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  • Radiology Program > Prior Approval Procedures

    Services Requiring Prior Approval

    Please refer to the charts later in this chapter for a list of services (and CPT-4 codes) that require prior approval:

    Each procedure requires a separate prior approval. Prior approvals are specific to the CPT-4 code and site location. They are valid for 45 days from the approval date.

    Prior approval is required for services performed in the following places of service:

    • Outpatient hospital facilities
    • Freestanding radiology facilities
    • Radiology office-based settings
    • Non-radiology office-based settings

    Neither prior approval nor referral is required for:

    • Inpatient hospitalization
    • Services rendered in hospital emergency departments
    • Services provided when one of EmblemHealth's companies is the secondary insurer
    • Pulmonary perfusion imaging

    The following services do not require prior approval but may require a referral from the member's PCP:

    • Basic X-rays
    • Mammograms
    • Bone density tests

    Who Requests Prior Approval

    It is the responsibility of the referring practitioner (i.e., the practitioner developing the patient's treatment plan) to obtain the prior approval before services are rendered. If the referring and rendering practitioners are different, the rendering practitioner is encouraged to confirm that a prior approval is on file before services are rendered. The rendering practitioner is ultimately responsible for ensuring that all applicable radiology imaging procedures at the applicable service location have received all necessary prior approvals.

    How To Obtain Prior Approval

    Before requesting prior approval from eviCore, please have the patient's medical records on hand and complete the request form specific to the procedure being requested. These request forms are available at the links below and at evicore.com. They list all clinical questions the practitioner must answer during the initial prior approval review.

    Once the form is complete, submit prior approval requests in one of three ways:

    • Online: Visit www.evicore.com. To submit online requests, the ordering physician must be a registered user. To register for a user ID and password, visit www.evicore.com and click the "Register" button.
    • By phone: Call 1-866-417-2345 for GHI HMO, HIP and EmblemHealth CompreHealth EPO and Vytra plan members. Call 1-800-835-7064 for EmblemHealth EPO/PPO and EmblemHealth Medicare PPO plan members. Representatives are available Monday through Friday, from 7 am to 7 pm, EST. The program is closed New Year's Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, the Friday after Thanksgiving and Christmas Day.
    • By fax: Fax the completed request form to 1-800-540-2406.

    Please have the following information available when you call:

    • The completed form, as noted above
    • The patient's full name, member ID number and insurance information
    • The exam(s) requested for the patient
    • The working diagnosis or rule-out
    • The signs and symptoms that call for the exam, as well as their duration
    • Any previous imaging studies performed, corresponding results or pertinent lab results
    • History of prior treatment methods, drugs, surgery or other therapies, as well as duration of prior treatment
    • Any other information indicating the need for the exam

    Expedited Approval Requests

    Carecorenational.com cannot be used for expedited approval requests. These requests must be processed through the eviCore call center. Call 1-866-417-2345 for GHI HMO, HIP, EmblemHealth CompreHealth EPO, EmblemHealth Medicare HMO, and Vytra plan members. Call 1-800-835-7064 for EmblemHealth EPO/PPO and EmblemHealth Medicare PPO plan members. Utilization review staff is available 24 hours a day, 7 days a week. The program is closed New Year's Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, the Friday after Thanksgiving and Christmas Day.

    Urgent Requests

    If the treatment is medically urgent and must be performed outside eviCore's business hours, the physician may deliver treatment and must submit the prior approval request (with supporting clinical documentation) within two (2) business days. Urgent requests are reviewed against medical necessity criteria, and an approval is issued as long as the request meets these medical necessity criteria. Urgent requests will be completed within 24 hours of receiving the request.

    Carecorenational.com cannot be used for urgent approval requests. These requests must be processed through the eviCore call center. Call 1-866-417-2345 for GHI HMO, HIP, EmblemHealth CompreHealth EPO, EmblemHealth Medicare HMO and Vytra plan members. Call 1-800-835-7064 for EmblemHealth EPO/PPO and EmblemHealth Medicare PPO plan members. Utilization review staff is available 24 hours a day, 7 days a week. The program is closed New Year's Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, the Friday after Thanksgiving and Christmas Day.

