yourcare health plan 2015 cpt code/prior authorization … cpt code list for... · yourcare health...

PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHPRadiology MRI 70336 MRI TMJ Tempomandibular joint/jaw PA Medical Necessity Review

Radiology CT SCANS 70450 CT Head/Brain w/o Contrast PA Medical Necessity Review

Radiology CT SCANS 70470 CT Head/Brain w/o & w/ Contrast PA Medical Necessity Review

Radiology CT SCANS 70480 CT Orbit w/o Contrast Temporal Bone/Mastoid/Ears PA Medical Necessity Review

Radiology CT SCANS 70481 CT Orbit w/ Contrast Temporal Bone/Mastoid/Ears PA Medical Necessity Review

Radiology CT SCANS 70482 CT Orbit w/o & w/ Contrast Temporal Bone/Mastoid/Ears PA Medical Necessity Review

Radiology CT SCANS 70486 CT Maxllfcl w/o Contrast Sinus/Denta Scan/TMJ PA Medical Necessity Review

Radiology CT SCANS 70487 CT Maxllfcl w/ Contrast Sinus/Denta Scan/TMJ PA Medical Necessity Review

Radiology CT SCANS 70488 CT Maxllfcl w/o & w/ Contrast Sinus/Denta Scan/TMJ PA Medical Necessity Review

YourCare Health Plan 2015 CPT Code/Prior Authorization List

Programs: Radiology, Cardiology, Radiation Therapy , and Sleep ManagementPlan Implementation: 07/17/2015

Radiology CT SCANS 70488 CT Maxllfcl w/o & w/ Contrast Sinus/Denta Scan/TMJ PA Medical Necessity Review

Radiology CT SCANS 70490 CT Soft Tissue Neck w/o Contrast Parotid; Not used for Cervical Bone PA Medical Necessity Review

Radiology CT SCANS 70491 CT Soft Tissue Neck w/ Contrast Parotid; Not used for Cervical Bone PA Medical Necessity Review

Radiology CT SCANS 70492 CT Soft Tissue Neck w/o & w/ Contrast Parotid; Not used for Cervical Bone PA Medical Necessity Review

Radiology CT SCANS 70496 Ct Angiography Head PA Medical Necessity Review

Radiology CT SCANS 70498 Ct Angiography Neck PA Medical Necessity Review

Radiology MRI 70540 MRI Face, Orbit, Neck w/o Contrast Sinus/3 areas (soft tissue neck) eyes/temporal PA Medical Necessity Review

Radiology MRI 70542 MRI Face, Orbit, Neck w/ Contrast Gadolinium PA Medical Necessity Review

Radiology MRI 70543 MRI Face, Orbit, Neck w & w/o Contrast Gadolinium PA Medical Necessity Review

Radiology MRA 70544 MRA Head w/o Contrast Also known as MRV PA Medical Necessity Review

Radiology MRA 70545 MRA Head w/ Contrast Gadolinium/ Also known as MRV PA Medical Necessity Review

Radiology MRA 70546 MRA Head w & w/o Contrast Gadolinium/ Also known as MRV PA Medical Necessity Review

Radiology MRA 70547 MRA Neck w/o Contrast Also known as MRV PA Medical Necessity Review

Radiology MRA 70548 MRA Neck w/ Contrast Gadolinium/ Also known as MRV PA Medical Necessity Review

Radiology MRA 70549 MRA Neck w & w/o Contrast Gadolinium/ Also known as MRV PA Medical Necessity Review

Radiology MRI 70551 MRI Head w/o Contrast IACs (Internal Auditory Canal) PA Medical Necessity Review

Radiology MRI 70552 MRI Head w/ Contrast IACs (Internal Auditory Canal) PA Medical Necessity Review

Radiology MRI 70553 MRI Head w/ & w/o Contrast IACs (Internal Auditory Canal) PA Medical Necessity Review

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PROGRAM MODALITY CPT CODE PROCEDURE DESCRIPTION AKA's or EXTRA INFORMATION Medicaid, CHP



Radiology MRI

70554

MRI, Brain, Functional MRI; Including Test Selection and Administration of Repetitive Body Part Movement and/or Visual Stimulation, Not Requiring Physician or Psychologist Administration

PA Medical Necessity Review

Radiology MRI70555

MRI, Brain, Functional MRI; Requiring Physician or Psychologist Administration of Entire Neurofunctional Testing


Radiology CT SCANS 71250 CT Thorax w/o Contrast Can be CT Chest or a Ultrafast‐CT/EBT/EBCTPA Medical Necessity Review

Radiology CT SCANS 71260 CT Thorax w/ Contrast Chest/Ultrafast CT/EBT/EBCT PA Medical Necessity Review

d l 71270 CT Thorax w/o & w/ Contrast Chest/Ultrafast CT/EBT/EBCT d lRadiology CT SCANS 71270 CT Thorax w/o & w/ Contrast Chest/Ultrafast CT/EBT/EBCT PA Medical Necessity Review

Radiology CT SCANS 71275 Ct Angiography Chest PA Medical Necessity Review

Radiology MRI 71550 MRI Chest w/o Contrast Brachial Plexus PA Medical Necessity Review

Radiology MRI 71551 MRI Chest w/ Contrast PA Medical Necessity Review

Radiology MRI 71552 MRI Chest w/ & w/o Contrast Gadolinium PA Medical Necessity Review

Radiology MRA 71555 MRA Chest (Emc Myocardium) w/ or w/o Contrast

Gadolinium/ Also known as MRVPA Medical Necessity Review

Radiology CT SCANS 72126 CT C Spine w/ Contrast PA Medical Necessity Review

Radiology CT SCANS 72127 CT C Spine w/o & w/ Contrast PA Medical Necessity Review

Radiology CT SCANS 72128 CT T Spine w/o Contrast PA Medical Necessity Review

Radiology CT SCANS 72129 CT T Spine w/ Contrast PA Medical Necessity Review

Radiology CT SCANS 72130 CT T Spine w/o & w/ Contrast PA Medical Necessity Review

Radiology CT SCANS 72132 CT L Spine w/ Contrast Includes Sacrum PA Medical Necessity Review

Radiology CT SCANS 72133 CT L Spine w/o & w/ Contrast Includes Sacrum PA Medical Necessity Review

Radiology MRI 72141 MRI Cervical Spine w/o Contrast Vertebrae of the Neck PA Medical Necessity Review

Radiology MRI 72142 MRI Cervical Spine w/ Contrast Gadolinium PA Medical Necessity Review

Radiology MRI 72146 MRI Thoracic Spine w/o Contrast PA Medical Necessity Review

Radiology MRI 72147 MRI Thoracic Spine w/ Contrast Gadolinium PA Medical Necessity Review

Radiology MRI 72148 MRI Lumbar Spine w/o Contrast Includes Sacrum PA Medical Necessity Review

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Radiology MRI 72149 MRI Lumbar Spine w/ Contrast Gadolinium ‐ Includes Sacrum PA Medical Necessity Review

Radiology MRI 72156 MRI C Spine w/ & w/o Contrast Gadolinium PA Medical Necessity Review

Radiology MRI 72157 MRI T Spine w/ & w/o Contrast Gadolinium PA Medical Necessity Review

Radiology MRI 72158 MRI L Spine w/ & w/o Contrast Gadolinium ‐ Includes Sacrum PA Medical Necessity Review

Radiology MRA 72159 MRA Spinal Canal w/ or w/o Contrast Gadolinium/ Also known as MRV Excluded from program

Radiology CT SCANS 72191 CT Angiography Pelvis Aortic Aneurysm Excluded from program

Radiology CT SCANS 72192 CT Pelvis w/o Contrast Below Belly Button/Coccyx PA Medical Necessity Review

Radiology CT SCANS 72193 CT Pelvis w/ Contrast Below Belly Button/Coccyx PA Medical Necessity Review

Radiology CT SCANS 72194 CT Pelvis w/o & w/ Contrast Below Belly Button/Coccyx PA Medical Necessity ReviewRadiology CT SCANS 72194 CT Pelvis w/o & w/ Contrast Below Belly Button/Coccyx PA Medical Necessity Review

Radiology MRI 72195 MRI Pelvis w/o Contrast Coccyx PA Medical Necessity Review

Radiology MRI 72196 MRI Pelvis w/ Contrast Gadolinium/coccyx PA Medical Necessity Review

Radiology MRI 72197 MRI Pelvis w & w/o Contrast Gadolinium/coccyx PA Medical Necessity Review

Radiology MRA 72198 MRA Pelvis w/ or w/o Contrast Gadolinium/ Also known as MRV Excluded from program

Radiology CT SCANS 73200 CT Upper Extremity w/o Contrast Hand/Arm/Shoulder/ Elbow/Wrist PA Medical Necessity Review

Radiology CT SCANS 73201 CT Upper Extremity w/ Contrast Hand/Arm/Shoulder/ Elbow/Wrist PA Medical Necessity Review

Radiology CT SCANS 73202 CT Upper Extremity w/o & w/ Contrast Hand/Arm/Shoulder/ Elbow/Wrist PA Medical Necessity Review

Radiology CT SCANS 73206 CT Angiography Upper Extremity Hand/Arm/Shoulder/ Elbow/Wrist Excluded from program

Radiology MRI 73218 MRI Upper Extremity w/o Contrast Hand/Arm/Axilla PA Medical Necessity Review

Radiology MRI 73219 MRI Upper Extremity w/ Contrast Hand/Arm/Axilla‐Gadolinium PA Medical Necessity Review

Radiology MRI 73220 MRI Upper Extremity w & w/o Contrast Hand/Arm/Axilla‐Gadolinium PA Medical Necessity Review

Radiology MRI 73221 MRI Upper Extremity w/o Contrast Shoulder/Elbow/Wrist PA Medical Necessity Review

Radiology MRI 73222 MRI Upper Extremity w/ Contrast ArthrogramShoulder/Elbow/Wrist‐Gadolinium PA Medical Necessity Review

Radiology MRI 73223 MRI Upper Extremity Joint w & w/o Contrast Shoulder/Elbow/Wrist‐Gadolinium PA Medical Necessity Review

Radiology MRA 73225 MRA Upper Extremity w/ or w/o Contrast Gadolinium/ Also known as MRV Excluded from program

