CPT Radiology Codes Requiring Review by AIM Effective 01/01/2016

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1 CPT Radiology Codes Requiring Review by AIM Effective 01/01/2016 When a service is authorized only one test per group is payable. *Secondary codes or add-on codes do not require preauthorization or separate review. CPT Description Group CT abdomen; without CT abdomen; with Abdomen - CT CT abdomen; without followed by MRI abdomen; without MRI abdomen; with Abdomen - MRI MRI abdomen; without followed by CTA abdomen Angiography, Abdomen - CT MRA abdomen; with or without Angiography, Abdomen - MRA MRA chest; with or without Angiography, Chest - MRA CTA head Angiography, Head - CT MRA head; without MRA head; with Angiography, Head - MRA MRA head; without followed by CTA lower extremity Angiography, Lower Extremity - CT MRA lower extremity; with or without Angiography, Lower Extremity - MRA CTA neck Angiography, Neck - CT MRA neck; without MRA neck; with Angiography, Neck - MRA MRA neck; without followed by CTA pelvis Angiography, Pelvis - CT MRA pelvis; with or without Angiography, Pelvis - MRA MRA spinal canal and contents with or without Angiography, Spinal Canal & Contents - MRA CTA upper extremity Angiography, Upper Extremity - CT MRA upper extremity; with or without Angiography, Upper Extremity - MRA CT bone mineral density study; axial skeleton Bone Density (CT) MRI bone marrow blood supply Bone Marrow Blood Supply - MRI MRI brain; without MRI brain; with Brain (Includes IACs, Pituitary) - MRI MRI brain; without followed by PET brain, metabolic evaluation MRI breast; unilateral PET brain, perfusion evaluation MRI breast; bilateral Brain Imaging (PET Scan) Breast (MR Mammography) - MRI MRI Cardiac for morphology and function without material; MRI Cardiac for morphology and function without material; with stress imaging MRI Cardiac for morphology and function without material(s), followed by material(s) and further Cardiac - MRI sequences; MRI Cardiac for morphology and function without material(s), followed by material(s) and further sequences; with stress imaging Cardiac blood pool, gated equilibrium; planar, single study, wall motion plus ejection fraction Cardiac blood pool gated equilibrium; planar, multiple studies, wall motion study plus ejection fraction Cardiac blood pool first pass tech; single study, wall motion study plus ejection fraction Cardiac Blood Pool Imaging/MUGA Cardiac blood pool first pass tech; multiple studies, wall motion study plus ejection fraction Cardiac blood pool gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction

2 75571 Computed tomography, heart, without material, with quantitative evaluation of coronary calcium Cardiac CT - Calcium Scoring Computed tomography, heart, with material, for evaluation of cardiac structure and morphology (including 3D image post processing, assessment of cardiac function, and evaluation of venous structures, if performed) Computed tomography, heart, with material, for Cardiac CT - Structure/Morphology 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) PET myocardial, metabolic evaluation PET myocardial, perfusion, single study Cardiac Imaging (PET Scan) PET myocardial, perfusion, multiple studies CT cervical spine; without CT cervical spine; with Cervical Spine - CT CT cervical spine; without followed by MRI cervical spine; without MRI cervical spine; with Cervical Spine - MRI MRI cervical spine; without followed by MRI chest; without MRI chest; with Chest - MRI MRI chest; without followed by CT thorax; without (non-cardiac) CT thorax; with (non-cardiac) Chest (Thorax) - CT CT thorax; without followed by (noncardiac) Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with material, including 3D image post processing (including evaluation of cardiac structure and morphology, assessment Coronary (Cardiac) CTA of cardiac function, and evaluation of venous structures, if performed) CT Abdomen & Pelvis without CT Abdomen & Pelvis with CT Abdomen & Pelvis wo/w CT Abdomen/Pelvis Combination CTA Abdomen/Pelvis wo/w CTA Abdomen aorta w bilateral iliofemoral low extremity runoff CTA Abdomen Aorta w Low Extremity Runoff CTA chest (non-coronary) CTA Chest (Non-coronary) Computed tomographic (CT) colonography, diagnostic, including image post processing; without material Computed tomographic (CT) colonography, diagnostic, including image post processing; with material(s) including non- images, if performed Functional MRI brain not requiring physician or psychologist Functional MRI brain requiring physician or psychologist CT orbit, sella or posterior fossa; without CT orbit, sella or posterior fossa; with CT orbit, sella or posterior fossa; without followed by CT head or brain; without CT head or brain; with CT head or brain; without followed by Planar, infarct avid; qualitative or quantitative Planar, infarct avid; with ejection fraction by first pass technique SPECT, infarct avid; with or without quantification Diagnostic Virtual Colonoscopy Functional MRI Brain Head - CT Head/Brain - CT Infarct Scan for MI < 8 Weeks

