CLICK on the LISTS Below CT - Computed Tomography CTA Computed Tomographic Angiography CT - Computed Tomography Radiation Treatment Planning Studies

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1 PROCEDURE LISTS CT/CTA, MRI/MRA, PET, Nuclear Cardiac Imaging (MPI), 3D Rendering, US & Cardiology CLICK on the LISTS Below CT - Computed Tomography CTA Computed Tomographic Angiography CT - Computed Tomography Radiation Treatment Planning Studies MRI - Magnetic Resonance Imaging MRA Magnetic Resonance Angiography MPI - Myocardial Perfusion Imaging and Nuclear Cardiac Imaging Positron Emission Tomography (PET) and PET/CT 3D RENDERING ULTRASOUND (US) CARDIOLOGY Outcomes Focused Cardiac Imaging (OFCI) Program NOTE: These procedure codes listed herein are provided for informational purposes only. Each health plan has a specific list of procedure codes that require pre-authorization. An individual plan s pre-authorization list may differ slightly from the ones posted here. CPT (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA).

2 0042T 0066T 0067T 0144T 0145T 0146T 0147T 0148T 0149T 0150T 0151T PROCEDURE LISTS - By Modality and In Numerical Order CT - Computed Tomography Cerebral perfusion analysis using CT with contrast CT COLONOGRAPHY (ie. virtual colonoscopy); Screening CT COLONOGRAPHY (ie. virtual colonoscopy); Diagnostic CT HEART, WO contrast, including post processing and evaluation of coronary calcium CT HEART, WO contrast followed by contrast and further sections, including cardiac gating and 3D image post processing; cardiac structure and morphology CTA CORONARY ARTERIES (including native and anomalous coronary arteries, coronary bypass grafts), without quantitative evaluation of coronary calcium CTA CORONARY ARTERIES (including native and anomalous coronary arteries, coronary bypass grafts), with quantitative evaluation of coronary calcium CTA CORONARY ARTERIES and cardiac structure and morphology (including native and anomalous coronary arteries, coronary bypass grafts), without quantitative evaluation of coronary calcium CTA CORONARY ARTERIES and cardiac structure and morphology (including native and anomalous coronary arteries, coronary bypass grafts), with quantitative evaluation of coronary calcium CT HEART, without contrast material followed by contrast material(s) and further sections, including cardiac gating and 3D image post processing; cardiac structure and morphology in congenital heart disease CT HEART, W/O, followed by contrast, including cardiac gating and 3D image post processing; function evaluation (left and right ventricular function, ejection fraction and segmental wall motion) CT Head without contrast CT Head with contrast CT Head with & without contrast W & W/O CT Orbit, sella, or posterior fossa or outer, middle, or inner ear without contrast CT Orbit, sella, or posterior fossa or outer, middle, or inner ear with contrast CT Orbit, sella, or posterior fossa or outer, middle, or inner ear W & W/O CT Maxillofacial area, (sinus) without contrast CT Maxillofacial area, (sinus) with contrast CT Maxillofacial area, (sinus) with & without contrast W & W/O CT Soft-tissue Neck without contrast CT Soft-tissue Neck with contrast CT Soft-tissue Neck with & without contrast W & W/O CT Chest without contrast CT Chest with contrast CT Chest with and without contrast W & W/O CT Cervical Spine without contrast CT Cervical Spine with contrast CT Cervical Spine with and without contrast W & W/O CT Thoracic Spine without contrast CT Thoracic Spine with contrast CT Thoracic Spine with and without contrast W & W/O RETURN Page 2 of 24

3 CT - Computed Tomography CT Lumbar Spine without contrast CT Lumbar Spine with contrast CT Lumbar Spine with and without out contrast W & W/O CT Pelvis without contrast CT Pelvis with contrast CT Pelvis with and without contrast W & W/O CT Upper Extremity without contrast CT Upper Extremity with contrast CT Upper Extremity with and without contrast W & W/O CT Lower Extremity without contrast CT Lower Extremity with contrast CT Lower Extremity with and without contrast W & W/O CT Abdomen without contrast CT Abdomen with contrast CT Abdomen with and without contrast W & W/O CT Limited or Localized follow-up Unlisted CT procedure (eg, diagnostic, interventional) CT Guidance for stereotactic localization CT Guidance for needle placement (eg, biopsy, aspiration, injection); radiological S & I CT Guidance for, and monitoring of, parenchymal tissue ablation CT BONE MINERAL DENSITY study, 1 or more sites, axial skeleton CT BONE MINERAL DENSITY study, 1 or more sites, appendicular S8092 CT ELECTRON BEAM (Ultrafast CT) for calcium scoring RETURN Page 3 of 24

