Computerized Tomography (CT) CPT Description CT abdomen; w/o contrast Abdomen

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1 Empire BlueCross BlueShield Diagnostic Imaging and Cardiology Program and Enhanced Cardiology: cardiac catheterization, arterial ultrasound, and percutaneous coronary intervention (PCI) CPT Code List Computerized Tomography (CT) CPT Description CT abdomen; w/o contrast Abdomen CT abdomen; with contrast CT abdomen; w/o contrast followed by contrast CT thorax; w/o contrast Chest CT thorax; with contrast CT thorax; w/o contrast followed by contrast CT upper extremity; w/o contrast Upper Extremity CT upper extremity; with contrast CT upper extremity; w/o contrast followed by contrast CT lower extremity; w/o contrast Lower Extremity CT lower extremity; with contrast CT lower extremity; w/o contrast followed by contrast CT head or brain; w/o contrast Head CT head or brain; with contrast CT head or brain; w/o contrast followed by contrast Orbit CT orbit, sella or posterior fossa; w/o contrast CT orbit, sella or posterior fossa; with contrast Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

2 70482 CT orbit, sella or posterior fossa; w/o contrast followed by contrast Sinus Neck Pelvis Cervical Spine Thoracic Spine Lumbar Spine Abdomen and Pelvis CT maxillofacial area; w/o contrast CT maxillofacial area; with contrast CT maxillofacial area; w/o contrast followed by contrast CT soft tissue neck; w/o contrast CT soft tissue neck; with contrast CT soft tissue neck; w/o contrast followed by contrast CT pelvis; w/o contrast CT pelvis; with contrast CT pelvis w/o contrast followed by contrast CT cervical spine; w/o contrast CT cervical spine; with contrast CT cervical spine; w/o contrast followed by contrast CT thoracic spine; w/o contrast CT thoracic spine; with contrast CT thoracic spine; w/o contrast followed by contrast CT lumbar spine; w/o contrast CT lumbar spine; with contrast CT lumbar spine; w/o contrast followed by contrast CT abdomen and pelvis; w/o contrast CT abdomen and pelvis; with contrast CT abdomen and pelvis; w/o contrast followed by contrast Computerized Tomography Angiography (CTA) CPT Description Abdomen CTA abdomen CTA abdominal aorta & bilateral iliofemoral lower extremity runoff

3 Abdomen and Pelvis CTA abdomen & pelvis wo/w contrast Chest CTA chest Upper Extremity CTA upper extremity Lower Extremity CTA lower extremity Head CTA head Neck CTA neck Pelvis CTA pelvis Magnetic Resonance Imaging (MRI) CPT Description MRI abdomen; w/o contrast Abdomen MRI abdomen; with contrast MRI abdomen; w/o contrast followed by contrast Bone Marrow MRI bone marrow blood supply Breast MRI breast; unilateral MRI breast; bilateral MRI chest; w/o contrast Chest MRI chest; with contrast MRI chest; w/o contrast followed by contrast MRI Cardiac for morphology and function without contrast material; MRI Cardiac for morphology and function without contrast material; with stress imaging Cardiac MRI Cardiac for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; MRI Cardiac for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging

4 Upper Extremity Non-joint Upper Extremity Any Joint Lower Extremity 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 by contrast 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 MRI lower extremity, other than joint w/o contrast MRI lower extremity, other than joint w contrast MRI lower extremity, other than joint w/o contrast followed by contrast MRI lower extremity, any joint w/o contrast MRI lower extremity, any joint w contrast MRI lower extremity, any joint w/o contrast followed by contrast TMJ MRI temporomandibular joint(s) MRI orbit, face and neck; w/o contrast Orbit MRI orbit, face and neck; with contrast MRI orbit, face and neck; w/o contrast followed by contrast MRI brain; w/o contrast Brain MRI brain; with contrast MRI brain; w/o contrast followed by contrast MRI pelvis; w/o contrast Pelvis MRI pelvis; with contrast MRI pelvis; w/o contrast followed by contrast Cervical Spine MRI cervical spine; w/o contrast MRI cervical spine; with contrast

