Page 1 PRE-ORIZATION S MANAGED BY 77080 DA Bone Density, Axial 77082 DA Bone Density, Vert F 70370 Throat -Ray and Fluoroscopy 70373 Contrast -Ray of Larynx 72291 Perq Verte/Sacroplsty, Fluor 72292 Perq Verte/Sacroplsty, CT 74210 Contrast -Ray Exam of Throat 74220 Contrast -Ray, Esophagus 74230 Cine/Vid -Ray, Throat/ Esophagus 74235 Remove Esophagus Obstruction 74240 -Ray Exam, Upper GI Tract 74241 -Ray Exam, Upper GI Tract 74245 -Ray Exam, Upper GI Tract 74246 Contrast -Ray Upper GI Tract 74247 Contrast -Ray Upper GI Tract 74249 Contrast -Ray Upper GI Tract 74250 -Ray Exam of Small Bowel 74260 -Ray Exam of Small Bowel 74270 Contrast -Ray Exam of Colon 74280 Contrast -Ray Exam of Colon 74283 Contrast -Ray Exam of Colon 74430 Contrast -Ray, Bladder 74480 -Ray Control, Catheter Insert 74485 -Ray Guide, GU Dilation 75894 -Rays, Transcatheter Therapy 75901 Remove CVA Device Obstruct 75902 Remove CVA Lumen Obstruct 75960 Transcatheter IV Stent RS&I 75966 Repair Arterial Blockage 75968 Repair Artery Blockage, each 75970 Vascular Biopsy 75978 Repair Venous Blockage 76000 Fluoroscope Examination 76001 Fluoroscope Exam, extensive 76120 Cine/Video -Rays 76496 Fluoroscopic Procedure 76496 Fluoroscopic Procedure 77001 Fluoroguide for Vein Device 77002 Needle Localization by -Ray 77003 Fluoroguide for Spine Inject 77051 Computer D Mammogram Add-On 77052 Comp Screen Mammogram Add-On PRE-ORIZATION S MANAGED BY 77055 Mammogram, one breast 77056 Mammogram, both breasts 77057 Mammogram, screening G0202 Diagnostic Mammography, producing direct digital image, bilateral, all views G0204 Diagnostic Mammography, producing direct digital image, bilateral, all views G0206 Diagnostic Mammography, producing direct digital image, unilateral, all views 70030 -Ray Eye for Foreign Body 70100 -Ray Exam of Jaw 70110 -Ray Exam of Jaw 70120 -Ray Exam of Mastoids 70130 -Ray Exam of Mastoids 70134 -Ray Exam of Middle Ear 70140 -Ray Exam of Facial Bones 70150 -Ray Exam of Facial Bones 70160 -Ray Exam of Nasal Bones 70190 -Ray Exam of Eye Sockets 70200 -Ray Exam of Eye Sockets 70210 -Ray Exam of Sinuses 70220 -Ray Exam of Sinuses 70240 -Ray Exam, Pituitary Saddle 70250 -Ray Exam of Skull 70260 -Ray Exam of Skull 70300 -Ray Exam of Teeth 70310 -Ray Exam of Teeth 70320 Full Mouth -Ray of Teeth 70328 -Ray Exam of Jaw Joint 70330 -Ray Exam of Jaw Joints 70350 -Ray Head for Orthodontia 70355 Panoramic -Ray of Jaws 70360 -Ray Exam of Neck 70371 Speech Evaluation, complex 70380 -Ray Exam of Salivary Gland 71010 Chest -Ray 71015 Chest -Ray 71020 Chest -Ray 71021 Chest -Ray 71022 Chest -Ray 71023 Chest -Ray and Fluoroscopy 71030 Chest -Ray 71034 Chest -Ray and Fluoroscopy 71035 Chest -Ray
Page 2 PRE-ORIZATION S MANAGED BY 71100 -Ray Exam of Ribs 71101 -Ray Exam of Ribs/Chest 71110 -Ray Exam of Ribs 71111 -Ray Exam of Ribs/Chest 71120 -Ray Exam of Breastbone 71130 -Ray Exam of Breastbone 72010 -Ray Exam of Spine 72020 -Ray Exam of Spine 72040 -Ray Exam of Neck Spine 72050 -Ray Exam of Neck Spine 72052 -Ray Exam of Neck Spine 72069 -Ray Exam of Trunk Spine 72070 -Ray Exam of Thoracic Spine 72072 -Ray Exam of Thoracic Spine 72074 -Ray Exam of Thoracic Spine 72080 -Ray Exam of Trunk Spine 72090 -Ray Exam of Trunk Spine 72100 -Ray Exam of Lower Spine 72110 -Ray Exam of Lower Spine 72114 -Ray Exam of Lower Spine 72120 -Ray Exam of Lower Spine 72170 -Ray Exam of Pelvis 72190 -Ray Exam of Pelvis 72200 -Ray Exam Sacroiliac Joints 72202 -Ray Exam Sacroiliac Joints 72220 -Ray Exam of Tailbone 73000 -Ray Exam of Collar Bone 73010 -Ray Exam of Shoulder Blade 73020 -Ray Exam of Shoulder 73030 -Ray Exam of Shoulder 73050 -Ray Exam of Shoulders 73060 -Ray Exam of Humerus 73070 -Ray Exam of Elbow 73080 -Ray Exam of Elbow 73090 -Ray Exam of Forearm 73092 -Ray Exam of Arm, Infant 73100 -Ray Exam of Wrist 73110 -Ray Exam of Wrist 73120 -Ray Exam of Hand 73130 -Ray Exam of Hand 73140 -Ray Exam of Finger(s) 73500 -Ray Exam of Hip PRE-ORIZATION S MANAGED BY 73510 -Ray Exam of Hip 73520 -Ray Exam of Hips 73530 -Ray Exam of Hip 73540 -Ray Exam of Pelvis and Hips 73550 -Ray Exam of Thigh 73560 -Ray Exam of Knee, 1 or 2 73562 -Ray Exam of Knee, 3 73564 -Ray Exam, Knee, 4 or more 73565 -Ray Exam of Knees 73590 -Ray Exam of Lower Leg 73592 -Ray Exam of Leg, Infant 73600 -Ray Exam of Ankle 73610 -Ray Exam of Ankle 73620 -Ray Exam of Foot 73630 -Ray Exam of Foot 73650 -Ray Exam of Heel 73660 -Ray Exam of Toe(s) 74000 -Ray Exam of Abdomen 74010 -Ray Exam of Abdomen 74020 -Ray Exam of Abdomen 74022 -Ray Exam Series, Abdomen 74290 Contrast -Ray, Gallbladder 74291 Contrast -Rays, Gallbladder 74301 -Rays at Surgery Add-On 74400 Contrast -Ray, Urinary Tract 74410 Contrast -Ray, Urinary Tract 74415 Contrast -Ray, Urinary Tract 74710 -Ray Measurement of Pelvis 76010 -Ray, Nose to Rectum 76098 -Ray Exam, Breast Specimen 76100 -Ray Exam of Body Section 76101 Complex Body Section -Ray 76102 Complex Body Section -Rays 76125 Cine/Video -Rays Add-On 76140 -Ray Consultation 76499 Radiographic Procedure 77031 Stereotactic Guide for Breast B 77032 Guidance For Needle, Breast 77053 -Ray of Mammary Duct 77054 -Ray of Mammary Ducts 77071 -Ray Stress View 77072 -Rays for Bone Age
Page 3 PRE-ORIZATION S MANAGED BY 77073 -Rays, Bone Length Studies 77074 -Rays, Bone Survey, limited 77075 -Rays, Bone Survey, complete 77076 -Rays, Bone Survey, infant 77077 Joint Survey, single view 76506 Echo Exam of Head 76604 US Exam, Chest 76776 US Exam K Transpl with Doppler 76800 US Exam, Spinal Canal 76831 Echo Exam, Uterus 76872 US, Transrectal 76873 Echograp Trans R, Pros Study 76881 76882 Ultrasound, Extremity, Nonvascular, real-time with image documentation, complete Ultrasound, Extremity, Nonvascular, real-time with image documentation, limited 76885 US Exam Infant Hips, Dynamic 76886 US Exam Infant Hips, Static 76970 Ultrasound Exam Follow-Up 76975 GI Endoscopic Ultrasound 76999 Echo Examination Procedure 93880 Carotid Duplex Sonogram Bilateral 93882 Unilateral or Limited Study 93886 Transcranial Doppler Study of the intracranial arteries, complete study 93888 Limited study 93925 Duplex Scan of lower extremity arteries or arterial bypass grafts, complete bilateral study 93926 Limited study 93930 Duplex Scan of upper extremity arteries or arterial bypass grafts, complete bilateral study 93931 Limited study 93970 Duplex Scan of extremity veins, complete bilateral study 93971 Unilateral or limited study 93975 Duplex Scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal or retroperitoneal organs, complete 93976 Limited study 93978 Duplex Scan of aorta, IVC, iliac vasculature or bypass grafts, complete study 93979 Unilateral or limited PRE-ORIZATION S MANAGED BY 93980 Duplex Scan of arterial inflow and venous outflow or penile vessels, complete study 93981 Follow-up or limited study 76536 US Exam of Head and Neck 76700 US Exam, Abdomen, complete 76705 Echo Exam of Abdomen 76770 US Exam Abdomen Back Wall, complete 76775 US Exam Abdomen Back Wall, limited 76856 Ultrasound Pelvic Non-Obstetric, complete 76857 Ultrasound Pelvic, Non-Obstetric, limited