    Non-Urgent Requests

    Non-urgent requests will be completed within three (3) business days of receiving all necessary information, or within the time frames otherwise required by the member's benefit plan (see Standard Pre-Service Review in the Care Management chapter). In most cases, staff will review and determine prior approvals during the initial phone call, as long as all the required information is provided. The review and determination processes may, however, take longer if member or practitioner eligibility verification is required, or if the request requires additional clinical review (see Standard Pre-Service Review in the Care Management chapter).

    A physician with office hours later than the call center's may initiate a case through carecorenational.com which will be processed on the next business day.

    Modifying a Prior Approval Request

    If it becomes necessary to change or update the procedure after prior approval is obtained, the program must be contacted no later than 48 hours after the modified procedure is performed. If the prior approval for the treatment plan is not updated and the claim does not match the authorized procedures, the claim will be denied for payment, with no liability to the member.

    Verifying the Prior Approval Status

    To verify the status of a prior approval request, either call eviCore at the applicable number below or visit the Authorization Lookup section at evicore.com.

    Call 1-866-417-2345 for GHI HMO, HIP, EmblemHealth CompreHealth EPO, EmblemHealth Medicare HMO and Vytra plan members. Call 1-800-835-7064 for GHI HMO, GHI EPO/PPO, EmblemHealth EPO/PPO and EmblemHealth Medicare PPO plan members.

    Note: While the program may approve or deny a prior approval request, this determination is based on medical necessity only. Always verify member eligibility, benefits and copayments with EmblemHealth directly at www.emblemhealth.com.

    Determination Disagreement

    If the referring physician disagrees with the determination, contact the Peer-to-Peer Consultation Line to discuss the case with a medical director. Call 1-866-417-2345 for GHI HMO, HIP, EmblemHealth CompreHealth EPO, EmblemHealth Medicare HMO and Vytra plans. Call 1-800-835-7064 for GHI HMO, GHI EPO/PPO, EmblemHealth EPO/PPO and EmblemHealth Medicare PPO plan members.

    Claims will be denied and the member will not be liable for payment if:

    • A prior approval was required but not obtained for the CPT-4 code performed.
    • Procedures are performed at a service location other than the address on the prior approval issued.

    Radiology Program Prior Approval Code List For HIP, EmblemHealth CompreHealth EPO and EmblemHealth Medicare HMO

    Radiology Program Prior Approval Code List
    For GHI HMO, HIP, EmblemHealth CompreHealth EPO, EmblemHealth Medicare HMO and Vytra

