PRE-CERT Required - CPT LIST

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Adam Glenn
7 years ago
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1 70336 MRI T/M JOINT WITHOUT MRI NECK/FACE/ORBITS W/O Order this study alone for disorders arising BELOW the palate. For oral cavity, floor of mouth, oropharynx, MRI NECK/FACE/ORBITS WITH & WITHOUT submandibular glands, larynx/hypopharynx, and thyroid/parathyroid. This request would also be appropriate for the common lump in the neck when it arises below the angle of the jaw MRA HEAD WITHOUT MRA HEAD WITH & WITHOUT MRA NECK WITHOUT MRA NECK WITH MRA NECK WITH & WITHOUT MRI BRAIN W/OUT MRI BRAIN WITH & WITHOUT Order this study AND MRI NECK/FACE/ORBITS W&W/O for disorders originating at or above the level of the palate. The Neck is needed for comprehensive staging. For palate (hard or soft), nasal cavity, paranasal sinus, nasopharynx, parotid and parapharyngeal space. This category would be appropriate for the lump in the neck that arises above the angle of the jaw MRI CHEST WITHOUT MRI CHEST WITH & WITHOUT MRA CHEST WITH OR WITHOUT MRI SPINE CERVICAL WITHOUT MRI SPINE THORACIC WITHOUT MRI SPINE LUMBAR WITHOUT MRI SPINE CERVICAL WITH & WITHOUT Always order w/o contrast except for: MS, history of cancer or Always order w/o contrast except for: history of cancer or MRI SPINE THORACIC WITH & WITHOUT MRI SPINE LUMBAR WITH & WITHOUT Always order w/o contrast except for: history of cancer or MRI PELVIS WITHOUT MRI PELVIS WITH & WITHOUT Pelvis / Hips order w/o contrast except for: Arthrogram, lump or mass, schedule w/ & MRA PELVIS WITH OR WITHOUT MRI UPPER EXTREMITY WITHOUT Order for humerus, forearm or hand. Order for humerus, forearm or hand. Always order w/o MRI UPPER EXTREMITY WITH & WITHOUT MRI JOINT UPPER EXTREMITY WITHOUT Order for shoulder, wrist, fingers or elbow MRI ARTHROGRAM SHOULDER, ELBOW, WRIST Order for shoulder, elbow, wrist Order for shoulder, wrist, fingers or elbow. Always order w/o MRI JOINT UPPER EXTREMITY WITH & WITHOUT MRA UPPER EXTREMITY WITH OR WITHOUT This is NOT a covered service by Medicare. Order for humerus, forearm or hand.

2 73718 MRI LOWER EXTREMITY NOT JOINT WITHOUT Order for thigh, femur, lower leg, foot or toe. Order for thigh, femur,lower leg, foot or toe. Always order w/o MRI LOWER EXTREMITY NOT JOINT WITH & WITHOUT MRI JOINT LOWER EXTREMITY WITHOUT Order for hip, knee or ankle MRI JOINT LOWER EXTREMITY WITH Order for hip, knee or ankle. Order for hip, knee or ankle. Always order w/o contrast MRI JOINT LOWER EXTREMITY WITH & WITHOUT except for: Arthrogram, lump or mass, schedule w/ & w/o contrast MRA LOWER EXTREMITY Order for thigh, femur, lower leg, foot or toe MRI ABDOMEN WITHOUT MRI ABDOMEN WITH & WITHOUT Liver / Kidneys / Pancreas order w/ & w/o contrast except for: MRCP or Adrenals, order MRA ABDOMEN WITH OR WITHOUT MRI BREAST UNILATERAL WITHOUT AND/OR WITH Pre-cert 3D Reconstruction (76377) with this Breast MRI for all providers except Aetna (all plans), Amerihealth HMO, Horizon (Direct Access & NJ Direct), and Oxford (all plans) MRI BREAST BILATERAL WITHOUT AND/OR WITH CAT SCAN HEAD WITHOUT CAT SCAN HEAD WITH CAT SCAN HEAD WITH & WITHOUT CAT SCAN HEAD ORBITS / IACS WITHOUT Pre-cert 3D Reconstruction (76377) with this Breast MRI for all providers except Aetna (all plans), Amerihealth HMO, Horizon (Direct Access & NJ Direct), and Oxford (all plans) CAT SCAN HEAD ORBITS / IACS WITH CAT SCAN HEAD ORBITS / IACS WITH & WITHOUT CAT SCAN FACIAL BONES / SINUSES WITHOUT CAT SCAN FACIAL BONES WITH CAT SCAN FACIAL BONES WITH & WITHOUT CAT SCAN NECK WITHOUT CAT SCAN NECK WITH CAT SCAN NECK WITH & WITHOUT CAT SCAN ANGIO HEAD WITH Includes non-contrast if performed CAT SCAN ANGIO NECK WITH Includes non-contrast if performed CAT SCAN CHEST WITHOUT CAT SCAN CHEST WITH CAT SCAN CHEST WITH & WITHOUT CAT SCAN ANGIO CHEST WITH Includes non-contrast if performed CAT SCAN SPINE CERVICAL WITHOUT CAT SCAN SPINE CERVICAL WITH

