High Tech Imaging Quick Reference Guide 1
High Tech Imaging Authorizations may now be requested through our secure provider portal, BlueAccess. Getting Started Step 1: Log into BlueAccess from www.bcbst.com site as shown below by entering your User ID and Password.. Note: if you do not have a User ID and Password, contact your ebusiness Marketing Representative or Service Center for personal assistance with registration and/or training (see contact information on last page of quick reference guide) Step 1: Log In to BlueAccess Register Now Step 2: Click the Service Center link Step 2: Click Service Center 2
Step 3: Click the Outpatient Surgical Procedure / High Tech Imaging Authorization Form. Step 3: Click Authorization Form The authorization form displays. Step 4: Enter the requested date of service and the Patient ID number Step 5: Click Search button. Step 4: Enter Date of Service and Patient ID Step 5: Enter Search 3
The member information should display on the screen as shown below. Step 6: Click the Continue button Member Information Displays Step 6: Click Continue Step 7: Complete authorization form & then click the complete button NOTE: Please leave the Admitting Facility field blank if the procedure is performed in an office setting. We added Office as an option when the procedure is in an office setting. Step 7: Complete Authorization Form Step 7: Click Complete Button 4
The Review the Outpatient Surgical Procedure/High Tech Imaging Summary page displays. Step 8: If the summary page is correct, click the Continue button. If something needs to be edited, please click the Back button Step 8: Click Continue Button Back Button You will be re-directed to the Clinical Certification page. Step 9: Click the continue button if the fax and phone numbers are correct. Step 9: Click Continue 5
Step 10: Enter patient s phone number & click the Submit button Step 10: Enter Phone number & Click Submit Step 11: Click the Continue button Step 11: Click Continue 6
Step 12: Select answer from drop down list as shown below Step 13: Click the Submit button or you may check the Finish Later check box Step 13: Click Submit Step 12: Select Answer Step 14: Check Clinical Certification check boxes Step 15: Click the Submit Case button Step 14: Read & Click Check Box Step 15: Submit Case 7
Clinical Certification An example of the approved clinical certification is displayed below. 8
Authorization Inquiry / Lookup Step 1: Click on the BCBST High Tech Imaging Program link Note: The bullets underneath the BCBST High Tech Imaging Program include helpful resource documents including a list of codes that require prior-authorization and a training quick reference guide. You may also click the click here link to begin a new authorization. Step 1: Click Application Link Link to Authorization Forms Resource Documents 9
The evicore page displays Step 2: Enter Provider NPI number and click the Submit button Step 2: Enter Provider NPI number and click Submit Step 3: Enter the Patient ID number and date of birth Step 4: Click the Search button Step 3: Enter Patient ID and Date of Birth Step 4: Click the Search Button 10
The Authorization Lookup Information displays as shown below. Note: If you need to change a service code, you may do so my clicking on the Change Service Code button You may view correspondence by clicking the View Correspondence button Change Service Code Clicking the Change Service Code button will display the following screen where you may click the Continue button to change the service code. Continue 11
Clicking the View Correspondence button will display all correspondence regarding the authorization. Step 5: Click the view button to view correspondence documents. Step 5: Click View Button Resources: You can find the Radiology Prior Authorization Program CPT List below or on our website at: http://www.bcbst.com/providers/hti/hticodelist.pdf CPT is a registered trademark of the American Medical Association. 12