4 CTA - Computed Tomographic Angiography CT Angiography (CTA), Head- includes post-processing CT Angiography (CTA), Neck-includes post-processing CT Angiography (CTA), Chest (NON-CORONARY) includes post-processing CT Angiography (CTA) Pelvis-includes post-processing CT Angiography (CTA) Upper Extremity-includes post-processing CT Angiography (CTA) Lower Extremity- includes post-processing CT Angiography (CTA) Abdomen- W & W/O includes post-processing CT Angiography (CTA) Abdominal Aorta and bilateral iliofemoral lower extremity runoff RETURN Page 4 of 24

5 CT Computed Tomography Radiation Treatment Planning Studies CT Guidance for placement of radiation therapy fields Therapeutic radiology treatment planning; simple Therapeutic radiology treatment planning; intermediate Therapeutic radiology treatment planning; complex Therapeutic radiology simulation-aided field setting; simple Therapeutic radiology simulation-aided field setting; intermediate Therapeutic radiology simulation-aided field setting; complex Therapeutic radiology simulation-aided field setting; three-dimensional RETURN Page 5 of 24

6 MRI Magnetic Resonance Imaging 0159T CAD, including computer algorithm analysis, BREAST MRI MRI Temporomandibular Joint (s) {TMJ} MRI Orbit, Face and/or Neck without contrast MRI Orbit, Face and/or Neck with contrast MRI Orbit, Face and/or Neck with and without contrast W & W/O MRI Brain (Head) without contrast MRI Brain (Head) with contrast MRI Brain (Head) with and without contrast W & W/O MRI Brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration MRI, Brain, functional MRI; requiring physician or psychologist administration of testing MRI Chest without contrast MRI Chest with contrast MRI Chest with and without contrast W & W/O MRI Cervical Spine without contrast MRI Cervical Spine with contrast MRI Thoracic Spine without contrast MRI Thoracic Spine with contrast MRI Lumbar Spine without contrast MRI Lumbar Spine with contrast MRI Cervical Spine with and without contrast W & W/O MRI Thoracic Spine with and without contrast W & W/O MRI Lumbar Spine with and without contrast W & W/O MRI Pelvis without contrast MRI Pelvis with contrast MRI Pelvis with and without contrast W & W/O MRI Upper Extremity-other than joint-without contrast MRI Upper Extremity-other than joint-with contrast MRI Upper Extremity-other than joint-with and without contrast W & W/O MRI Any Joint of Upper Extremity--without contrast MRI Any Joint of Upper Extremity--with contrast MRI Any Joint of Upper Extremity with and without contrast W & W/O MRI Lower Extremity-other than joint-without contrast MRI Lower Extremity-other than joint-with contrast MRI Lower Extremity-other than joint-with and without contrast W & W/O MRI Any Joint of Lower Extremity--without contrast MRI Any Joint of Lower Extremity--with contrast MRI Any Joint of Lower Extremity with and without contrast W & W/O MRI Abdomen without contrast MRI Abdomen with contrast MRI Abdomen with and without contrast W & W/O RETURN Page 6 of 24

7 MRI Magnetic Resonance Imaging Cardiac MRI for morphology and function without contrast materials Cardiac MRI for morphology and function without contrast materials; with flow/velocity Cardiac MRI for morphology and function without contrast materials; with stress imaging Cardiac MRI for morphology and function without contrast materials; with flow/velocity and stress Cardiac MRI for morphology and function WO, followed by contrast Cardiac MRI for morphology and function WO, followed by contrast with flow/velocity Cardiac MRI for morphology and function WO, followed by contrast; with stress imaging Cardiac MRI for morphology and function WO, followed by contrast; with flow/velocity and stress MR Spectroscopy (MRS) Unlisted MR procedure (eg, diagnostic, interventional) MR Guidance for needle placement (eg, biopsy, aspiration, injection); radiological S & I MR Guidance for, and monitoring of, parenchymal tissue ablation MRI BREAST, without and/or with contrast UNILATERAL MRI BREAST, without and/or with contrast BILATERAL MRI Bone Marrow blood supply S8035 Magnetic Source Imaging S8037 MRCP (Magnetic Resonance Cholangiopancreatography) S8042 MRI Low Field RETURN Page 7 of 24

