DIAGNOSTIC IMAGING PRIOR NOTIFICATION PROGRAM CPT Code List

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1 DIAGNOSTIC IMAGING PRIOR NOTIFICATION PROGRAM CPT Code List CPT4 New Description CT Abdomen wo/w iv contrast CT Abdomen/Pelvis wo/w iv contrast CT Ankle wo/w iv contrast CT Cardiac w iv contrast CT Chest wo/w iv contrast 0144T CT Coronary/Calcium Score wo iv contrast CT C-Spine wo/w iv contrast CT C-Spine Discogram spine CT Elbow wo/w iv contrast CT Facial Bones wo/w iv contrast CT Femur wo/w iv contrast CT Foot wo/w iv contrast CT GU Tract wo/w iv contrast CT Guided Aspiration Aspiration CT Guided Biopsy Biopsy CT Hand wo/w iv contrast CT Head wo/w iv contrast CT Hip wo iv contrast CT Humerus wo/w iv contrast CT Internal Auditory Canals wo/w iv contrast CT Kidneys wo/w iv contrast CT Knee wo/w iv contrast CT Liver wo/w iv contrast CT L-Spine wo/w iv contrast CT L-Spine Discogram CT Maxillofacial wo/w iv contrast CT Midfoot/Forefoot wo/w iv contrast CT Neck wo/w iv contrast CT Orbits wo/w iv contrast CT Orbits/Sella/Inner Ear/Posterior Fossa wo/w iv contrast CT Other wo/w iv contrast CT Pelvis wo/w iv contrast CT Pituitary Gland wo/w iv contrast CT Radius/Ulna wo/w iv contrast CT Sacroiliac Joints wo/w iv contrast CT Sacrum/Coccyx wo/w iv contrast CT Shoulder wo/w iv contrast CT Sinuses wo/w iv contrast 1 P a g e

2 70488 CT Sinuses Limited wo/w iv contrast CT Skull wo/w iv contrast CT Sternoclavicular wo/w iv contrast CT Sternoclavicular Joints wo/w iv contrast CT Sternum wo/w iv contrast CT Temporal Bones wo/w iv contrast CT Temporomandibular Joints wo/w iv contrast CT Thyroid Gland wo/w iv contrast CT Tibia/Fibula wo/w iv contrast CT T-Spine wo/w iv contrast CT T-Spine Discogram spine CT Ureter wo/w iv contrast CT Urogram wo/w iv contrast CT Virtual Colonoscopy Diagnostic 0066T CT Virtual Colonoscopy Screening CT Wrist wo/w iv contrast CTA Abdomen w iv contrast CTA Abdominal Aorta w iv contrast CTA Abdominal Arteries w iv contrast CTA Chest w iv contrast 0149T CTA Coronary Arteries w iv contrast CTA Head w iv contrast w iv contrast CTA Lower Extremity w iv contrast CTA Neck w iv contrast CTA Pelvis w iv contrast CTA Upper Extremity w iv contrast CT Abdomen Appendix w iv contrast CT Abdomen Appendix wo iv contrast CT Abdomen w iv contrast CT Abdomen wo iv contrast CT Abdomen-Pelvis, w iv contrast CT Abdomen-Pelvis wo iv contrast CT Abdomen-Pelvis wo iv contrast CT Ankle w iv contrast CT Ankle wo iv contrast CT Ankle w iv contrast CT Ankle wo iv contrast CT Anteversion Bilat Hips-Knees wo iv contrast CT Cervical w iv contrast CT Cervical wo iv contrast CT Cervical-Lumbar w iv contrast CT Cervical-Lumbar w iv contrast CT Cervical-Thoracic OPCU w iv contrast 2 P a g e