5 Thoracic Spine Lumbar Spine MRI cervical spine; w/o contrast followed by contrast MRI thoracic spine; w/o contrast MRI thoracic spine; with contrast MRI thoracic spine; w/o contrast followed by contrast MRI lumbar spine; w/o contrast MRI lumbar spine; with contrast MRI lumbar spine; w/o contrast followed by contrast Magnetic Resonance Angiography (MRA) CPT Description Abdomen MRA abdomen; with or w/o contrast Chest MRA chest; with or w/o contrast Upper Extremity MRA upper extremity; with or w/o contrast Lower Extremity MRA lower extremity; with or w/o contrast MRA head; w/o contrast Head MRA head; with contrast MRA head; w/o contrast followed by contrast MRA neck; w/o contrast Neck MRA neck; with contrast MRA neck; w/o contrast followed by contrast Pelvis MRA pelvis; with or w/o contrast Spinal Canal MRA spinal canal and contents with or w/o contrast Magnetic Resonance Spectroscopy (MRS) CPT Description MR Spectroscopy QCT Bone Densitometry CPT Description CT bone mineral density study; axial skeleton 77078

6 Nuclear Cardiology CPT Description 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) Myocardial Perfusion Imaging 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 reinjection Myocardial perfusion imaging, planar (including 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) 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 pharmacologic) Infarct Imaging Cardiac Blood Pool 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 Gated equilibrium; planar, single study, wall motion plus ejection fraction Gated equilibrium; planar, multiple studies, wall motion study plus ejection fraction

7 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 (PET) CPT Description Brain Imaging PET brain, metabolic evaluation PET brain, perfusion evaluation PET myocardial, metabolic evaluation Myocardial Imaging PET myocardial, perfusion, single study PET myocardial, perfusion, multiple studies PET and PET/CT Fusion CPT Description PET imaging, limited PET imaging, skull to mid-thigh PET imaging, whole body PET imaging with concurrent CT, limited PET imaging with concurrent CT, skull to mid-thigh PET imaging with concurrent CT, whole body Screening CT Colonoscopy CPT Description Diagnostic CT Colonography CPT Description Computed tomographic (CT) colonography, screening, including image post processing Computed tomographic (CT) colonography, diagnostic, including image post processing; without contrast material Computed tomographic (CT) colonography, diagnostic, including image post processing; with contrast material(s) including non-contrast images, if performed

8 Functional MRI Brain CPT Description Functional MRI brain not requiring physician administration Functional MRI brain requiring physician administration CT Heart for Calcium Scoring CPT Description CT Heart for Structure & Morph CPT Description Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium 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) 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) CTA Heart Incl Structure & Morph CPT Description Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image post processing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures if performed) Add-on Procedures CPT Description CT or MRI Grouping & D Reconstruction of CT or MRI images

9 Cardiac MRI Grouping Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure) Cardiac Blood Pool Grouping Group 82 valid with code only MRI Fetal Cardiac blood pool imaging, gated equilibrium, single study, at rest, with right ventricular ejection fraction by first pass technique (Add-on to only) Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; each additional gestation (List separately in addition to code for primary procedure 74712) CT Grouping Limited follow-up CT Echocardiogram CPT Description Stress Echo (SE) Transthoracic Stress Echo, complete Transthoracic Stress Echo, complete w cont EKG Transthoracic Echo cardiac anomalies Transthoracic Echo cardiac anomalies, limited Resting Trans Echo (TTE) Transthoracic Echo complete w color & spectral Transthoracic Echo complete wo color & spectral Transthoracic Echo limited Transesophageal Echo Transesophageal Echo probe only Transesophageal Echo (TEE) Transesophageal Echo interpretation Transesophageal Echo congenital Transesophageal Echo congenital, probe only Transesophageal Echo congenital interpretation Echo Add-On Codes CPT Description Doppler Echo complete Doppler Echo limited Doppler Echo flow velocity