    Effective January 1, 2016
    Radiology CPT Code Procedure Description

    70336

    MAGNETIC RESONANCE IMAGING TMJ

    70450

    COMPUTED TOMOGRAPHY HEAD/BRAIN WITHOUT CONTRAST

    70460

    COMPUTED TOMOGRAPHY HEAD/BRAIN WITH CONTRAST

    70470

    COMPUTED TOMOGRAPHY HEAD/BRAIN WITHOUT AND WITH CONTRAST

    70480

    COMPUTED TOMOGRAPHY ORBIT WITHOUT CONTRAST

    70481

    COMPUTED TOMOGRAPHY ORBIT WITH CONTRAST

    70482

    COMPUTED TOMOGRAPHY ORBIT WITHOUT AND WITH CONTRAST

    70486

    COMPUTED TOMOGRAPHY MAXILLOFACIAL WITHOUT CONTRAST

    70487

    COMPUTED TOMOGRAPHY MAXILLOFACIAL WITH CONTRAST

    70488

    COMPUTED TOMOGRAPHY MAXILLOFACIAL WITHOUT AND WITH CONTRAST

    70490

    COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST

    70491

    COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST

    70492

    COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT AND WITH CONTRAST

    70496

    COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD

    70498

    COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK

    70540

    MAGNETIC RESONANCE IMAGING FACE, ORBIT, NECK WITHOUT CONTRAST

    70542

    MAGNETIC RESONANCE IMAGING FACE, ORBIT, NECK WITH CONTRAST

    70543

    MAGNETIC RESONANCE IMAGING FACE, ORBIT, NECK WITH AND WITHOUT CONTRAST

    70544

    MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST

    70545

    MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITH CONTRAST

    70546

    MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITH AND WITHOUT CONTRAST

    70547

    MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST

    70548

    MAGNETIC RESONANCE ANGIOGRAPHY NECK WITH CONTRAST

    70549

    MAGNETIC RESONANCE ANGIOGRAPHY NECK WITH AND WITHOUT CONTRAST

    70551

    MAGNETIC RESONANCE IMAGING HEAD WITHOUT CONTRAST

    70552

    MAGNETIC RESONANCE IMAGING HEAD WITH CONTRAST

    70553

    MAGNETIC RESONANCE IMAGING HEAD WITH AND WITHOUT CONTRAST

    70554

    MAGNETIC RESONANCE IMAGING, BRAIN, FUNCTIONAL MAGNETIC RESONANCE IMAGING; INCLUDING TEST SELECTION AND ADMINISTRATION OF REPETITIVE BODY PART MOVEMENT AND/OR VISUAL STIMULATION, NOT REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION

    70555

    MAGNETIC RESONANCE IMAGING, BRAIN, FUNCTIONAL MAGNETIC RESONANCE IMAGING; REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION OF ENTIRE NEUROFUNCTIONAL TESTING