3 72129 CT Cervical-Thoracic OPCU w iv contrast CT Chest w iv contrast CT Chest wo iv contrast CT Chest-Abdomen-Pelvis w iv contrast CT Chest-Abdomen-Pelvis wo iv contrast CT Clavicle LT, w contrast CT Clavicle LT, wo contrast CT Clavicle RT, w contrast CT Clavicle RT, wo contrast CT Coronary Arteries Calcium Score Cardiology w iv contrast CT Coronary Arteries w Calcium Score Radiology w iv contrast CT Coronary wo Calcium Score Cardiology wo iv contrast CT EAR AXL OR CRNL w iv contrast CT EAR AXL OR CRNL wo iv contrast CT EAR AXL/CRNL w iv contrast CT EAR AXL/CRNL wo iv contrast CT Elbow w iv contrast CT Elbow wo iv contrast CT Elbow w iv contrast CT Elbow wo iv contrast CT ENTEROGRAPHY w iv contrast CT ENTEROGRAPHY w iv contrast CT ENTEROGRAPHY wo iv contrast CT ENTEROGRAPHY wo iv contrast CT ENTEROGRAPHY wo iv contrast CT Entire Spine, w iv contrast CT Entire Spine, w iv contrast CT Entire Spine, w iv contrast CT Femur w iv contrast CT Femur wo iv contrast CT Femur w iv contrast CT Femur wo iv contrast CT Foot w iv contrast CT Foot wo iv contrast CT Foot w iv contrast CT Foot wo iv contrast CT Forearm w iv contrast CT Forearm wo iv contrast CT Forearm w iv contrast CT Forearm wo iv contrast CT Hand w iv contrast CT Hand wo iv contrast CT Hand w iv contrast 3 P a g e

4 73200 CT Hand wo iv contrast CT Head Peds wo iv contrast CT Head Stealth w iv contrast CT Head Stealth wo iv contrast CT Head w iv contrast CT Head wo iv contrast CT Hip w iv contrast CT Hip wo iv contrast CT Hip w iv contrast CT Hip wo iv contrast CT Humerus w iv contrast CT Humerus wo iv contrast CT Humerus w iv contrast CT Humerus wo iv contrast CT Knee w iv contrast CT Knee wo iv contrast CT Knee w iv contrast CT Knee wo iv contrast CT Lumbar w iv contrast CT Lumbar wo iv contrast CT Maxface AXL OR CRNL w iv contrast CT Maxface AXL OR CRNL wo iv contrast CT Maxface AXL/CRNL W CONT w iv contrast CT Maxface AXL/CRNL W CONT wo iv contrast CT Neck Soft Tissue w iv contrast CT Neck Soft Tissue wo iv contrast CT Neck-Chest w iv contrast CT Neck-Chest w iv contrast CT Neck-Chest wo iv contrast CT Neck-Chest wo iv contrast CT Orbit AXL OR CRNL w iv contrast CT Orbit AXL OR CRNL wo iv contrast CT Orbit AXL/CRNL w iv contrast CT Orbit AXL/CRNL wo iv contrast CT PE Study w Venous Leg w iv contrast CT Pelvis Delayed wo iv contrast CT Pelvis w iv contrast CT Pelvis wo iv contrast CT Portable Head wo iv contrast CT Post/Fossa wo iv contrast CT Renal Stone w CRNL wo iv contrast CT Sacrum/Coccyx w iv contrast CT Sacrum/Coccyx wo iv contrast 4 P a g e

5 73201 CT Scapula w iv contrast CT Scapula wo iv contrast CT Scapula w iv contrast CT Scapula wo iv contrast CT Shoulder w iv contrast CT Shoulder wo iv contrast CT Shoulder w iv contrast CT Shoulder wo iv contrast CT Sinus Stealth wo iv contrast CT Sternum LTD wo iv contrast CT Sternum LTD w iv contrast CT Thoracic Spine w iv contrast CT Thoracic Spine wo iv contrast CT Thoracic-Lumbar w iv contrast CT Thoracic-Lumbar w iv contrast CT Thoracic-Lumbar wo iv contrast CT Thoracic-Lumbar wo iv contrast CT Tib/Fib w iv contrast CT Tib/Fib wo iv contrast CT Tib/Fib w iv contrast CT Tib/Fib wo iv contrast CT TMJ'S wo iv contrast CT Trauma Chest w iv contrast CT Trama Face/Mandible wo iv contrast CT Wrist w iv contrast CT Wrist wo iv contrast CT Wrist w iv contrast CT Wrist wo iv contrast CTA Chest and CT Abdomen-Pelvis w iv contrast fmr Brain wo iv contrast CAT Scan Follow-up Study X-Ray Eye for Foreign Body CT Scan for Localization PR CT Angio Abd&Pelvis Contrast Mtrl w/wo Cntrs MR Abdomen wo/w iv contrast MR Adrenal Glands wo/w iv contrast MR Ankle wo/w iv contrast MR Bone Marrow Marrow Blood Supply MR Brachial Plexus wo/w iv contrast MR Brain wo/w iv contrast MR Breast wo/w iv contrast MR Cardiac wo/w iv contrast MR Chest wo/w iv contrast 5 P a g e

