IMAGING PROCEDURES REQUIRING PRECERTIFICATION

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1 IMAGING PROCEDURES REQUIRING PRECERTIFICATION Below is a list of the imaging CPT codes that require precertification for commercial and Medicare Members. Please note that other procedures may be added as necessary; Oxford will inform you of all changes through thequarterly Program & Policy Update publication. Clinical notes are required for the codes that are checked; please use the attached form for those studies. Every year the AMA makes changes to the CPT manual. The bolded codes below indicate codes that have been added by the AMA. CT SCANS CT HEAD/BRAIN W/O CONTRAST CT HEAD/BRAIN W/CONTRAST CT HEAD/BRAIN W/O AND W/CONTRAST CT ORBIT W/O CONTRAST CT ORBIT W/CONTRAST CT ORBIT W/O AND W/CONTRAST CT MAXLLFCL W/O CONTRAST CT MAXLLFCL W/CONTRAST CT MAXLLFCL W/O AND W/CONTRAST CT SOFT TISSUE W/O CONTRAST CT SOFT TISSUE W/CONTRAST CT SOFT TISSUE W/O AND W/CONTRAST CT ANGIOGRAPHY, HEAD CT ANGIOGRAPHY, NECK CT THORAX W/O CONTRAST CT THORAX W/ CONTRAST CT THORAX W/O AND W/CONTRAST CT ANGIOGRAPHY CHEST CT C SPINE W/O CONTRAST CT C SPINE W/ CONTRAST CT C SPINE W/O AND W/CONTRAST CT T SPINE W/O CONTRAST CT T SPINE W/CONTRAST CT T SPINE W/O AND W/CONTRAST CT L SPINE W/O CONTRAST CT L SPINE W/CONTRAST CT L SPINE W/O AND W/CONTRAST CT ANGIOGRAPHY PELVIS CT PELVIS W/O CONTRAST CT PELVIS W/CONTRAST CT PELVIS W/O AND W/CONTRAST CT ANGIOGRAPHY UPPER EXTREMITY CT UPPER EXTREMITY W/O CONTRAST CT UPPER EXTREMITY W/CONTRAST CT UPPER EXTREMITY W/O AND W/CONTRAST CT LOWER EXTREMITY W/O CONTRAST CT LOWER EXTREMITY W/CONTRAST

2 73702 CT LOWER EXTREMITY W/O AND W/CONTRAST CT ANGIOGRAPHY LOWER EXTREMITY CT ABDOMEN W/O CONTRAST CT ABDOMEN W/CONTRAST CT ABDOMEN W/O AND W/CONTRAST CT ANGIOGRAPHY ABDOMEN CT ANGIOGRAPHY ABDOMINAL AORTA XRAY SUPERVISION AND INTPRETATION, PERCUTANEOUS VERTEBRALPLASTY PER VERTEBRAL BODY UNDER CT GUIDANCE CT BONE DENSITY STUDY CT LIMITED OR LOCALIZED FOLLOW-UP STUDY MRI MRI TMJ MRI FACE, ORBIT, NECK W/O CONTRAST MRI FACE, ORBIT, NECK WITH CONTRAST MRI FACE, ORBIT, NECK W/ & W/O CONTRAST MRI HEAD W/O CONTRAST MRI HEAD W/CONTRAST MRI HEAD W/ & W/O CONTRAST MRI CHEST W/O CONTRAST MRI CHEST W/ CONTRAST MRI CHEST W/ & W/O CONTRAST MRI CERVICAL SPINE W/O CONTRAST MRI CERVICAL SPINE W/CONTRAST MRI THORACIC SPINE W/O CONTRAST MRI THORACIC SPINE W/CONTRAST MRI LUMBAR SPINE W/O CONTRAST MRI LUMBAR SPINE W/CONTRAST MRI C SPINE W/ & W/O CONTRAST MRI T SPINE W/ & W/O CONTRAST MRI L SPINE W/ & W/O CONTRAST MRI PELVIS W/O CONTRAST MRI PELVIS W/CONTRAST MRI PELVIS W/ & W/O CONTRAST MRI UPPER EXTREMITY OTHER THAN JOINT W/O CONTRAST MRI UPPER EXTREMITY OTHER THAN JOINT W/ CONTRAST MRI UPPER EXTREMITY OTHER THAN JOINT W/ & W/O CONTRAST MRI UPPER EXTREMITY JOINT W/O CONTRAST MRI UPPER EXTREMITY JOINT W/ CONTRAST MRI UPPER EXTREMITY JOINT W/ & W/O CONTRAST MRI LOWER EXTREMITY OTHER THAN JOINT W/O CONTRAST MRI LOWER EXTREMITY OTHER THAN JOINT W/ CONTRAST MRI LOWER EXTREMITY OTHER THAN JOINT W/ & W/O CONTRAST MRI LOWER EXTREMITY JOINT W/O CONTRAST MRI LOWER EXTREMITY JOINT W/ CONTRAST MRI LOWER EXTREMITY JOINT W & W/O CONTRAST MRI ABDOMEN W/O CONTRAST MRI ABDOMEN W/ CONTRAST MRI ABDOMEN W/ & W/O CONTRAST CARDIAC MRI FOR MORPHOLOGY W/O CONTRAST (GATED HEART)

