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1 2015 CPT List: VIVA HEALTH 2015 CPT CODE LIST Last ed: 9/23/2014 CCN s: Last sent to Plan: 1/14/2015 Last change made on: 1/14/2015 TMJ Tempomandibular joint/jaw Not Covered Not covered CT HEAD/BRAIN W/O 1/3/11added Medicare specific criteria CT HEAD/BRAIN W/ 1/3/11added Medicare specific criteria CT HEAD/BRAIN W/O & W/ 1/3/11added Medicare specific criteria CT ORBIT W/O Temporal Bone/Mastoid/Ears CT ORBIT W/ Temporal Bone/Mastoid/Ears CT ORBIT W/O & W/ Temporal Bone/Mastoid/Ears CT MAXLLFCL W/O Sinus/Denta Scan/TMJ CT MAXLLFCL W/ Sinus/Denta Scan/TMJ CT MAXLLFCL W/O & W/ Sinus/Denta Scan/TMJ CT SOFT TISSUE NECK W/O Parotid; Not used for Cervical Bone CT SOFT TISSUE NECK W/ Parotid; Not used for Cervical Bone CT SOFT TISSUE NECK W/O & W/ Parotid; Not used for Cervical Bone CT ANGIOGRAPHY HEAD CT ANGIOGRAPHY NECK FACE, ORBIT, NECK W/O Sinus/3 areas (soft tissue neck) eyes/temporal FACE, ORBIT, NECK W/ FACE, ORBIT, NECK W & W/O HEAD W/O Also known as HEAD W/ / Also known as HEAD W & W/O / Also known as NECK W/O Also known as NECK W / Also known as NECK W & W/O / Also known as HEAD W/O IACs (Internal Auditory Canal) Page 1 of 14

2 2015 CPT List: HEAD W/ IACs (Internal Auditory Canal) HEAD W/ & W/O IACs (Internal Auditory Canal) 70554, brain, functional ; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration 70555, brain, functional ; requiring physician or psychologist administration of entire neurofunctional testing CT THORAX W/O Can be CT Chest or a Ultrafast CT/EBT/EBCT CT THORAX W/ Chest/Ultrafast CT/EBT/EBCT CT THORAX W/O & W/ Chest/Ultrafast CT/EBT/EBCT CT ANGIOGRAPHY CHEST, NON CORONARY CHEST W/O Brachial Plexus CHEST W CHEST W & W/O CHEST (EXC MYOCARDIUM) W/ OR W/O / Also known as CT C SPINE W/O CT C SPINE W/ CT C SPINE W/O & W/ CT T SPINE W/O CT T SPINE W/ CT T SPINE W/O & W/ CT L SPINE W/O Includes Sacrum CT L SPINE W/ Includes Sacrum CT L SPINE W/O & W/ Includes Sacrum CERVICAL SPINE W/O Vertebrae of the Neck CERVICAL SPINE W/ THORACIC SPINE W/O THORACIC SPINE W/ LUMBAR SPINE W/O Includes Sacrum LUMBAR SPINE W/ Includes Sacrum Page 2 of 14

3 2015 CPT List: C SPINE W/ & W/O T SPINE W/ & W/O L SPINE W/ & W/O Includes Sacrum SPINAL CANAL W/ OR W/O CT ANGIOGRAPHY PELVIS / Also known as Aortic Aneurysm 12/13/11 Confirmed this is on list and should be PA Med Necessity review CT PELVIS W/O Below Belly Button/Coccyx CT PELVIS W/ Below Belly Button/Coccyx CT PELVIS W/O & W/ Below Belly Button/Coccyx PELVIS W/O Coccyx PELVIS W /coccyx PELVIS W & W/O /coccyx PELVIS W/ OR W/O / Also known as CT UPPER EXTREMITY W/O Hand/Arm/Shoulder/ Elbow/Wrist CT UPPER EXTREMITY W/ Hand/Arm/Shoulder/ Elbow/Wrist CT UPPER EXTREMITY W/O & W/ Hand/Arm/Shoulder/ Elbow/Wrist CT ANGIOGRAPHY UPPER EXTREMITY Hand/Arm/Shoulder/ Elbow/Wrist UPPER EXTREMITY W/O Hand/Arm/Axilla UPPER EXTREMITY W Hand/Arm/Axilla UPPER EXTREMITY W & W/O Hand/Arm/Axilla UPPER EXTREMITY JOINT W/O Shoulder/Elbow/Wrist UPPER EXTREMITY JOINT W Arthrogram Shoulder/Elbow/Wrist UPPER EXTREMITY JOINT W & W/O Shoulder/Elbow/Wrist UPPER EXTREMITY W/ OR W/O CT LOWER EXTREMITY W/O / Also known as Hip/Leg/Knee/Ankle/ Foot 12/13/11 Confirmed this is on list and should be PA Med Necessity review CT LOWER EXTREMITY W/ Hip/Leg/Knee/Ankle/ Foot CT LOWER EXTREMITY W/O & W/ Hip/Leg/Knee/Ankle/ Foot CT ANGIOGRAPHY LOWER EXTREMITY Hip/Leg/Knee/Ankle/ Foot LOWER EXTREMITY W/O Foot/Leg Page 3 of 14