6 74183 MR Cholangiopancreatography wo/w iv contrast MR C-Spine wo/w iv contrast MR Elbow wo/w iv contrast MR Femur wo/w iv contrast MR Foot wo/w iv contrast MR Hand wo/w iv contrast MR Hip wo/w iv contrast MR Humerus wo/w iv contrast MR Internal Auditory Canals MR Kidneys wo/w iv contrast MR Knee wo/w iv contrast MR Liver wo/w iv contrast MR L-Spine wo/w iv contrast MR Mediastinum wo/w iv contrast MR Midfoot/Forefoot wo/w iv contrast MR Neck wo/w iv contrast MR Orbits wo/w iv contrast MR Other wo/w iv contrast MR Ovaries wo/w iv contrast MR Pelvis wo/w iv contrast MR Pituitary Gland wo/w iv contrast MR Prostate wo/w iv contrast MR Radius/Ulna wo/w iv contrast MR Rectum wo/w iv contrast MR Sacrum/Coccyx wo/w iv contrast MR Shoulder wo/w iv contrast MR Sinuses wo/w iv contrast MR Spectroscopy wo iv contrast MR Spleen wo/w iv contrast MR Temporomandibular Joints wo iv contrast MR Tibia/Fibula wo/w iv contrast MR T-Spine wo/w iv contrast MR Uterus wo/w iv contrast MR Wrist wo/w iv contrast MRA Abdomen wo/w iv contrast MRA Brain wo/w iv contrast MRA Carotids wo/w iv contrast MRA Chest wo/w iv contrast MRA Lower Extremity wo/w iv contrast MRA Neck wo/w iv contrast MRA Pelvis wo/w iv contrast MRA Spinal Canal wo/w iv contrast MRA Upper Extremity wo/w iv contrast 6 P a g e

7 74185 MRV Abdomen wo/w iv contrast MRV Brain wo/w iv contrast MRV Lower Extremity wo/w iv contrast MRV Upper Extremity wo/w iv contrast MR MRCP WITH EOVIST wo/w iv contrast MR ABD HEPATOBILIARY wo iv contrast MR ABDOMEN wo iv contrast MR ENTEROGRAPHY wo iv contrast MR ABDOMEN w iv contrast MR ANGIO ABDOMEN wo iv contrast MR ANGIO ABDOMEN w iv contrast MR ANGIO PELVIS w iv contrast MR ANGIO PELVIS wo iv contrast MR ANGIO CHEST wo iv contrast MR ANGIO CHEST w iv contrast MR ANGIO HEAD wo iv contrast MR ANGIO HEAD w iv contrast MR ANGIO LOWER EXT w iv contrast MR ANGIO LOWER EXT wo iv contrast MR ANGIO NECK wo iv contrast MR ANGIO NECK w iv contrast MR BREAST BILAT DIAG wo iv contrast MR BREAST BILAT IMPLANTS wo iv contrast MR BREAST BILAT SCREEN wo iv contrast MR AXILLA wo iv contrast MR AXILLA wo iv contrast MR CHEST wo iv contrast MR CHEST w iv contrast MR CARDIAC MORPH wo iv contrast MR MYOCARDIUM wo iv contrast MR BRAIN / STEM w iv contrast MR BRAIN / STEM PEDS wo iv contrast MR BRAIN / STEM wo iv contrast MR VENOUS HEAD wo iv contrast MR ORBIT wo iv contrast MR ORBIT w iv contrast MR CARDIAC wo iv contrast MR ANKLE wo iv contrast MR ANKLE wo iv contrast MR ANKLE w iv contrast MR ANKLE w iv contrast MR FEMUR wo iv contrast MR FEMUR wo iv contrast 7 P a g e