Radiology CT SCANS 73700 CT Lower Extremity w/o Contrast Hip/Leg/Knee/Ankle/ Foot PA Medical Necessity Review

Radiology CT SCANS 73701 CT Lower Extremity w/ Contrast Hip/Leg/Knee/Ankle/ Foot PA Medical Necessity Review

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Radiology CT SCANS 73702 CT Lower Extremity w/o & w/ Contrast Hip/Leg/Knee/Ankle/ Foot PA Medical Necessity Review

Radiology CT SCANS 73706 CT Angiography Lower Extremity Hip/Leg/Knee/Ankle/ Foot Excluded from program

Radiology MRI 73718 MRI Lower Extremity w/o Contrast Foot/Leg PA Medical Necessity Review

Radiology MRI 73719 MRI Lower Extremity w/ Contrast Foot/Leg‐Gadolinium PA Medical Necessity Review

Radiology MRI 73720 MRI Lower Extremity w/ & w/o Contrast Foot/Leg‐Gadolinium PA Medical Necessity Review

Radiology MRI 73721 MRI Lower Extremity w/o Contrast Hip/Knee/Ankle PA Medical Necessity Review

Radiology MRI 73722 MRI Lower Extremity w/ Contrast ArthrogramHip/Knee/Ankle‐Gadolinium PA Medical Necessity Review

Radiology MRI 73723 MRI Lower Extremity Joint w/ & w/o Contrast Hip/Knee/Ankle‐Gadolinium PA Medical Necessity Review

Radiology MRA 73725 MRA Lower Extremity w/ or w/o Contrast Gadolinium/ Also known as MRV Excluded from program

Radiology CT SCANS 74150 CT Abdomen w/o Contrast Diaphragm to Belly Button PA Medical Necessity Review

Radiology CT SCANS 74160 CT Abdomen w/ Contrast Aneurysm/Diaphragm to Belly Button PA Medical Necessity Review

Radiology CT SCANS 74170 CT Abdomen w/o & w/ Contrast Diaphragm to Belly Button PA Medical Necessity Review

Radiology CT SCANS 74174Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing

Excluded from program

Radiology CT SCANS 74175 Ct Angiography Abdomen Diaphragm to Belly Button Excluded from program

Radiology MRI 74181 MRI Abdomen w/o Contrast MRCP‐MR Cholangiogram PA Medical Necessity Review

Radiology MRI 74182 MRI Abdomen w/ Contrast MRCP‐MR Cholangiogram Gadolinium PA Medical Necessity Review

Radiology MRI 74183 MRI Abdomen w/ & w/o Contrast MRCP‐MR Cholangiogram Gadolinium PA Medical Necessity Review

Radiology MRA 74185 MRA Abdomen w/ or w/o Contrast Also known as MRV Excluded from program

Radiology MRI 75557 Cardiac MRI For Morphology And Function Without Contrast Material Excluded from program

Radiology MRI75559

Cardiac MRI For Morphology And Function Without Contrast Material; With Stress Imaging Excluded from program

Radiology MRI75561

Cardiac MRI For Morphology And Function Without Contrast Material(s), Followed By Contrast Material(s) And Further Sequences


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Radiology MRI

75563Cardiac MRI For Morphology And Function Without Contrast Material(s), Followed By Contrast Material(s) And Further Sequences; With Stress Imaging


Radiology CT SCANS 76380 CT Limited or Localized Follow‐Up Study Excluded from program

Radiology MRI 76390 MRI Spectroscopy MRS Excluded from program

Radiology CT SCANS 76497 Unlisted Computed Tomography Procedure Excluded from program

Radiology MRI 76498 Unlisted MRI Procedure Redirect to valid code

Radiology MRI 76499 Unlisted Radiologic Procedure Excluded from program

Radiology ULTRASOUND U/S OB Pelvis, Pregnant Uterus, First Trimester gy76801

/ , g ,<14 Weeks Single Or First Gestation Excluded from program

Radiology ULTRASOUND76802

U/S OB Pelvis, Pregnant Uterus, First Trimester <14 Weeks Each Additional Gestation

Multiple Gestation onlyExcluded from program

Radiology ULTRASOUND 76805 U/S OB Pelvis, Pregnant Uterus, B‐Scan (Allowed Once Per Gestation)

Level 1 Excluded from program

Radiology ULTRASOUND

76810U/S OB Pelvis Complete, Multiple Gestation after 1st Trimester (Allowed Once For Each Additional Fetus per Gestation; Must Be Billed With 76805)

Multiple Gestation only



76811

US Pregnant Uterus Fetal & Maternal Eval Plus Fetal Anatomic Eval Transabdominal Single or First Gestation (Allowed Once Per Gestation; Second Study Allowed If Performed By A Different Physician)

Level 2


Cardiology CARDIAC IMPLANTABLES 33206Insertion Of New Or Replacement Of Permanent Pacemaker With Transvenous Electrode(s); Atrial PA Medical Necessity Review

Cardiology CARDIAC IMPLANTABLES 33207Insertion Of New Or Replacement Of Permanent Pacemaker With Transvenous Electrode(s); Ventricular


Cardiology CARDIAC IMPLANTABLES 33208Insertion Of New Or Replacement Of Permanent Pacemaker With Transvenous Electrode(s); Atrial And Ventricular


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Cardiology CARDIAC IMPLANTABLES 33212Insertion or Replacement of Permanent Pacemaker Pulse Generator Only; Single Chamber, Atrial or Ventricular



76812

US Pregnant Uterus Fetal & Maternal Eval Plus Fetal Anatomic Eval Transabdominal Each Additional Gestation (Allowed Once For Each Additional Fetus Per Gestation; Must Be Billed With 76811; Second Study Allowed If Performed By A Different Physician)

Multiple Gestation only


Radiology ULTRASOUND Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or

76813

y ,transvaginal approach; single or first gestation. (Allowed once per gestation) Excluded from program


76814

Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; each additional gestation (List separately in addition to code for primary procedure) (Allowed once for each additional fetus per gestation)



76815

U/S Pregnant Uterus, Real Time w/ Image Documentation, Limited (E.G. Fetal Heart Beat, Placental Location, Fetal Position and/or Qualitative Amniotic Fluid Volume), 1 or More Fetuses

One CPT code per DOS regardless the # of fetuses


Radiology ULTRASOUND 76816 U/S OB Pelvis Follow Up or Repeat One exam per fetus Excluded from program

Radiology ULTRASOUND 76817 US Pregnant Uterus Transvaginal One CPT code per DOS regardless the # of fetuses Excluded from program

Radiology ULTRASOUND 76818 Fetal Biophysical Profile One exam per fetus Excluded from program

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Radiology ULTRASOUND 76819 Fetal Biophysical Profile w/o Stress Non Stress One exam per fetusExcluded from program

Radiology ULTRASOUND 76820 Doppler Velocimetry, Fetal; Umbilical Artery One exam per fetus Excluded from program

Radiology ULTRASOUND 76821 Doppler Velocimetry, Fetal; Middle Cerebral Artery

One exam per fetusExcluded from program

Radiology ULTRASOUND 76825 U/S OB Echocardiography, Fetal, Cardiovascular System

Fetal EchoOne exam per fetus Excluded from program

Radiology ULTRASOUND 76826 Follow Up or Repeat Study One exam per fetus Excluded from program

Radiology ULTRASOUND 76827 Doppler Echocardiography Fetal Complete One exam per fetus Excluded from program

Radiology ULTRASOUND 76828 Follow Up or Repeat Study One exam per fetus Excluded from program

R di l ULTRASOUND U/S G i i l E d iRadiology ULTRASOUND 76975 U/S Gastrointestinal, Endoscopic Excluded from program

Radiology CT SCANS 77011 CT Guidance Sterotactic Localization Excluded from program

Radiology CT SCANS 77012 CT Guidance Needle BX‐RAD S & I Excluded from program

Radiology CT SCANS 77013 CT Guidance for and Monitoring of Tissue Ablation Excluded from program

Radiology CT SCANS 77014 CT Guidance for Placement of Radiation Therapy Fields Excluded from program

Radiology MRI 77021 MRI Guidance for Needle Placement Excluded from program

Radiology MRI 77022 MRI Guidance for and Monitoring of Tissue Ablation Excluded from program

Radiology MRI 77058 MRI Breast w/ and/or w/o Contrast; UnilateralUnilateral‐One‐Gadolinium PA Medical Necessity Review

Radiology MRI 77059 MRI Breast Bilateral Both PA Medical Necessity Review

Radiology CT SCANS 77078 CT Bone Density Study, Axial Skeleton Excluded from program

Radiology CT SCANS 77079 CT Bone Density Study, Appendicular SkeletonExcluded from program

Radiology MRI 77084 MRI Bone Marrow Blood Supply Excluded from program

Radiology NUCLEAR MED 78000 Thyroid uptake; single determination Redirect to valid code

Radiology NUCLEAR MED 78001 Thyroid uptake; multiple determinations Redirect to valid code

Radiology NUCLEAR MED78003

Thyroid uptake stimulation, suppression or discharge (not including initial uptake studies) Redirect to valid code

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Radiology NUCLEAR MED 78006 Thyroid imaging, with uptake; single determination Redirect to valid code

Radiology NUCLEAR MED 78007 Thyroid imaging, multiple determinations Redirect to valid code

Radiology NUCLEAR MED 78010 Thyroid imaging; only Redirect to valid code

Radiology NUCLEAR MED 78011 Thyroid imaging; with vascular flow Redirect to valid code

Radiology NUCLEAR MED

78012Thyroid Uptake, Single or Multiple Quantitative Measurements(s) (Including Stimulation, Suppression, or Discharge, When Performed) Excluded from program


Thyroid Imaging (Including Vascular Flow, When Performed) Excluded from program78013 Performed) p g


78014

Thyroid Imaging (Including Vascular Flow, When Performed); With Single or Multiple Uptake(s) Quantitative Measurement(s) (Including Stimulation, Suppression, or Discharge, When Performed)


Radiology NUCLEAR MED 78015 Thyroid Met Imaging Excluded from program

Radiology NUCLEAR MED 78016 Thyroid Met Imaging with Additional Studies Excluded from program