4 2015 CPT List: LOWER EXTREMITY W Foot/Leg LOWER EXTREMITY W & W/O Foot/Leg LOWER EXTREMITY JOINT W/O Hip/Knee/Ankle LOWER EXTREMITY JOINT W Arthrogram Hip/Knee/Ankle LOWER EXTREMITY JOINT W & W/O Hip/Knee/Ankle LOWER EXTREMITY W/ OR W/O / Also known as CT ABDOMEN W/O Diaphragm to Belly Button CT ABDOMEN W/ Aneurysm/Diaphragm to Belly Button CT ABDOMEN W/O & W/ Diaphragm to Belly Button CT ANGIOGRAPHY, ABDOMEN AND PELVIS, WITH MATERIAL(S), INCLUDING NON IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING New code effective 1/1/12, CT abdomen and pelvis are now combined in a single code, when CTA abd & pelvis done in same session. 12/13/11 New code added CT ANGIOGRAPHY ABDOMEN Diaphragm to Belly Button COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT MATERIAL New 2011 Code COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH MATERIAL(S) New 2011 Code COMPUTED TOMOGRAPHY, New 2011 Code ABDOMEN AND PELVIS; WITHOUT MATERIAL IN ONE OR BOTH BODY REGIONS, FOLLOWED BY MATERIAL(S) AND FURTHER SECTIONS IN ONE OR BOTH BODY REGIONS ABDOMEN W/O MRCP MR Cholangiogram ABDOMEN W MRCP MR Cholangiogram ABDOMEN W & W/O MRCP MR Cholangiogram ABDOMEN W/ OR W/O Also known as COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY, DIAGNOSTIC, INCLUDING IMAGE POSTPROCESSING; WITHOUT MATERIAL Replaced 0066T & 0067T COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY, DIAGNOSTIC, INCLUDING IMAGE POSTPROCESSING; WITH MATERIAL(S) INCLUDING NON IMAGES, IF PERFORMED Replaced 0066T & 0067T COMPUTED TOMOGRAPHIC (CT) Replaced 0066T & 0067T COLONOGRAPHY, SCREENING, INCLUDING IMAGE POSTPROCESSING Investigational Not covered CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT MATERIAL CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT MATERIAL; WITH STRESS IMAGING Page 4 of 14

