DAKOTACARE SPECIALIZED IMAGING NOTIFICATION

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1 DAKOTACARE SPECIALIZED IMAGING NOTIFICATION Computerized Tomography (CT) CPT Description- Abdomen CT abdomen; w/o contrast CT abdomen; with contrast CT abdomen; w/o contrast followed Chest CT thorax; w/o contrast CT thorax; with contrast CT thorax; w/o contrast followed Upper Extremity CT upper extremity; w/o contrast CT upper extremity; with contrast CT upper extremity; w/o contrast followed Lower Extremity CT lower extremity; w/o contrast CT lower extremity; with contrast CT lower extremity; w/o contrast followed Head CT head or brain; w/o contrast CT head or brain; with contrast CT head or brain; w/o contrast followed Orbit CT orbit, sella or posterior fossa; w/o contrast CT orbit, sella or posterior fossa; with contrast CT orbit, sella or posterior fossa; w/o contrast followed Sinus CT maxillofacial area; w/o contrast CT maxillofacial area; with contrast CT maxillofacial area; w/o contrast followed Neck CT soft tissue neck; w/o contrast CT soft tissue neck; with contrast CT soft tissue neck; w/o contrast followed Pelvis CT pelvis; w/o contrast CT pelvis; with contrast CT pelvis; w/o contrast followed Cervical Spine CT cervical spine; w/o contrast CT cervical spine; with contrast CT cervical spine; w/o contrast followed Thoracic Spine CT thoracic spine; w/o contrast CT thoracic spine; with contrast CT thoracic spine; w/o contrast followed MM\CPT Code List for Specialized Imaging Notifications(AuthorAS)(PW-PPPortMD)( ).xlsx 1 of 5

2 Lumbar Spine CT lumbar spine; w/o contrast CT lumbar spine; with contrast CT lumbar spine; w/o contrast followed Abdomen & Pelvis CT abdomen and pelvis; w/o contrast CT abdomen and pelvis; with contrast CT abdomen and pelvis; w/o contrast followed Computed Tomography CPT Description- Angiography (CTA) Abdomen CTA abdomen; w/o contrast followed and further Abdomen and Pelvis CTA abdomen and pelvis; w/out contrast followed and further Abdominal Arteries CTA abdominal aorta & bilateral iliofemoral lower extremity runoff; w/o contrast followed and further Chest CTA chest; w/o contrast followed and further Upper Extremity CTA upper extremity; w/o contrast followed and further Lower Extremity CTA lower extremity; w/o contrast followed and further Head CTA head; w/o contrast followed and further Neck CTA neck; w/o contrast followed and further Pelvis CTA pelvis; w/o contrast followed and further Imaging (MRI) Abdomen MRI abdomen; w/o contrast MRI abdomen; with contrast MRI abdomen; w/o contrast followed Bone Marrow MRI bone marrow blood supply (Replaces 76400) Breast MRI breast; unilateral (Replaces 76093) MRI breast; bilateral (Replaces 76094) MM\CPT Code List for Specialized Imaging Notifications(AuthorAS)(PW-PPPortMD)( ).xlsx 2 of 5

3 Chest MRI chest; w/o contrast MRI chest; with contrast MRI chest; w/o contrast followed Cardiac Cardiac MRI for morphology and function w/o contrast material Cardiac MRI for morphology and function w/o contrast material; with stress imaging Cardiac MRI for morphology and function w/o contrast material(s), followed material(s) and further sequences; with stress imaging Upper Extremity Non-joint MRI upper extremity, other than joint w/o contrast MRI upper extremity, other than joint with contrast MRI upper extremity, other than joint w/o contrast followed Upper Extremity Any Joint MRI upper extremity, any joint w/o contrast MRI upper extremity, any joint with contrast MRI upper extremity, any joint w/o contrast followed by contrast Lower Extremity MRI lower extremity, other than joint w/o contrast MRI lower extremity, other than joint with contrast MRI lower extremity, other than joint w/o contrast followed MRI lower extremity, any joint w/o contrast MRI lower extremity, any joint with contrast MRI lower extremity, any joint w/o contrast followed by contrast TMJ MRI temporomandibular joint(s) Orbit MRI orbit, face and neck; w/o contrast MRI orbit, face and neck; with contrast MRI orbit, face and neck; w/o contrast followed Brain MRI brain; w/o contrast MRI brain; with contrast MRI brain; w/o contrast followed Pelvis MRI pelvis; w/o contrast MRI pelvis; with contrast MRI pelvis; w/o contrast followed Cervical Spine MRI cervical spine; w/o contrast MRI cervical spine; with contrast MRI cervical spine; w/o contrast followed MM\CPT Code List for Specialized Imaging Notifications(AuthorAS)(PW-PPPortMD)( ).xlsx 3 of 5

4 Thoracic Spine MRI thoracic spine; w/o contrast MRI thoracic spine; with contrast MRI thoracic spine; w/o contrast followed Lumbar Spine MRI lumbar spine; w/o contrast MRI lumbar spine; with contrast MRI lumbar spine; w/o contrast followed Angiography (MRA) Abdomen MRA abdomen; with or w/o contrast Chest MRA chest; with or w/o contrast Upper Extremity C8934 MRA upper extremity; with contrast C8935 MRA upper extremity; w/o contrast C8936 MRA upper extremity; w/o contrast followed MRA upper extremity; with or w/o contrast Lower Extremity MRA lower extremity; with or w/o contrast Head MRA head; w/o contrast MRA head; with contrast MRA head; w/o contrast followed Neck MRA neck; w/o contrast MRA neck; with contrast MRA neck; w/o contrast followed Pelvis MRA pelvis; with or w/o contrast Spinal Canal C8931 MRA spinal canal & contents; with contrast C8932 MRA spinal canal & contents; w/o contrast C8933 MRA spinal canal & contents; w/o contrast followed MRA spinal canal & contents; with or w/o contrast Spectroscopy (MRS) MR Spectroscopy MM\CPT Code List for Specialized Imaging Notifications(AuthorAS)(PW-PPPortMD)( ).xlsx 4 of 5

5 Nuclear Cardiology CPT Description- Myocardial Perfusion Imaging SPECT, single study at rest or stress SPECT, Multiple studies, at rest and/or stress and/or redistribution and/or rest reinjection Planar, single study at rest or stress Planar multiple studies, at rest and/or stress and/or redistribution and/or rest reinjection Infarct Imaging Planar, Infarct avid; qualitative or quantitative Planar, Infarct avid; with ejection fraction by first pass technique SPECT, Infarct avid; with or w/o quantification Cardiac Blood Pool Imaging Gated equilibrium; planar, single study, wall motion plus ejection fraction Gated equilibrium; planar, multiple studies, wall motion study plus ejection fraction First pass tech; single study, wall motion study plus ejection fraction First pass tech; multiple studies, wall motion study plus ejection fraction Gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction Positron Emission Tomography CPT Description- (PET) Brain Imaging PET brain, metabolic evaluation PET brain, perfusion evaluation Myocardial Imaging PET myocardial, metabolic evaluation PET myocardial, perfusion, single study PET myocardial, perfusion, multiple studies CT/PET Fusion CPT Description- Tumor Imaging PET tumor imaging, limited PET tumor imaging, skull to mid-thigh PET tumor imaging, whole body PET tumor imaging with concurrent CT, limited PET tumor imaging with concurrent CT, skull to mid-thigh PET tumor imaging with concurrent CT, whole body *Please note: Notification is not required for echocardiograms or HIDA scans. MM\CPT Code List for Specialized Imaging Notifications(AuthorAS)(PW-PPPortMD)( ).xlsx 5 of 5

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