or follow-up 76870 US Exam, Scrotum 75574 Computed Tomographic angiography, heart, coronary arteries and bypass grafts (when present) 93303 Echo Transthoracic 93304 Echo Transthoracic 93306 Echo Transthoracic 93307 Echo Exam of Heart 93308 Echo Exam of Heart 93312 Echo Transesophageal 93313 Echo Transesophageal 93314 Echo Transesophageal 93315 Echo Transesophageal 93316 Echo Transesophageal 93317 Echo Transesophageal 93318 Echo Transesophageal Intra-op 93320 Doppler Echo Exam, Heart 93321 Doppler Echo Exam, Heart 93325 Doppler Color Flow 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 C8929 TTE with/without fol with con, Doppler 93350 Echo Transthoracic 93351 Stress Echocardiography including stress ECG 93352 Echo Transthoracic C8928 TTE with/without fol with con stres
Page 4 PRE-ORIZATION S MANAGED BY C8930 TTE with/without contr, cont ECG 78414 Nuclear Exam of Heart Flow 78428 Nuclear Exam, Heart Shunt 78466 Myocardial or Heart Muscle Imaging Infarct 78468 Myocardial or Heart Muscle Ejection Fraction 78469 Tomographic SPECT with/without quantitation 78472 Cardiac or Heart Blood Pool Imaging 78473 MUGA Heart Scan 78481 Heart First Pass, single 78483 Heart First Pass, multiple 78494 78496 Cardiac Blood Pool Imaging, gated equilibrium, SPECT, at rest, wall motion Cardiac Blood Pool Imaging, gated equilibrium, single study, at rest, with 78499 Cardiovascular Nuclear Exam 78990 Provide Radioisotope(s) 78451 Myocardial or Heart Muscle SPECT, Single 78452 Thallium SPECT, Myocardial/Heart 78453 Myocardial or Heart Thallium Perfusion, single study 78454 Myocardial or Heart Muscle Perfusion, multiple studies A9500 Tc99m Sestamibi A9502 Tc99m Tetrofosmin A9505 TL201 Thallium 33510 CABG Vein, Single 33511 CABG Vein, Two 33512 CABG Vein, Three 33513 CABG Vein, Four 33514 CABG Vein, Five 33516 CABG Vein, Six or more 33517 CABG Artery-Vein, Single 33518 CABG Artery-Vein, Two 33519 CABG Artery-Vein, Three 33521 CABG Artery-Vein, Four 33522 CABG Artery-Vein, Five 33523 CABG Artery-Vein, Six or more 33533 CABG Arterial, Single 33534 CABG Arterial, Two 33535 CABG Arterial, Three 33536 CABG Arterial, Four or more 93452 Left Heart Cath with Ventrclgrphy PRE-ORIZATION S MANAGED BY 93453 R&L Heart Cath with Ventriclgrphy 93454 Coronary Artery Angio S&I 93455 Coronary Art/Grft Angio S&I 93456 Coronary Art/Grft Angio S&I 93457 Coronary Art/Grft Angio S&I 93458 L Heart Artery/Ventricle Angio 93459 L Heart Art/Grft Angio 93460 R&L Heart Art/Ventricle Angio 93461 R&L Heart Art/Ventricle Angio 33221 Insertion of pacemaker pulse generator only, with existing multiple leads 33224 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator (including ) 33225 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing at time of insertion of pacing cardioverter-defibrillator or pacemaker pulse generator (including ) 33229 Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator, multiple lead system 33231 Insertion of pacing cardioverterdefibrillator pulse generator only, with existing multiple leads 33264 Removal of pacing cardioverterdefibrillator pulse generator with replacement of pacing cardioverterdefibrillator pulse generator, multiple lead system 33230 Insertion of pacing cardioverterdefibrillator pulse generator only, with existing dual leads 33240 Insertion of pacing cardioverterdefibrillator pulse generator only, with existing single lead 33249 Insertion or replacement of permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber 33262 Removal of pacing cardioverterdefibrillator pulse generator with replacement of pacing cardioverterdefibrillator pulse generator, single lead system 33263 Removal of pacing cardioverterdefibrillator pulse generator with replacement of pacing cardioverterdefibrillator pulse generator, dual lead system 33206 Insertion of new or replacement of permanent pacemaker with transvenous electrode(s), atrial
