial, metabolic evaluation Intravascular optical coherence tomography (coronary native vessel or graft) during diagnostic 0291T evaluation and/or therapeutic intervention, including imaging supervision, interpretation, and report; initial vessel Intravascular optical coherence tomography (coronary native vessel or graft) during diagnostic evaluation and/or therapeutic intervention, including imaging supervision, interpretation, and report; 0292T each additional vessel Intravascular catheter-based coronary vessel or graft spectroscopy (e.g. infared) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report, 0205T each vessel (add -on) Abdominal and Pelvic Imaging 74150 CT abdomen, without contrast 74160 CT abdomen, with contrast 74170 CT abdomen, without contrast, followed by re-imaging with contrast 74181 MRI abdomen; without contrast (See also S8037) Page 3 of 6
Code Code Description MRI Abdomen 74182 MRI abdomen; with contrast 74183 MRI abdomen; without contrast, followed by re-imaging with contrast CTA Abdomen 74175 CTA, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing MRA Abdomen 74185 MRA abdomen, without or with contrast CTA of the Abdominal Aorta - Lower 75635 Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including noncontrast images, if performed, and image postprocessing (See also 74174) Run-Off 72192 CT pelvis, without contrast CT Pelvis 72193 CT pelvis, with contrast 72194 CT pelvis without contrast, followed by re-imaging with contrast 72195 MRI pelvis, without contrast MRI Pelvis 72196 MRI pelvis, with contrast 72197 MRI pelvis, without contrast, followed by re-imaging with contrast CTA Pelvis 72191 CTA, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing MRA Pelvis 72198 MRA, pelvis, without contrast, followed by re-imaging with contrast 74176 CT, abdomen and pelvis, without contrast CT Abdomen and 74177 CT, abdomen and pelvis, with contrast Pelvis 74178 CT, abdomen and pelvis, without contrast in one or both body regions, followed by re-imaging with Combination contrast material(s) in one or both body regions CTA Abdomen and Pelvis Combination 74174 CTA, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing 74263 Screening CT colonography including image postprocessing CT Colonography 74261 Diagnostic CT colonography without contrast 74262 Diagnostic CT colonography with contrast including non-contrast images if performed MRCP S8037 Magnetic Resonance Cholangiopancreatography (MRCP) (See also 74181) CT Cervical Spine MRI Cervical Spine CT Thoracic Spine MRI Thoracic Spine CT Lumbar Spine MRI Lumbar Spine Spine Imaging 72125 CT cervical spine, without contrast 72126 CT cervical spine, with contrast 72127 CT cervical spine, without contrast, followed by re-imaging with contrast 72141 MRI cervical spine, without contrast 72142 MRI cervical spine, with contrast 72156 MRI cervical spine, without contrast, followed by re-imaging with contrast 72128 CT thoracic spine, without contrast 72129 CT thoracic spine, with contrast 72130 CT thoracic spine, without contrast, followed by re-imaging with contrast 72146 MRI thoracic spine, without contrast 72147 MRI thoracic spine, with contrast 72157 MRI thoracic spine, without contrast, followed by re-imaging with contrast 72131 CT lumbar spine, without contrast 72132 CT lumbar spine, with contrast 72133 CT lumbar spine, without contrast, followed by re-imaging with contrast 72148 MRI lumbar spine, without contrast 72149 MRI lumbar spine, with contrast 72158 MRI lumbar spine, without contrast, followed by re-imaging with contrast MRA Spinal Canal 72159 MRA spinal canal C8931 Magnetic resonance angiography with contrast, spinal canal and contents C8932 Magnetic resonance angiography without contrast, spinal canal and contents C8933 Magnetic resonance angiography without contrast followed by contrast, spinal canal and contents Discogram 72285 Cervical-Thoracic Discogram Upper Imaging CT Upper MRI Upper (Any Joint) MRI Upper (Non- 73200 CT upper extremity, without contrast 73201 CT upper extremity, with contrast 73202 CT upper extremity, without contrast, followed by re-imaging with contrast 73221 MRI upper extremity, any joint, without contrast 73222 MRI upper extremity, any joint, with contrast 73223 MRI upper extremity, any joint, without contrast, followed by re-imaging with contrast 73218 MRI upper extremity, other than joint, without contrast Page 4 of 6
