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; without material 1/1/2011 74177 Computed tomography, abdomen and pelvis; with 1/1/2011 Computed tomography, abdomen and pelvis; without 74178 material in one or both body regions, followed by material(s) and further sections in one or both 1/1/2011 body regions Chest 71250 CT thorax; w/o 5 71260 CT thorax; with 71270 CT thorax; w/o followed by Upper 73200 CT upper extremity; w/o Extremity 73201 CT upper extremity; with 11 73202 CT upper extremity; w/o followed by Lower 73700 CT lower extremity; w/o Extremity 73701 CT lower extremity; with 12 73702 CT lower extremity; w/o followed by Head 70450 CT head or brain; w/o 3 70460 CT head or brain; with 70470 CT head or brain; w/o followed by Orbit 70480 CT orbit, sella or posterior fossa; w/o 1 70481 CT orbit, sella or posterior fossa; with 70482 CT orbit, sella or posterior fossa; w/o followed by Sinus 70486 CT maxillofacial area; w/o 2 70487 CT maxillofacial area; with 70488 CT maxillofacial area; w/o followed by Neck 70490 CT soft tissue neck; w/o 4 70491 CT soft tissue neck; with 70492 CT soft tissue neck; w/o followed by Pelvis 72192 CT pelvis; w/o 7 72193 CT pelvis; with 72194 CT pelvis w/o followed by Cervical 72125 CT cervical spine; w/o Spine 72126 CT cervical spine; with 8 72127 CT cervical spine; w/o followed by Thoracic 72128 CT thoracic spine; w/o Spine 72129 CT thoracic spine; with 9 72130 CT thoracic spine; w/o followed by Lumbar 72131 CT lumbar spine; w/o - 1 -
Spine 10 72132 CT lumbar spine; with 72133 CT lumbar spine; w/o followed by Computerized Tomography Angiography (CTA) Abdomen 79 Abdominal Arteries 80 74175 CTA abdomen 75635 CTA abdominal aorta & bilateral iliofemoral lower extremity runoff 74174 CTA abdomen & pelvis 1/1/2012 Chest 75 75 Upper Extremity 77 Lower Extremity 78 Head 72 Neck 73 Pelvis 76 71275 CTA chest (noncoronary) 73206 CTA upper extremity 73706 CTA lower extremity 70496 CTA head 70498 CTA neck 72191 CTA pelvis Magnetic Resonance Imaging (MRI) - 2 - Abdomen 74181 MRI abdomen; w/o 26 74182 MRI abdomen; with 74183 MRI abdomen; w/o followed by Bone Marrow 30 77084 MRI bone marrow blood supply 7/1/2008 Breast 77058 MRI breast; unilateral 29 77059 MRI breast; bilateral Chest 71550 MRI chest; w/o 25 71551 MRI chest; with 71552 MRI chest; w/o followed by Cardiac 75557 MRI cardiac for morphology & function, w/o 1/1/2008 18 MRI cardiac for morphology & function, w/o ; 75559 w/stress imaging 1/1/2008 75561 MRI cardiac for morphology & function, w/o ; followed by & further sequences 1/1/2008 75563 MRI cardiac for morphology & function, w/o ; followed by & further sequences; w/stress imaging 1/1/2008
Upper 73218 MRI upper extremity, other than joint w/o Extremity 73219 MRI upper extremity, other than joint with Non-joint 14 MRI upper extremity, other than joint w/o 73220 followed by Upper 73221 MRI upper extremity, any joint w/o Extremity 73222 MRI upper extremity, any joint with Any Joint 47 MRI upper extremity, any joint w/o followed by 73223 Lower 73718 MRI lower extremity, other than joint w/o Extremity 46 73719 MRI lower extremity, other than joint w 73720 MRI lower extremity, other than joint w/o followed by 73721 MRI lower extremity, any joint w/o 73722 MRI lower extremity, any joint w 73723 MRI lower extremity, any joint w/o followed by TMJ 24 70336 MRI temporomandibular joint(s) Orbit 70540 MRI orbit, face and neck; w/o 23 70542 MRI orbit, face and neck; with 70543 MRI orbit, face and neck; w/o followed by Brain 70551 MRI brain; w/o 13 70552 MRI brain; with 70553 MRI brain; w/o followed by Brain FMRI 70554 FMRI brain; by tech 82 70555 FMRI brain; by phys/psych Pelvis 72195 MRI pelvis; w/o 27 72196 MRI pelvis; with 72197 MRI pelvis; w/o followed by Cervical 72141 MRI cervical spine; w/o Spine 72142 MRI cervical spine; with 15 72156 MRI cervical spine; w/o followed by Thoracic 72146 MRI thoracic spine; w/o Spine 72147 MRI thoracic spine; with 16 72157 MRI thoracic spine; w/o followed by Lumbar 72148 MRI lumbar spine; w/o Spine 72149 MRI lumbar spine; with 17 72158 MRI lumbar spine; w/o followed by Fetal 74712 74713 MRI fetal; including placental and maternal pelvic imaging (initial gestation) MRI fetal; including placental and maternal pelvic imaging (each additional gestation) 1/1/2016 1/1/2016-3 -