Page 5 PRE-ORIZATION S MANAGED BY 33207 33208 33212 33213 33214 33227 33228 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) 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 93565 Inject L Ventr/Atrial Angio 93566 Inject R Ventr/Atrial Angio 93567 Inject Suprvlv Aortography 93568 Inject Pulm Art Heart Cath 92920 Prq Cardiac Angioplasty, 1 Art 92921 Prq Cardiac Angio, Add Art 92924 Prq Card Angio/Athrect, 1 Art 92925 Prq Card/Angio/Athrect, Add 92928 Prq Card Stent with Angio, 1 Vsl 92929 Prq Card Stent with Angio, Add 92933 Prq Card Stent/Ath/Angio 92934 Prq Card Stent/Ath/Angio 92937 Prq Revasc Byp Graft, 1 Vsl 92938 Prq Revasc Byp Graft, Add 92941 Prq Card Revasc Mi, 1 Vsl 92943 Prq Card Revasc Chronic, 1 Vsl 92944 Prq Card Revasc Chronic, Add 92973 Percut Coronary Thrombectomy C9600 Percutaneous Transcatheter Placement of drug-eluting intracoronary stent(s), with coronary angioplasty when performed, single major coronary artery or branch PRE-ORIZATION S MANAGED BY C9601 C9602 C9603 C9604 C9605 C9606 C9607 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) Percutaneous Transluminal Coronary Atherectomy, with drug-eluting intracoronary stent, with coronary angioplasty when performed, single major coronary artery or branch 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) 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 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) 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, single vessel Percutaneous Transluminal Revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drugeluting intracoronary stent, atherectomy and angioplasty; single vessel
Page 6 PRE-ORIZATION S MANAGED BY C9608 Percutaneous Transluminal Revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drugeluting intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft (list separately in addition to code for primary procedure) G0290 Drug-eluting Stents, single 19296 Applicator Insertion Breast (breast surgeon) 19297 Applicator Insertion Breast (breast surgeon) 19298 Applicator Insertion Breast (breast surgeon) 76950 Ultrasonic Guidance 77014 Computed Tomography Guidance 77261 Clinical Treatment Planning - simple 77262 Clinical Treatment Planning - intermediate 77263 Clinical Treatment Planning - complex 77280 Simulation simple 77285 Simulation - intermediate 77290 Simulation - complex 77295 3D - Isodose Plan 77300 Dosimetry - Basic Radiation Calculation 77301 LMRT - Isodose Plan 77305 Teletherapy Isodose Plan - simple 77310 Teletherapy Isodose Plan - intermediate 77315 Teletherapy Isodose Plan - complex 77321 Isodose Plan - special 77326 77327 77328 Brachytherapy Isodose Calculation - simple Brachytherapy Isodose Calculation - intermediate Brachytherapy Isodose Calculation - complex 77331 Dosimetry - special 77332 Treatment Devices - simple 77333 Treatment Devices - intermediate 77334 Treatment Devices - complex 77336 Weekly Physics Consultation 77338 MLC Devices for LMRT 77370 Special Medical Radiation Physics Consultation 77371 Radiation Treatment SRS 77372 Radiation Treatment SRS PRE-ORIZATION S MANAGED BY 77373 77399 77401 77402 77403 77404 77406 77407 77408 77409 77411 77412 