8 MRA Magnetic Resonance Angiography MR Angiography (MRA) Head without contrast MR Angiography (MRA) Head with contrast MR Angiography (MRA) Head with and without contrast W & W/O MR Angiography (MRA) Neck without contrast MR Angiography (MRA) Neck with contrast MR Angiography (MRA) Neck with and without contrast W & W/O MR Angiography (MRA) Chest (excluding myocardium)- W or W/O MR Angiography (MRA) Spinal Canal and contents MR Angiography (MRA) Pelvis -with or without contrast MR Angiography (MRA) Upper Extremity -with or without contrast MR Angiography (MRA) Lower Extremity-with or without contrast MR Angiography (MRA) Abdomen-with or without contrast RETURN Page 8 of 24

9 MPI Myocardial Perfusion Imaging NCM Nuclear Cardiac Imaging MPI; (planar) single study, at rest or stress MPI; (planar) multiple studies, at rest and/or stress MPI; (SPECT) single study at rest or stress MPI; (SPECT) multiple studies at rest and/or stress Myocardial Imaging, infarct avid, planar; qualitative or quantitative Myocardial Imaging, infarct avid, planar; w/ EF by first pass technique Myocardial Imaging, infarct avid, planar; tomographic SPECT Cardiac Blood Pool imaging, gated equilibrium; planar, single study at rest or stress Cardiac Blood Pool imaging, gated equilibrium; multiple studies, wall motion plus ejection fraction, at rest and stress, Myocardial perfusion study with wall motion Myocardial perfusion study with ejection fraction (EF) Cardiac Blood Pool imaging, (planar), first pass technique; single study, at rest or with stress, wall motion study plus ejection fraction Cardiac Blood Pool imaging, (planar), first pass technique; multiple studies at rest and with stress, wall motion study plus ejection fraction Cardiac Blood Pool imaging, gated equilibrium, SPECT Cardiac Blood Pool imaging, gated equilibrium, RV EF by first pass UNLISTED NCM Nuclear Cardiac Imaging Unlisted cardiovascular procedure, diagnostic nuclear medicine RETURN Page 9 of 24

10 PET and PET/CT - Positron Emission Tomography PET Cardiac (myocardial imaging) metabolic evaluation PET Cardiac (myocardial imaging), perfusion single study at rest or stress PET Cardiac (myocardial imaging), perfusion multiple studies rest/stress PET Brain metabolic evaluation PET Brain perfusion evaluation PET Imaging; limited area (ex: chest, head/neck) PET Imaging; skull base to mid-thigh PET Imaging; whole body PET/CT; limited area (ex: chest, head/neck) PET/CT; skull base to mid-thigh PET/CT; whole body G0219 PET imaging whole body; melanoma for non-covered indications G0235 PET imaging, any site, not otherwise specified PET imaging, for initial diagnosis of breast cancer and/or surgical planning for breast G0252 cancer (e.g. initial staging of axillary lymph nodes) S8085 F-18 FDG Imaging Using Dual Head Coincidence Detection System RETURN Page 10 of 24

11 D RENDERING 3D Rendering with interpretation and reporting of CT, MRI, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation 3D Rendering with interpretation and reporting of CT, MRI, ultrasound, or other tomographic modality; requiring image postprocessing on an independent workstation RETURN Page 11 of 24

