Primary Care Physicians: Internal Medicine, Family Practice, Pediatrics 71010, 71020, 71021, 71022, 71030, 71100, 71101, 71110, 72010, 72020, 72040, 72050, 72052, 72070, 72080, 72100, 72110, 72114, 72170, 73000, 73010, 73020, 73030, 73050, 73060, 73070, 73080, 73090, 73092, 73100, 73110, 73120, 73130, 73140, 73500, 73510, 73520, 73540, 73550, 73560, 73562, 73564, 73565, 73590, 73592, 73600, 73610, 73620, 73630, 73650, 74000, 74010, 74020, 74022 Focus on chest x-ray, abdominal x-ray, and long bones Allergy & Immunology 71010, 71020, 71021, 71022, 71030 Focus on chest x-ray Anesthesia 72275, 72285, 72291, 72292, 72295, 77003 Diagnostic and localization tests for pain management Breast Surgeon 77051, 77052, 77053, 77054, 77055, 77056, 77057, 77058, 77059, 76645 Breasts and mammography x-rays Cardiology (Includes Cardiothoracic Surgery and Cardiovascular Disease) 71010, 71020, 71021, 71022, 71030, 76930**, 78414, 78428, 78451, 78452, 78453, 78454, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78494, 78496, 75635,75574, 70498, 71275 Focus on chest x-ray, nuclear cardiology, echocardiology, and x-ray incidental to injections or biopsies. Procedures requiring prior authorization Pediatric Cardiology 71010, 71020, 71030, 76825, 76826, 76827, 76828 Plain films and x-ray incidental to injections and/or biopsy **Approved for hospital setting only 1 of 7
Interventional Cardiology 71090, 75625, 75630, 75650, 75658, 75660, 75662, 75665, 75671, 75676, 75680, 75685, 75710, 75716,75722, 75724, 75726, 75756, 75774, 75896, 75898, 75960, 75962, 75964, 75966, 75968 Peripheral vascular x-rays. Italicized codes are no longer current Chiropractic 72010, 72020, 72040, 72050, 72052, 72069, 72070, 72080, 72090, 72100, 72110, 72114 Spinal x-ray Critical Care Emergency Medicine ** 75790, ** 75894,** 75978, **76937 71010, 71020, 71021, 71022, 71030, 71100, 71101, 71110, 72010, 72020, 72040, 72050, 72052, 72070, 72080, 72100, 72110, 72114, 72170, 73000, 73010, 73020, 73030, 73050, 73060, 73070, 73080, 73090, 73092, 73100, 73110, 73120, 73130, 73140, 73500, 73510, 73520, 73540, 73550, 73560, 73562, 73564, 73565, 73590, 73592, 73600, 73610, 73620, 73630, 73650, 73660, 74000, 74010, 74020, 74022 Angiography, transcatheter procedures, ultrasonic guidance. Italicized code is no longer current Services related to trauma and acute conditions. Endocrinology 76536, 76942, 77080, 77082 Chest and abdominal x-rays, utrasound guidance services, and bone densitometry services. Gastroenterology 76975 Urgent x-rays associated with GI diagnoses. **Approved for hospital setting only 2 of 7
General Dentistry, Dental Facility, Dentistry Endodontics/Periodotics 70300, 70310, 70320, 70350, 70355 All dental x-rays Geriatric Medicine 71010, 71020, 71021, 71022, 71030, 74000, 74010, 74020, 74022 Gynecology Oncology 76700, 76801, 76830, 76856, 76942,76857 Diagnostic of uterus (transabdominal and transvaginal), first trimester ultrasounds, and image guided biopsies. Gynecology Only 74740, 76645, 76700, 76801, 76830, 76831, 76856, 76857, 76942, 76948, 77080, 77081 Diagnostic of uterus (transabdominal and transvaginal) and first trimester ultrasounds, bone densitometry Hand Surgery 73000, 73010, 73020, 73030, 73050, 73060, 73070, 73080, 73090, 73092, 73100, 73110, 73120, 73130, 73140, 77071, 76942, 76881, 76882, Plain films of the upper extremities. Head and Neck Surgery 70371, 76942 X-ray for biopsy **Approved for hospital setting only 3 of 7