BlueCross BlueShield of Tennessee RADIOLOGY PRIOR AUTHORIZATION PROGRAM CPT LIST VSHP West Grand Region members (effective 11/01/08) VSHP East Grand Region members (effective 1/1/09) CPT is a registered trademark of the American M edical Association CPT DESCRIPTION CODE HTI PRIOR AUTHORIZATION REQUIRED DATE REQUIRED AUTHORIZATION TERM ED 70336 MRI Temporomandibular Joint (s) {TMJ} 70450 CThead without contrast 70460 CThead with contrast 70470 CThead with & without contrast W&W/O 70480 CT Orbit, sella, or posterior fossa or outer, middle, or inner ear without contrast 70481 CT Orbit, sella, or posterior fossa or outer, middle, or inner ear with contrast 70482 CT Orbit, sella, or posterior fossa or outer, middle, or inner ear W&W/O 70486 CT Maxillofacial area, (sinus) without contrast 70487 CT Maxillofacial area, (sinus) with contrast 70488 CT Maxillofacial area, (sinus) with & without contrast W&W/O 70490 CT Soft-tissue Neck without contrast 70491 CT Soft-tissue Neck with contrast 70492 CT Soft-tissue Neck with & without contrast W&W/O 70496 CTA HEAD, with contrast material(s), including non-contrast images, if performed, and image post-processing (DESCRIPTION CHANGE) 70498 CTA NECK, with contrast material(s), including non-contrast images, if performed, and image post-processing (DESCRIPTION CHANGE) 70540 Magnetic resonance (e.g., proton) imaging, orbit, f ace, and/or neck; without contrast material(s) (DESCRIPTION CHANGE) 70542 Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; with contrast material(s) (DESCRIPTION CHANGE) 70543 Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and further sequences (DESCRIPTION CHANGE) 70544 MR Angiography (MRA) Head without contrast 70545 MR Angiography (MRA) Head with contrast 70546 MR Angiography (MRA) Head with and without contrast W&W/O 70547 MR Angiography (MRA) Neck without contrast 70548 MR Angiography (MRA) Neck with contrast 70549 MR Angiography (MRA) Neck with and without contrast W&W/O 70551 MRI Brain (Head) without contrast 70552 MRI Brain (Head) with contrast 70553 MRI Brain (Head) with and without contrast W&W/O 70554 Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration 1/1/2007 N/A 70555 Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing 1/1/2007 N/A 71250 CT Chest without contrast
71260 CT Chest with contrast 71270 CT Chest with and without contrast W&W/O 71275 CTA CHEST, (non-coronary), with contrast material(s), including non-contrast images, if performed, and image postprocessing (DESCRIPTION CHANGE) 71550 MRI Chest without contrast 71551 MRI Chest with contrast 71552 MRI Chest with and without contrast W&W/O 71555 MR Angiography (MRA) Chest (excluding myocardium)-with or w/o contrast 72125 CT Cervical Spine without contrast 72126 CT Cervical Spine with contrast 72127 CT Cervical Spine with and without contrast W&W/O 72128 CT Thoracic Spine without contrast 72129 CT Thoracic Spine with contrast 72130 CT Thoracic Spine with and without contrast W&W/O 72131 CT Lumbar Spine without contrast 72132 CT Lumbar Spine with contrast 72133 CT Lumbar Spine with and without contrast W&W/O 72141 MRI Cervical Spine without contrast 72142 MRI Cervical Spine with contrast 72146 MRI Thoracic Spine without contrast 72147 MRI Thoracic Spine with contrast 72148 MRI Lumbar Spine without contrast 72149 MRI Lumbar Spine with contrast 72156 MRI Cervical Spine with and without contrast W&W/O 72157 MRI Thoracic Spine with and without contrast W&W/O 72158 MRI Lumbar Spine with and without contrast W&W/O 72159 MR Angiography (MRA) Spinal Canal and contents-with or w/o contrast 72191 CTA PELVIS, with contrast material(s), including non-contrast images, if performed, and image post-processing (DESCRIPTION CHANGE) 72192 CT Pelvis without contrast 72193 CT Pelvis with contrast 72194 CT Pelvis with and without contrast W&W/O 72195 MRI Pelvis without contrast 72196 MRI Pelvis with contrast 72197 MRI Pelvis with and without contrast W&W/O 72198 MR Angiography (MRA) Pelvis -with or without contrast 73200 CT Upper Extremity without contrast 73201 CT Upper Extremity with contrast 73202 CT Upper Extremity with and without contrast W&W/O 73206 CTA Upper Extremity, with contrast material(s), including non-contrast images, if performed, and image postprocessing (DESCRIPTION CHANGE) 73218 MRI Upper Extremity-other than joint -without contrast 73219 MRI Upper Extremity-other than joint -with contrast 73220 MRI Upper Extremity-other than joint -with and without contrast 73221 MRI Any Joint of Upper Extremity--without contrast 73222 MRI Any Joint of Upper Extremity--with contrast