12 ULTRASOUND (US) Echoencephalography, real time with image documentation (gray scale) Ophthalmic ultrasound, diagnostic; B-scan and quantitative A-scan Ophthalmic ultrasound, diagnostic; quantitative A-scan only Ophthalmic ultrasound, diagnostic; B-scan (W or W/O superimposed A-scan Ophthalmic ultrasound, diagnostic; anterior segment ultrasound, immersion Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral Ophthalmic biometry by ultrasound echography, A-scan Ophthalmic biometry by ultrasound echography, A-scan; W lens power calculation Ophthalmic ultrasonic foreign body localization Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), B-scan and/or real time with image documentation Ultrasound, chest, (includes mediastinum) real time with image documentation Ultrasound breast(s) (unilateral or bilateral), real time with image documentation Ultrasound, abdominal, B-scan and/or real time with image documentation; complete Ultrasound, abdominal, B-scan and/or real time with image documentation; limited Ultrasound, retroperitoneal (eg, renal, aorta, nodes), B-scan and/or real time with image documentation; complete Ultrasound, retroperitoneal (eg, renal, aorta, nodes), B-scan and/or real time with image documentation; limited Ultrasound, transplanted kidney, real time and duplex Doppler with image documentation Ultrasound, spinal canal and contents Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (<14 weeks 0 days), transabdominal approach; single or first gestation each additional gestation (List separately in addition to code for primary procedure) Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation each additional gestation (List separately in addition to code for primary procedure) Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation each additional gestation (List separately in addition to code for primary procedure) Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; each additional gestation RETURN Page 12 of 24

13 ULTRASOUND (US) Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), one or more fetuses Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, reevaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus Ultrasound, pregnant uterus, real time with image documentation, transvaginal Fetal biophysical profile; with non-stress testing Fetal biophysical profile; without non-stress testing Doppler velocimetry, fetal; umbilical artery Doppler velocimetry, fetal; middle cerebral artery Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording; Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording; follow-up or repeat study Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; complete Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; follow-up or repeat study Ultrasound, transvaginal Saline infusion sonohysterography (SIS), including color flow Doppler, when performed Ultrasound, pelvic (nonobstetric), B-scan and/or real time with image documentation, complete Ultrasound, pelvic (nonobstetric), B-scan and/or real time with image documentation, limited or follow-up Ultrasound, scrotum and contents Ultrasound, transrectal Ultrasound, transrectal: prostate volume study for brachytherapy treatment planning (separate procedure) Ultrasound, extremity, non-vascular, real time with image documentation Ultrasound, infant hips, real time with image documentation; dynamic (requiring physician manipulation) Ultrasound, infant hips, real time with image documentation; limited, static (not requiring physician manipulation) Radiological guidance (ie, fluoroscopy, ultrasound, or CT), for percutaneous drainage with placement of catheter, radiological S & I Ultrasonic guidance for pericardiocentesis, imaging S & I Ultrasonic guidance for endomyocardial biopsy, imaging S & I Ultrasound guided compression repair of arterial pseudoaneurysm or arteriovenous fistulae (includes diagnostic ultrasound evaluation) RETURN Page 13 of 24

14 ULTRASOUND (US) Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites (List separately in addition to code for primary procedure) Ultrasound guidance for, and monitoring of, parenchymal tissue ablation Ultrasonic guidance for intrauterine fetal transfusion or cordocentesis imaging SI Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection) S&I Ultrasonic guidance for chorionic villus sampling, imaging S & I Ultrasonic guidance for amniocentesis, imaging S & I Ultrasonic guidance for aspiration of ova, imaging S & I Ultrasound study follow-up (specify) Non-invasive physiologic studies of extracranial arteries, complete bilateral study Duplex scan of extracranial arteries; complete bilateral study Duplex scan of extracranial arteries; unilateral or limited study Transcranial Doppler study of the intracranial arteries; complete study Transcranial Doppler study of the intracranial arteries; limited study Transcranial Doppler study of the intracranial arteries; vasoreactive study Transcranial Doppler study of the intracranial arteries; emboli detection W/O intravenous microbubble injection Transcranial Doppler study of the intracranial arteries; emboli detection with intravenous microbubble injection Non-invasive physiologic studies of upper or lower extremity arteries, single level, bilateral (eg, ankle/brachial indices, Doppler waveform analysis, volume plethysmography, transcutaneous oxygen tension measurement) Non-invasive physiologic studies of upper or lower extremity arteries, multiple levels or with provocative functional maneuvers, complete bilateral study (eg, segmental blood pressure measurements, segmental Doppler waveform analysis, segmental volume plethysmography, segmental transcutaneous oxygen tension measurements, measurements with postural provocative tests, measurements with reactive hyperemia) Non-invasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, complete bilateral study Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited study Non-invasive physiologic studies of extremity veins, complete bilateral study (eg, Doppler waveform analysis with responses to compression and other maneuvers, phleborheography, impedance plethysmography) Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study RETURN Page 14 of 24