Radiology NUCLEAR MED 78018 Thyroid Scan Whole Body For CA thyroid (I‐ 31 scan) Excluded from program

Radiology NUCLEAR MED 78020 Thyroid Carcinoma Metastases Uptake Excluded from program


78070Parathyroid Planar Imaging (Including Subtraction, When Performed)


Radiology NUCLEAR MED 78075 Adrenal Nuclear Imaging MIBG Excluded from program

Radiology NUCLEAR MED 78099 Unlisted Endocrine Procedure Excluded from program

Radiology NUCLEAR MED 78102 Bone Marrow Imaging, Limited Excluded from program

Radiology NUCLEAR MED 78103 Bone Marrow Imaging, Multiple Excluded from program

Radiology NUCLEAR MED 78104 Bone Marrow Imaging, Whole Body Excluded from program

Radiology NUCLEAR MED 78135 Differential Organ/Tissues Kinetic Excluded from program

Radiology NUCLEAR MED 78140 Labeled Red Cell Sequestration Excluded from program

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Radiology NUCLEAR MED 78185 Spleen Imaging w & w/o Vascular Flow Excluded from program

Radiology NUCLEAR MED 78190 Platelet Survival, Kinetics Excluded from program

Radiology NUCLEAR MED 78191 Platelet Survival Excluded from program

Radiology NUCLEAR MED 78195 Lymph System Imaging MIBG Excluded from program

Radiology NUCLEAR MED 78199 Unlisted Hematopoetic Procedure Excluded from program

Radiology NUCLEAR MED 78201 Liver Imaging Excluded from program

Radiology NUCLEAR MED 78202 Liver Imaging w/ Flow Excluded from program

Radiology NUCLEAR MED 78205 Liver Imaging Spect Excluded from program

Radiology NUCLEAR MED 78206 Liver Imaging Spect w/ Vascular Flow Excluded from programRadiology NUCLEAR MED 78206 Liver Imaging Spect w/ Vascular Flow Excluded from program

Radiology NUCLEAR MED 78215 Liver and Spleen Imaging Red Cell Tagging Excluded from program

Radiology NUCLEAR MED 78216 Liver and Spleen Imaging w/ Flow Excluded from program

Radiology NUCLEAR MED 78226 Hepatobiliary system imaging, including gallbladder when present; Excluded from program


78227

Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention, including quantitative measurement(s) when performed


Radiology NUCLEAR MED 78230 Salivary Gland Imaging Excluded from program

Radiology NUCLEAR MED 78231 Serial Salivary Gland Excluded from program

Radiology NUCLEAR MED 78232 Salivary Gland Function Test Excluded from program

Radiology NUCLEAR MED 78258 Esophagus Motility Study Excluded from program

Radiology NUCLEAR MED 78261 Gastric Mucosa Imaging Excluded from program

Radiology NUCLEAR MED 78262 Gastroesophagael Reflum Emam Excluded from program

Radiology NUCLEAR MED 78264 Gastric Emptying Study Excluded from program

Radiology NUCLEAR MED 78278 GI Bleeder Scan Excluded from program

Radiology NUCLEAR MED 78282 GI Protein Loss Exam Excluded from program

Radiology NUCLEAR MED 78290 Meckel's Diverticulum Imaging Excluded from program

Radiology NUCLEAR MED 78291 Leveen Shunt Patency Exam Excluded from program

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Radiology NUCLEAR MED 78299 Unlisted Gastroinestinal Procedure Excluded from program

Radiology NUCLEAR MED 78300 Bone or Joint Imaging Ltd One Bone Excluded from program

Radiology NUCLEAR MED 78305 Bone or Joint Imaging Multiple More than one Bone Excluded from program

Radiology NUCLEAR MED 78306 Bone Scan Whole Body Used Often with CA studies/All bones Excluded from program

Radiology NUCLEAR MED 78315 Bone and/or Joint Imaging; 3 Phase Study OsteomyelitisTechnesium 99 Excluded from program

Radiology NUCLEAR MED 78320 Bone Joint Imaging Tomo Test Spect Excluded from program

Radiology NUCLEAR MED 78399 Unlisted Musculoskeletal Procedure Excluded from program

Radiology NUCLEAR MED 78414 Non‐Imaging Heart Function Excluded from program

Radiology NUCLEAR MED 78428 Cardiac Shunt Imaging Excluded from program

Radiology NUCLEAR MED 78445 Radionuclide Venogram Non‐Cardiac Excluded from program

Radiology NUCLEAR MED 78456 Acute Venous Thrombosis Imaging Excluded from program

Radiology NUCLEAR MED 78457 Venous Thrombosis Imaging Unilateral Excluded from program

Radiology NUCLEAR MED 78458 Venous Thrombosis Imaging Bilateral Excluded from program

Radiology PET SCANS 78459 Myocardial Imaging, Positron Emission Tomography (PET) Metabolic Eval. PA Medical Necessity Review

Radiology NUCLEAR MED 78466 Myocardial Infarction Scan Excluded from program

Radiology NUCLEAR MED 78468 Heart Infarct Image Ef Excluded from program

Radiology NUCLEAR MED 78469 Heart Infarct Image Spect Excluded from program

Radiology NUCLEAR MED 78472 Gated Heart, Rest or Stress Excluded from program

Radiology NUCLEAR MED 78473 Cardiac Blood Pool Muga Scan Excluded from program

Radiology NUCLEAR MED 78481 Heart First Pass Single PA Medical Necessity Review

Radiology NUCLEAR MED 78483 Cardiac Blood Pool Imaging, Multi PA Medical Necessity Review

Radiology PET SCANS78491

Myocardial Imaging, Positron Emission Tomography (PET), Perfusion; Single Study At Rest Or Stress



Myocardial Imaging, Positron Emission Tomography (PET), Perfusion; Multiple Studies At Rest Or Stress


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Radiology NUCLEAR MED 78494 Cardiac Blood Pool Imaging, Spect PA Medical Necessity Review

Radiology NUCLEAR MED 78496 Cardiac Blood Pool Imaging, Single at Rest PA Medical Necessity Review

Cardiology CARDIAC IMPLANTABLES 33213 Insertion Of Pacemaker Pulse Generator Only; With Existing Dual Leads PA Medical Necessity Review

Radiology NUCLEAR MED 78499 Unlisted Cardiovascular Procedure Excluded from program

Cardiology CARDIAC IMPLANTABLES 33214

Upgrade Of Implanted Pacemaker System, Conversion Of Single Chamber System To Dual Chamber System (Includes Removal Of Previously Placed Pulse Generator, Testing Of Existing Lead, Insertion Of New Lead, Insertion Of New Generator)


)


Pulmonary ventilation imaging (eg, aerosol or gas) Excluded from program

Radiology NUCLEAR MED 78580 Pulmonary perfusion imaging (eg, particulate);Excluded from program

Radiology NUCLEAR MED 78582 Pulmonary ventilation (eg, aerosol or gas) and perfusion imaging Excluded from program


Quantitative differential pulmonary perfusion, including imaging when performed Excluded from program


Quantitative differential pulmonary perfusion and ventilation (eg, aerosol or gas), including imaging when performed


Radiology NUCLEAR MED 78599 Unlisted Respiratory Procedure Excluded from program

Radiology NUCLEAR MED 78600 Brain Imaging Ltd Static Excluded from program

Radiology NUCLEAR MED 78601 Brain Ltd Imaging and Flow Excluded from program

Radiology NUCLEAR MED 78605 Brain Imaging Complete Excluded from program

Radiology NUCLEAR MED 78606 Brain Imaging Complete w/ Flow Excluded from programRadiology NUCLEAR MED 78607 Brain Imaging Spect SPECT Excluded from program

Radiology PET SCANS 78608 Brain Imaging, Positron Emission Tomography (PET) Metabolic Evaluation PA Medical Necessity Review

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Radiology PET SCANS 78609 Brain Imaging, Positron Emission Tomography (PET) Perfusion Evaluation PA Medical Necessity Review

Radiology NUCLEAR MED 78610 Brain Flow Imaging Only Excluded from program

Radiology NUCLEAR MED 78630 Cisternogram (Cerebrospinal Fluid Flow) Excluded from program

Radiology NUCLEAR MED 78635 Cerebrospinal Ventriculography Excluded from program

Radiology NUCLEAR MED 78645 CSF Shunt Evaluation Excluded from program

Radiology NUCLEAR MED 78647 Cerebrospinal Fluid Scan Spect Excluded from program

Radiology NUCLEAR MED 78650 CSF Leakage Detection and Localization Excluded from program

Radiology NUCLEAR MED 78660 Radiopharmaceutical Dacryocystorgraphy Excluded from program

Radiology NUCLEAR MED 78699 Unlisted Nuclear Medicine Procedure Excluded from program

Radiology NUCLEAR MED 78700 Kidney Imaging Morphology Excluded from program

Radiology NUCLEAR MED 78701 Kidney Imaging Morphology w/ Vascular FlowExcluded from program

Radiology NUCLEAR MED 78707 Kidney Imaging Morphology w/ Vascular Flow and Function Study

Renal ScanExcluded from program


Kidney Imaging Morphology w/ Vascular Flow and Function, Single w/ Pharm Intervention Excluded from program

Radiology NUCLEAR MED 78709 Kidney Imaging Morphology w/ Vascular Flow, Multi, w/o and w/ Pharm Intervention

Captorpril/Renal Scan/MAG 3Excluded from program

Radiology NUCLEAR MED 78710 Kidney Imaging, Spect Excluded from program

Radiology NUCLEAR MED 78725 Kidney Function Study, Non‐Image RadioisotropicExcluded from program

Radiology NUCLEAR MED 78730 Urinary Bladder Residual Study Excluded from program

Radiology NUCLEAR MED 78740 Ureteral Reflum Study VCUG/Cystogram Excluded from program

Radiology NUCLEAR MED 78761 Testicular Imaging w/ Vascular Flow Excluded from program

Radiology NUCLEAR MED 78799 Unlisted Genitourinary Procedure Excluded from program

Radiology NUCLEAR MED 78800 Radiopharm Localization of Tumor, Limited AreaExcluded from program

Radiology NUCLEAR MED 78801 Radiopharm Localization of Tumor, Multi Areas Gallium Scan/Mammo Scintogram/OctreoScan Excluded from program