Hematology 71100 Infectious Disease 71010, 71020, 71021, 71022, 71030, 74000, 74010, 74020, 74022 Maternal and Fetal Medicine/ Neonatal-Perinatal Medicine 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76815, 76816, 76817, 76818, 76819, 76820, 76821,76825, 76826, 76827, 76828, 76830, 76831, 76856, 76857, 76941, 76942, 76945, 76946, 76948 All obstetric ultrasound and x-ray associated with fertility evaluation Nephrology ***75978, ***75710, ***75791, ***75962 ***payable to a boarded Nephrologist for management of the renal dialysis patients. Neurology 76942, 76881, 76882, Neurosurgery 77001, 77002, 77003, 72040, 76942, 76881, 76882, Fluoroscopic guidance services **Approved for hospital setting only 4 of 7
Obstetrics & Gynecology 74740, 76645, 76700, 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76815, 78616, 76817, 76818, 76819, 76820, 76821, 76830, 76831, 76856, 76857, 76942, 76945, 76946, 76948, 77080, 77081, 76857 All gynecologic and obstetric x-ray, bone densitometry Occupational Medicine 71010, 71020, 71021, 71022, 71030, 74000, 74010, 74020, 74022 Oncology 71100 Ophthalmology 70030, 76510, 76511, 76512, 76513, 76514, 76516, 76519, 76529 Studies of the eye Oral Surgery 70100, 70110, 70140, 70150, 70300, 70310, 70320, 70328, 70330, 70350, 70355 Dental, jaw, and face x-ray services Orthopaedic Surgery 71100, 71101, 71110, 71120, 71130, 72010, 72020, 72040, 72050, 72052, 72069, 72070, 72080, 72090, 72100, 72110, 72114, 72120, 72170, 72190, 72200, 72220, 73000, 73010, 73020, 73030, 73050, 73060, 73070, 73080, 73090, 73092, 73100, 73110, 73120, 73130, 73140, 73500, 73510, 73520, 73540, 73550, 73560, 73562, 73564, 73565, 73590, 73592, 73600, 73610, 73620, 73630, 73650, 73660, 76000, 77001, 77002, 77003, 77071, 77072, 77073, 77074, 77075, 77076,76942, 76881, 76882 Plain films of the bones and fluoroscopic guidance **Approved for hospital setting only 5 of 7
Otolaryngology 70210, 70220, 70371, 76536, 76942 X-ray for biopsy & procedure Pain Medicine 70371, 72275, 72285, 72291, 72292, 72295, 76942, 77001, 77002, 77003, Diagnostic and localization tests for pain management, x-ray for needle guided procedures Physical Medicine & Rehabilitation 77001, 77002, 77003, 70371, 76942, 76881, 76882 X-ray for needle guided procedures Plastic Surgery 76000, 77077 Fluoroscopy, joint survey Podiatric Surgery 73600, 73610, 73620, 73630, 73650, 73660, 77071 Plain film of the feet Podiatry 73600, 73610, 73620, 73630, 73650, 73660, 77071 Plain films of the feet **Approved for hospital setting only 6 of 7
Pulmonary Disease 71010, 71020, 71021, 71022, 71030, 74000, 74010, 74020, 74022 Reproductive Endocrinology 74740, 76645, 76700, 76801, 76802, 76805, 76810, 76811, 76812,76813, 76814, 76815, 76816, 76817, 76818, 76819, 76820, 76821, 76830, 76831, 76856, 76857, 76942, 76945, 76946, 76948 Encompass the services related to endocrine and obstetric/gynecology x-ray, all x-ray guided procedures, and retrievals Rheumatology 71010, 71020, 71021, 71022, 71030, 72202, 74000, 74010, 74020, 74022, 77080, 76942, 76881, 76882, radiologic examination, bone densitometry Surgery 76937, 76942 Guided biopsies Urology 74400, 74410, 74415, 74420, 74425, 74430, 74440, 74445, 74450, 74455, 76870, 76872, 76775, 76873, 76942, 76856 Genital x-ray procedures and biopsy procedures Vascular Surgery 75625**, 75630**, 75650 **, 75658**, 75660 **, 75662 **, 75665 **, 75671**, 75676**, 75680**, 75685**, 75710, 75716**, 75722* *, 75724**, 75726**, 75736**, 75756**, 75774**,75790, 75791**, 75820**, 75827, 75833**, 75894**, 75896**, 75898**, 75940**, 75952**, 75953**, 75960**, 75962, 75964**, 75966**, 75968**, 75978,76937 77001, 77002, 77003 X-rays related to angiography, venography, and other invasive vascular services, fluoroscopic guidance services. Italicized codes are no longer current **Approved for hospital setting only 7 of 7