15 ULTRASOUND (US) Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; limited study Duplex scan of arterial inflow and venous outflow of penile vessels; complete study Duplex scan of arterial inflow and venous outflow of penile vessels; limited study Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow) Vessel mapping of vessels for hemodialysis access (services for preoperative vessel G0365 mapping prior to creation of hemodialysis access using an autogenous hemodialysis conduit, including arterial inflow and venous outflow Ultrasound, B-scan and/or real time with image documentation; for abdominal aortic G0389 aneurysm (AAA) screening RETURN Page 15 of 24

16 Outcomes Focused Cardiac Imaging (OFCI) Program CT/CTCA CARDIAC CT and CT Coronary Angiography (CTCA) CT HEART, without contrast material, including image post processing and 0144T quantitative evaluation of coronary calcium [DO NOT use 0144T in conjunction with 0145T-0151T.] CT HEART, with contrast material(s), including noncontrast images, if performed, 0145T cardiac gating and 3D image post-processing; cardiac structure and morphology CT HEART, with contrast material(s), including noncontrast images, if performed, cardiac gating and 3D image post-processing; CTA of coronary arteries, (including 0146T native and anomalous coronary arteries, coronary bypass grafts), without quantitative evaluation of coronary calcium CT HEART, with contrast material(s), including noncontrast images, if performed, cardiac gating and 3D image post-processing; CTA of coronary arteries, (including 0147T native and anomalous coronary arteries, coronary bypass grafts), with quantitative evaluation of coronary calcium CT HEART, with contrast material(s), including noncontrast images, if performed, cardiac gating and 3D image post-processing; cardiac structure and morphology 0148T and CTA of coronary arteries, (including native and anomalous coronary arteries, coronary bypass grafts), without quantitative evaluation of coronary calcium CT HEART, with contrast material(s), including noncontrast images, if performed, cardiac gating and 3D image post-processing; cardiac structure and morphology 0149T and CTA of coronary arteries, (including native and anomalous coronary arteries, coronary bypass grafts), with quantitative evaluation of coronary calcium CT HEART, with contrast material(s), including noncontrast images, if performed, 0150T cardiac gating and 3D image post-processing; cardiac structure and morphology in congenital heart disease CT HEART, with contrast material(s), including noncontrast images, if performed, cardiac gating and 3D image post-processing; function evaluation (left and right +0151T ventricular function, ejection fraction and segmental wall motion) (List separately in addition to code for primary procedure) [Use 0151T in conjunction with 0145T-0150T.] DO NOT USE WITH 0144T. S8092 CT ELECTRON BEAM (Ultrafast CT) for calcium scoring RETURN Page 16 of 24

17 Outcomes Focused Cardiac Imaging (OFCI) Program MRI CARDIAC Magnetic Resonance Imaging (MRI) Cardiac MRI for morphology and function without contrast material; Cardiac MRI for morphology and function without contrast material; with flow/velocity Cardiac MRI for morphology and function without contrast material; with stress imaging Cardiac MRI for morphology and function without contrast material; with flow/velocity quantification and stress Cardiac MRI for morphology and function without contrast, followed by contrast; Cardiac MRI for morphology and function without contrast, followed by contrast and further sequences; with flow/velocity quantification Cardiac MRI for morphology and function without contrast, followed by contrast and further sequences; with stress imaging Cardiac MRI for morphology and function without contrast, followed by contrast and further sequences; with flow/velocity quantification and stress Only one procedure code in the series should be reported per imaging session. Cardiac MRI studies may be performed at rest and/or during pharmacologic stress. o Use the appropriate stress testing code from the series: in addition to 75559, 75560, 75563, and D Rendering (CPT and 76377) should not be used in conjunction with cardiac MRI. 3D 3D RENDERING 3D Rendering with interpretation and reporting of CT, MRI, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation [Use in conjunction with code(s) for base imaging procedure(s).] 3D Rendering with interpretation and reporting of CT, MRI, ultrasound, or other tomographic modality; requiring image postprocessing on an independent workstation [Use in conjunction with code(s) for base imaging procedure(s).] PET CARDIAC Positron Emission Tomography (PET) Myocardial imaging, positron emission tomography (PET), metabolic evaluation Myocardial imaging, positron emission tomography (PET), perfusion; single study at rest or stress Myocardial imaging, positron emission tomography (PET), perfusion; multiple studies at rest and/or stress Cardiac PET studies (78491 and 78492) may be performed at rest and/or during pharmacologic stress. o Use the appropriate stress testing code from the series: in addition to and D Rendering (CPT and 76377) should not be used in conjunction with cardiac PET. RETURN Page 17 of 24