Magnetic Resonance Angiography (MRA) Abdomen 33 74185 MRA abdomen; with or w/o Chest 32 71555 MRA chest; with or w/o Upper Extremity 35 73225 MRA upper extremity; with or w/o Lower Extremity 36 73725 MRA lower extremity; with or w/o Head 70544 MRA head; w/o 31 70545 MRA head; with 70546 MRA head; w/o followed by Neck 70547 MRA neck; w/o 74 70548 MRA neck; with 70549 MRA neck; w/o followed by Pelvis 34 72198 MRA pelvis; with or w/o Spinal Canal 37 72159 MRA spinal canal and contents with or w/o 81 Magnetic Resonance Spectroscopy (MRS) 76390 MR Spectroscopy (Non-covered by Original Medicare and Blue Medicare HMO and Blue Medicare PPO) Nuclear Cardiology Myocardial Perfusion Imaging 19 78451 78452 78453 78454 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 78466 Planar, infarct avid; qualitative or quantitative - 4 -
Imaging Planar, infarct avid; with ejection fraction by first pass 78468 technique 44 78469 SPECT, infarct avid; with or w/o quantification Cardiac Blood Pool Gated equilibrium; planar, single study, wall motion plus Imaging 78472 ejection fraction 82 78473 Gated equilibrium; planar, multiple studies, wall motion study plus ejection fraction 78481 First pass tech; single study, wall motion study plus ejection fraction 78483 First pass tech; multiple studies, wall motion study plus ejection fraction 78494 Gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction Positron Emission Tomography (PET) Brain 78608 PET brain, metabolic evaluation Imaging 42 78609 PET brain, perfusion evaluation Myocardial 78459 PET myocardial, metabolic evaluation Imaging 78491 PET myocardial, perfusion, single study 71 78492 PET myocardial, perfusion, multiple studies Tumor 78811 PET tumor imaging, limited Imaging 78812 PET tumor imaging, skull base to mid-thigh PET 78813 PET tumor imaging, whole body PET/CT 78814 PET tumor imaging with concurrent CT, limited 84 PET tumor imaging with concurrent CT, skull to midthigh 78815 78816 PET tumor imaging with concurrent CT, whole body CTA Heart Incl. Structure & Morphology 100 or 75574 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 75571 CT heart, w/o, with quantitative evaluation of coronary calcium 99 CT Heart for Structure & Morphology or 75572 CT heart, with material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and - 5 -
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 86 74261 74262 74263 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) 93350 Transthoracic Stress Echo, complete 1/15/2012 93351 Transthoracic Stress Echo, complete w/cont. EKG 1/15/2012 Resting Trans Echo (TTE) Transesophageal Echo (TEE) 93303 Transthoracic Echo cardiac anomalies 1/15/2012 93304 Transthoracic Echo cardiac anomalies, limited 1/15/2012 93306 Transthoracic Echo complete w/color & spectral 1/15/2012 93307 Transthoracic Echo complete w/o color & spectral 1/15/2012 93308 Transthoracic Echo limited 1/15/2012 93312 Transesophageal Echo 1/15/2012 93313 Transesophageal Echo probe only 93314 Transesophageal Echo interpretation 1/15/2012 1/15/2012 93315 Transesophageal Echo congenital 1/15/2012 93316 Transesophageal Echo congenital, probe only 1/15/2012 93317 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 -
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 -