8 73719 MR FEMUR w iv contrast MR FEMUR w iv contrast MR FOOT wo iv contrast MR FOOT wo iv contrast MR FORE FOOT wo iv contrast MR FORE FOOT wo iv contrast MR HIND FOOT wo iv contrast MR HIND FOOT wo iv contrast MR FOOT w iv contrast MR FOOT w iv contrast MR FORE FOOT w iv contrast MR FORE FOOT w iv contrast MR HIND FOOT w iv contrast MR HIND FOOT w iv contrast MR HIP w iv contrast MR HIP w iv contrast MR HIP wo iv contrast MR HIP wo iv contrast MR KNEE PEDS wo iv contrast MR KNEE PEDS wo iv contrast MR KNEE wo iv contrast MR KNEE wo iv contrast MR KNEE PEDS w iv contrast MR KNEE PEDS w iv contrast MR KNEE w iv contrast MR KNEE w iv contrast MR TIB/FIB w iv contrast MR TIB/FIB w iv contrast MR TIB/FIB wo iv contrast MR TIB/FIB wo iv contrast MR ORBIT FACE NECK wo iv contrast MR ORBIT FACE NECK w iv contrast MR BRACHIAL PLEXUS wo iv contrast MR NECK SINGLE SERIES wo iv contrast MR NECK SOFT TISSUE wo iv contrast MR NECK SOFT TISSUE w iv contrast MR PELVIS wo iv contrast MR PELVIS w iv contrast MR CERVICAL SPINE wo iv contrast MR CERVICAL SPINE w iv contrast MR LUMBAR SPINE wo iv contrast MR LUMBAR SPINE w iv contrast MR SACRUM wo iv contrast 8 P a g e

9 72146 MR THORACIC SPINE wo iv contrast MR THORACIC SPINE w iv contrast MR ENTIRE SPINE wo iv contrast MR ENTIRE SPINE wo iv contrast MR ENTIRE SPINE wo iv contrast MR ELBOW wo iv contrast MR ELBOW wo iv contrast MR ELBOW w iv contrast MR ELBOW w iv contrast MR FOREARM wo iv contrast MR FOREARM wo iv contrast MR FOREARM w iv contrast MR FOREARM w iv contrast MR FINGER w iv contrast MR FINGER w iv contrast MR FINGER wo iv contrast MR FINGER wo iv contrast MR HAND wo iv contrast MR HAND wo iv contrast MR HAND w iv contrast MR HAND w iv contrast MR HUMERUS w iv contast MR HUMERUS w iv contast MR HUMERUS wo iv contast MR HUMERUS wo iv contast MR SHOULDER wo iv contrast MR SHOULDER wo iv contrast MR SHOULDER w iv contrast MR SHOULDER w iv contrast MR WRIST wo iv contrast MR WRIST wo iv contrast MR WRIST w iv contrast MR WRIST w iv contrast NM Bone 3 Phase NM Bone Regional Limited NM Bone Regional Multiple NM Bone SPECT NM Bone Whole Body NM Brain NM Brain w vascular flow NM Brain SPECT NM Cardiac Ejection Fraction NM Cardiac Shunt Assessment 9 P a g e

10 78800 NM Gallium NM Gastric Emptying NM GI Bleed NM Hepatobiliary NM Liver/Spleen NM Lung Quantitative Perfusion NM Lung Quantitative Ventilation/Perfusion NM Lung Ventilation/Perfusion NM Lymphoscintigraphy NM Meckel's Scan NM MIBG NM MUGA NM MUGA NM Myocardial Perfusion NM Parathyroid Gland NM RBC Liver/Spleen NM Renal NM Renal Cystogram NM Renal Cystogram single study wo pharmacological intervention NM Renal Cystogram single study w pharmacological intervention NM Sentinel Node Injection NM Testicular NM Thyroid Gland NM Thyroid Gland Uptake Only NM Urea Breath Test NM Venogram NM White Blood Cell NM Chg Nuclear Therapy IV NM Chg Salivary Gland Imaging NM Chg CSF Fluid Scan Cisternography NM Chg CSF Shunt Evaluation NM Chg Gastroesophageal Reflux Exam NM Chg Liver Image (3-D) w flow NM Chg Thyroid Met Imaging Whole Body NM Nuclear RX, Oral Admin NM Abscess Imaging, Whole Body NM Hematopoietic Nuclear TX PET Brain PET Brain Perfusion PET Breast PET Esophageal PET Head PET Lung 10 P a g e

11 78811 PET Lymphoma PET Melanoma PET Myocardial PET Myocardial Perfusion PET Neck PET Ovarian PET Skull Base to Thighs PET Whole Body PET/CT Limited PET/CT Skull Base to Thighs PET/CT Whole Body 11 P a g e

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