3 75553 CARDIAC MRI MORPHOLOGY W/CONTRAST CARDIAC MRI COMPLETE W/ OR W/O MORPHOLOGY CARDIAC MRI LIMITED CARDIAC MRI VELOCITY FLOW MRI BREAST W/ AND/OR W/O CONTRAST MRI BREAST BILATERAL MRI SPECTROSCOPY MRI GUIDANCE FOR PLACEMENT RADIOLOGICAL SUPERVISION AND INTERPRETATION MRI BONE MARROW BLOOD SUPPLY UNLISTED PROCEDURE MRA MRA HEAD W/O CONTRAST MRA HEAD W/ CONTRAST MRA HEAD W/ & W/O CONTRAST MRA NECK W/O CONTRAST MRA NECK W/ CONTRAST MRA NECK W/ & W/O CONTRAST MRA CHEST (EXC MYOCARDIUM) W/ OR W/O CONTRAST MRA SPINAL CANAL W/ OR W/O CONTRAST MRA PELVIS W/ OR W/O CONTRAST MRA UPPER EXTREMITY W/ OR W/O CONTRAST MRA LOWER EXTREMITY W/ OR W/O CONTRAST MRA ABDOMEN W/ OR W/O CONTRAST PET SCANS CPT CODE DESCRIPTION MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) METABOLIC EVAL MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION; SINGLE STUDY AT REST OR STRESS MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION; MULTIPLE STUDIES AT REST OR STRESS BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) METABOLIC EVALUATION BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) METABOLIC EVALUATION, PERFUSION EVALUATION TUMOR IMAGING (PET SCAN) NUCLEAR MEDICINE THYROID RAI UPTAKE THYROID, MULTIPLE UPTAKES THYROID SUPPRESS OR STIMULATION THYROID UPTAKE AND SCAN THYROID, IMAGE, MULTIPLE UPTAKES THYROID SCAN ONLY THYROID IMAGING WITH FLOW THYROID MET IMAGING THYROID MET IMAGING WITH ADDITIONAL STUDIES THYROID SCAN WHOLE BODY THYROID CARCINOMA METASTASES UPTAKE