5 2015 CPT List: CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT MATERIAL(S), FOLLOWED BY MATERIAL(S) AND FURTHER SEQUENCES CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT MATERIAL(S), FOLLOWED BY MATERIAL(S) AND FURTHER SEQUENCES; WITH STRESS IMAGING CARDIAC MAGNETIC RESONANCE IMAGING FOR VELOCITY FLOW MAPPING COMPUTED TOMOGRAPHY, HEART, WITHOUT MATERIAL, WITH QUANTITATIVE EVALUATION OF CORONARY CALCIUM REPLACES 0144T Add on authorized wiith primary code Replaces 0144T COMPUTED TOMOGRAPHY, HEART, Replaces 0145T WITH MATERIAL, FOR EVALUATION OF CARDIAC STRUCTURE AND MORPHOLOGY (INCLUDING 3D IMAGE POSTPROCESSING, ASSESSMENT OF CARDIAC FUNCTION, AND EVALUATION OF VENOUS STRUCTURES, IF PERFORMED) REPLACES 0145T COMPUTED TOMOGRAPHY, HEART, Replaces 0150T WITH MATERIAL, FOR EVALUATION OF CARDIAC STRUCTURE AND MORPHOLOGY IN THE SETTING OF CONGENITAL HEART DISEASE (INCLUDING 3D IMAGE POSTPROCESSING, ASSESSMENT OF LV CARDIAC FUNCTION, RV STRUCTURE AND FUNCTION AND EVALUATION OF VENOUS STRUCTURES, IF PERFORMED) REPLACES 0150T COMPUTED TOMOGRAPHIC Replaces: 0146T; 0147T; 0148T & ANGIOGRAPHY, HEART, CORONARY 0149T ARTERIES AND BYPASS GRAFTS (WHEN PRESENT), WITH MATERIAL, INCLUDING 3D IMAGE POSTPROCESSING (INCLUDING EVALUATION OF CARDIAC STRUCTURE AND MORPHOLOGY, ASSESSMENT OF CARDIAC FUNCTION, AND EVALUATION OF VENOUS STRUCTURES, IF PERFORMED) REPLACES 0146T 0149T CT ANGIOGRAPHY ABDOMINAL AORTA Aortic Aneurysm 2/7/11 ADD TO CCN LIST AS ADD ON AUTH WITH PRIMARY CODES 11/15/11 Added to list per Dr. Weiner 11/15/11 Added to list per Dr. Weiner 11/15/11 Added to list per Dr. Weiner 3DI D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision ; not requiring image postprocessing on an independent workstation Effective 1/1/13 includes image postprocessing under concurrent supervision 3DI D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation Effective 1/1/13 includes image postprocessing under concurrent supervision CT LIMITED OR LOCALIZED FOLLOW UP STUDY SPECTROSCOPY UNLISTED COMPUTED TOMOGRAPHY PROCEDURE MRS Investigational Redirect to Valid code Not Covered Redirect to Valid code 12/13/11 for Medicare, revised from Investigational to Not Covered. 12/13/11 Confirmed this is on list and should be redirected UNLISTED PROCEDURE Redirect to Valid code Redirect to Valid code Page 5 of 14

6 2015 CPT List: UNLISTED RADIOLOGIC PROCEDURE U/S OB PELVIS, PREGNANT UTERUS, FIRST TRIMESTER <14 WEEKS SINGLE OR FIRST GESTATION U/S OB PELVIS, PREGNANT UTERUS, FIRST TRIMESTER <14 WEEKS EACH ADDITIONAL GESTATION Multiple Gestation Only used along with U/S OB PELVIS, PREGNANT UTERUS, Level 1 B SCAN (Allowed once per gestation) U/S OB PELVIS COMPLETE, MULTIPLE GESTATION AFTER 1ST TRIMESTER (Allowed once for each additional fetus per gestation; must be billed with 76805) Multiple Gestation Only used along with US PREGNANT UTERUS FETAL & Level 2 MATERNAL EVAL PLUS FETAL ANATOMIC EVAL TRANSABDOMINAL SINGLE OR FIRST GESTATION (Allowed once per gestation; second study allowed if performed by a different physician) US PREGNANT UTERUS FETAL & Multiple Gestation MATERNAL EVAL PLUS FETAL Only used along with ANATOMIC EVAL TRANSABDOMINAL EACH ADDITIONAL GESTATION (Allowed once for each additional fetus per gestation; must be billed with 76811; second study allowed if performed by a different physician) Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation. (Allowed once per gestation) Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; each additional gestation (List separately in addition to code for primary procedure) (Allowed once for each additional fetus per gestation) U/S PREGNANT UTERUS, REAL TIME W/IMAGE DOCUMENTATION, LIMITED (e.g. fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 OR MORE FETUSES Only one CPT code per DOS regardless the number of fetuses U/S OB PELVIS FOLLOW UP OR REPEAT US PREGNANT UTERUS TRANSVAGINAL Only one CPT code per DOS regardless the number of fetuses FETAL BIOPHYSICAL PROFILE FETAL BIOPHYSICAL PROFILE W/O STRESS NON STRESS DOPPLER VELOCIMETRY, FETAL; UMBILICAL ARTERY DOPPLER VELOCIMETRY, FETAL; MIDDLE CEREBRAL ARTERY U/S OB ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM Fetal Echo FOLLOW UP OR REPEAT STUDY DOPPLER ECHOCARDIOGRAPHY FETAL COMPLETE FOLLOW UP OR REPEAT STUDY Page 6 of 14

