authorization assistance is available - valley … · cpt code guidelines for x-ray, ... 70540 mri...
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SDI Patient Assistance Programs available by calling (602) 521-6203
AT-A-GLANCEINSURANCE PLANSTax ID Number: 200382536
SCHEDULING: (623) 847-2000 • FAX: (623) 847-2001 PET/IR SCHEDULING: (623) 842-5614
NUCLEAR MEDICINE SCHEDULING: (623) 842-5910 DIGITAL RECORDS/PATIENT REPORTS: (623) 842-5620
IT SUPPORT LINE: (602) 521-6373 www.valleyradiolgists.com
AETNA (ALL PRODUCTS*)
AMBETTER
ARIZONA CARE NETWORK
ARIZONA FOUNDATION
BANNER HEALTH NETWORK
BEECH STREET
BCBS – AZ (ALL STATES)
CIGNA (ALL PRODUCTS* – INCLUDES GREATWEST AND GWH)
CORECHOICE
COVENTRY HEALTH CARE (ALL PRODUCTS*)
FIRST HEALTH
GALAXY HEALTH
HEALTH MANAGEMENT NETWORK – AMN/RAN/HMN
HEALTH NET (ALL PRODUCTS *- EXCEPT AZPCP)
HUMANA (ALL PRODUCTS *– EXCEPT HMOx)
INTEGRATED HEALTH PLAN
MULTIPLAN
OPTUM MEDICAL NETWORK (FORMERLY LIFEPRINT)
PPO NEXT
PRIVATE HEALTHCARE SYSTEMS (PHCS)
THREE RIVERS PROVIDER NETWORK
TRICARE/UHC MILITARY & VETERANS SERVICES
UNITEDHEALTHCARE (ALL PRODUCTS*)
UA HEALTHCARE (ALL PRODUCTS*)
USA MANAGED CARE
VA (DEPARTMENT OF VETERANS AFFAIRS - INCLUDES TRI-WEST VAPC3)
WORKERS COMPENSATION (MOST PLANS)
MEDICARESDI AND AFFILIATES ARE IN NETWORK WITH A FULL RANGE OF TRADITIONAL MEDICARE AND MEDICARE ADVANTAGE PLANS.
INCLUDING BUT NOT LIMITED TO:
AHCCCSSDI AND AFFILIATES ARE IN NETWORK WITH ALL MARICOPA COUNTY AHCCCS PLANS (PLUS RELATED MEDICARE ADVANTAGE & ALTCS PLANS).
INCLUDING BUT NOT LIMITED TO:
BANNER HEALTH NETWORK
BLUE CROSS BLUE SHIELD ADVANTAGE
HEALTH CHOICE GENERATIONS
TRADITIONAL MEDICARE (FFS)/RAILROAD MEDICARE
MERCY CARE ADVANTAGE
ONECARE
OPTUMCARE
UNITEDHEALTHCARE AARP MEDICARECOMPLETE
BANNER-UNIVERSITY FAMILY CARE
CARE 1ST
CENPATICO
HEALTH CHOICE ARIZONA (EXCEPT ESSENTIALS)
INDIAN HEALTH SERVICES
MERCY CARE PLAN
MERCY MARICOPA INTEGRATED CARE
UNITEDHEALTHCARE COMMUNITY PLAN (FORMERLY APIPA & EVERCARE)
UNIVERSITY FAMILY CARE/BANNER
AUTHORIZATION ASSISTANCE IS AVAILABLE
*SOME NARROW NETWORKS MAY BE EXCLUDED
Plans we are NOT contracted with: • Caremore • Kaiser Permanente (CA HMO plan) • Out of State Medicaid • Out of State Medicare Advantage Plans • Health Partners
• SMIL, EVDI and Valley Radiologists are affiliates of Southwest Diagnostic Imaging (SDI). All share the same Tax ID and extensive network of plans. • This At-A-Glance reference is intended to be a guide. For the full list or with questions call (623) 931-1128.