77413 77414 77416 Stereotactic Body Radiation Therapy Unlisted Procedure for Physics Dosimetry and Devices 77417 Port Films 77418 Intensity Modulated Treatment 77421 Stereoscopic -ray Guidance 77422 77423 77424 77425 77427 77431 77432 77435 77469 77470 77499 High Energy Neutron Radiation Treatment High Energy Neutron Radiation Treatment Intra-Operative Radiation Treatment, -ray or electron single treatment session Intra-Operative Radiation Treatment, -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 77520 Proton Treatment 77522 Proton Treatment
Page 7 PRE-ORIZATION S MANAGED BY 77523 Proton Treatment 77525 Proton Treatment 77600 Hyperthermia, externally generated 77605 Hyperthermia, externally generated 77610 77615 77620 Hyperthermia, generated by interstitial probe Hyperthermia, generated by interstitial probe Hyperthermia, generated by intracavitary probe 77761 Intracavitary Radiation - simple 77762 Intracavitary Radiation - intermediate 77763 Intracavitary Radiation - complex 77776 Interstitial Radiation - simple 77777 Interstitial Radiation - intermediate 77778 Interstitial Radiation- complex 77785 High Dose Rate Brachytherapy 77786 High Dose Rate Brachytherapy 77787 High Dose Rate Brachytherapy 77789 Brachytherapy Surface Application 77790 Supervision Handling Loading Rad Source 77799 Unlisted Procedure Clinical Brachytherapy 0073T Compensator-based Modulation Treatment 0182T High Dose Rate Electronic Brachytherapy 0197T Intrafraction Tracking G0173 G0251 G0339 G0340 Linear Accelerator Stereotactic Radiosurgery LINAC Stereotactic Radiosurgery Stereotactic Body Radiation Therapy Stereotactic Body Radiation Therapy 70450 CT Brain, Head 70460 CT Head or Brain with Contrast 70470 CT Head or Brain without/with Contrast 70480 70481 70482 70486 70487 CT Orbit, eye socket, sella turcica, posterior fossa, ear, etc. CT Orbit, eye socket, sella turcica, posterior fossa, ear with contrast CT Orbit, eye socket, sella turcica, posterior fossa, ear, with/without contrast CT Sinus, face, jaw, mandible, maxillofacial, no contrast CT Face, jaw or mandible, maxillofacial, with contrast PRE-ORIZATION S MANAGED BY 70488 70490 70491 70492 CT Face, jaw or mandible, maxillofacial, without/with contrast CT Neck soft tissues, larynx, thyroid, etc., no contrast CT Neck soft tissues, larynx, thyroid, etc., with contrast CT Neck soft tissues, larynx, thyroid, etc., without/with contrast 70496 CT Angiography, head 70498 CT Angiography, Neck 70540 MRI Face, neck, orbit 70542 MRI Orbit, face, neck with dye 70543 MRI Orbit, face, neck without/with dye 70544 MR Angiography, head without dye 70545 MR Angiography, head with dye 70546 MR Angiography, head without/with dye 70547 MR Angiography, neck without dye 70548 MR Angiography, neck with dye 70549 70551 70552 70553 MR Angiography, neck without/with dye MRI Brain, head, brainstem without contrast MRI Head, brain, brainstem with contrast MRI Head, brain, brainstem without/with contrast 70554 FMRI Brain by tech 70555 FMRI Brain by phys/psych 93462 L Heart Cath trnsptl puncture 93463 Drug Admin and Hemodynmic Meas 93464 Exercise with Hemodynamic Meas 78012 78013 78014 78015 78016 78017 78018 78020 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) 78070 Parathyroid Scan 78071 Parathyroid Planar Imaging, with tomographic (SPECT)
