Read CR_AIM 2012 CPT Listing 1-1-2012_POSTED v2.xls text version

Code List for Anthem Blue Cross and Blue Shield Imaging Services Program Effective 1/1/2012

Revenue Code Description 0340 Nuclear Medicine - General 0341 Nuclear Medicine - Diagnostic 0349 Nuclear Medicine - Other 0350 CT Scan - General 0351 CT Scan - Head Scan 0352 CT Scan - Body Scan 0359 CT Scan - Other 0404 Other Imaging - PET 0610 0611 0612 0614 0615 0616 0618 0619 Computerized Tomography (CT) CPT Abdomen 74150 74160 74170 Chest 71250 71260 71270 Upper 73200 Extremity 73201 73202 Lower Extremity 73700 73701 73702 70450 70460 70470 70480 70481 70482 70486 70487 70488 70490 70491 70492 72192 72193 72194 72125 72126 72127 72128 72129 72130 72131 72132 72133 74176 74177 74178 Magnetic Resonance Technology - General Classification Magnetic Resonance Technology MRI - Brain Magnetic Resonance Technology MRI - Spinal Cord Magnetic Resonance Technology MRI - Other Magnetic Resonance Technology MRA - Head and Neck Magnetic Resonance Technology MRA - Lower Extremities Magnetic Resonance Technology MRA - Other Magnetic Resonance Imaging - Other

Description CT abdomen; w/o contrast CT abdomen; with contrast CT abdomen; w/o contrast followed by contrast CT thorax; w/o contrast CT thorax; with contrast CT thorax; w/o contrast followed by contrast CT upper extremity; w/o contrast CT upper extremity; with contrast CT upper extremity; w/o contrast followed by contrast CT lower extremity; w/o contrast CT lower extremity; with contrast CT lower extremity; w/o contrast followed by contrast CT head or brain; w/o contrast CT head or brain; with contrast CT head or brain; w/o contrast followed by contrast CT orbit, sella or posterior fossa; w/o contrast CT orbit, sella or posterior fossa; with contrast CT orbit, sella or posterior fossa; w/o contrast followed by contrast CT maxillofacial area; w/o contrast CT maxillofacial area; with contrast CT maxillofacial area; w/o contrast followed by contrast CT soft tissue neck; w/o contrast CT soft tissue neck; with contrast CT soft tissue neck; w/o contrast followed by contrast CT pelvis; w/o contrast CT pelvis; with contrast CT pelvis w/o contrast followed by contrast CT cervical spine; w/o contrast CT cervical spine; with contrast CT cervical spine; w/o contrast followed by contrast CT thoracic spine; w/o contrast CT thoracic spine; with contrast CT thoracic spine; w/o contrast followed by contrast CT lumbar spine; w/o contrast CT lumbar spine; with contrast CT lumbar spine; w/o contrast followed by contrast CT abdomen and pelvis; w/o contrast CT abdomen and pelvis; with contrast CT abdomen and pelvis; w/o contrast followed by contrast

Head

Orbit

Sinus

Neck

Pelvis

Cervical Spine Thoracic Spine Lumbar Spine Abdomen and Pelvis

Computerized Tomography Angiography (CTA) CPT 74175 Abdomen Abdominal Arteries 75635 74174 71275 73206 73706 70496 70498 72191

Description CTA abdomen CTA abdominal aorta & bilateral iliofemoral lower extremity runoff CTA abdomen & pelvis CTA chest CTA upper extremity CTA lower extremity CTA head CTA neck CTA pelvis

Chest Upper Extremity Lower Extremity Head Neck Pelvis

Magnetic Resonance Imaging (MRI) Abdomen

Bone Marrow Breast Chest

Cardiac

CPT 74181 74182 74183 77084 77058 77059 71550 71551 71552 75557 75559 75561

Description MRI abdomen; w/o contrast MRI abdomen; with contrast MRI abdomen; w/o contrast followed by contrast MRI bone marrow blood supply MRI breast; unilateral MRI breast; bilateral MRI chest; w/o contrast MRI chest; with contrast MRI chest; w/o contrast followed by contrast MRI Cardiac for morphology and function without contrast material; MRI Cardiac for morphology and function without contrast material; with stress imaging MRI Cardiac for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; MRI Cardiac for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging MRI upper extremity, other than joint w/o contrast MRI upper extremity, other than joint with contrast MRI upper extremity, other than joint w/o contrast followed by contrast MRI upper extremity, any joint w/o contrast MRI upper extremity, any joint with contrast MRI upper extremity, any joint w/o contrast followed by contrast MRI lower extremity, other than joint w/o contrast MRI lower extremity, other than joint w contrast MRI lower extremity, other than joint w/o contrast followed by contrast MRI lower extremity, any joint w/o contrast MRI lower extremity, any joint w contrast MRI lower extremity, any joint w/o contrast followed by contrast MRI temporomandibular joint(s) MRI orbit, face and neck; w/o contrast MRI orbit, face and neck; with contrast MRI orbit, face and neck; w/o contrast followed by contrast MRI brain; w/o contrast MRI brain; with contrast MRI brain; w/o contrast followed by contrast MRI pelvis; w/o contrast MRI pelvis; with contrast MRI pelvis; w/o contrast followed by contrast MRI cervical spine; w/o contrast MRI cervical spine; with contrast MRI cervical spine; w/o contrast followed by contrast MRI thoracic spine; w/o contrast MRI thoracic spine; with contrast MRI thoracic spine; w/o contrast followed by contrast MRI lumbar spine; w/o contrast MRI lumbar spine; with contrast MRI lumbar spine; w/o contrast followed by contrast MRI