    71250

    COMPUTED TOMOGRAPHY THORAX WITHOUT CONTRAST

    71260

    COMPUTED TOMOGRAPHY THORAX WITH CONTRAST

    71270

    COMPUTED TOMOGRAPHY THORAX WITHOUT AND WITH CONTRAST

    71275

    COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST, NON-CORONARY

    71550

    MAGNETIC RESONANCE IMAGING CHEST WITHOUT CONTRAST

    71551

    MAGNETIC RESONANCE IMAGING CHEST WITH CONTRAST

    71552

    MAGNETIC RESONANCE IMAGING CHEST WITH AND WITHOUT CONTRAST

    71555

    MAGNETIC RESONANCE ANGIOGRAPHY CHEST (EXC MYOCARDIUM) WITH OR WITHOUT CONTRAST

    72125

    COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST

    72126

    COMPUTED TOMOGRAPHY CERVICAL SPINE WITH CONTRAST

    72127

    COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT AND WITH CONTRAST

    72128

    COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST

    72129

    COMPUTED TOMOGRAPHY THORACIC SPINE WITH CONTRAST

    72130

    COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT AND WITH CONTRAST

    72131

    COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST

    72132

    COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST

    72133

    COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT AND WITH CONTRAST

    72141

    MAGNETIC RESONANCE IMAGING CERVICAL SPINE WITHOUT CONTRAST

    72142

    MAGNETIC RESONANCE IMAGING CERVICAL SPINE WITH CONTRAST

    72146

    MAGNETIC RESONANCE IMAGING THORACIC SPINE WITHOUT CONTRAST

    72147

    MAGNETIC RESONANCE IMAGING THORACIC SPINE WITH CONTRAST

    72148

    MAGNETIC RESONANCE IMAGING LUMBAR SPINE WITHOUT CONTRAST

    72149

    MAGNETIC RESONANCE IMAGING LUMBAR SPINE WITH CONTRAST

    72156

    MAGNETIC RESONANCE IMAGING C SPINE WITH AND WITHOUT CONTRAST

    72157

    MAGNETIC RESONANCE IMAGING T SPINE WITH AND WITHOUT CONTRAST

    72158

    MAGNETIC RESONANCE IMAGING L SPINE WITH AND WITHOUT CONTRAST

    72159

    MAGNETIC RESONANCE ANGIOGRAPHY SPINAL CANAL WITH OR WITHOUT CONTRAST

    72191

    COMPUTED TOMOGRAPHIC ANGIOGRAPHY PELVIS

    72192

    COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST

    72193

    COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST

    72194

    COMPUTED TOMOGRAPHY PELVIS WITHOUT AND WITH CONTRAST

    72195

    MAGNETIC RESONANCE IMAGING PELVIS WITHOUT CONTRAST

    72196

    MAGNETIC RESONANCE IMAGING PELVIS WITH CONTRAST

    72197

    MAGNETIC RESONANCE IMAGING PELVIS WITH AND WITHOUT CONTRAST

    72198

    MAGNETIC RESONANCE ANGIOGRAPHY PELVIS WITH OR WITHOUT CONTRAST

    73200

    COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST

    73201

    COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST

    73202

    COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT AND WITH CONTRAST

    73206

    COMPUTED TOMOGRAPHIC ANGIOGRAPHY UPPER EXTREMITY

    73218

    MAGNETIC RESONANCE IMAGING UPPER EXTREMITY WITHOUT CONTRAST

    73219

    MAGNETIC RESONANCE IMAGING UPPER EXTREMITY WITH CONTRAST

    73220

    MAGNETIC RESONANCE IMAGING UPPER EXTREMITY WITH AND WITHOUT CONTRAST

    73221

    MAGNETIC RESONANCE IMAGING UPPER EXTREMITY JOINT WITHOUT CONTRAST

    73222

    MAGNETIC RESONANCE IMAGING UPPER EXTREMITY JOINT WITH CONTRAST

    73223

    MAGNETIC RESONANCE IMAGING UPPER EXTREMITY JOINT WITH AND WITHOUT CONTRAST

    73225

    MAGNETIC RESONANCE ANGIOGRAPHY UPPER EXTREMITY WITH OR WITHOUT CONTRAST

    73700

    COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST

    73701

    COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST

    73702

    COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT AND WITH CONTRAST

    73706

    COMPUTED TOMOGRAPHIC ANGIOGRAPHY LOWER EXTREMITY

    73718

    MAGNETIC RESONANCE IMAGING LOWER EXTREMITY WITHOUT CONTRAST

    73719

    MAGNETIC RESONANCE IMAGING LOWER EXTREMITY WITH CONTRAST

    73720

    MAGNETIC RESONANCE IMAGING LOWER EXTREMITY WITH AND WITHOUT CONTRAST

    73721

    MAGNETIC RESONANCE IMAGING LOWER EXTREMITY JOINT WITHOUT CONTRAST

    73722

    MAGNETIC RESONANCE IMAGING LOWER EXTREMITY JOINT WITH CONTRAST

    73723

    MAGNETIC RESONANCE IMAGING LOWER EXTREMITY JOINT WITH AND WITHOUT CONTRAST

    73725

    MAGNETIC RESONANCE ANGIOGRAPHY LOWER EXTREMITY WITH OR WITHOUT CONTRAST

    74150

    COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST

    74160

    COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST

    74170

    COMPUTED TOMOGRAPHY ABDOMEN WITHOUT AND WITH CONTRAST

    74174

    COMPUTED TOMOGRAPHIC ANGIOGRAPHY, ABDOMEN AND PELVIS, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING

    74175

    COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN

    74176

    COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL

    74177

    COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL(S)

    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

    74181

    MAGNETIC RESONANCE IMAGING ABDOMEN WITHOUT CONTRAST

    74182

    MAGNETIC RESONANCE IMAGING ABDOMEN WITH CONTRAST

    74183

    MAGNETIC RESONANCE IMAGING ABDOMEN WITH AND WITHOUT CONTRAST

    74185

    MAGNETIC RESONANCE ANGIOGRAPHY ABDOMEN WITH OR WITHOUT CONTRAST

    74261

    COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY, DIAGNOSTIC, INCLUDING IMAGE POSTPROCESSING; WITHOUT CONTRAST MATERIAL

    74262

    COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY, DIAGNOSTIC, INCLUDING IMAGE POSTPROCESSING; WITH CONTRAST MATERIAL(S) INCLUDING NON-CONTRAST IMAGES, IF PERFORMED