7 2015 CPT List: U/S GASTROINTESTINAL, ENDOSCOPIC CT GUIDANCE STEREOTACTIC LOCALIZATION CT GUIDANCE NEEDLE BX RAD S & I CT GUIDANCE FOR AND MONITORING OF TISSUE ABLATION CT GUIDANCE FOR PLACEMENT OF RADIATION THERAPY FIELDS GUIDANCE FOR NEEDLE PLACEMENT GUIDANCE FOR AND MONITORING OF TISSUE ABLATION BREAST W/ AND/OR W/O ; UNILATERAL Unilateral One BREAST BILATERAL Both CT BONE DENSITY STUDY, AXIAL SKELETON CT BONE DENSITY STUDY, APPENDICULAR SKELETON BONE MARROW BLOOD SUPPLY THYROID RAI UPTAKE to Thyroid uptake; single determination to Thyroid uptake; multiple determinations to Thyroid uptake stimulation, suppression or discharge (not including initial uptake studies) to Thyroid imaging, with uptake; single determination to Thyroid imaging, multiple determinations to Thyroid imaging; only to Thyroid imaging; with vascular flow to Thyroid uptake, single or multiple quantitative measurement(s) (including stimulation, suppression, or discharge, when performed) New code effective 1/1/13 replacing 78000, 78001, and Thyroid imaging (including vascular flow, when performed); New code replacing and Thyroid imaging (including vascular flow, when performed); with single or multiple uptake(s) quantitative measurement(s) (including stimulation, suppression, or discharge, when performed) New code replacing and THYROID MET IMAGING THYROID MET IMAGING WITH ADDITIONAL STUDIES THYROID SCAN WHOLE BODY For CA thyroid (I 31 scan) Page 7 of 14

8 2015 CPT List: THYROID CARCINOMA METASTASES UPTAKE (add on code use w/ code only) Use with only Effective 1/1/13 Revised to Parathyroid planar imaging (including "Parathyroid planar imaging subtraction, when performed) (including subtraction, when performed)" instead of Parathyroid planar imaging (including subtraction, when performed); with Effective 1/1/13 New code tomographic (SPECT) includes tomographic (SPECT) Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT), and concurrently acquired computed tomography (CT) for anatomical localization Effective 1/1/13 New code includes tomographic (SPECT), and concurrently acquired computed tomography (CT) for anatomical localization ADRENAL NUCLEAR IMAGING MIBG UNLISTED ENDOCRINE PROCEDURE BONE MARROW IMAGING, LIMITED BONE MARROW IMAGING, MULTIPLE BONE MARROW IMAGING, WHOLE BODY DIFFERENTIAL ORGAN/TISSUES KINETIC LABELED RED CELL SEQUESTRATION SPLEEN IMAGING W/WO VASCULAR FLOW PLATELET SURVIVAL, KINETICS PLATELET SURVIVAL LYMPH SYSTEM IMAGING MIBG UNLISTED HEMATOPOETIC PROCEDURE LIVER IMAGING LIVER IMAGING W FLOW LIVER IMAGING SPECT LIVER IMAGING SPECT W VASCULAR FLOW LIVER AND SPLEEN IMAGING Red Cell Tagging LIVER AND SPLEEN IMAGING W FLOW LIVER FUNCTION STUDY New code effective 1/1/12, crosswalks to HIDA SCAN New code effective 1/1/12, crosswalks to SALIVARY GLAND IMAGING SERIAL SALIVARY GLAND Page 8 of 14