18 Outcomes Focused Cardiac Imaging (OFCI) Program NCM Nuclear Cardiac Imaging (NCM) MPI; (planar) single study, at rest or stress (exercise and/or pharmacologic), with or without quantification MPI; multiple studies (planar), at rest and/or stress (exercise and/or pharmacologic), and redistribution and/or rest injection, with or without quantification MPI; tomographic (SPECT) single study (including attenuation correction when performed), at rest or stress (exercise and/or pharmacologic), with or without quantification MPI; tomographic (SPECT) multiple studies (including attenuation correction when performed), at rest and/or stress (exercise and/or pharmacologic), and redistribution and/or rest injection, with or without quantification Myocardial Imaging, infarct avid, planar; qualitative or quantitative Myocardial Imaging, infarct avid, planar; with ejection fraction by first pass technique Myocardial Imaging, infarct avid, planar; tomographic SPECT with or without quantification Cardiac Blood Pool Imaging, gated equilibrium; planar, single study at rest or stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without additional quantitative processing Cardiac Blood Pool Imaging, gated equilibrium; multiple studies, wall motion study plus ejection fraction, at rest and stress (exercise and/or pharmacologic), with or without additional quantification Myocardial perfusion study with wall motion, qualitative or quantification study (List separately in addition to code for primary procedure) [78478 may be used in conjunction with 78460, 78461, 78464, and ] Myocardial perfusion study with ejection fraction (EF) (List separately in addition to code for primary procedure) [78480 may be used in conjunction with 78460, 78461, 78464, and ] Cardiac Blood Pool Imaging planar, first pass technique; single study, at rest or with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification Cardiac Blood Pool Imaging, (planar), first pass technique; multiple studies at rest and with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification Cardiac Blood Pool Imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction, with or without quantitative processing Cardiac Blood Pool Imaging, gated equilibrium, single study, at rest, with right ventricular ejection fraction by first pass technique (List in addition to code for primary procedure) [Use this code in conjunction with 78472] [78496 may be used in conjunction with ] Unlisted cardiovascular procedure, diagnostic nuclear medicine CODING NOTE: Myocardial perfusion imaging (MPI) and cardiac blood pool imaging studies may be performed at rest and/or during stress. When completed during exercise and/or pharmacologic stress, providers are to use the appropriate stress testing code from the series: in addition to codes: and RETURN Page 18 of 24

19 Outcomes Focused Cardiac Imaging (OFCI) Program STRESS STRESS TESTING Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report CPT is used alone to report a standard exercise stress test, (for example, a Bruce protocol treadmill stress test (TMT), without a nuclear imaging component. Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; physician supervision only, without interpretation and report Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; tracing only, without interpretation and report Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; interpretation and report only TTE TRANSTHORACIC ECHO (TTE) Transthoracic echocardiography for congenital cardiac anomalies; complete Transthoracic echocardiography for congenital cardiac anomalies; follow-up study Echocardiography, transthoracic, real time with image documentation (2D), includes M mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography Echocardiography, transthoracic, real time with image documentation (2D), includes M- mode recording, when performed, complete, without spectral or color Doppler echocardiography [DO NOT use in conjunction with 93320, 93321, and ] Echocardiography, transthoracic, real time with image documentation (2D), includes M mode recording, when performed, follow-up or limited study Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); complete [93320 may be used in conjunction with and ] Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); follow-up or limited study [93321 may be used in conjunction with 93303, 93304, and ] Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiographic imaging) [93325 may be used in conjunction with 93303, 93304, and 93308] RETURN Page 19 of 24