4 78070 PARATHYROID NUCLEAR IMAGING ADRENAL NUCLEAR IMAGING UNLISTED ENDOCRINE PROCEDURE, DIAGNOSTIC NUCLEAR MEDICINE BONE MARROW IMAGING, LIMITED BONE MARROW IMAGING, MULTIPLE BONE MARROW IMAGING, WHOLE BODY PLASMA VOLUME, SINGLE PLASMA VOLUME, MULTIPLE SAMPLING RED CELL VOLUME DETERMINATION, SINGLE SAMPLING RED CELL VOLUME DETERMINATION, MULTIPLE SAMPLING WHOLE BLOOD VOLUME DETERMINATION, SEP PLASMA & RED CELL RED CELL SURVIVAL STUDY DIFFERENTIAL ORGAN / TISSUES KINETIC LABELED RED CELL SEQUESTRATION PLASMA RADIOIRON DISAPEARANCE RADIOIRON ORAL ABSORPTION RED CELL IRON UTILIZATION TOTAL BODY IRON ESTIMATION SPLEEN IMAGING W & W/O VAS FLOW PLATELET SURVIVAL, KINETICS PLATELET SURVIVAL LYMPH SYSTEM IMAGING UNLISTED HEMATOPOIETIC DIAGNOSTIC NUCLEAR MED LIVER IMAGING LIVER IMAGING WITH FLOW LIVER IMAGING SPECT (3-D) LIVER IMAGING SPECT W/ VASCULAR FLOW LIVER & SPLEEN IMAGING LIVER & SPLEEN IMAGING WITH FLOW LIVER FUNCTION STUDY HIDA SCAN SALIVARY GLAND IMAGING SERIAL SALIVARY GLAND SALIVARY GLAND FUNCTION EXAM ESOPHOGUS MOTILITY STUDY GASTRIC MUCOSA IMAGING GASTROESOPHAGEAL REFLUX EXAM GASTRIC EMPTYING STUDY VIT-B12 ABSORPTION EXAM VIT-B12 ABSORPTION EXAM, LF VIT-B12 ABSORPTION EXAM COMBINED GI BLEEDER SCAN GI PROTEIN LOSS EXAM MECKEL S DIVERTICULUM IMAGING LEVEEN SHUNT PATENCY EXAM UNLISTED GASTROINTESTINAL BONE OR JOINT IMAGING LTD BONE OR JOINT IMAGING MULTIPLE BONE SCAN WHOLE BODY BONE SCAN 3-PHASE STUDY BONE JOINT IMAGING TOMO TEST BONE MINERAL, SINGLE PHOTON BONE MINERAL, DUAL PHOTON UNLISTED MUSCULOSKELETAL

5 78414 NON-IMAGING HEART FUNCTION CARDIAC SHUNT IMAGING RADIONUCLIDE VENOGRAM NON-CARDIAC VENOUS THROMBOSIS STUDY VENOUS THROMBOSIS IMAGING UNILATERAL VENOUS THROMBOSIS IMAGES, BILATERAL THALLIUM SCAN REST ONLY MYOCARDIAL PERF STRESS OR REST MULTIPLE STUDY HEART IMAGE (3-D) SINGLE MYOCARDIAL PERF W/SPECT MULTIPLE MYOCARDIAL INFARCTION SCAN HEART INFARCT IMAGE EF HEART INFARCT IMAGE 3-D GATED HEART, RESTING CARDIAC BLOOD POOL MUGA SCAN MYOCARDIAL WALL MOTION STUDY HEART FIRST PASS SINGLE CARDIAC BLOOD POOL IMAGING MULTIPLE CARDIAC BLOOD POOL IMAGING, SPECT CARDIAC BLOOD POOL IMAGING SINGLE STUDY AT REST (USE WITH 78472) UNLISTED CARDIOVASCULAR NUCLEAR EXAM PULMONARY PERFUSION IMAGING PULMONARY PERFUSION WITH VENT SINGLE BREATH PULMONARY PERFUSION W/ WASHOUT, W/ OR W/O SINGLE BREATH PULMONARY VENTILATION IMAGING PULMONARY VENTILATION MULTI PULMONARY PERFUSION W/ VENTILATION VENT IMAGE 1 BREATH, 1 PROJECTION VENT IMAGE 1 PROJECTION, GAS VENT IMAGE MULTI PROJECTION, GAS LUNG DIFFERENTIAL FUNCTION UNLISTED RESPIRATORY NUCLEAR EXAM BRAIN IMAGING LTD STATIC BRAIN LTD IMAGING AND FLOW BRAIN IMAGING COMPLETE BRAIN IMAGING COMPLETE WITH FLOW BRAIN IMAGING 3-D BRAIN FLOW IMAGING ONLY CREBRAL BLOOD FLOW IMAGING CISTERNOGRAM (CEREBROSPINAL FLUID FLOW) CEREBROSPINAL VENTRICULOGRAPHY CSF SHUNT EVALUATION CEREBROSPINAL FLUID SCAN CSF LEAKAGE DETECTION AND LOCALIZATION RADIOPHARMACEUTICAL DACRYOCYSTOGRAPHY UNLISTED DIAGNOSTIC NUCLEAR MED PROCEDURE KIDNEY IMAGING (STATIC) KIDNEY IMAGING W/VASCULAR FLOW KIDNEY IMAGING W/FUNCTION STUDY KIDNEY IMAGING W/VASCULAR FLOW & FUNCTIONAL SINGLE STUDY KIDNEY IMAGING SINGLE STUDY W/PHARM. INTERVENTION KIDNEY IMAGING MULTIPLE STUDIES W/ & W/O PHARM. INTERVENTION KIDNEY IMAGING TOMOGRAPHIC (SPECT)