73223 MRI Any Joint of Upper Extremity with and without contrast 73225 MR & Angiography /O (MRA) Upper Extremity-with or without contrast 73700 CT Lower Extremity without contrast 73701 CT Lower Extremity with contrast 73702 CT Lower Extremity with and without contrast W&W/O 73706 CTA Lower Extremity, with contrast material(s), including noncontrast images, if performed, and image post-processing (DESCRIPTION CHANGE) 73718 MRI Lower Extremity-other than joint without contrast 73719 MRI Lower Extremity-other than joint with contrast 73720 MRI Lower Extremity-other than joint with and without contrast 73721 MRI Any Joint of Lower Extremity without contrast 73722 MRI Any Joint of Lower Extremity with contrast 73723 MRI Any Joint of Lower Extremity with and without contrast 73725 MR Angiography (MRA) Lower Extremity-with or without contrast 74150 CT Abdomen without contrast 74160 CT Abdomen with contrast 74170 CT Abdomen with and without contrast W&W/O 74174 CTA; abdomen and pelvis; with contrast material(s) including noncontrast images, if 1/1/2012 N/A 74175 CTA ABDOMEN, with contrast material(s), including noncontrast images, if performed, and image post-processing (DESCRIPTION CHANGE) Computed tomography, abdomen and pelvis; without contrast 74176 material 1/1/2011 N/A Computed tomography, abdomen and pelvis; with contrast 74177 material(s) 1/1/2011 N/A 74178 Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions 1/1/2011 N/A 74181 MRI Abdomen without contrast 74182 MRI Abdomen with contrast 74183 MRI Abdomen with and without contrast W&W/O 74185 MR Angiography (MRA) Abdomen with or without contrast 74261 Computed tomographic (CT) colonography, diagnostic, including image post processing; without contrast material 74262 Computed tomographic (CT) colonography, diagnostic, including image post processing; with contrast material(s) including non-contrast images, if performed 74263 Computed tomographic (CT) colonography, screening, including image 75552 DELETED CODE 8/1/2006 12/31/2007 75553 DELETED CODE 8/1/2006 12/31/2007 75554 DELETED CODE 8/1/2006 12/31/2007 75555 DELETED CODE 8/1/2006 12/31/2007 75556 DELETED CODE 8/1/2006 12/31/2007 75571 Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium 75572 Computed tomography heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image post processing, assessment of cardiac function, and evaluation of venous structures, if performed)
75573 Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image post processing, assessment of LV cardiac function, RV structure and function and evaluation of venous structures, if performed 75574 Computed tomographic angiography, heart, coronary arteries and bypass grafts (when 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) 75557 Cardiac MRI for morphology and function without contrast materials 1/1/2008 N/A 75558 DELETED CODE 1/1/2008 12/31/2009 75559 Cardiac MRI for morphology and function without contrast materials; with stress imaging 1/1/2008 N/A 75560 DELETED CODE 1/1/2008 12/31/2009 75561 Cardiac MRI for morphology and function without contrast materials, followed by contrast material(s) and further sequences 1/1/2008 N/A 75562 DELETED CODE 1/1/2008 12/31/2009 75563 Cardiac MRI for morphology and function without contrast materials, followed by contrast material(s) and further sequences; with stress imaging 1/1/2008 N/A 75564 DELETED CODE 1/1/2008 12/31/2009 75635 CTA ABDOMINAL AORTA and bilateral iliofemoral lower extremity runoff, with contrast material(s), including non-contrast images, if performed, and image post-processing (DESCRIPTION CHANGE) 75565 Cardiac