20 Outcomes Focused Cardiac Imaging (OFCI) Program TEE TRANSESOPHAGEAL ECHO (TEE) Echocardiography, transesophageal, (TEE) real-time with image documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report Echocardiography, transesophageal, (TEE) real-time with image documentation (2D) (with or without M-mode recording); placement of transesophageal probe only Echocardiography, transesophageal, (TEE) real-time with image documentation (2D) (with or without M-mode recording); image acquisition, interpretation & report only Transesophageal echocardiography (TEE) for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report Transesophageal echocardiography (TEE) for congenital cardiac anomalies; placement of transesophageal probe only Transesophageal echocardiography (TEE) for congenital cardiac anomalies; image acquisition, interpretation & report only Transesophageal echocardiography (TEE) for monitoring purposes, including probe placement, real-time 2D image acquisition and interpretation leading to ongoing assessment of cardiac pumping function and to therapeutic measures on an immediate time basis Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); complete [93320 may be used in conjunction with 93312, 93314, 93315, and ] Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); follow-up or limited study [93321 may be used in conjunction with 93312, 93314, 93315, and ] Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiographic imaging) [93325 may be used in conjunction with 93312, 93314, 93315, and ] RETURN Page 20 of 24

21 Outcomes Focused Cardiac Imaging (OFCI) Program ECHO STRESS ECHO Echocardiography, transthoracic, real-time with image documentation (2D), includes M- mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report [Use the appropriate stress testing codes from the series, in addition to CPT to report the exercise stress portion of the study.] Echocardiography, transthoracic, real-time with image documentation (2D), includes M- mode recording when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, including performance of continuous electrocardiographic monitoring, with physician supervision [DO NOT use in conjunction with or ] Use of echocardiographic contrast agent during stress echocardiography [DO NOT use more than once per stress echocardiogram.] Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); complete [93320 may be used in conjunction with and 93351] Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); follow-up or limited study [93321 may be used in conjunction with and 93351] Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiographic imaging) [93325 may be used in conjunction with and 93351] RETURN Page 21 of 24

22 Outcomes Focused Cardiac Imaging (OFCI) Program DOPPLER DOPPLER ECHOCARDIOGRAPHY Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); complete [93320 may be used in conjunction with 93303, 93304, 93312, 93314, 93315, 93317, 93350, and 93351] Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); follow-up or limited study [93320 may be used in conjunction with 93303, 93304, 93308, 93312, 93314, 93315, 93317, 93350, and 93351] Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiographic imaging) [93325 may be used in conjunction with 93303, 93304, 93308, 93312, 93314, 93315, 93317, 93350, and 93351] The procedures listed above are performed in addition to the primary procedure. o These additional procedures are designated in CPT as add-on codes with the symbol +. o Add-on codes can also be identified by specific wording in the description. For example, the codes for Doppler echocardiography include the phrase: (List separately in addition to codes for echocardiographic imaging) o Add-on codes are always performed in addition to the primary procedure and must never be reported as a stand-alone code. o All add-on codes are exempt from use of the multiple procedures modifier (-51). RETURN Page 22 of 24