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Radiology NUCLEAR MED 78802 Radiopharm Localization of Tumor, Whole Body Gallium Scan/Octreo ScanExcluded from program

Radiology NUCLEAR MED 78803 Radiopharm Localization of Tumor, Spect Gallium Scan/FUO Excluded from program


78804Radiopharmaceutical Localization of Tumor or Distribution of Radiopharmaceutical Agent(s); Whole Body, Requiring 2 or More Days Imaging Excluded from program

Radiology NUCLEAR MED 78805 Radiopharm Localization of Abscess, Limited Area Gallium Scan/Indium Scan/WBC Scan/MBIGExcluded from program

Radiology NUCLEAR MED 78806 Radiopharm Localization of Abscess, Whole Body Gallium Scan/Indium Scan/WBC Scan/MBIGExcluded from program

Radiology NUCLEAR MED Radiopharm Localization of Abscess Spect Galliium Scan/Indium Scan/WBC Scan/MBIGRadiology NUCLEAR MED 78807 Radiopharm Localization of Abscess, Spect Galliium Scan/Indium Scan/WBC Scan/MBIGExcluded from program


Positron Emission Tomography (PET) Imaging; Limited Area (Eg, Chest, Head/Neck) PA Medical Necessity Review

Radiology PET SCANS 78812 Positron Emission Tomography (PET) Imaging; Skull Base To Mid‐Thigh PA Medical Necessity Review

Radiology PET SCANS 78813 Positron Emission Tomography (PET) Imaging; Whole Body PA Medical Necessity Review

Radiology PET SCANS

78814

Positron Emission Tomography (PET) with Concurrently Acquired Computer Tomography (CT) for Attenuation Correction and Anatomical Localization Imaging; Limited Area (Eg Chest, Head/Neck)

PET with CT


Radiology PET SCANS

78815

Positron Emission Tomography (PET) with Concurrently Acquired Computer Tomography (CT) for Attenuation Correction and Anatomical Localization Imaging; Skull Base to Mid‐Thigh

PET with CT


Radiology PET SCANS

78816

Positron Emission Tomography (PET) with Concurrently Acquired Computer Tomography (CT) for Attenuation Correction and Anatomical Localization Imaging; Whole Body

PET with CT


Radiology NUCLEAR MED 78999 Unlisted Misc. Procedeure Diagnostic Nuclear Med Excluded from program

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Radiology T‐CODES 0042T CT Perfusion BrainInvestigational

Radiology T‐CODES

0159T

Computer‐Aided Detection, Including Computer Algorithm Analysis of MRI Image Data For Lesion Detection/Characterization, Pharmacokinetic Analysis, with Further Physician Review for Interpretation, Breast MRI (List Separately In Addition To Code For Primary Procedure)

Not Covered

Radiology CT SCANS 70460 CT Head/Brain w/ Contrast PA Medical Necessity Review

Radiology CT SCANS 72125 CT C Spine w/o Contrast PA Medical Necessity Review72125 y

Radiology CT SCANS 72131 CT L Spine w/o Contrast PA Medical Necessity Review

Radiology CT SCANS 74176 Computed Tomography, Abdomen and Pelvis; without Contrast Material PA Medical Necessity Review

Radiology CT SCANS 74177 Computed Tomography, Abdomen and Pelvis; with Contrast Material(s) PA Medical Necessity Review

Radiology CT SCANS 74178

Computed Tomography, Abdomen And Pelvis; Without Contrast Material In One Or Both Body Regions, Followed By Contrast Material(s) And Further Sections In One Or Both Body Regions


RadiologyCT SCANS 74261

Computed Tomographic (CT) Colonography, Diagnostic, Including Image Postprocessing; Without Contrast Material


Radiology

CT SCANS 74262Computed Tomographic (CT) Colonography, Diagnostic, Including Image Postprocessing; With Contrast Material(s) Including Non‐Contrast Images, If Performed


RadiologyCT SCANS 74263 Computed Tomographic (CT) Colonography,

Screening, Including Image Postprocessing PA Medical Necessity Review

Radiology MRI75565

Cardiac MRI For Velocity Flow Mapping (List Separately In Addition To Code For Primary Procedure)


RadiologyCT SCANS 75571 CT Heart Without Contrast Material, With

Quantitive Evaluation Of Coronary Calcium PA Medical Necessity Review

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Radiology CT SCANS 75572 Cardiac CT For Morphology PA Medical Necessity Review

Radiology CT SCANS 75573 Cardiac CT For Congenital HD PA Medical Necessity Review

Radiology CT SCANS 75574 CT Angio Coronary Artery PA Medical Necessity Review

Radiology CT SCANS 75635 CT Angiography Abdominal Aorta Aortic Aneurysm Excluded from program

Radiology 3DI 76376

3D Rendering With Interpretation And Reporting Of Computed Tomography, Magnetic Resonance Imaging, Ultrasound, Or Other Tomographic Modality With Image Postprocessing Under Concurrent Supervision; Not Requiring Image Postprocessing On An Independent Workstation


Radiology 3DI 76377

3D Rendering With Interpretation And Reporting Of Computed Tomography, Magnetic Resonance Imaging, Ultrasound, Or Other Tomographic Modality With Image Postprocessing Under Concurrent Supervision; Requiring Image Postprocessing On An Independent Workstation



Parathyroid Planar Imaging (Including Subtraction, When Performed); With Tomographic (Spect)



78072

Parathyroid Planar Imaging (Including Subtraction, When Performed); With Tomographic (Spect), And Concurrently Acquired Computed Tomography (CT) For Anatomical Localization


Radiology NUCLEAR MED 78451 MPI, Spect, Single Rest or Stress PA Medical Necessity Review

Radiology NUCLEAR MED 78452 MPI, Spect, Multiple Rest or Stress PA Medical Necessity Review

Radiology NUCLEAR MED 78453 MPI, Planar, Single Rest or Stress PA Medical Necessity Review

Radiology NUCLEAR MED 78454 MPI, Planar, Multiple Rest or Stress Excluded from program

Radiology C‐CODES C8900 MRA with Contrast, Abdomen Excluded from program

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Radiology C‐CODES C8901 MRA without Contrast, Abdomen Excluded from program

Radiology C‐CODES C8902 MRA with and without Contrast, Abdomen Excluded from program

Radiology C‐CODES C8903 MRI with Contrast, Breast; Unilateral Excluded from program

Radiology C‐CODES C8904 MRI without Contrast, Breast; Unilateral Excluded from program

Radiology C‐CODES C8905 MRI with and without Contrast, Breast; Unilateral Excluded from program

Radiology C‐CODES C8906 MRI with Contrast, Breast; Bilateral Excluded from program

Radiology C‐CODES C8907 MRI without Contrast, Breast; Bilateral Excluded from program

Radiology C‐CODES C8908 MRI with and without Contrast, Breast; Bilateral Excluded from program

Radiology C‐CODES C8909 MRA with Contrast, Chest (Excluding Myocardium) Excluded from program

Radiology C‐CODES C8910 MRA without Contrast, Chest (Excluding Myocardium) Excluded from program

Radiology C‐CODES C8911 MRA with and Without Contrast, Chest (Excluding Myocardium) Excluded from program

Radiology C‐CODES C8912 MRA with Contrast, Lower Extremity Excluded from program

Radiology C‐CODES C8913 MRA without Contrast, Lower Extremity Excluded from program

Radiology C‐CODES C8914 MRA with and Without Contrast, Lower Extremity Excluded from program

Radiology C‐CODES C8918 MRA with Contrast, Pelvis Excluded from program

Radiology C‐CODES C8919 MRA without Contrast, Pelvis Excluded from program

Radiology C‐CODES C8920 MRA with and without Contrast, Pelvis Excluded from program

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Radiology C‐CODES

C8921

Transthoracic Echocardiography w/Contrast For Congenital Cardiac Anomalies; Complete


Radiology C‐CODESC8922

Transthoracic Echocardiography w/Contrast for Congenital Cardiac Anomalies; F/U or Limited Study


Radiology C‐CODESC8923

Transthoracic Echocardiography w/Contrast, Real‐Time w/Image Documentation (2D), w or w/o M‐Mode Recording; Complete


Radiology C‐CODES

C8924Transthoracic Echocardiography w/Contrast, Real‐Time w/Image Documentation (2D), w or w/o M‐Mode Recording; F/U Or Limited Study Excluded from program

Radiology C‐CODES

C8928

Transthoracic Echocardiography with Contrast, Real Time w/Image Documentation (2D), w/ or w/o M‐Mode Recording, During Rest And Cardiovascular Stress Test, w/Interpretation and Report (Crosswalked To Either 93350 Or 93351)


RADIOLOGY C‐CODES

C8929

Transthoracic Echocardiography with Contrast, or without Contrast Followed By with Contrast, Real‐Time with Image Documentation (2D), Includes M‐Mode Recording, When Performed, Complete, with Spectral Doppler Echocardiography, and with Color Flow Doppler Echocardiography


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RADIOLOGY C‐CODES

C8930

Transthoracic Echocardiography, with Contrast, or without Contrast Followed By with Contrast, 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; Including Performance of Continuous Electrocardiographic Monitoring, with Physician Supervision


RADIOLOGY C‐CODES C8931 Magnetic Resonance Angiography with Contrast, Spinal Canal and Contents Excluded from program

RADIOLOGY C‐CODES C8932 Magnetic Resonance Angiography without Contrast, Spinal Canal and Contents Excluded from program

RADIOLOGY C‐CODESC8933

Magnetic Resonance Angiography without Contrast Followed by with Contrast, Spinal Canal and Contents


RADIOLOGY C‐CODES C8934 Magnetic Resonance Angiography with Contrast, Upper Extremity Excluded from program

RADIOLOGY C‐CODES C8935 Magnetic Resonance Angiography without Contrast, Upper Extremity Excluded from program

RADIOLOGY C‐CODESC8936

Magnetic Resonance Angiography without Contrast Followed by with Contrast, Upper Extremity


Radiology G‐CODESG0219

Pet Imaging Whole Body; Melanoma for Non‐Covered Indications Investigational

Radiology G‐CODES G0235 Pet Imaging, Any Site, Not Otherwise SpecifiedRedirect to valid code