Code Code Description (Non- 73219 MRI upper extremity, other than joint, with contrast Joint) 73220 MRI upper extremity, other than joint, without contrast, followed by re-imaging with contrast CTA, upper extremity, with contrast material(s), including noncontrast images, if performed, and 73206 image postprocessing CTA/MRA Upper MRA, upper extremity, without and with contrast (Note: Upper MRA is not currently a covered benefit by the Centers for Medicare and Medicaid Services, through a National Coverage 73225 Determination) Lower Imaging 73700 CT, lower extremity, without contrast CT Lower 73701 CT, lower extremity, with contrast 73702 CT, lower extremity, without contrast, followed by re-imaging with contrast 73718 MRI, lower extremity, other than joint, without contrast 73719 MRI, lower extremity, other than joint, with contrast MRI Lower 73720 MRI, lower extremity, other than joint, without contrast followed by re-imaging with contrast (Joint 73721 MRI, lower extremity, any joint, without contrast and Non-Joint) 73722 MRI,lower extremity, any joint, with contrast 73723 MRI, lower extremity, any joint, without contrast followed by re-imaging with contrast CTA Lower 73706 CTA, lower extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing MRA Lower 73725 MRA, lower extremity, without contrast followed by re-imaging with contrast PET - Other Applications, Including Oncologic Tumor Imaging 78811 PET imaging, limited area 78812 PET imaging, skull to mid-thigh Dedicated PET 78813 PET imaging, whole body Imaging G0219 PET imaging whole body; melanoma for non covered indications G0235 PET imaging, any site, not otherwise specified G0252 PET imaging, full and partial-ring PET scanners only, for initial A9586 Florbetapir F 18, diagnostic, per study dose, up to 10 millicuries (AMYViD) 78814 PET imaging, with concurrently acquired CT for attenuation correction and anatomic localization; limited area PET/CT Imaging 78815 PET imaging, with concurrently acquired CT for attenuation correction and anatomic localization; skull base to mid-thigh 78816 PET imaging, with concurrently acquired CT for attenuation correction and anatomic localization; whole body Other MRS 76390 Magnetic Resonance Spectroscopy (MRS) MRI - Bone Marrow Blood Supply 77084 MRI bone marrow blood supply SPECT for Non- Cardiovascular Indications Other CT Other MRI Other 78205 Liver imaging, SPECT 78206 Liver imaging with vascular flow, SPECT 78320 Bone and/or joint imaging; tomographic SPECT 78607 Brain imaging, tomographic (SPECT) 78647 Cerebrospinal fluid flow, tomographic (SPECT) 78710 Kidney imaging morphology; tomographic (SPECT) 78803 Radiopharmaceutical localization of tumor; tomographic SPECT 78807 Radiopharmaceutical localization of inflammatory process tomographic SPECT A9507 Indium In-111 capromab pendetide, diagnostic, per study dose, up to 10 millicuries [Prostascint] 76380 CT, limited or localized follow up study 76497 Unlisted CT 76498 Unlisted MRI S8042 MRI, low field 76499 Unlisted diagnostic radiographic procedure 78999 Unlisted miscellaneous procedure, diagnostic nuclear medicine 78699 Unlisted nervous system procedure, diagnostic nuclear medicine (when specified as SPECT/ SISCOM for the preoperative evaluation of individuals with intractable focal epliepsy S8085 Fluorine-18 fluorodeoxyglucose (F-18 FDG) imaging using dual-head coincidence detection system (non dedicated PET scan) A9584 (SPECT) Iodine I -123 ioflupane, diagnostic, per study dose, up to 5 millicuries (DaT scan) 340 Nuclear Medicine - General Page 5 of 6
Revenue Codes Post-Service Review of 3D Rendered Images Code Code Description 341 Nuclear Medicine - Diagnostic 349 Nuclear Medicine - Other 350 CT Scan - General 351 CT Scan - Head Scan 352 CT Scan - Body Scan 359 CT Scan - Other 404 Other Imaging - PET 610 Magnetic Resonance Technology - General Classification 611 Magnetic Resonance Technology MRI - Brain 612 Magnetic Resonance Technology MRI - Spinal Cord 614 Magnetic Resonance Technology MRI - Other 615 Magnetic Resonance Technology MRA - Head and Neck 616 Magnetic Resonance Technology MRA - Lower Extremities 618 Magnetic Resonance Technology MRA - Other 619 Magnetic Resonance Imaging - Other 3D rendering with interpretation and reporting of CT, MRI, ultrasound, or other tomographic modality; 76376 not requiring image postprocessing on an independent workstation. This code is used in conjunction with code(s) for base imaging procedure(s). 3D rendering with interpretation and reporting of CT, MRI, ultrasound, or other tomographic modality; requiring image postprocessing on an independent workstation. This code is used in conjunction with 76377 code(s) for base imaging procedure(s). Page 6 of 6