23 Outcomes Focused Cardiac Imaging (OFCI) Program CATH DIAGNOSTIC LEFT HEART CATHETERIZATION Catheter placement in coronary artery(s), arterial coronary conduit(s), and/or venous coronary bypass graft(s) for coronary angiography without concomitant left heart catheterization (Diagnostic coronary artery catheterization w/o left heart catheterization) Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous (Left heart catheterization by percutaneous puncture) Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; by cutdown (Left heart catheterization by incision/surgical dissection to expose artery) Left heart catheterization by left ventricular puncture (Left heart catheterization by percutaneous left ventricular puncture) Combined transseptal and retrograde left heart catheterization (Left heart catheterization by transseptal route) Injection procedure during cardiac catheterization; for selective opacification of arterial conduits (eg, internal mammary), whether native or used for bypass (Coronary angiography of one or more arterial bypass grafts or arterial conduits) Injection procedure during cardiac catheterization; for selective opacification of aortocoronary venous bypass grafts, one or more coronary arteries (Coronary angiography of one or more venous bypass grafts) Injection procedure during cardiac catheterization; for selective left ventricular or left atrial angiograph (Contrast injection of left ventricle or left atrium) Injection procedure during cardiac catheterization; for aortography (Aortography of the ascending aorta and arch) Injection procedure during cardiac catheterization; for selective angiography (injection of radiopaque material may be by hand) (Coronary angiography of one or more native coronary arteries) Imaging supervision, interpretation and report for injection procedure(s) during cardiac catheterization; ventricular and/or atrial angiography (Imaging supervision for heart chambers) Imaging supervision, interpretation and report for injection procedure(s) during cardiac catheterization; pulmonary angiography, aortography, and/or selective coronary angiography including venous bypass grafts and arterial conduits (whether native or used in bypass) (Imaging supervision for vessels [pulmonary vessels, aorta, coronary arteries, bypass grafts, arterial conduits) RETURN Page 23 of 24

24 Outcomes Focused Cardiac Imaging (OFCI) Program RADIO RADIOPHARMACEUTICALS A9500 Technetium Tc-99m sestamibi, diagnostic, per study dose, up to 40 millicuries (Use A9500 for Cardiolite ) A9502 Technetium Tc-99m tetrofosmin, diagnostic, per study dose [Use A9502 for Myoview ] A9505 Thallium Tl-201 thallous chloride, diagnostic, per millicurie [Use A9505 for MIBG and Thallous Chloride, USP] A9526 Nitrogen N-13 ammonia, diagnostic, per study dose, up to 40 millicuries [Use A9526 with perfusion cardiac PET scans, CPT and ] A9538 Technetium Tc-99m pyrophosphate, diagnostic, per study dose, up to 25 millicuries [Use A9538 for infarct avid MPI studies ] A9552 Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries [Use A9552 with metabolic cardiac PET studies ] A9555 Rubidium Rb-82, diagnostic, per study dose, up to 60 millicuries [Use A9555 with perfusion Cardiac PET scans, and ] A9560 Technetium Tc-99m labeled red blood cells, diagnostic, per study dose, up to 30 millicuries (Use this code with MUGA scans)) [Use A9560 with MUGA scans.] CONT CONTRAST AGENTS A9576 Injection, gadoteridol, (ProHance Multipack), per ml A9577 Injection, gadobenate dimeglumine (MultiHance), per ml A9578 Injection, gadobenate dimeglumine (MultiHance Multipack), per ml A9579 Injection, gadolinium-based magnetic resonance contrast, not otherwise specified per ml [Use A9579 for Omniscan ] A9700 Supply of injectable contrast material for use in echocardiography, per study Q9951 Low osmolar contrast material, 400 or greater mg/ml iodine concentration, per ml Q9953 Injection iron-based magnetic resonance contrast agent, per ml Q9955 Injection, perflexane lipid microspheres, per ml [Use for Imagent ] Q9956 Injection, octafluoropropane microspheres, per ml [Use for Optison ] Q9957 Injection, perflutren lipid microspheres, per ml [Use for Definity ] Q9965 Low osmolar contrast material, mg/ml iodine concentration, per ml [Use Q9965 for Omnipaque 140, Omnipaque 180, Optiray 160] Q9966 Low osmolar contrast material, mg/ml iodine concentration, per ml [Use Q9966 for Omnipaque 240, Optiray 240] Q9967 Low osmolar contrast material, mg/ml iodine concentration, per ml [Use Q9967 for Omnipaque 300, & 350, Optiray 300, & 320, Oxilan 300, Oxilan 350] PHARMACOLOGIC STRESS AGENTS GENERIC BRAND HCPCS Dipyridamole Persantine J1245 Injection, dipyridamole, per 10 mg Adenosine Adenoscan J0152 Injection, adenosine, for diagnostic use, 30 mg Dobutamine Dobutrex J1250 Injection, dobutamine HCL, per 250 mg Regadenoson Lexiscan J2785 Injection, regadenoson. 0.1mg RETURN Page 24 of 24