3 72127 CAT SCAN SPINE CERVICAL WITH & WITHOUT CAT SCAN SPINE THORACIC WITHOUT CAT SCAN SPINE THORACIC WITH CAT SCAN SPINE THORACIC WITH & WITHOUT CAT SCAN SPINE LUMBOSACRAL WITHOUT CAT SCAN SPINE LUMBOSACRAL WITH CAT SCAN SPINE LUMBOSACRAL WITH & WITHOUT CAT SCAN ANGIO PELVIS WITH Includes non-contrast if performed Order w/o contrast for high creatnine levels. Pre-certify CPT CAT SCAN PELVIS WITHOUT CAT SCAN PELVIS WITH Pre-certify CPT Codes for BOTH Abdomen & Pelvis for GI, Appendix, and Always order w/ & w/o for a history of cancer. Pre-certify CPT CAT SCAN PELVIS WITH & WITHOUT CAT SCAN UPPER EXTREMITY WITHOUT CAT SCAN UPPER EXTREMITY WITH CAT SCAN UPPER EXTREMITY WITH & WITHOUT CAT SCAN ANGIO UPPER EXTREMITY WITH & WITHOUT CAT SCAN LOWER EXTREMITY WITHOUT CAT SCAN LOWER EXTREMITY WITH CAT SCAN LOWER EXTREMITY WITH & WITHOUT CAT SCAN ABDOMEN WITHOUT CAT SCAN ABDOMEN WITH CAT SCAN ABDOMEN WITH & WITHOUT Order w/o contrast for high creatnine levels. Pre-certify CPT Pre-certify CPT Codes for BOTH Abdomen & Pelvis for GI, Appendix, y and y y CAT SCAN ANGIO ABDOMEN WITH & WITHOUT CT Combined Codes for Abdomen and Pelvis performed on the same day (effective Jan. 2011): CT ABDOMEN AND PELVIS WITHOUT CT ABDOMEN AND PELVIS WITH CT ABDOMEN AND PELVIS WITH & WITHOUT

4 75635 CAT SCAN ANGIO ABDOMINAL AORTA & BILATERAL ILEOFEMORAL US PREGNANCY 0-13 WEEKS US PREGNANCY 0-13 WKS (ADDITIONAL FETUS) US PREGNANCY WEEKS US PREGNANCY WKS (ADDITIONAL FETUS) This exam US PREGNANCY LIMITED evaluates limited anatomy (fetal heart beat, placental location, fetal position and/or quantitative amniotic fluid volume). Order as a follow-up to re-evaluate fetal size by measuring the amniotic US PREGNANCY FOLLOW-UP fluid index (AFI) or estimated fetal weight (EFW) and/or to reevaluate organ systems suspected or confirmed to be abnormal on a previous scan US PREGNANCY TRANSVAGINAL US PREGNANCY NON-STRESS BIOPHYSICAL PROFILE If this code is US PREGNANCY BIOPHYSICAL PROFILE used for the second or any other additional fetuses, it should be pre-certified with either or US ECHOCARDIOGRAM WITH DOPPLER This procedure requires pre-certification through HORIZON, US CARDIOGRAM This procedure requires pre-certification through HORIZON, US CARDIOGRAM LIMITED/FOLLOW-UP This procedure requires pre-certification through HORIZON, US CARDIOGRAM COLOR FLOW This procedure requires pre-certification through HORIZON (as of 3/1/08) and AETNA NORTH (as of 9/1/08) HYSTEROSALPINGOGRAM PET (FDG) BRAIN - METABOLIC MEDICARE: If PET is ordered for Alzheimer's, the patient needs to have BOTH a recent CT or MRI AND an mini-mental status exam prior to scheduling. Also - Medicare only pays for ONE life-time study.if you need help scheduling this PET scan, call Betsy in the PET Scheduling Department at PET/CT SCAN - LIMITED AREA Head & Neck Only. If not Head & Neck use If you need help scheduling this PET/CT scan, call Betsy at

5 78815 PET/CT SCAN SKULL BASE TO MID-THIGH For Oncology - Cancer Staging. If you need help scheduling this PET/CT scan, call Betsy at PET/CT SCAN WHOLE BODY WITH EXTREMITIES For Melanoma and Multiple Myeloma. If you need help scheduling this PET/CT scan, call Betsy at

Diagnostic Imaging Prior Review Code List 3 rd Quarter 2016

Diagnostic Imaging Prior Review Code List 3 rd Quarter 2016 Computerized Tomography (CT) Abdomen 6 Abdomen/Pelvis Combination 101 Service 74150 CT abdomen; w/o 74160 CT abdomen; with 74170 CT abdomen; w/o followed by 74176 Computed tomography, abdomen and pelvis;