9 2015 CPT List: SALIVARY GLAND FUNCTION TEST ESOPHAGUS MOTILITY STUDY GASTRIC MUCOSA IMAGING GASTROESOPHAGAEL REFLUX EXAM GASTRIC EMPTYING STUDY GI BLEEDER SCAN GI PROTEIN LOSS EXAM MECKEL'S DIVERTICULUM IMAGING LEVEEN SHUNT PATENCY EXAM UNLISTED GASTROINTESTINAL PROCEDURE BONE OR JOINT IMAGING LTD One Bone BONE OR JOINT IMAGING MULTIPLE More than one Bone BONE SCAN WHOLE BODY Used Often with CA studies/all bones BONE AND/OR JOINT IMAGING; 3 PHASE STUDY Osteomyelitis Technesium BONE JOINT IMAGING TOMO TEST SPECT UNLISTED MUSCULOSKELETAL PROCEDURE NON IMAGING HEART FUNCTION CARDIAC SHUNT IMAGING RADIONUCLIDE VENOGRAM NON CARDIAC 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) New Code/ Replaces updated to exclude this code effective 1/16/ MYOCARDIAL PERFUSION IMAGING, New Code/ Replaces 78465; 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 (EXERCISE OR PHARMACOLOGIC) AND/OR REDISTRIBUTION AND/OR REST REINJECTION updated to exclude this code effective 1/16/2015. Page 9 of 14

10 2015 CPT List: MYOCARDIAL PERFUSION IMAGING, New Code/ Replaces 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, New Code/ Replaces 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) AND/OR REDISTRIBUTION AND/OR REST REINJECTION ACUTE VENOUS THROMBOSIS IMAGING updated to exclude this code effective 1/16/2015. updated to exclude this code effective 1/16/ VENOUS THROMBOSIS IMAGING UNILATERAL VENOUS THROMBOSIS IMAGING BILATERAL MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) METABOLIC EVAL MYOCARDIAL INFARCTION SCAN HEART INFARCT IMAGE EF HEART INFARCT IMAGE SPECT GATED HEART, REST OR STRESS CARDIAC BLOOD POOL MUGA SCAN HEART FIRST PASS SINGLE CARDIAC BLOOD POOL IMAGING, MULTI 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 CARDIAC BLOOD POOL IMAGING, SPECT CARDIAC BLOOD POOL IMAGING, SINGLE AT REST (Use with 78472) UNLISTED CARDIOVASCULAR PROCEDURE PULMONARY VENTILATION IMAGING (EG, AEROSOL OR GAS) PULMONARY PERFUSION IMAGING PULMONARY VENTILATION (EG, AEROSOL OR GAS) AND PERFUSION IMAGING QUANTITATIVE DIFFERENTIAL PULMONARY PERFUSION, INCLUDING IMAGING WHEN PERFORMED New code effective 1/1/12, crosswalk(s) to deletd codes 78586, 78587, 78591, or Effective 1/1/12 description specific to particulate test (Lung Scan) New code effective 1/1/12, crosswalk(s) to deleted codes 78584, or New code effective 1/1/12, crosswalk NA Page 10 of 14

11 2015 CPT List: QUANTITATIVE DIFFERENTIAL PULMONARY PERFUSION AND VENTILATION (EG, AEROSOL OR GAS), INCLUDING IMAGING WHEN PERFORMED New code effective 1/1/12, crosswalks to deleted code UNLISTED RESPIRATORY PROCEDURE BRAIN IMAGING LTD STATIC BRAIN LTD IMAGING AND FLOW BRAIN IMAGING COMPLETE BRAIN IMAGING COMPLETE W FLOW BRAIN IMAGING SPECT SPECT BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) METABOLIC EVALUATION BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION EVALUATION BRAIN FLOW IMAGING ONLY 12/13/11 Confirmed this is on list and should be PA Med Necessity review CISTERNOGRAM (Cerebrospinal Fluid Flow) CEREBROSPINAL VENTRICULOGRAPHY CSF SHUNT EVALUATION CEREBROSPINAL FLUID SCAN SPECT CSF LEAKAGE DETECTION AND LOCALIZATION RADIOPHARMACEUTICAL DACRYOCYSTORGRAPHY UNLISTED ICINE PROCEDURE KIDNEY IMAGING MORPHOLOGY KIDNEY IMAGING MORPHOLOGY W VASCULAR FLOW KIDNEY IMAGING MORPHOLOGY W VASCULAR FLOW AND FUNCTION STUDY Renal Scan KIDNEY IMAGING MORPHOLOGY W VASCULAR FLOW AND FUNCTION, SINGLE W PHARM INTERVENTION KIDNEY IMAGING MORPHOLOGY W VASCULAR FLOW, MULTI, W/O AND W PHARM INTERVENTION Captorpril/Renal Scan/MAG KIDNEY IMAGING, SPECT KIDNEY FUNCTION STUDY, NON IMAGE RADIOISOTROPIC URINARY BLADDER RESIDUAL STUDY URETERAL REFLUX STUDY VCUG/Cystogram TESTICULAR IMAGING W VASCULAR FLOW Page 11 of 14