6 78715 KIDNEY VASCULAR FLOW ONLY KIDNEY FUNCTION STUDY NON-IMAGING RADIOISOTOPIC URINARY BLADDER RESIDUAL STUDY URETERAL REFLUX STUDY TESTICULAR IMAGING TESTICULAR IMAGING W/VASCULAR FLOW UNLISTED GENITOURINARY PROCEDURE RADIOPHARM LOCALIZATION OF TUMOR, LIMITED AREA RADIOPHARM LOCALIZATION OF TUMOR, MULTIPLE AREAS RADIOPHARM LOCALIZATION OF TUMOR, WHOLE BODY RADIOPHARM LOCALIZATION OF TUMOR TOMOGRAPHIC (SPECT) RADIOPHARM LOCALIZATION OF ABSCESS, LIMITED AREA RADIOPHARM LOCALIZATION OF ABSCESS, WHOLE BODY RADIOPHARM LOCALIZTION OF ABSCESS, TOMOGRAPHIC SPECT UNLISTED MISC. PROCEDURE OBSTETRICAL ULTRASOUNDS *FOURTH AND SUBSEQUENT (4+) REQUIRE PRECERTIFICATION CPT CODE DESCRIPTION ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME W/IMAGE DOCUMENTATION, COMPLETE FETAL AND MATERNAL EVALUATION COMPLETE-FETAL AND MATERNAL EVALUATION, MULTIPLE GESTATION, AFTER THE FIRST TRIMESTER LIMITED-FETAL SIZE, HEART BEAT, PLACENTAL LOCATION, FETAL POSITION OR EMERGENCY IN THE DELIVERY ROOM FOLLOW UP OR REPEAT FETAL BIOPHYSICAL PROFILE FETAL BIOPHYSICAL PROFILE; WITHOUT STRESS OR NON-STRESS TESTING ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, REAL TIME W/IMAGE DOCUMENTATION (2D), W/ OR W/O M-MODE RECORDING FOLLOW UP OR REPEAT STUDY DOPPLER ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, PULSED WAVE AND/OR CONTINUOUS WAVE W/SPECTRAL DISPLAY, COMPLETE FOLLOW UP OR REPEAT STUDY ECHOGRAPHY, TRANSVAGINAL HYSTEROSONOGRAPHY, W/ OR W/O COLOR FLOW DOPPLER MISCELLANEOUS DEXA BONE DENSITY ENDOSCOPIC ULTRASOUND

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