MRI for velocity flow mapping 76070 DELETED CODE 8/1/2006 12/31/2006 76071 DELETED CODE 8/1/2006 12/31/2006 76093 DELETED CODE 8/1/2006 12/31/2006 76094 DELETED CODE 8/1/2006 12/31/2006 76376 3 D rendering with interpretation and reporting of Computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring post processing on an independent workstation 76377 3 D rendering requiring post processing on an independent workstation 76380 CT Limited or Localized follow-up 76390 MR Spectroscopy 76400 DELETED CODE 8/1/2006 12/31/06 76497 Unlisted Computed Tomography procedure (e.g., diagnostic, interventional) 76498 Unlisted Magnetic Resonance procedure (e.g., diagnostic, interventional) 77011 Computed tomography guidance for stereotactic localization 1/1/2007 5/25/2007 77012 Computed tomography guidance for needle placement, (e.g., 1/1/2007 5/25/2007 biopsy, aspiration, injection, localization device), RS&I* 77014 Computed tomography guidance for placement of radiation therapy fields 77021 Magnetic resonance guidance for needle placement, (e.g., biopsy, needle aspiration, injection, or placement of localization device), RS&I* 77058 Magnetic resonance imaging, breast, without and/or with contrast, unilateral 1/1/2007 5/25/2007 1/1/2007 5/25/2007 1/1/2007 N/A
77059 Magnetic resonance imaging, breast, without and/or with contrast, bilateral 77078 CT Bone Mineral Density Study, one or more sites; axial skeleton (e.g., hips, pelvis, spine) 1/1/2007 N/A 1/1/2007 N/A 77079 DELETED CODE 1/1/2007 12/31/2011 77084 Magnetic resonance imaging, bone marrow blood supply 1/1/2007 N/A 78414 Determination of central c-v hemodynamics (non-imaging) (e.g., 8/1/2006 4/1/2007 ejection fraction with probe technique) with or without pharmacologic intervention or exercise, single or multiple determinations 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 pharmocologic) and/or redistribution and/or rest reinjection 78453 Myocardial perfusion imaging, planar (including qualititative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise 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 pharmocologic) and/or redistribution and/or rest reinjection 78459 PET Cardiac (myocardial imaging) metabolic evaluation 78460 DELETED CODE 8/1/2006 12/31/2009 78461 DELETED CODE 8/1/2006 12/31/2009 78464 DELETED CODE 8/1/2006 12/31/2009 78465 DELETED CODE 8/1/2006 12/31/2009 78466 Myocardial Imaging, infarct avid, planar; qualitative or quantitative 78468 Myocardial Imaging, infarct avid, planar; w/ef by first pass technique 78469 Myocardial Imaging, infarct avid, planar; tomographic SPECT 78472 Cardiac Blood Pool imaging, gated equilibrium; planar, single study at rest or stress, wall motion study plus ejection fraction, with or without additional quantitative processing 78473 Cardiac Blood Pool imaging, gated equilibrium; multiple studies, wall motion plus ejection fraction, at rest and stress, with or without additional quantitative 78478 DELETED CODE 8/1/2006 12/31/2009 78480 DELETED CODE 8/1/2006 12/31/2009 78481 Cardiac Blood Pool imaging, (planar), first pass technique; single study, at rest or with stress, wall motion study plus ejection fraction Cardiac Blood Pool imaging, (planar), first pass technique; multiple 78483 studies at rest and with stress, wall motion study plus ejection fraction 78491 PET Cardiac (myocardial imaging) perfusion single study at rest or stress 78492 PET Cardiac (myocardial imaging) perfusion multiple studies rest and/or stress 78494 Cardiac Blood Pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction 8/1/2006 N/A