Page 8 PRE-ORIZATION S MANAGED BY 78072 Parathyroid Planar Imaging, with tomographic (SPECT) and concurrently acquired CT 78075 Adrenal Scan or Isotope Imaging 78099 Endocrine Nuclear Procedure 78102 Bone Marrow, limited area 78103 Bone Marrow, multiple areas 78104 Bone Marrow, whole body 78110 Plasma Volume 78111 Nuclear Exam, Plasma Volume 78120 78121 78122 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 78130 Red Cell Survival Exam 78135 Differential Organ/Tissue Kinetics (EG, splenic and/or hepatic sequestration) 78140 RBC or Red Blood Cell Sequestration Study 78160 Plasma Radioiron Disappearance (Turnover) Rate 78185 Spleen Imaging Only, with or without vascular flow 78190 Kinetics, study of platelet survival, with or without differential organ/tissue 78191 Platelet Survival Study 78192 78193 78195 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 78199 Blood/Lymph Nuclear Exam 78201 Hepatic or Liver Scan, static only 78202 Hepatic or Liver Scan, with vascular flow 78205 Hepatic or Liver Scan, SPECT 78206 78215 78216 78220 78223 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 Liver Function with hepatobiliary agents Hepatobiliary, TC HIDA scan - biliary tract, gall bladder 78226 Hepatobiliary System Imaging 78227 Hepatobiliary System Imaging with drug 78230 Salivary Gland Imaging 78231 Salivary Gland Imaging, with multiple images PRE-ORIZATION S MANAGED BY 78232 Salivary Gland Function Study 78258 Esophageal Motility or Esophageal Scan 78261 Stomach or Gastric Mucosa or Lining Study 78262 Gastro-esophageal Reflux Study 78264 Stomach or Gastric Emptying Study 78270 Vitamin B-12 Absorption Study or Schilling Test, no intrinsic factor 78271 Vitamin B-12 Absorption Study or Schilling Test, with intrinsic factor 78272 Vitamin B-12 Absorption Study or Schilling Test, combined without and with 78276 Nuclear Exam, GI Blood Loss 78278 Nuclear Scan, GI Blood Loss 78280 GI Blood Loss Exam 78282 GI Protein Loss Exam 78290 Nuclear Scan of Bowel 78291 Test Venous Drain, abdomen 78299 GI Nuclear Procedure 78300 Bone Scan and/or Joint Limited Area 78305 Bone Scan and/or Joint Multiple Areas 78306 Bone or Skeleton Scan, whole body 78315 Nuclear Scan of Bone 78320 Bone and/or Joint Multiple Areas, tomographic or SPECT 78350 Bone Mineral, single photon 78351 Bone Density Dual Photon, osteoporosis study 78399 Musculoskeletal Nuclear Exam 78445 Vascular Flow Imaging or Isotope Angiography or Isotope Venography 78456 Acute Venous Thrombus Image 78457 Venous Thrombosis or Blood Clot Imaging, unilateral 78458 Venous Thrombosis or Blood Clot Imaging, bilateral 78459 Myocardial Imaging, PET 78491 Heart Image (PET), single 78492 Heart Image (PET), multiple 78579 Lung Ventilation Imaging 78580 Lung 78582 Lung Ventilation and Perfusion Imaging 78584 Lung Perfusion 78585 Lung Perfusion Imaging, rebreathing and washout, with/without single breath 78586 Lung
Page 9 PRE-ORIZATION S MANAGED BY 78587 Lung 78588 Pulmonary Perfusion Imaging, particulate, with ventilation imaging, aerosol 78591 Lung 78593 78594 78596 Lung Ventilation Imaging, gaseous, with rebreathing and washout, single pro Lung Ventilation Imaging, gaseous, with rebreathing and washout, multiple pro Lung Scan Differential Function (Ventilation/Perfusion) Study 78597 Lung Perfusion Differential 78598 Lung Perfusion and Ventilation Differential 78599 Unlisted Respiratory Procedure 78600 Nervous System, Brain 78601 Nervous System, Brain 78605 Nervous System, Brain 78606 Brain Scan or Imaging, with vascular flow 78607 Brain Scan or Imaging SPECT or tomographic 78608 Brain PET [Positron Emission Tomography] 78609 Brain PET [Positron Emission Tomography] Perfusion 78610 Brain 78630 Cerebrospinal Fluid 78635 Cerebrospinal Fluid 78645 