Diagnostic Imaging Prior Review Code List 3 rd Quarter 2016

Transcription

1 Computerized Tomography (CT) Abdomen 6 Abdomen/Pelvis Combination 101 Service CT abdomen; w/o CT abdomen; with CT abdomen; w/o followed by Computed tomography, abdomen and pelvis; without material 1/1/ Computed tomography, abdomen and pelvis; with 1/1/2011 Computed tomography, abdomen and pelvis; without material in one or both body regions, followed by material(s) and further sections in one or both 1/1/2011 body regions Chest CT thorax; w/o CT thorax; with CT thorax; w/o followed by Upper CT upper extremity; w/o Extremity CT upper extremity; with CT upper extremity; w/o followed by Lower CT lower extremity; w/o Extremity CT lower extremity; with CT lower extremity; w/o followed by Head CT head or brain; w/o CT head or brain; with CT head or brain; w/o followed by Orbit CT orbit, sella or posterior fossa; w/o CT orbit, sella or posterior fossa; with CT orbit, sella or posterior fossa; w/o followed by Sinus CT maxillofacial area; w/o CT maxillofacial area; with CT maxillofacial area; w/o followed by Neck CT soft tissue neck; w/o CT soft tissue neck; with CT soft tissue neck; w/o followed by Pelvis CT pelvis; w/o CT pelvis; with CT pelvis w/o followed by Cervical CT cervical spine; w/o Spine CT cervical spine; with CT cervical spine; w/o followed by Thoracic CT thoracic spine; w/o Spine CT thoracic spine; with CT thoracic spine; w/o followed by Lumbar CT lumbar spine; w/o - 1 -

2 Spine CT lumbar spine; with CT lumbar spine; w/o followed by Computerized Tomography Angiography (CTA) Abdomen 79 Abdominal Arteries CTA abdomen CTA abdominal aorta & bilateral iliofemoral lower extremity runoff CTA abdomen & pelvis 1/1/2012 Chest Upper Extremity 77 Lower Extremity 78 Head 72 Neck 73 Pelvis CTA chest (noncoronary) CTA upper extremity CTA lower extremity CTA head CTA neck CTA pelvis Magnetic Resonance Imaging (MRI) Abdomen MRI abdomen; w/o MRI abdomen; with MRI abdomen; w/o followed by Bone Marrow MRI bone marrow blood supply 7/1/2008 Breast MRI breast; unilateral MRI breast; bilateral Chest MRI chest; w/o MRI chest; with MRI chest; w/o followed by Cardiac MRI cardiac for morphology & function, w/o 1/1/ MRI cardiac for morphology & function, w/o ; w/stress imaging 1/1/ MRI cardiac for morphology & function, w/o ; followed by & further sequences 1/1/ MRI cardiac for morphology & function, w/o ; followed by & further sequences; w/stress imaging 1/1/2008

3 Upper MRI upper extremity, other than joint w/o Extremity MRI upper extremity, other than joint with Non-joint 14 MRI upper extremity, other than joint w/o followed by Upper MRI upper extremity, any joint w/o Extremity MRI upper extremity, any joint with Any Joint 47 MRI upper extremity, any joint w/o followed by Lower MRI lower extremity, other than joint w/o Extremity MRI lower extremity, other than joint w MRI lower extremity, other than joint w/o followed by MRI lower extremity, any joint w/o MRI lower extremity, any joint w MRI lower extremity, any joint w/o followed by TMJ MRI temporomandibular joint(s) Orbit MRI orbit, face and neck; w/o MRI orbit, face and neck; with MRI orbit, face and neck; w/o followed by Brain MRI brain; w/o MRI brain; with MRI brain; w/o followed by Brain FMRI FMRI brain; by tech FMRI brain; by phys/psych Pelvis MRI pelvis; w/o MRI pelvis; with MRI pelvis; w/o followed by Cervical MRI cervical spine; w/o Spine MRI cervical spine; with MRI cervical spine; w/o followed by Thoracic MRI thoracic spine; w/o Spine MRI thoracic spine; with MRI thoracic spine; w/o followed by Lumbar MRI lumbar spine; w/o Spine MRI lumbar spine; with MRI lumbar spine; w/o followed by Fetal MRI fetal; including placental and maternal pelvic imaging (initial gestation) MRI fetal; including placental and maternal pelvic imaging (each additional gestation) 1/1/2016 1/1/