78496 Cardiac Blood Pool imaging, gated equilibrium, single study, at rest, with right ventricular EF by first pass technique 78499 Unlisted cardiovascular procedure, diagnostic nuclear medicine 10/1/2008 N/A 78608 PET Brain metabolic evaluation 78609 PET Brain perfusion evaluation 78811 Positron emission tomography (PET) imaging; limited area (DESCRIPTION CHANGE) 78812 Positron emission tomography (PET) imaging; skull base to mid-thigh (DESCRIPTION CHANGE) 78813 Positron emission tomography (PET) imaging; whole body (DESCRIPTION CHANGE) 78814 Positron emission tomography (PET) imaging with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; limited area (DESCRIPTION CHANGE) 78815 Positron emission tomography (PET) imaging with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; skull base to mid- thigh (DESCRIPTION CHANGE) 78816 Positron emission tomography (PET) imaging with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; whole body (DESCRIPTION CHANGE) 0144T DELETED CODE 8/1/2006 12/31/2009 0145T DELETED CODE 8/1/2006 12/31/2009 0146T DELETED CODE 8/1/2006 12/31/2009 0147T DELETED CODE 8/1/2006 12/31/2009 0148T DELETED CODE 12/31/2009 0149T DELETED CODE 8/1/2006 12/31/2009 0150T DELETED CODE 8/1/2006 12/31/2009 0151T DELETED CODE 8/1/2006 12/31/2009 0159T Computer-aided detection, including computer algorithm analysis of 1/1/2007 N/A MI image data for lesion detection/characterization, pharmacokinetic analysis, with further physician review for interpretation, breast MRI. 0066T DELETED CODE 8/1 /2006 12/31/2009 0067T DELETED CODE 8/1 /2006 12/31/2009 C8900 Magnetic resonance angiography with contrast, abdomen C8901 Magnetic resonance angiography without contrast, abdomen C8902 Magnetic resonance angiography without contrast followed by with contrast C8903 Magnetic resonance imaging with contrast, breast ; unilateral C8904 Magnetic resonance imaging without contrast, breast; unilateral C8905 Magnetic resonance imaging without contrast followed by with contrast b t C8906 Magnetic resonance imaging with contrast, breast; bilateral C8907 Magnetic resonance imaging without contrast, breast; bilateral C8908 Magnetic resonance imaging without contrast followed by with contrast b t C8909 Magnetic resonance angiography with contrast, chest (excluding myocardium) C8910 Magnetic resonance angiography without contrast, chest (excluding myocardium) C8911 Magnetic resonance angiography without contrast followed by with contrast, chest (excluding myocardium) C8912 Magnetic resonance angiography with contrast, lower extremity C8913 Magnetic resonance angiography without contrast, lower extremity C8914 Magnetic resonance angiography without contrast followed by with contrast, lower C8918 Magnetic resonance angiography with contrast, pelvis
C8919 Magnetic resonance angiography without contrast, pelvis C8920 Magnetic resonance angiography without contrast followed by with contrast, pelvis 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 WITH CONTRAST, SPINAL CANAL AND CONTENTS C8934 MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, UPPER EXTREMITY C8935 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, UPPER EXTREMITY C8936 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, UPPER EXTREMITY G0219 PET imaging whole body; melanoma for non-covered indications 1/1/2011 1/1/2011 1/1/2011 1/1/2011 N/A N/A N/A N/A 1/1/2011 N/A 1/1/2011 N/A 10/1/2008 N/A G0235 PET imaging, any site, not otherwise specified 10/1/2008 N/A G0252 PET imaging, full and partial-ring PET scanners only, for initial 10/1/2008 N/A diagnosis of breast cancer and/or surgical planning f or breast cancer (e.g., initial staging of axillary lymph nodes) S8032 Low-dose computed tomography for lung cancer screening 10/1/2014 N/A S8035 Magnetic source imaging S8037 Magnetic Resonance Cholangiopancreatography (MRCP) S8042 Magnetic Resonance Imaging (MRI), Low-field S8085 Fluorine-1 8 Fluorodeoxyglucose (F-1 8 FDG) Imaging using dualhead coincidence detection system (non-dedicated PET scan) S8092 Electron Beam Computed Tomography (also known as Ultrafast CT, Cine CT) Covered Services specifically exclude mammography, inpatient radiology services, radiology services rendered in an Emergency Department of a hospital, radiation therapy services, interventional radiology procedures, services provided outside the BlueCross BlueShield of Tennessee Service Area for fully insured (non-aso) commercial M embers, and all other outpatient diagnostic services other than the MRI, MRA, MRS, CT or PET services.