75563

Upper Extremity Non-joint

73218 73219 73220 73221 73222 73223 73718 73719 73720 73721 73722 73723

Upper Extremity Any Joint

Lower Extremity

TMJ Orbit

70336 70540 70542 70543 70551 70552 70553 72195 72196 72197 72141 72142 72156 72146 72147 72157 72148 72149 72158 S8042

Brain

Pelvis

Cervical Spine Thoracic Spine

Lumbar Spine MRI Magnetic Resonance Angiography (MRA) Abdomen Chest Upper Extremity Lower Extremity Head

CPT 74185 71555 73225 73725 70544 70545 70546 70548 70549 72198 72159

Description MRA abdomen; with or w/o contrast MRA chest; with or w/o contrast MRA upper extremity; with or w/o contrast MRA lower extremity; with or w/o contrast MRA head; w/o contrast MRA head; with contrast MRA head; w/o contrast followed by contrast MRA neck; with contrast MRA neck; w/o contrast followed by contrast MRA pelvis; with or w/o contrast MRA spinal canal and contents with or w/o contrast

Pelvis Spinal Canal

Magnetic Resonance Spectroscopy (MRS)

CPT 76390 CPT 77078 70547 CPT 78451

Description MR Spectroscopy Description CT bone mineral density study; axial skeleton MRA neck; w/o contrast Description 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) 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 reinjection 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) Planar, infarct avid; qualitative or quantitative Planar, infarct avid; with ejection fraction by first pass technique SPECT, infarct avid; with or w/o quantification Gated equilibrium; planar, single study, wall motion plus 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

QCT Bone Densitometry Neck Nuclear Cardiology Myocardial Perfusion Imaging

78452

78453

78454

Infarct Imaging

78466 78468

78469 Cardiac Blood Pool Imaging 78472 78473 78481 78483 78494

Positron Emission Tomography (PET) Brain Imaging Myocardial Imaging

CPT 78608 78609 78459 78491 78492 CPT 78811 78812 78813 78814 78815 78816

Description PET brain, metabolic evaluation PET brain, perfusion evaluation PET myocardial, metabolic evaluation PET myocardial, perfusion, single study PET myocardial, perfusion, multiple studies Description PET imaging, limited PET imaging, skull to mid-thigh PET imaging, whole body PET imaging with concurrent CT, limited PET imaging with concurrent CT, skull to mid-thigh PET imaging with concurrent CT, whole body

PET and PET/CT Fusion

Screening CT Colonoscopy CPT 74263

Description Computed tomographic (CT) colonography, screening, including image postprocessing

Diagnostic CT Colonography

CPT 74261

Description Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including non-contrast images, if performed

74262

Functional MRI Brain

CPT 70554 70555

Description Functional MRI brain not requiring physician administration Functional MRI brain requiring physician administration

CT Heart for Calcium Scoring

CPT 75571

Description Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium

CT Heart for Structure & Morph

CPT 75572

Description Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed) Computed tomography, heart, with contrast 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)

75573

CTA Heart Incl Structure & Morph

CPT 75574

Description Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures if performed)

Add-on Procedures CT or MRI Grouping

CPT 76376 *& 76377 * 75565 *

Description 3 D Reconstruction of CT or MRI images

Cardiac MRI Grouping

Cardiac Blood Pool Grouping Group 82 valid with code 78472 only

78496 *

Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure) Cardiac blood pool imaging, gated equilibrium, single study, at rest, with right ventricular ejection fraction by first pass technique (Add-on to 78472 only)

Echocardiography Services CPT Code List**

Echocardiogram Stress Echo (SE) CPT Description 93350 Transthoracic Stress Echo, complete 93351 Transthoracic Stress Echo, complete w cont EKG 93303 93304 93306 93307 93308 93312 93313 93314 93315 93316 93317 Echo Add-On Codes CPT 93320 * 93321 * 93325 * 93352 * Transthoracic Echo cardiac anomalies Transthoracic Echo cardiac anomalies, limited Transthoracic Echo complete w color & spectral Transthoracic Echo complete wo color & spectral Transthoracic Echo limited Transesophageal Echo Transesophageal Echo probe only Transesophageal Echo interpretation Transesophageal Echo congenital Transesophageal Echo congenital, probe only Transesophageal Echo congenital interpretation Description Doppler Echo complete Doppler Echo limited Doppler Echo flow velocity Echo contrast agent (SE only)

Resting Trans Echo (TTE)

Transesophageal Echo (TEE)

* Denotes a CPT code that is on the add-on/secondary code included in the grouper, but not requiring separate review. ** These codes have changed fromvoluntary to required for Anthem Blue Cross and Blue Shield (Anthem) members Pre-certification requirements apply to all Local Groups. DaimlerChrysler, Delphi, Ford Motor Group, General Motors, and Southwest Community Health Center are not Pre-certification requirements apply to the Federal Employee Program (FEP) HMO but are not applicable for Please contact 800-676-BLUE (2583) to verify pre-certification requirements for Blue Card business

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