4 Magnetic Resonance Angiography (MRA) Abdomen MRA abdomen; with or w/o Chest MRA chest; with or w/o Upper Extremity MRA upper extremity; with or w/o Lower Extremity MRA lower extremity; with or w/o Head MRA head; w/o MRA head; with MRA head; w/o followed by Neck MRA neck; w/o MRA neck; with MRA neck; w/o followed by Pelvis MRA pelvis; with or w/o Spinal Canal MRA spinal canal and contents with or w/o 81 Magnetic Resonance Spectroscopy (MRS) MR Spectroscopy (Non-covered by Original Medicare and Blue Medicare HMO and Blue Medicare PPO) Nuclear Cardiology 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); single study, at rest or stress 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 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 Planar, infarct avid; qualitative or quantitative - 4 -

5 Imaging Planar, infarct avid; with ejection fraction by first pass technique SPECT, infarct avid; with or w/o quantification Cardiac Blood Pool Gated equilibrium; planar, single study, wall motion plus Imaging 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 (PET) Brain PET brain, metabolic evaluation Imaging PET brain, perfusion evaluation Myocardial PET myocardial, metabolic evaluation Imaging PET myocardial, perfusion, single study PET myocardial, perfusion, multiple studies Tumor PET tumor imaging, limited Imaging PET tumor imaging, skull base to mid-thigh PET PET tumor imaging, whole body PET/CT PET tumor imaging with concurrent CT, limited 84 PET tumor imaging with concurrent CT, skull to midthigh PET tumor imaging with concurrent CT, whole body CTA Heart Incl. Structure & Morphology 100 or CT angiography, heart, coronary 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) CT Heart for Calcium Scoring 98 or CT heart, w/o, with quantitative evaluation of coronary calcium 99 CT Heart for Structure & Morphology or CT heart, with material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and - 5 -

6 75573 evaluation of venous structures, if performed) CT heart, 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) Diagnostic CT Colonography OR CT Colonography, diagnostic, including image postprocessing, w/o CT Colonography, diagnostic, including image postprocessing, with CT Colonography, screening, including image postprocessing, with Echocardiography Services As of 1/1/2014 preauthorization for these echocardiography services will be required for both Commercial and Blue Medicare HMO\PPO members. Echocardiogram or Stress Echo (SE) Transthoracic Stress Echo, complete 1/15/ Transthoracic Stress Echo, complete w/cont. EKG 1/15/2012 Resting Trans Echo (TTE) Transesophageal Echo (TEE) Transthoracic Echo cardiac anomalies 1/15/ Transthoracic Echo cardiac anomalies, limited 1/15/ Transthoracic Echo complete w/color & spectral 1/15/ Transthoracic Echo complete w/o color & spectral 1/15/ Transthoracic Echo limited 1/15/ Transesophageal Echo 1/15/ Transesophageal Echo probe only Transesophageal Echo interpretation 1/15/2012 1/15/ Transesophageal Echo congenital 1/15/ Transesophageal Echo congenital, probe only 1/15/ Transesophageal Echo congenital interpretation 1/15/2012 Low dose CT lung screening Preauthorization for Blue Medicare HMO\PPO members should utilize the following code: Low Dose CT lung or G0297 Low-dose Computed Tomography For Lung Cancer 1/1/2016 Low dose CT lung screening Preauthorization for Commercial members should utilize the following code: - 6 -

7 Low Dose CT lung or S8032 Low-dose Computed Tomography For Lung Cancer 1/1/2015 * Investigational procedure/non-covered ** No additional reimbursement provided for calcium scoring component - 7 -