    74263

    COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY, SCREENING, INCLUDING IMAGE POSTPROCESSING

    75635

    COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA

    76376

    3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND OR OTHER TOMOGRAPHIC MODALITY; NOT REQUIRING IMAGE POSTPROCESSING ON AN INDEPENDENT WORKSTATION

    76377

    3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND OR OTHER TOMOGRAPHIC MODALITY; REQUIRING IMAGE POSTPROCESSING ON AN INDEPENDENT WORKSTATION

    76380

    COMPUTED TOMOGRAPHY LIMITED OR LOCALIZED FOLLOW-UP STUDY

    76390

    MAGNETIC RESONANCE IMAGING SPECTROSCOPY

    76801

    ULTRASOUND OBSTETRICAL PELVIS, PREGNANT UTERUS, FIRST TRIMESTER <14 WEEKS SINGLE OR FIRST GESTATION

    76802

    ULTRASOUND OBSTETRICAL PELVIS, PREGNANT UTERUS, FIRST TRIMESTER <14 WEEKS EACH ADDITIONAL GESTATION

    76805

    ULTRASOUND OBSTETRICAL PELVIS, PREGNANT UTERUS, B-SCAN (ALLOWED ONCE PER GESTATION)

    76810

    ULTRASOUND OBSTETRICAL PELVIS COMPLETE, MULTIPLE GESTATION AFTER 1ST TRIMESTER (ALLOWED ONCE FOR EACH ADDITIONAL FETUS PER GESTATION; MUST BE BILLED WITH 76805)

    76811

    ULTRASOUND PREGNANT UTERUS FETAL AND MATERNAL EVAL PLUS ULTRASOUND FETAL ANATOMIC EVAL TRANSABDOMINAL SINGLE OR FIRST GESTATION (ALLOWED ONCE PER GESTATION; SECOND STUDY ALLOWED IF PERFORMED BY A DIFFERENT PHYSICIAN)

    76812

    ULTRASOUND PREGNANT UTERUS FETAL AND MATERNAL EVAL PLUS ULTRASOUND FETAL ANATOMIC EVAL TRANSABDOMINAL EACH ADDITIONAL GESTATION (ALLOWED ONCE FOR EACH ADDITIONAL FETUS ULTRASOUND PER GESTATION; MUST BE BILLED WITH 76811; SECOND STUDY ALLOWED IF PERFORMED BY A DIFFERENT PHYSICIAN)

    76813

    ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FIRST TRIMESTER FETAL NUCHAL TRANSLUCENCY MEASUREMENT, TRANSABDOMINAL OR TRANSVAGINAL APPROACH; SINGLE OR FIRST GESTATION (ALLOWED ONCE PER GESTATION)

    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

    ULTRASOUND PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, LIMITED (E.G., FETAL HEART BEAT, PLACENTAL LOCATION, FETAL POSITION AND/OR QUALITATIVE AMNIOTIC FLUID VOLUME), 1 OR MORE FETUSES