CPT Code Guidelines for X-Ray, CT and MRIMRI Head and Neck (soft tissue)70540 MRI Orbit, Face, Neck, Sella w/o70543 MRI Orbit, Face, Neck, Sella w/wo70551 MRI Brain w/o70553 MRI Brain w/wo70553 MRI Brain IAC w/wo70553 MRI Brain Pituitary w/wo
MRI Breast77059 MRI Bilateral Breast w/wo
MRI Spine72141 MRI Cervical Spine w/o72156 MRI Cervical Spine w/wo72146 MRI Thoracic Spine w/o72157 MRI Thoracic Spine w/wo72148 MRI Lumbar Spine w/o72158 MRI Lumbar Spine w/wo72195 MRI Sacrum & Coccyx w/o72197 MRI Sacrum & Coccyx w/wo
MRI Upper Extremity73218 MRI Upper Extremity, No Joint, w/o73220 MRI Upper Extremity, No Joint w/wo (Humerus/Forearm/Hand)73221 MRI Upper Extremity Joint w/o73223 MRI Upper Extremity Joint w/wo (Shoulder/Elbow/Wrist)
MRI Abdomen & Pelvis74181 MRI Abdomen w/o74181 MRCP w/o74183 MRI Abdomen w/wo74183 MRI Abdomen w/wo Eovist72195 MRI Pelvis w/o72197 MRI Pelvis w/wo
MRI Lower Extremity73718 MRI Lower Extremity, No Joint, w/o73720 MRI Lower Extremity, No Joint, w/wo (Femur/Tib/Fib/Foot)73721 MRI Lower Extremity Joint w/o73723 MRI Lower Extremity Joint w/wo (Hip/Knee/Ankle)
MR Angiography70544 MRA Head/COW w/o70546 MRA Head/COW w/wo70547 MRA Neck w/o70549 MRA Neck w/wo74185 MRA Abdomen w/o or w/wo
CT Head & Neck70450 CT Brain w/o Contrast70470 CT Brain w/wo Contrast70486 CT Sinus w/o70486 CT Facial Bones w/o Contrast70487 CT Facial Bones with Contrast70488 CT Facial Bones w/wo Contrast70480 CT Orbits w/o Contrast70481 CT Orbits with Contrast70482 CT Orbits w/wo Contrast70480 CT Temporal Bones w/o Contrast70481 CT Temporal Bones with Contrast70482 CT Temporal Bones w/wo Contrast70490 CT Soft Tissue Neck w/o Contrast70491 CT Soft Tissue Neck with Contrast70492 CT Soft Tissue Neck w/wo Contrast
CT Chest71250 CT Chest w/o Contrast71260 CT Chest with Contrast75571 CT Calcium Scoring71250 CT Low Dose Lung Screening
CT Extremity 73200 CT Upper Extremity w/o (Shoulder/Humerus/Elbow/ Forearm/Wrist/Hand) 73700 CT Lower Extremity w/o (Hip/Femur/Knee/Tib/Fib/ Ankle/Foot)
CT Spine 72125 Cervical Spine w/o Contrast 72128 Thoracic Spine w/o Contrast 72131 Lumbar Spine w/o Contrast
CT Abdomen & Pelvis74176 CT Abdomen & Pelvis w/o74177 CT Abdomen & Pelvis with74178 CT Abdomen & Pelvis w/wo74261 Virtual Colonoscopy Diagnostic74263 Virtual Colonoscopy Screening
CT Angiography70496 CTA Head w/wo70496/70498 CTA Carotids w/wo71275 CTA Chest/Thoracic Aorta w/wo71275 CTA Pulmonary Arteries (PE) w/wo75572 CTA Cardiac - Lt Atrium & Pulmonary Vein w/wo75574 CTA Coronary Arteries with Calcium Score w/wo75635 CTA Abdominal Aorta with Runoff w/wo74174 CTA Abdomen & Pelvis w/woDigital X-Ray Head and Neck
70110 Mandible Complete70140 Facial Bones Less than3 views70150 Facial Bones Complete70160 Nasal Bones Complete70200 Orbits Complete 4 Views Minimum70210 Sinus Less than 3 Views70220 Sinus Complete70250 Skull Less than 4 Views70260 Skull Complete70360 Soft Tissue Neck Lateral
Digital X-Ray Chest71020 Chest; 2 Views71100 Ribs; Unilateral,2 Views71101 Ribs; Bilateral, 3 Views71130 Sternoclavicular Joints
Digital X-Ray Spine72040 Cervical Spine 2-3 Views72050 Cervical Spine Complete72072 Thoracic Spine 3 Views72100 Lumbar 2-3 Views72110 Lumbar Spine Complete72114 Lumbar Complete w/Flexion & Extension
Digital X-Ray Upper Extremities73000 Clavicle Unilateral Complete73030 Shoulder Unilateral Complete73050 AC Joints 2 Views73060 Humerus 2 Views73080 Elbow Unilateral Complete73090 Forearm Unilateral 2 Views73110 Wrist Unilateral Complete73130 Hand Unilateral Complete
Digital X-Ray Abdomen74000 Abdomen/KUB Single View74020 Abdomen 2 View Supine & Erect Digital X-Ray Lower Extremities73510 Hip Unilateral 2 Views73520 Hips Bilateral w/AP Pelvis73540 Hips/Pelvis Infant73550 Femur 2 Views73562 Knee Unilateral Complete73565 Bilateral Standing Knees73590 Tibia/Fibula 2 Views73592 Lower Ext. Infant 2 views73610 Ankle Unilateral Complete73630 Foot Unilateral Complete
To schedule an appointment Call 623-847-2000.VR 408 - 01/2018
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