Cerebrospinal Fluid 78647 Cerebrospinal Fluid 78650 Cerebrospinal Fluid Leakage Detection And Localization 78655 Nuclear Exam of eye lesion 78660 Tear Flow, 1 Not 8 78699 Nervous System Nuclear Exam 78700 Renal or Kidney Imaging, static 78701 78707 Renal or Kidney Imaging, with vascular flow Renal or Kidney Imaging, with vascular flow and function study 78708 Kidney Flow and Function Image 78709 Kidney Flow and Function Image 78710 Renal or Kidney Imaging, SPECT 78725 Kidney, no pharmaceuticals 78726 Kidney, with pharmaceuticals 78727 Renal or Kidney Transplant Evaluation 78730 Urinary Bladder Residual Study PRE-ORIZATION S MANAGED BY 78740 Ureteral Reflux Study 78761 Scan of Testes/Blood Flow 78799 Genitourinary Nuclear Exam 78800 Nuclear Tumor Localization, limited 78801 Nuclear Tumor Localization, multiple 78802 Nuclear Tumor Localization, whole body 78803 Tomographic (SPECT) 78804 Tumor Imaging, whole body 78805 Abscess Localization or Gallium Scan, limited area 78806 Abscess Localization or Gallium Scan, whole body 78807 Tomographic (SPECT) 78811 Tumor Imaging (PET), limited 78812 Tumor Image (PET), skull-thigh 78813 Tumor Image (PET), full body 78814 Tumor Image PET/CT, limited 78815 Tumor Image PET/CT, skull-thigh 78816 Tumor Image PET/CT, full body 78999 Nuclear, Unlisted Exam 79000 Initial Hyperthyroid Therapy 79005 Nuclear Rx, Oral Admin 79101 Nuclear Rx, IV Admin 79200 Intracavitary Nuclear Treatment 79440 Nuclear Joint Therapy 79445 Nuclear Rx, Intra-Arterial 79999 Nuclear Medicine Therapy 0042T 0042T CT with Contrast, Cerebral Perfusion Analysis CT with Contrast, Cerebral Perfusion Analysis 0159T CAD Breast MRI 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 76375 CT Multiplanar Reconstructions A9503 Tc99m Medronate 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
Page 10 PRE-ORIZATION S MANAGED BY A9547 Indium In-111 Oxyquinoline, diagnostic, per 0.5 millicurie 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 C8900 MRA with contrast, abdomen C8901 MRA without contrast, abdomen C8902 MRA without/with contrast, abdomen C8903 MRI with contrast, breast, unilateral C8904 MRI without contrast, breast, unilateral C8905 MRI without/with contrast, breast, unilateral C8906 MRI with contrast, breast, bilateral C8907 MRI without contrast, breast, bilateral C8908 MRI without/with contrast, breast, bilateral C8909 MRA with contrast, chest C8910 MRA without contrast, chest C8911 MRA without/with contrast, chest excl myocardium C8912 MRA with contrast, lower extremity C8913 MRA without contrast, lower extremity C8914 MRA without/with contrast, lower extremity C8918 MRA with contrast, pelvis C8919 MRA with contrast, pelvis C8920 MRA without/with contrast, pelvis C8931 MRA with contrast, spinal canal and contents C8932 MRA without contrast, spinal canal and contents C8933 MRA, without contrast followed by with contrast, spinal canal and contents C8934 MRA, with contrast, upper extremity C8935 MRA, without contrast, upper extremity C8936 MRA, without contrast followed by with contrast, upper extremity G0062 Peripheral Bone Densitometry G0063 Central Bone Densitometry G0288 Reconstruction, CTA of aorta for surgical planning for vascular surgery S8035 Magnetic Source Imaging PRE-ORIZATION S MANAGED BY S8040 Topographic Brain Mapping S8085 Fluorine-18 Fluorodeoxyglucose G0219 PET Imaging Whole Body, melanoma for non-covered indications G0235 PET, not otherwise specified G0252 PET Imaging, initial D S8037 MRCP S8042 MRI Low Field S8092 Electron Beam Computed Tomography