Radiology G‐CODES

G0252Pet Imaging, Full and Partial‐Ring Pet Scanners Only for Initial Diagnosis of Breast Cancer and/or Surgical Planning for Breast Cancer Redirect to valid code

Cardiology CARDIAC IMPLANTABLES 33221 Insertion Of Pacemaker Pulse Generator Only; With Existing Multiple Leads PA Medical Necessity Review

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Insertion Of Pacing Electrode, Cardiac Venous System, For Left Ventricular Pacing, With Attachment To Previously Placed Pacemaker Or Implantable Defibrillator Pulse Generator (Including Revision Of Pocket, Removal, Insertion, And/Or Replacement Of Existing Generator)



Insertion Of Pacing Electrode, Cardiac Venous System, For Left Ventricular Pacing, At Time Of Insertion Of Implantable Defibrillator Or Pacemaker Pulse Generator (Eg, For Upgrade To Dual Chamber System) (List Separately In

PA Medical Necessity ReviewDual Chamber System) (List Separately In Addition To Code For Primary Procedure)

Cardiology CARDIAC IMPLANTABLES 33227Removal Of Permanent Pacemaker Pulse Generator With Replacement Of Pacemaker Pulse Generator; Single Lead System


Cardiology CARDIAC IMPLANTABLES 33228Removal of Permanent Pacemaker Pulse Generator with Replacement of Pacemaker Pulse Generator; Dual Lead System


Cardiology CARDIAC IMPLANTABLES 33229Removal Of Permanent Pacemaker Pulse Generator With Replacement Of Pacemaker Pulse Generator; Multiple Lead System


Cardiology CARDIAC IMPLANTABLES 33230 Insertion Of Implantable Defibrillator Pulse Generator Only; With Existing Dual Leads PA Medical Necessity Review

Cardiology CARDIAC IMPLANTABLES 33231 Insertion Of Implantable Defibrillator Pulse Generator Only; With Existing Multiple Leads PA Medical Necessity Review

Cardiology CARDIAC IMPLANTABLES 33240 Insertion Of Implantable Defibrillator Pulse Generator Only; With Existing Single Lead PA Medical Necessity Review

Cardiology CARDIAC IMPLANTABLES 33249Insertion Or Replacement Of Permanent Implantable Defibrillator System With Transvenous Lead(s), Single Or Dual Chamber PA Medical Necessity Review

Cardiology CARDIAC IMPLANTABLES 33262Removal Of Implantable Defibrillator Pulse Generator With Replacement Of Implantable Defibrillator Pulse Generator; Single Lead System PA Medical Necessity Review

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Cardiology CARDIAC IMPLANTABLES 33263Removal Of Implantable Defibrillator Pulse Generator With Replacement Of Implantable Defibrillator Pulse Generator; Dual Lead System PA Medical Necessity Review

Cardiology CARDIAC IMPLANTABLES 33264Removal of Implantable Defibrillator Pulse Generator with Replacement of Pacing Cardioverter‐Defibrillator Pulse Generator; Multiple Lead System


Insertion Or Replacement Of Permanent Subcutaneous Implantable Defibrillator System, with Subcutaneous Electrode, Including Defibrillation Threshold Evaluation, Indication of

Cardiology CARDIAC IMPLANTABLES 33270 Arrythmia,Evaluation Of Sensing For Arrythmia Termination, and Programming Or Reprogramming Of Sensing Or Therapeutic Parameters When Performed


Cardiology MRI 75557Cardiac Magnetic Resonance Imaging For Morphology And Function Without Contrast Material


Cardiology MRI 75559Cardiac Magnetic Resonance Imaging For Morphology And Function Without Contrast Material; With Stress Imaging


Cardiology MRI 75561Cardiac Magnetic Resonance Imaging For Morphology And Function Without Contrast Material(S), Followed By Contrast Material(S) And Further Sequences


Cardiology MRI 75563

Cardiac Magnetic Resonance Imaging For Morphology And Function Without Contrast Material(S), Followed By Contrast Material(S) And Further Sequences; With Stress Imaging


Cardiology MRI 75565Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure)


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Cardiology CT SCANS 75571Computed Tomography, Heart, Without Contrast Material, With Quantitative Evaluation Of Coronary Calcium

Excluded from program(Managed Under Radiology)

Cardiology CT SCANS 75572

Computed Tomography, Heart, With Contrast Material, For Evaluation Of Cardiac Structure And Morphology (Including 3D Image Post processing, 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


p gy g gDisease (Including 3D Image Post processing, Assessment Of LV Cardiac Function, RV Structure And Function And Evaluation Of Venous Structures, If Performed)


Radiology CT SCANS S8032

Low‐Dose Computed Tomography for Lung Cancer Screening



Computed Tomographic Angiography, Heart, Coronary Arteries And Bypass Grafts (When Present), With Contrast Material, Including 3D Image Post processing (Including Evaluation Of Cardiac Structure And Morphology, Assessment Of Cardiac Function, And Evaluation Of Venous Structures, If Performed)


Radiology S‐CODES S8037 Magnetic Resonance Cholangiopancreatography (MRCP) Redirect to valid code

Radiology S‐CODES S8042 Magnetic Resonance Imaging (MRI), Low‐Field Redirect to valid code

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Cardiology NUCLEAR STRESS 78451

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)


Radiology S‐CODES

S8080

Scintimammography (Radioimmunoscintigraphy of the Breast), Unilateral, Including Supply of Radiopharmaceutical

Excluded from programS8080 p g


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 (Exercise Or Pharmacologic) and/or Redistribution and/or Rest Reinjection


Radiology S‐CODES

S8085

Fluorine‐18 Fluorodeomyglucose (F‐18 Fdg) Imaging Using Dual Head Coincidence Detection System. (Non‐Dedicated PET Scan)

Investigational

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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)


Radiology S‐CODES

S8092

Electron Beam Computed Tomography (Also Known as Ultrafast CT, Cinet)



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) and/or Redistribution and/or Rest Reinjection


Cardiology PET 78459 PET Myocardial Imaging; Positron Emission Tomography (PET) Metabolic Evaluation


Cardiology NUCLEAR MED 78472 Gated Cardiac Radionuclide Angiography Excluded from program

Cardiology NUCLEAR MED 78473 Gated Multiple Cardiac Radionuclide AngiographyExcluded from program

Cardiology NUCLEAR MED 78481 Planar First Pass Cardiac Radionuclide Angiography


Cardiology NUCLEAR MED 78483 Planar First Pass Multiple Cardiac Radionuclide Angiography


Cardiology PET 78491Myocardial Perfusion Imaging, Positron Emission Tomography (PET) Single Study, Rest or Stress Excluded from program

(Managed Under Radiology)

Cardiology PET 78492Myocardial Perfusion Imaging, Positron Emission Tomography (PET) Multiple Studies, Rest and/or Stress


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Cardiology NUCLEAR MED 78494 SPECT Equilbrium Cardiac Radionuclide Angiography


Cardiology NUCLEAR MED 78496 SPECT EquilbriumMultiple Radionuclide Angiography


Cardiology ECHOCARDIOGRAPHY 93303 Transthoracic Echocardiography For Congenital Cardiac Anomalies; Complete Excluded from program

Cardiology ECHOCARDIOGRAPHY 93304Transthoracic Echocardiography For Congenital Cardiac Anomalies; Follow‐Up Or Limited Study Excluded from program

C di l ECHOCARDIOGRAPHY 93306

Echocardiography, Transthoracic, Real‐Time With Image Documentation (2D), Includes M‐Mode Recording, When Performed, Complete, With

E l d d fCardiology ECHOCARDIOGRAPHY 93306g, , p ,

Spectral Doppler Echocardiography, And With Color Flow Doppler Echocardiography


Cardiology ECHOCARDIOGRAPHY 93307Echocardiography, Transthoracic, Real‐Time With Image Documentation (2D) With Or Without M‐Mode Recording; Complete


Cardiology ECHOCARDIOGRAPHY 93308Echocardiography, Transthoracic, Real‐Time With Image Documentation (2D) With Or Without M‐Mode Recording; Follow‐Up Or Limited Study Excluded from program

Cardiology ECHOCARDIOGRAPHY 93320Doppler Echocardiography, Pulsed Wave and/or Continuous Wave With Spectral Display; Complete


Cardiology ECHOCARDIOGRAPHY 93321Doppler Echocardiography, Pulsed Wave and/or Continuous Wave With Spectral Display; Follow‐Up Or Limited Study


Cardiology ECHOCARDIOGRAPHY 93325 Doppler Echocardiography Color Flow Velocity Mapping Excluded from program

Cardiology ECHO STRESS 93350

Echocardiography, Transthoracic, Real‐Time With Image Documentation (2D), With Or Without M‐Mode Recording, During Rest And Cardiovascular Stress Test, With Interpretation And Report


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Cardiology ECHO STRESS 93351

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; Including Performance Of Continuous Electrocardiographic Monitoring, With Supervision By A Physician Or Other Qualified Health Care Professional.