10 93352 Echo contrast agent (SE only) The codes listed below are effective March 1, 2016 RT and/or LT Heart Cath with Coronary Angiography CPT Description CATH PLMT R HRT & ARTS W/NJX & ANGIO IMG S&I CATH PLMT R HRT/ARTS/GRFTS W/NJX& ANGIO IMG S&I CATH PLMT L HRT & ARTS W/NJX & ANGIO IMG S&I CATH PLMT L HRT/ARTS/GRFTS WNJX & ANGIO IMG S&I R & L HRT CATH WINJX HRT ART& L VENTR IMG R& L HRT CATH W/INJEC HRT ART/GRFT& L VENT I Add-On Codes (Note: Add-On Codes do not require an authorization.) RT and/or LT Heart Cath with Coronary Angiography CPT Description LEFT HEART CATH BY TRANSEPTAL PUNCTURE MEDICATION ADMIN & HEMODYNAMIC MEASURMENT PHYSIOLOGIC EXERCISE STUDY & HEMODYNAMIC MEASU NJX SEL R VENT/ATRIAL ANGIO HRT CATH W/S&I NJX SUPRAVALV AORTOG HRT CATH W/S&I NJX PULMONARY ANGIO HRT CATH W/S&I Duplex Scan Aorta, IVC & Iliac Vessels CPT Description DUP-SCAN AORTA IVC ILIAC VASCL/BPGS COMPLETE DUP-SCAN AORTA IVC ILIAC VASCL/BPGS UNI/LMTD

11 Duplex Scan Extracranial Arteries CPT Description DUPLEX SCAN EXTRACRANIAL ART COMPL BI STUDY DUPLEX SCAN EXTRACRANIAL ART UNI/LMTD STUDY NIV Physiologic Studies Extremity Arteries CPT Description NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 2 LEVEL NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY 3 LEVLS N-INVAS PHYSIOLOGIC STD LXTR ART COMPL BI Duplex Scan Lower Extremity Arteries CPT Description DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STUDY DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STUDY Duplex Scan Upper Extremity Arteries CPT Description DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STUDY DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STUDY Percutaneous Coronary Intervention (PCI) CPT Description PRQ CARDIAC ANGIOPLAST 1 ART PRQ CARD ANGIO/ATHRECT 1 ART PRQ CARD STENT W/ANGIO 1 VSL PRQ CARD STENT/ATH/ANGIO PRQ REVASC BYP GRAFT 1 VSL PRQ CARD REVASC CHRONIC 1VSL 92943

12 Add-On Codes (Note: Add-On Codes do not require an authorization) Percutaneous Coronary Intervention (PCI) CPT PRQ CARDIAC ANGIO ADDL ART PRQ CARD ANGIO/ATHRECT ADDL PRQ CARD STENT W/ANGIO ADDL PRQ CARD STENT/ATH/ANGIO PRQ REVASC BYP GRAFT ADDL PRQ CARD REVASC CHRONIC ADDL Description Coronary Angiography CPT Description CATH PLACEMENT & NJX CORONARY ART ANGIO IMG S&I CATH PLMT & NJX CORONARY ART/GRFT ANGIO IMG S&I Add-On Codes (Note: Add-On Codes do not require an authorization.) Coronary Angiography CPT Description NJX SUPRAVALV AORTOG HRT CATH W/S&I RT and/or LT Heart Cath without Coronary Angiography CPT Description RIGHT HEART CATH O2 SATURATION & CARDIAC OUTPUT L HRT CATH W/NJX L VENTRICULOGRAPHY IMG S&I R & L HRT CATH W/NJX L VENTRICULOG IMG S&I RT HEART CATH CONGENITAL

13 93531 R & L HEART CATH CONGENITAL R & L HEART CATH CONGENITAL R & L HEART CATH CONGENITAL Add-On Codes (Note: Add-On Codes do not require an authorization.) RT and/or LT Heart Cath without Coronary Angiography CPT Description LEFT HEART CATH BY TRANSEPTAL PUNCTURE MEDICATION ADMIN & HEMODYNAMIC MEASURMENT PHYSIOLOGIC EXERCISE STUDY & HEMODYNAMIC MEASU NJX SEL R VENT/ATRIAL ANGIO HRT CATH W/S&I NJX SUPRAVALV AORTOG HRT CATH W/S&I NJX PULMONARY ANGIO HRT CATH W/S&I INJECT CONGENITAL CARD CATH INJECT HRT CONGNTL ART/GRFT INJECT L VENTR/ATRIAL ANGIO

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