3 73700 CT lower extremity; without CT lower extremity; with Lower Extremity - CT CT lower extremity; without followed by MRI lower extremity, other than joint without MRI lower extremity, other than joint w MRI lower extremity, other than joint without followed by MRI lower extremity, any joint without Lower Extremity Joint/Non-joint - MRI MRI lower extremity, any joint w MRI lower extremity, any joint without followed by CT lumbar spine; without CT lumbar spine; with Lumbar Spine - CT CT lumbar spine; without followed by MRI lumbar spine; without MRI lumbar spine; with Lumbar Spine - MRI MRI lumbar spine; without followed by S8032 Low Dose CT Lung Cancer Screening Lung Cancer Screening - Low Dose CT G0297 Low dose CT lung screening Lung Cancer Screening Low Dose CT Medicare CT maxillofacial area (sinus); without CT maxillofacial area (sinus); with Maxillofacial Area (Sinus) - CT CT maxillofacial area (sinus); without followed by MRI Fetal MRI Fetal Myocardial perfusion SPECT single study including qualitative or quantitative wall motion, ejection fraction by 1st pass or gated technique, rest or stress Myocardial perfusion SPECT multiple studies including qualitative or quantitative wall motion, ejection fraction by 1st pass or gated technique, rest and/or stress Myocardial Perfusion Imaging Myocardial perfusion planar single study including qualitative or quantitative wall motion, ejection fraction by 1st pass or gated technique, rest or stress Myocardial perfusion planar multiple studies including qualitative or quantitative wall motion, ejection fraction by 1st pass or gated technique, rest and/or stress CT soft tissue neck; without CT soft tissue neck; with Neck (Soft Tissue) - CT CT soft tissue neck; without followed by MRI orbit, face and neck; without MRI orbit, face and neck; with Orbit, Face, Soft Tissue Neck - MRI MRI orbit, face and neck; without followed by CT pelvis; without CT pelvis; with Pelvis - CT CT pelvis; without followed by MRI pelvis; without MRI pelvis; with Pelvis - MRI MRI pelvis; without followed by PET tumor imaging, limited PET tumor imaging, skull to mid-thigh PET tumor imaging, whole body PET tumor imaging with concurrent CT, limited PET or PET/CT PET tumor imaging with concurrent CT, skull to mid-thigh PET tumor imaging with concurrent CT, whole body Computed tomographic (CT) colonography, screening, including image post processing Screening Virtual Colonoscopy MR Spectroscopy Spectroscopy - MRI MRI temporomandibular joint(s) Temporomandibular Joints (TMJ) - MRI

4 72128 CT thoracic spine; without CT thoracic spine; with Thoracic Spine - CT CT thoracic spine; without followed by MRI thoracic spine; without MRI thoracic spine; with Thoracic Spine - MRI MRI thoracic spine; without followed by CT upper extremity; without CT upper extremity; with Upper Extremity - CT CT upper extremity; without followed by MRI upper extremity, any joint without MRI upper extremity, any joint with Upper Extremity Joint - MRI MRI upper extremity, any joint without followed by MRI upper extremity, other than joint without MRI upper extremity, other than joint with MRI upper extremity, other than joint without followed by CPT* Description Group or D rendering w interpretation and reporting of CT, MRI, ultrasound or other tomography requiring or not requiring image post processing on an independent workstation Limited follow-up CT Cardiac blood pool imaging, gated equilibrium, single study, at rest, with right ventricular ejection fraction by first pass technique (Add-on code to only) Add-on Codes* Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure) Magnetic resonance (e.g., proton) imaging, fetal, including placental an maternal pelvic imaging when performed; each additional gestation (list separately in addition to code from primary procedure 74712) Upper Extremity Non-Joint (includes Brachialplexus) - MRI

5 Secondary/Add-on CPT Codes Secondary codes do not require preauthorization or separate review Applicable Groups CPT Description 1-12, 13-17, 23-27, 29, 30, 46, 47, or D rendering w interpretation and reporting of CT, MRI, ultrasound or other tomography requiring or not requiring image postprocessing on an independent workstation Magnetic resonance (eg, proton) imaging, fetal, including placental an maternal pelvid imaging when performed; each additional gestation (list separately in addition to code from primary procedure 74712)

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