    76816

    ULTRASOUND OBSTETRICAL PELVIS FOLLOW-UP OR REPEAT

    76817

    ULTRASOUND PREGNANT UTERUS TRANSVAGINAL

    76818

    FETAL BIOPHYSICAL PROFILE

    76819

    FETAL BIOPHYSICAL PROFILE WITHOUT STRESS NON STRESS

    76820

    DOPPLER VELOCIMETRY, FETAL; UMBILICAL ARTERY

    76821

    DOPPLER VELOCIMETRY, FETAL; MIDDLE CEREBRAL ARTERY

    76825

    ULTRASOUND OBSTETRICAL ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM

    76826

    FOLLOW-UP OR REPEAT STUDY

    76827

    DOPPLER ECHOCARDIOGRAPHY FETAL COMPLETE

    76828

    FOLLOW-UP OR REPEAT STUDY

    76975

    ULTRASOUND GASTROINTESTINAL, ENDOSCOPIC

    77021

    MAGNETIC RESONANCE IMAGING GUIDANCE FOR NEEDLE PLACEMENT

    77022

    MAGNETIC RESONANCE IMAGING GUIDANCE FOR AND MONITORING OF TISSUE ABLATION

    77058

    MAGNETIC RESONANCE IMAGING BREAST WITH AND/OR WITHOUT CONTRAST; UNILATERAL

    77059

    MAGNETIC RESONANCE IMAGING BREAST BILATERAL

    77084

    MAGNETIC RESONANCE IMAGING BONE MARROW BLOOD SUPPLY

    78000

    THYROID RAI UPTAKE

    78001

    THYROID MULTIPLE UPTAKE

    78003

    THYROID SUPPRESS OR STIMULATION

    78006

    THYROID UPTAKE AND SCAN

    78007

    THYROID IMAGE, MULTIPLE UPTAKES

    78010

    THYROID SCAN ONLY

    78011

    THYROID IMAGING WITH FLOW

    78015

    THYROID MET IMAGING

    78016

    THYROID MET IMAGING WITH ADDITIONAL STUDIES

    78018

    THYROID SCAN WHOLE BODY

    78020

    THYROID CARCINOMA METASTASES UPTAKE

    78070

    PARATHYROID NUCLEAR IMAGING

    78075

    ADRENAL NUCLEAR IMAGING

    78102

    BONE MARROW IMAGING, LIMITED

    78103

    BONE MARROW IMAGING, MULTIPLE

    78104

    BONE MARROW IMAGING, WHOLE BODY

    78185

    SPLEEN IMAGING WITH OR WITHOUT VASCULAR FLOW

    78195

    LYMPH SYSTEM IMAGING

    78201

    LIVER IMAGING

    78202

    LIVER IMAGING WITH FLOW

    78205

    LIVER IMAGING SPECT

    78206

    LIVER IMAGING SPECT WITH VASCULAR FLOW

    78215

    LIVER AND SPLEEN IMAGING

    78216

    LIVER AND SPLEEN IMAGING WITH FLOW

    78226

    LIVER FUNCTION STUDY

    78227

    HIDA SCAN

    78230

    SALIVARY GLAND IMAGING

    78231

    SERIAL SALIVARY GLAND

    78232

    SALIVARY GLAND FUNCTION TEST

    78258

    ESOPHAGUS MOTILITY STUDY

    78261

    GASTRIC MUCOSA IMAGING

    78262

    GASTROESOPHAGEAL REFLUX EXAM

    78264

    GASTRIC EMPTYING STUDY

    78278

    GI BLEEDER SCAN

    78282

    GI PROTEIN LOSS EXAM

    78290

    MECKEL'S DIVERTICULUM IMAGING

    78291

    LEVEEN SHUNT PATENCY EXAM

    78300

    BONE OR JOINT IMAGING LIMITED

    78305

    BONE OR JOINT IMAGING MULTIPLE

    78306

    BONE SCAN WHOLE BODY

    78315

    BONE AND/OR JOINT IMAGING; 3 PHASE STUDY

    78320

    BONE JOINT IMAGING TOMO TEST SPECT

    78414

    NON-IMAGING HEART FUNCTION

    78428

    CARDIAC SHUNT IMAGING

    78445

    RADIONUCLIDE VENOGRAM NON-CARDIAC

    78456

    ACUTE VENOUS THROMBOSIS IMAGING

    78457

    VENOUS THROMBOSIS IMAGING UNILATERAL

    78458

    VENOUS THROMBOSIS IMAGING BILATERAL

    78466

    MYOCARDIAL INFARCTION SCAN

    78468

    HEART INFARCT IMAGE EF

    78469

    HEART INFARCT IMAGE SPECT

    78472

    GATED HEART, REST OR STRESS

    78473

    CARDIAC BLOOD POOL MUGA SCAN

    78481

    HEART FIRST PASS SINGLE

    78483

    CARDIAC BLOOD POOL IMAGING, MULTIPLE

    78494

    CARDIAC BLOOD POOL IMAGING, SPECT

    78496

    CARDIAC BLOOD POOL IMAGING, SINGLE AT REST

    78579

    PULMONARY VENTILATION IMAGING (E.G., AEROSOL OR GAS)