Use of echocardiographic contrast agent during

Cardiology ECHO STRESS 93352Use of echocardiographic contrast agent duringstress echocardiography (List separately in addition to code for primary procedure) Excluded from program

Cardiology CARDIAC CATH 93452Left Heart Catheterization Including Intraprocedural Injection(s) For Left Ventriculography, Imaging Supervision And Interpretation, When Performed


Cardiology CARDIAC CATH 93453

Combined Right And Left Heart Catheterization Including Intraprocedural Injection(s) For Left Ventriculography, Imaging Supervision And Interpretation, When Performed



Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation



Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation; With Catheter Placement(s) In Bypass Graft(s) (Internal Mammary Free Arterial Venous Grafts) Including


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Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation; With Right Heart Catheterization



Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation; With Catheter Placement(s) In Bypass Graft(s) (Internal Mammary, Free Arterial, Venous Grafts)


Including Intraprocedural Injection(s) For Bypass


Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation; With Left Heart Catheterization Including Intraprocedural Injection(s) For Left Ventriculography, When Performed



Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation; With Left Heart Catheterization Including Intraprocedural Injection(s) For Left Ventriculography, When Performed, Catheter Placement(s) In Bypass G ft( ) (I t l M F A t i l



Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation; With Right And Left Heart Catheterization Including


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Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation; With Right And Left Heart Catheterization Including Intraprocedural Injection(s) For Left Ventriculography, When Performed, Catheter Placement(s) In Bypass Graft(s) (Internal


Radiation Therapy CPT 0182T High Dose Rate Electronic Brachytherapy, Per Fraction PA Medical Necessity Review

Radiation Therapy CPT 0190T Placement Of Intraocular Radiation Source Applicator PA Medical Necessity Review

Radiology/Therapeutic ‐ General ClassificationRadiation Therapy REV Code 0330 Radiology/Therapeutic ‐ General Classification


Radiation Therapy REV Code 0333 Radiology/Therapeutic ‐ Radiation Therapy PA Medical Necessity Review

Radiation Therapy REV Code 0339 Radiology/Therapeutic ‐ Other PA Medical Necessity Review

Radiation Therapy REV Code 0344 Therapeutic Radiopharmaceuticals PA Medical Necessity Review

Radiation Therapy REV Code 0973 Professional Fees ‐ Radiology/Therapeutic PA Medical Necessity Review

Radiation Therapy CPT 19296

Placement Of Radiation Therapy After loading Expandable Catheter Into The Breast For Interstitial Radioelement Application Following Partial Mastectomy On Date Separate From Partial Mastectomy



Placement Of Radiation Therapy After loading Expandable Catheter Into The Breast For Interstitial Radioelement Application Following Partial Mastectomy, Concurrent With Partial Mastectomy)


Radiation Therapy CPT 19298Placement Of Radiation Therapy After loading Brachytherapy Catheter Into The Breast For Interstitial Radioelement Application Following Partial Mastectomy


Radiation Therapy CPT 31643Bronchoscopy (Rigid Or Flexible), With Placement Of Catheter For Intracavitary Radioelement Application


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Radiation Therapy CPT 32553Placement Of Interstitial Device For Radiation Therapy Guidance, Percutaneous, Intra‐Thoracic, Single Or Multiple


Radiation Therapy CPT 41019 Placement Of Needles, Catheters, And Other Devices Into The Head and/or Neck Region PA Medical Necessity Review


Upper Gastrointestinal Endoscopy Including Esophagus, Stomach And Either The Duodenum and/or Jejunum As Appropriate; W/ Transendoscopic Intraluminal Tube Or Catheter Placement


Placement Of Interstitial Device(s) For Radiation Therapy Guidance, Open, Intra‐Abdominal, Intra‐

Radiation Therapy CPT 49411py , p , ,

Pelvic and/or Retroperitoneum, Including Image Guidance, Single Or Multiple



Placement Of Interstitial Device(s) For Radiation Therapy Guidance (Eg, Fiducial Markers, Dosimeter), Open, Intra‐Abdominal, Intrapelvic, and/or Retroperitoneum, Including Image Guidance, If Performed, Single Or Multiple (List Separately In Addition To Code For Primary Procedure)


Radiation Therapy CPT 55875Transperineal Placement Of Needles Or Catheters Into Prostate For Interstitial Radioelement Application, With Or Out Cytosocopy


Radiation Therapy CPT 55876 Fiducial Marker Placement In The Prostate PA Medical Necessity Review


Placement Of Needles, Catheters, Or Other Device(s) Into The Head and/or Neck Region (Percutaneous, Transoral, Or Transnasal) For Subsequent Interstitial Radioelement Application


Radiation Therapy CPT 57155 Insertion Of Uterine Tandem and/or Vaginal Ovoids For Clinical Brachytherapy PA Medical Necessity Review

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Radiation Therapy CPT 57156Insertion Of A Vaginal Radiation After Loading Apparatus For Clinical Brachytherapy PA Medical Necessity Review

Radiation Therapy CPT 58346 Insertion Of Heyman Capsulesfor Clinical Brachytherapy PA Medical Necessity Review

Radiation Therapy CPT 76873 US Transrectal Prostate Volume Study For Brachytherapy PA Medical Necessity Review

Radiation Therapy CPT 76965 Ultrasound Guidance For Interstitial Radioelement Application PA Medical Necessity Review

Radiation Therapy CPT 77011 Computed Tomography Guidance For Stereotactic Localization PA Medical Necessity Review

R di ti Th CPT 77014 CT Guidance For Placement Of Radiation Therapy PA M di l N it R iRadiation Therapy CPT 77014 py

Fields PA Medical Necessity Review

Radiation Therapy CPT 77261 Therapeutic Radiology Treatment Planning; Simple PA Medical Necessity Review

Radiation Therapy CPT 77262 Therapeutic Radiology Treatment Planning; Intermediate PA Medical Necessity Review

Radiation Therapy CPT 77263 Therapeutic Radiology Treatment Planning; Complex PA Medical Necessity Review

Radiation Therapy CPT 77280 Therapeutic Radiology Simulation; Simple PA Medical Necessity Review

Radiation Therapy CPT 77285 Therapeutic Radiology Simulation; IntermediatePA Medical Necessity Review

Radiation Therapy CPT 77290 Therapeutic Radiology Simulation; Complex PA Medical Necessity Review

Radiation Therapy CPT 77293Respiratory Motion Management Simulation (List Separately In Addition To Code For Primary Procedure)


Radiation Therapy CPT 77295 3‐Dimensional Radiotherapy Plan, Including Dose‐Volume Histograms PA Medical Necessity Review

Radiation Therapy CPT 77299 Unlisted Procedure; Therapeutic Radiology Treatment Planning PA Medical Necessity Review

Radiation Therapy CPT 77300 Basic Radiation Dosimetry PA Medical Necessity Review

Radiation Therapy CPT 77301 IMRT Planning PA Medical Necessity Review

Radiation Therapy CPT 77306Teletherapy Isodose Plan; Simple (1 Or 2 Unmodified Ports Directed To A Single Area Of Interest), Includes Basic Dosimetry Calculation(s) PA Medical Necessity Review

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Teletherapy Isodose Plan; Complex (Multiple Treatment Areas, Tangential Ports, The Use Of Wedges, Blocking, Rotational Beam, Or Special Beam Considerations), Includes Basic Dosimetry Calculation(s)



Brachytherapy Isodose Plan; Simple (Calculation(s) Made From 1 To 4 Sources, Or Remote Afterloading Brachytherapy, 1 Channel), Includes Basic Dosimetry Calculation(S)


Brachytherapy Isodose Plan; Intermediate (Calculation(s) Made From 5 To 10 Sources, Or

Radiation Therapy CPT 77317( ( ) ,Remote Afterloading Brachytherapy, 2‐12 Channels), Includes Basic Dosimetry Calculation(S)



Brachytherapy Isodose Plan; Complex (Calculation(s) Made From Over 10 Sources, Or Remote Afterloading Brachytherapy, 12 Channels), Includes Basic Dosimetry Calculation(s)


Radiation Therapy CPT 77321 Special Teletherapy Port Plan, Particles, Hemibody, Total Body PA Medical Necessity Review

Radiation Therapy CPT 77331 Special Radiation Dosimetry PA Medical Necessity Review

Radiation Therapy CPT 77332 Treatment Devices; Simple PA Medical Necessity Review

Radiation Therapy CPT 77333 Treatment Devices; Intermediate PA Medical Necessity Review

Radiation Therapy CPT 77334 Treatment Devices; Complex PA Medical Necessity Review

Radiation Therapy CPT 77336 Continuing Medical Physics Consultation PA Medical Necessity Review

Radiation Therapy CPT 77338Multi‐Leaf Collimator (MLC) Device(s) For IMRT, Design And Construction Per IMRT Plan PA Medical Necessity Review

Radiation Therapy CPT 77370 Special Medical Physics Consultation PA Medical Necessity Review

Radiation Therapy CPT 77371Stereotactic Radiosurgery Treatment Delivery, Complete Course Of Treatment Of Cerebral Lesion(s) 1 Session, Multi‐Source Cobalt 60 Based PA Medical Necessity Review

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Radiation Therapy CPT 77372Stereotactic Radiosurgery Treatment Delivery, Complete Course Of Treatment Of Cerebral Lesion(s) 1 Session, Linac Based


Radiation Therapy CPT 77373Stereotactic Body Radiation Therapy Delivery Per Fraction 1 Or More Lesions; Including Image Guidance Not To Exceed 5 Fractions


Radiation Therapy CPT 77385Intensity Modulated Radiation Treatment Delivery (IMRT), Includes Guidance And Tracking, When Performed; Simple


Radiation Therapy CPT 77386Intensity Modulated Radiation Treatment Delivery (IMRT), Includes Guidance And Tracking, When Performed; Complex

PA Medical Necessity Review; p

Radiation Therapy CPT 77387Guidance For Localization Of Target Volume For Delivery Of Radiation Treatment Delivery, Includes Intrafraction Tracking, When Performed PA Medical Necessity Review

Radiation Therapy CPT 77399 Unlisted Procedure, Medical Radiation PhysicsPA Medical Necessity Review

Radiation Therapy CPT 77401 Radiation Treatment Delivery, Superficial and/or Ortho Voltage, Per Day PA Medical Necessity Review

Radiation Therapy CPT 77402Radiation Treatment Delivery; Single Treatment Area, One Or Two Ports; And Two Or Fewer Simple Blocks; >1 MEV; Simple


Radiation Therapy CPT 77407Radiation Treatment Delivery; Two Separate Treatment Areas; Three Or More Ports On A Single Treatment Area; Or Three Or More Simple Blocks; >1 MEV; Intermediate



Radiation Treatment Delivery; Three Or More Separate Treatment Areas; Custom Blocking; Tangential Ports; Wedges; Rotational Beam; Field‐In‐Field Or Other Tissue Compensation That Does Not Meet IMRT Guidelines; Or Electron Beam; >1 MEV; Complex


Radiation Therapy CPT 77417 Therapeutic Radiology Port Films PA Medical Necessity Review

Radiation Therapy CPT 77422 Neutron Beam TX, Simple PA Medical Necessity Review

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Radiation Therapy CPT 77423 Neutron Beam TX, Complex PA Medical Necessity Review