12 2015 CPT List: UNLISTED GENITOURINARY PROCEDURE RADIOPHARM LOCALIZATION OF TUMOR, LIMITED AREA RADIOPHARM LOCALIZATION OF TUMOR, MULTI AREAS Gallium Scan/Mammo Scintogram/OctreoScan RADIOPHARM LOCALIZATION OF TUMOR, WHOLE BODY Gallium Scan/Octreo Scan RADIOPHARM LOCALIZATION OF TUMOR, SPECT Gallium Scan/FUO RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR OR DISTRIBUTION OF RADIOPHARMACEUTICAL AGENT(S); WHOLE BODY, REQUIRING 2 OR MORE DAYS IMAGING RADIOPHARM LOCALIZATION OF ABSCESS, LIMITED AREA Gallium Scan/Indium Scan/WBC Scan/MBIG RADIOPHARM LOCALIZATION OF ABSCESS, WHOLE BODY Gallium Scan/Indium Scan/WBC Scan/MBIG RADIOPHARM LOCALIZATION OF ABSCESS, SPECT Galliium Scan/Indium Scan/WBC Scan/MBIG POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; LIMITED AREA (EG, CHEST, HEAD/NECK) POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; SKULL BASE TO MID THIGH POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; WHOLE BODY POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; LIMITED AREA (EG CHEST, HEAD/NECK) POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; SKULL BASE TO MID THIGH POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; WHOLE BODY UNLISTED MISC.PROCEDURE DIAGNOSTIC T CODES 0042T CT PERFUSION BRAIN Page 12 of 14

13 2015 CPT List: T CODES T CODES 0159T 0174T COMPUTER AIDED DETECTION, INCLUDING COMPUTER ALGORITHM ANALYSIS OF IMAGE DATA FOR LESION DETECTION/CHARACTERIZATION, PHARMACOKINETIC ANALYSIS, WITH FURTHER PHYSICIAN REVIEW FOR INTERPRETATION, BREAST (List separately in addition to code for primary procedure) COMPUTER AIDED DETECTION (CAD) INCLUDING COMPUTER ALGORITHM ANALYSIS OF DIGITAL IMAGE DATA FOR LESION DETECTION, WITH FURTHER PHYSICIAN REVIEW FOR INTERPRETATION AND REPORT, WITH OR WITHOUT DIGITIZATION OF FILM RADIOGRAPHIC IMAGES, CHEST RADIOGRAPH(S) PERFORMED CONCURRENT WITH PRIMARY INTERPRETATION T CODES 0175T COMPUTER AIDED DETECTION (CAD) INCLUDING COMPUTER ALGORITHM ANALYSIS OF DIGITAL IMAGE DATA FOR LESION DETECTION, WITH FURTHER PHYSICIAN REVIEW FOR INTERPRETATION AND REPORT, WITH OR WITHOUT DIGITIZATION OF FILM RADIOGRAPHIC IMAGES, CHEST RADIOGRAPH(S) PERFORMED REMOTE FROM PRIMARY INTERPRETATION C8900 WITH, ABDOMEN (crosswalked to 74185) crosswalked to C8901 WITHOUT, ABDOMEN (crosswalked to 74185) crosswalked to C8902 WITH AND WITHOUT, ABDOMEN (crosswalked to 74185) crosswalked to C8903 WITH, BREAST; UNILATERAL (crosswalked to 77058) crosswalked to C8904 WITHOUT, BREAST; UNILATERAL (crosswalked to 77058) crosswalked to C8905 WITH AND WITHOUT, crosswalked to BREAST; UNILATERAL (crosswalked to 77058) C8906 WITH, BREAST; BILATERAL (crosswalked to 77059) crosswalked to C8907 WITHOUT, BREAST; BILATERAL (crosswalked to 77059) crosswalked to C8908 WITH AND WITHOUT, crosswalked to BREAST; BILATERAL (crosswalked to 77059) C8909 WITH, CHEST (EXCLUDING MYOCARDIUM) (crosswalked to 71555) crosswalked to C8910 WITHOUT, CHEST (EXCLUDING MYOCARDIUM) (crosswalked to 71555) crosswalked to C8911 WITH AND WITHOUT, CHEST (EXCLUDING MYOCARDIUM) (crosswalked to 71555) crosswalked to C8912 WITH, LOWER EXTREMITY (crosswalked to 73725) crosswalked to C8913 WITHOUT, LOWER EXTREMITY (crosswalked to 73725) crosswalked to C8914 WITH AND WITHOUT, LOWER EXTREMITY (crosswalked to 73725) crosswalked to C8918 WITH, PELVIS (crosswalked to 72198) crosswalked to C8919 WITHOUT, PELVIS (crosswalked to 72198) crosswalked to Page 13 of 14