    78580

    PULMONARY PERFUSION IMAGING

    78582

    PULMONARY VENTILATION (E.G., AEROSOL OR GAS) AND PERFUSION IMAGING

    78597

    QUANTITATIVE DIFFERENTIAL PULMONARY PERFUSION, INCLUDING IMAGING, WHEN PERFORMED

    78598

    QUANTITATIVE DIFFERENTIAL PULMONARY PERFUSION AND VENTILATION (E.G., AEROSOL OR GAS), INCLUDING IMAGING, WHEN PERFORMED

    78600

    BRAIN IMAGING LIMITED STATIC

    78601

    BRAIN LIMITED IMAGING AND FLOW

    78605

    BRAIN IMAGING COMPLETE

    78606

    BRAIN IMAGING COMPLETE WITH FLOW

    78607

    BRAIN IMAGING SPECT

    78608

    BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), METABOLIC EVALUATION

    78609

    BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION EVALUATION

    78610

    BRAIN FLOW IMAGING ONLY

    78630

    CISTERNOGRAM (CEREBROSPINAL FLUID FLOW)

    78635

    CEREBROSPINAL VENTRICULOGRAPHY

    78645

    CEREBROSPINAL FLUID FLOW SHUNT EVALUATION

    78647

    CEREBROSPINAL FLUID SCAN SPECT

    78650

    CEREBROSPINAL FLUID FLOW LEAKAGE DETECTION AND LOCALIZATION

    78660

    RADIOPHARMACEUTICAL DACRYOCYSTORGRAPHY

    78700

    KIDNEY IMAGING MORPHOLOGY

    78701

    KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW

    78707

    KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW AND FUNCTION STUDY

    78708

    KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW AND FUNCTION, SINGLE WITH PHARM INTERVENTION

    78709

    KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW, MULTIPLE, WITHOUT AND WITH PHARM INTERVENTION

    78710

    KIDNEY IMAGING, SPECT

    78725

    KIDNEY FUNCTION STUDY, NON-IMAGE RADIOISOTROPIC

    78730

    URINARY BLADDER RESIDUAL STUDY

    78740

    URETERAL REFLUX STUDY

    78761

    TESTICULAR IMAGING WITH VASCULAR FLOW

    78800

    RADIOPHARM LOCALIZATION OF TUMOR, LIMITED AREA

    78801

    RADIOPHARM LOCALIZATION OF TUMOR, MULTIPLE AREAS

    78802

    RADIOPHARM LOCALIZATION OF TUMOR, WHOLE BODY

    78803

    RADIOPHARM LOCALIZATION OF TUMOR, SPECT

    78804

    RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR OR DISTRIBUTION OF RADIOPHARMACEUTICAL AGENT(S); WHOLE BODY, REQUIRING 2 OR MORE DAYS IMAGING

    78805

    RADIOPHARM LOCALIZATION OF ABSCESS, LIMITED AREA

    78806

    RADIOPHARM LOCALIZATION OF ABSCESS, WHOLE BODY

    78807

    RADIOPHARM LOCALIZATION OF ABSCESS, SPECT

    78811

    POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; LIMITED AREA (E.G., CHEST, HEAD/NECK)

    78812

    POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; SKULL BASE TO MID-THIGH

    78813

    POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; WHOLE BODY

    78814

    POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; LIMITED AREA (E.G., CHEST, HEAD/NECK)

    78815

    POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; SKULL BASE TO
    MID-THIGH

    78816

    POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; WHOLE BODY

    C8900

    MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, ABDOMEN

    C8901

    MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, ABDOMEN

    C8902

    MAGNETIC RESONANCE ANGIOGRAPHY WITH AND WITHOUT CONTRAST, ABDOMEN

    C8903

    MAGNETIC RESONANCE IMAGING WITH CONTRAST, BREAST; UNILATERAL

    C8904

    MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST, BREAST; UNILATERAL

    C8905

    MAGNETIC RESONANCE IMAGING WITH AND WITHOUT CONTRAST, BREAST; UNILATERAL

    C8906

    MAGNETIC RESONANCE IMAGING WITH CONTRAST, BREAST; BILATERAL

    C8907

    MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST, BREAST; BILATERAL

    C8908

    MAGNETIC RESONANCE IMAGING WITH AND WITHOUT CONTRAST, BREAST; BILATERAL

    C8909

    MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, CHEST (EXCLUDING MYOCARDIUM)