Radiation Therapy CPT 77424 Intraoperative Radiation Treatment Delivery, X‐Ray, Single Treatment Session PA Medical Necessity Review

Radiation Therapy CPT 77425 Intraoperative Radiation Treatment Delivery, Electrons, Single Treatment Session PA Medical Necessity Review

Radiation Therapy CPT 77427 Radiation Treatment Management, Five Treatments PA Medical Necessity Review

Radiation Therapy CPT 77431Radiation Treatment Management, With Complete Course Of Therapy Consisting Of 1 ‐2 Fractions


Radiation Therapy CPT 77432Stereotactic Radiation Treatment Management Cerebral Lesion(s) Complete Course Of PA Medical Necessity ReviewRadiation Therapy CPT 77432 Cerebral Lesion(s) Complete Course Of Treatment Consisting Of 1 Session


Radiation Therapy CPT 77435Stereotactic Body Radiation Treatment Management Per Treatment Course; 1 Or More Lesions, Including Image Guidance Entire Course Not To Exceed 5 Fractions


Radiation Therapy CPT 77469 Intraoperative Radiation Treatment ManagementPA Medical Necessity Review

Radiation Therapy CPT 77470Special Treatment Procedure (Eg. Total Body Radiation, Hemibody Radiation Or Per Oral Endocavity)


Radiation Therapy CPT 77499 Unlisted Procedure, Therapeutic Radiology Treatment Management PA Medical Necessity Review

Radiation Therapy CPT 77520 Proton Treatment Delivery, Simple w/o Compensation PA Medical Necessity Review

Radiation Therapy CPT 77522 Proton Treatment Delivery, Simple w/ Compensation PA Medical Necessity Review

Radiation Therapy CPT 77523 Proton Treatment Delivery, Intermediate PA Medical Necessity Review

Radiation Therapy CPT 77525 Proton Treatment Delivery, Complex PA Medical Necessity Review

Radiation Therapy CPT 77600 Hyperthermia Treatment; Externally Generated, Deep PA Medical Necessity Review

Radiation Therapy CPT 77605 Hyperthermia Treatment; Externally Generated, Superficial PA Medical Necessity Review

Radiation Therapy CPT 77610 Hyperthermia Generated By Interstitial Probe(s); 5 Or Fewer Applicators PA Medical Necessity Review

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Radiation Therapy CPT 77615 Hyperthermia Generated By Interstitial Probe(s); 5 Or More Applicators PA Medical Necessity Review

Radiation Therapy CPT 77620 Hyperthermia Generated By Intracavitary Probe(s) PA Medical Necessity Review

Radiation Therapy CPT 77750 Infusion Or Instillation Of Radioelement Solution (Includes 3‐Month Follow‐Up Care) PA Medical Necessity Review

Radiation Therapy CPT 77761 Intracavitary Radiation Source Application; Simple PA Medical Necessity Review

Radiation Therapy CPT 77762 Intracavitary Radiation Source Application; Intermediate PA Medical Necessity Review

Radiation Therapy CPT 77763 Intracavitary Radiation Source Application; Complex PA Medical Necessity Reviewp

Radiation Therapy CPT 77776 Interstitial Radiation Source; Simple PA Medical Necessity Review

Radiation Therapy CPT 77777 Interstitial Radiation Source; Intermediate PA Medical Necessity Review

Radiation Therapy CPT 77778 Interstitial Radiation Source; Complex PA Medical Necessity Review

Radiation Therapy CPT 77785 Remote After loading High Dose Rate Radionuclide Brachytherapy; 1 Channel PA Medical Necessity Review

Radiation Therapy CPT 77786 Remote After loading High Dose Rate Radionuclide Brachytherapy; 2‐12 Channels PA Medical Necessity Review

Radiation Therapy CPT 77787Remote After loading High Dose Rate Radionuclide Brachytherapy; Over 12 Channels PA Medical Necessity Review

Radiation Therapy CPT 77789 Apply Surface Radiation PA Medical Necessity Review

Radiation Therapy CPT 77790 Radio Isotope Supervision, Handling, LoadingPA Medical Necessity Review

Radiation Therapy CPT 77799 Radium/Radioisotope Therapy PA Medical Necessity Review

Radiation Therapy HCPS A4648 Tissue Marker, Implantable, Any Type Each PA Medical Necessity Review

Radiation Therapy HCPS A4650 Implant Radiation Dosimeter, Each PA Medical Necessity Review

Radiation Therapy HCPS C1715 Brachytherapy Needle PA Medical Necessity Review

Radiation Therapy HCPS C1716 Brachytherapy Source, Non‐Stranded, Gold‐198, Per ... PA Medical Necessity Review

Radiation Therapy HCPS C1717 Brachytherapy Source, Non‐Stranded, Gold‐198 Per… PA Medical Necessity Review

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Radiation Therapy HCPS C1719 Brachytherapy Source, Non‐Stranded, Non‐High Dose ... PA Medical Necessity Review

Radiation Therapy HCPS C1728 Catheter, Brachytherapy Seed Administration PA Medical Necessity Review

Radiation Therapy HCPS C2616 Brachytherapy Source, Non‐Stranded, Yttrium ‐90, Per Source PA Medical Necessity Review

Radiation Therapy HCPS C2634 Brachytherapy Source, Non‐Stranded, High Activity,... PA Medical Necessity Review

Radiation Therapy HCPS C2635 Brachytherapy Source, Non‐Stranded, High Activity,... PA Medical Necessity Review

Radiation Therapy HCPS C2636 Brachytherapy Linear Source, Non‐Stranded, Paladiu... PA Medical Necessity Review

Radiation Therapy HCPS C2637 Brachytherapy Source, Non‐Stranded, Ytterbium‐169,... PA Medical Necessity Review

Radiation Therapy HCPS C2638 Brachytherapy Source, Stranded, Iodine‐125, Per So... PA Medical Necessity Review

Radiation Therapy HCPS C2639 Brachytherapy Source, Non‐Stranded, Iodine‐125, Per... PA Medical Necessity Review

Radiation Therapy HCPS C2640 Brachytherapy Source, Stranded, Palladium‐103, Per... PA Medical Necessity Review

Radiation Therapy HCPS C2641 Brachytherapy Source, Non‐Stranded, Palladium‐103,... PA Medical Necessity Review

Radiation Therapy HCPS C2642 Brachytherapy Source, Stranded, Cesium‐131, Per So... PA Medical Necessity Review

Radiation Therapy HCPS C2643 Brachytherapy Source, Non‐Stranded, Cesium‐131, Per... PA Medical Necessity Review

Radiation Therapy HCPS C2644 Brachytherapy Source, Cesium‐131 Chloride Solution, Per Millicurie PA Medical Necessity Review

Radiation Therapy HCPS C2698 Brachytherapy Source, Stranded, Not Otherwise Spec... PA Medical Necessity Review

Radiation Therapy HCPS C2699 Brachytherapy Source, Non‐Stranded, Not Otherwise PA Medical Necessity Review

Radiation Therapy HCPS C9725 Placement Ofÿendorectal Intracavitary Applicator For High Intensity Brachytherapy PA Medical Necessity Review

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Radiation Therapy HCPS C9726Placement And Removal (If Performed) Of Applicator Into Breast For Radiation Therapy (Packaged Into Payment For 77424 And 77425 As Of Jan 1, 2014)


Radiation Therapy HCPS C9728Placement Of Interstitial Device(S) For Radiation Therapy/Surgery Guidance( Eg, Fiducial Markers, Dosimeter), Other Than Prostrate (Any Approach), Single Or Multiple


Radiation Therapy HCPS G0339 Robotic Stereotactic Surgery 1 Session PA Medical Necessity Review

Radiation Therapy HCPS G0340 Robotic Stereotactic Radio Surgery 2 Through 5 Sessions PA Medical Necessity Review

Ultrasonic Guidance For Placement Of RadiationRadiation Therapy HCPS G6001

Ultrasonic Guidance For Placement Of Radiation Therapy Fields. MPFS Code In Place Of 76950 For 2015


Radiation Therapy HCPS G6002Stereoscopic X‐Ray Guidance For Localization Of Target Volume For The Delivery Of Radiation Therapy. MPFS Code In Place Of 77421 For 2015 PA Medical Necessity Review

Radiation Therapy HCPS G6003

Radiation Treatment Delivery, Single Treatment Area, Single Port Or Parallel Opposed Ports, Simple Blocks Or No Blocks; Up To 5 MEV. MPFS Code In Place Of 77402 For 2015



Radiation Treatment Delivery, Single Treatment Area, Single Port Or Parallel Opposed Ports, Simple Blocks Or No Blocks; 6‐10 MEV. MPFS Code In Place Of 77403 For 2015



Radiation Treatment Delivery, Single Treatment Area, Single Port Or Parallel Opposed Ports, Simple Blocks Or No Blocks; 11‐19 MEV. MPFS Code In Place Of 77404 For 2015


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Radiation Treatment delivery, Single Treatment Area, Single Port Or Parallel Opposed Ports, Simple Blocks Or No Blocks; 20 MEV Or Greater. MPFS Code In Place Of 77406 For 2015



Radiation Treatment Delivery, 2 Separate Treatment Areas, 3 Or More Ports On A Single Treatment Area, Use Of Multiple Blocks; Up To 5 MEV. MPFS Code In Place Of 77407 For 2015


Radiation Treatment Delivery, 2 Separate Treatment Areas, 3 Or More Ports On A Single

Radiation Therapy HCPS G6008, g

Treatment Area, Use Of Multiple Blocks; 6‐10 MEV. MPFS Code In Place Of 77408 For 2015



Radiation Treatment Delivery, 2 Separate Treatment Areas, 3 Or More Ports On A Single Treatment Area, Use Of Multiple Blocks; 11‐19 MEV. MPFS Code In Place Of 77409 For 2015



Radiation Treatment Delivery, 2 Separate Treatment Areas, 3 Or More Ports On A Single Treatment Area, Use Of Multiple Blocks; 20 MEV Or Greater. MPFS Code In Place Of 77411 For 2015



Radiation Treatment Delivery, 3 Or More Separate Treatment Areas, Custom Blocking, Tangential Ports, Wedges, Rotational Beam, Compensators, Electron Beam; Up To 5 MEV. MPFS Code In Place Of 77412 For 2015