14 2015 CPT List: RADIOLOGY RADIOLOGY C8920 C8931 C8932 WITH AND WITHOUT, PELVIS (crosswalked to 72198) MAGNETIC RESONANCE ANGIOGRAPHY WITH, SPINAL CANAL AND CONTENTS (crosswalk to 72159) MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT, SPINAL CANAL AND CONTENTS crosswalked to (crosswalk to 72159) (crosswalk to 72159) RADIOLOGY C8933 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT FOLLOWED BY WITH, SPINAL CANAL AND CONTENTS (crosswalk to 72159) RADIOLOGY RADIOLOGY C8934 C8935 MAGNETIC RESONANCE ANGIOGRAPHY WITH, UPPER EXTREMITY MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT, UPPER EXTREMITY (crosswalk to 73225) (crosswalk to 73225) RADIOLOGY C8936 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT FOLLOWED BY WITH, UPPER EXTREMITY (crosswalk to 73225) RADIOLOGY G CODES G CODES G0219 G0235 PET IMAGING WHOLE BODY; MELANOMA FOR NON COVERED INDICATIONS PET IMAGING, ANY SITE, NOT OTHERWISE SPECIFIED Crosswalks to Crosswalks to Investigational Not Covered 12/13/11 Medicare revised from Investigational to Not Covered Redirect to valid code Redirect to valid code G CODES S CODES S CODES G0252 S8032 S8037 S8042 PET IMAGING, FULL AND PARTIAL RING PET SCANNERS ONLY FOR INITIAL DIAGNOSIS OF BREAST CANCER AND/OR SURGICAL PLANNING FOR BREAST CANCER LOW DOSE CT LUNG CANCER SCREENING MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP) CROSSWALK TO MAGNETIC RESONANCE IMAGING (), LOW FIELD (Crosswalk to any CPT code.) Crosswalks to Crosswalked to Crosswalked to any Redirect to valid code Redirect to valid code Redirect to valid code New Code Effective 10/1/14. Not Covered by Medicare, but plan chooses to require PA for the Medicare LOB. Redirect to valid code S CODES S CODES S8080 S8085 SCINTIMAMMOGRAPHY (RADIOIMMUNOSCINTIGRAPHY OF THE BREAST), UNILATERAL, INCLUDING SUPPLY OF RADIOPHARMACEUTICAL FLUORINE 18 FLUORODEOXYGLUCOSE (F 18 FDG) IMAGING USING DUAL HEAD COINCIDENCE DETECTION SYSTEM. (Non dedicated PET scan) S CODES S8092 ELECTRON BEAM COMPUTED TOMOGRAPHY (ALSO KNOWN AS ULTRAFAST CT, CINET) Page 14 of 14

PROCEDURE DESCRIPTION RADIOLOGY STUDIES

PROCEDURE DESCRIPTION RADIOLOGY STUDIES CPT CODE PROCEDURE DESCRIPTION RADIOLOGY STUDIES CT SCANS: 70450 CT HEAD/BRAIN W/O CONTRAST 70460 CT HEAD/BRAIN W/ CONTRAST 70470 CT HEAD/BRAIN W/O & W/ CONTRAST 70480 CT ORBIT W/O CONTRAST 70481 CT ORBIT

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