Radiation Treatment Delivery, 3 Or More Separate Treatment Areas, Custom Blocking, Tangential Ports, Wedges, Rotational Beam, Compensators, Electron Beam; 6‐10 MEV. MPFS Code In Place Of 77413 For 2015


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Radiation Treatment Delivery, 3 Or More Separate Treatment Areas, Custom Blocking, Tangential Ports, Wedges, Rotational Beam, Compensators, Electron Beam; 11‐19 MEV. MPFS Code In Place Of 77414 For 2015



Radiation Treatment Delivery, 3 Or More Separate Treatment Areas, Custom Blocking, Tangential Ports, Wedges, Rotational Beam, Compensators, Electron Beam; 20, MEV Or Greater. MPFS Code In Place Of 77416 For 2015


Intensity Modulated Treatment Delivery, Single


Intensity Modulated Treatment elivery, SingleOr Multiple Fields/Arcs,Via Narrow Spatially And Temporally Modulated Beams, Binary, Dynamic MLC, Per Treatment Session. MPFS Code In Place Of 77418 For 2015



Compensator‐Based Beam Modulation Treatment Delivery Of Inverse Planned Treatment Using 3 Or More High Resolution (Milled Or Cast) Compensator, Convergent Beam Modulated Fields, Per Treatment Session. MPFS Code In Place Of 0073t For 2015



Intra‐Fraction Localization And Tracking Of Target Or Patient Motion During Delivery Of Radiation Therapy (Eg, 3D Positional Tracking, Gating, 3D Surface Tracking), Each Fraction Of Treatment. MPFS Code In Place Of 0197t For 2015


Radiation Therapy HCPS Q3001 Radioelements For Brachytherapy, Any Type, Each PA Medical Necessity Review

Radiation Therapy HCPS S2095Transcatheter Occlusion Or Embolization For Tumor Destruction, Percutaneous, Any Method, Using Yttrium‐90 Microspheres


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Radiation Therapy HCPS S8030Scleral Application Of Tantalum Ring(s) For Localization Of Lesions For Proton Beam Therapy PA Medical Necessity Review

Sleep Therapies 94660Continuous Positive Airway Pressure Ventilation (CPAP), Initiation and Management PA Medical Necessity Review

Sleep Diagnostics 95782Polysomnography; Younger Than 6 Years, Sleep Staging With 4 Or More Additional Parameters Of Sleep, Attended By A Technologist PA Medical Necessity Review

Polysomnography; Younger Than 6 Years, Sleep Staging With 4 Or More Additional Parameters Of

Sleep Diagnostics 95783g g

Sleep, With Initiation Of Continuous Positive Airway Pressure Therapy Or Bi‐Level Ventilation, Attended By A Technologist


Sleep Diagnostics 95800Sleep Study, Unattended, Simultaneous Recording; Heart Rate, Oxygen Saturation, Respiratory Analysis (E.G., By Airflow or Peripheral Arterial Tone), and Sleep Time

Excluded From Program

Sleep Diagnostics 95801Sleep Study, Unattended, Simultaneous Recording; Minimum of Heart Rate, Oxygen Saturation, and Respiratory Analysis (E.G., By Airflow or Peripheral Arterial Tone)

Excluded From Program

Sleep Diagnostics 95805 Multiple Sleep Latency Test Or Maintenance Of Wakefulness Test PA Medical Necessity Review

Sleep Diagnostics 95806

Sleep Study, Unattended, Simultaneous Recording Of, Heart Rate, Oxygen Saturation, Respiratory Airflow, And Respiratory Effort (E.G. Thoracoabdominal Movement)


Sleep Diagnostics 95807Sleep Study, Simultaneous Recording Of Ventilation, Respiratory Effort, ECG Or Heart Rate, And Oxygen Saturation, Attended By A Technologist


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Sleep Diagnostics 95808Polysomnography; Any Age, Sleep Staging With 1‐3 Additional Parameters of Sleep, Attended By A Technologist


Sleep Diagnostics 95810Polysomnography; Age 6 Years or Older, Sleep Staging With 4 or More Additional Parameters of Sleep, Attended By A Technologist PA Medical Necessity Review


Polysomnography, Age 6 Years Or Older, Sleep Staging With 4 Or More Additional Parameters Of Sleep, With Initiation Of Continuous Positive Airway Pressure Therapy Or Bi‐Level Ventilation, Attended By A Technologist – Diagnostic Split‐ PA Medical Necessity Reviewp g 95811Night Study (Psg And Cpap Titration); Sleep Testing; Age ≥ 6 Years

y

Sleep Management of Care A4604 Tubing With Integrated Heating Element For Use With Positive Airway Pressure Device PA Medical Necessity Review


Polysomnography, Age 6 Years Or Older, Sleep Staging With 4 Or More Additional Parameters Of Sleep, With Initiation Of Continuous Positive Airway Pressure Therapy Or Bi‐Level Ventilation, Attended By A Technologist – Attended Titration Of Positive Airway Pressure; Sleep Testing; Age ≥ 6 Years


Sleep Management of Care A7027 Combination Oral/Nasal Mask, Used With CPAP, Each PA Medical Necessity Review

Sleep Management of Care A7028 Oral Cushion For Combination Oral/Nasal Mask, Replacement Only PA Medical Necessity Review

Sleep Management of Care A7029 Nasal Pillows For Combination Oral/Nasal Mask, Replacement Only, Pair PA Medical Necessity Review

Sleep Management of Care A7030 Full Face Mask Used With Positive Airway Pressure Device, Each PA Medical Necessity Review

Sleep Management of Care A7031 Face Mask Interface, Replacement For Full Face Mask, Each PA Medical Necessity Review

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Sleep Management of Care A7032 Cushion For Use On Nasal Mask Interface, Replace Only, Each PA Medical Necessity Review

Sleep Management of Care A7033 Pillow For Use On Nasal Cannula Type Interface, Replacement Only, Pair PA Medical Necessity Review

Sleep Management of Care A7034 Nasal Interface (Mask Or Cannula Type) Used With Positive Airway Pressure Device PA Medical Necessity Review

Sleep Management of Care A7035 Headgear Used With Positive Airway Pressure Device PA Medical Necessity Review

Sleep Management of Care A7036 Chinstrap Used With Positive Airway Pressure Device PA Medical Necessity Review

Sleep Management of Care A7037 Tubing Used With Positive Airway Pressure Device PA Medical Necessity Review

Sleep Management of Care A7038 Filter, Disposable, Used With Positive Airway Pressure Device PA Medical Necessity Review

Sleep Management of Care A7039 Filter, Non‐Disposable, Used With Positive Airway Pressure Device PA Medical Necessity Review

Sleep Management of Care A7044 Oral Interface Used With Positive Airway Pressure Device, Each PA Medical Necessity Review

Sleep Management of Care A7045Exhalation Port With Or Without Swivel Used With Accessories For Positive Airway Devices, Replacement Only


Sleep Management of Care A7046Water Chamber For Humidifier, Used With Positive Airway Pressure Device, Replacement, Each


Sleep Therapies E0470

Respiratory Assist Device, Bi‐Level Pressure Capability without Backup Rate Feature, Used with Noninvasive Interface, E.G. Nasal or Facial Mask (Intermittent Assist Device with Continuous Positive Airway Pressure Device)


Sleep Therapies E0471

Respiratory Assist Device, Bi‐Level Pressure Capability, with Back‐Up Rate Feature, Used with Noninvasive Interface, E.G. Nasal or Facial Mask (Intermittent Assist Device with Continuous Positive Airway Pressure Device)


Sleep Therapies E0561 Humidifier, Non‐Heated, Used with Positive Airway Pressure Device PA Medical Necessity Review

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Sleep Therapies E0562 Humidifier, Heated, Used with Positive Airway Pressure Device PA Medical Necessity Review

Sleep Therapies E0601 Positive Airway Pressure Therapy PA Medical Necessity Review

Sleep Diagnostics G0398

Home Sleep Study Test (HST) With Type II Portable Monitor, Unattended; Minimum Of 7 Channels: EEG, EOG, EMG, ECG/Heart Rate, Airflow, Respiratory Effort And Oxygen Saturation


Sleep Diagnostics G0399

Home Sleep Test (HST) With Type III Portable Monitor, Unattended; Minimum Of 4 Channels: 2 Respiratory Movement/Airflow, 1 ECG/Heart Rate And 1 Oxygen Saturation

PA Medical Necessity ReviewRate And 1 Oxygen Saturation

Sleep Diagnostics G0400Sleep Study, Unattended, Simultaneous Recording; Minimum Of Heart Rate, Oxygen Saturation, And Respiratory


Cardiology C‐CODES C8921 Transthoracic Echocardiography w/Contrast For Congenital Cardiac Anomalies; Complete Excluded from program

Cardiology C‐CODES C8922Transthoracic Echocardiography w/Contrast For Congenital Cardiac Anomalies; F/U Or Limited Study


Cardiology C‐CODES C8923Transthoracic Echocardiography w/Contrast, Real‐Time w/Image Documentation (2D), w/wo M‐Mode Recording; Complete


Cardiology C‐CODES C8924Transthoracic Echocardiography w/Contrast, Real‐Time w/Image Documentation (2D), w/wo M‐Mode Recording; F/U Or Limited Study Excluded from program

Cardiology C‐CODES C8928

Transthoracic Echocardiography w/Contrast, Real‐Time w/Image Documentation (2D), w/wo M‐Mode Recording, During Rest And Cardiovascular Stress Test, w/Interpretation And Report


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Transthoracic Echocardiography With Contrast, Or Without Contrast Followed By With Contrast, Real‐Time With Image Documentation (2D), Includes M‐Mode Recording, When Performed, Complete, With Spectral Doppler Echocardiography, And With Color Flow Doppler Echocardiography


Transthoracic Echocardiography, With Contrast, Or Without Contrast Followed By With Contrast, Real‐Time With Image Documentation (2D), Includes M‐Mode Recording, When Performed,


gDuring Rest And Cardiovascular Stress Test Using Treadmill, Bicycle Exercise and/or Pharmacologically Induced Stress, With Interpretation And Report; Including Performance Of Continuous Electrocardiographic Monitoring, With Physician Supervision


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