    C8910

    MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, CHEST (EXCLUDING MYOCARDIUM)

    C8911

    MAGNETIC RESONANCE ANGIOGRAPHY WITH AND WITHOUT CONTRAST, CHEST (EXCLUDING MYOCARDIUM)

    C8912

    MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, LOWER EXTREMITY

    C8913

    MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, LOWER EXTREMITY

    C8914

    MAGNETIC RESONANCE ANGIOGRAPHY WITH AND WITHOUT CONTRAST, LOWER EXTREMITY

    C8918

    MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, PELVIS

    C8919

    MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, PELVIS

    C8920

    MAGNETIC RESONANCE ANGIOGRAPHY WITH AND WITHOUT CONTRAST, PELVIS

    C8931

    MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, SPINAL CANAL AND CONTENTS

    C8932

    MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, SPINAL CANAL AND CONTENTS

    C8933

    MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, SPINAL CANAL AND CONTENTS

    C8934

    MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, UPPER EXTREMITY

    C8935

    MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, UPPER EXTREMITY

    C8936

    MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, UPPER EXTREMITY

    Note: This program does not change members' benefits, nor does it change claim submission procedures for providers with a current direct contract with one of EmblemHealth's companies. Radiologists directly contracted with eviCore are now required to submit claims to eviCore.

    Radiology Program Prior Approval Code List For EmblemHealth EPO/PPO and EmblemHealth Medicare PPO

    Radiology Program Prior Approval Code List For GHI EPO/PPO, EmblemHealth EPO/PPO and Medicare PPO
    Effective October 1, 2012
    Radiology CPT Code Procedure Description

    C8936

    MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, UPPER EXTREMITY (crosswalked to 73225)

    C8935

    MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, UPPER EXTREMITY (crosswalked to 73225)

    C8934

    MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, UPPER EXTREMITY (crosswalked to 73225)

    C8933

    MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, SPINAL CANAL AND CONTENTS (crosswalked to 72159)

    C8932

    MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, SPINAL CANAL AND CONTENTS (crosswalked to 72159)

    C8931

    MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, SPINAL CANAL AND CONTENTS (crosswalked to 72159)

    C8920

    MRA WITH AND WITHOUT CONTRAST, PELVIS (crosswalked to 72198)

    C8919

    MRA WITHOUT CONTRAST, PELVIS (crosswalked to 72198)

    C8918

    MRA WITH CONTRAST, PELVIS (crosswalked to 72198)

    C8914

    MRA WITH AND WITHOUT CONTRAST, LOWER EXTREMITY (crosswalked to 73725)

    C8913

    MRA WITHOUT CONTRAST, LOWER EXTREMITY (crosswalked to 73725)

    C8912

    MRA WITH CONTRAST, LOWER EXTREMITY (crosswalked to 73725)

    C8911

    MRA WITH AND WITHOUT CONTRAST, CHEST (EXCLUDING MYOCARDIUM) (crosswalked to 71555)

    C8910

    MRA WITHOUT CONTRAST, CHEST (EXCLUDING MYOCARDIUM) (crosswalked to 71555)

    C8909

    MRA WITH CONTRAST, CHEST (EXCLUDING MYOCARDIUM) (crosswalked to 71555)

    C8908

    MRI WITH AND WITHOUT CONTRAST, BREAST; BILATERAL (crosswalked to 77059)

    C8907

    MRI WITHOUT CONTRAST, BREAST; BILATERAL (crosswalked to 77059)

    C8906

    MRI WITH CONTRAST, BREAST; BILATERAL (crosswalked to 77059)

    C8905

    MRI WITH AND WITHOUT CONTRAST, BREAST; UNILATERAL (crosswalked to 77058)

    C8904

    MRI WITHOUT CONTRAST, BREAST; UNILATERAL (crosswalked to 77058)

    C8903

    MRI WITH CONTRAST, BREAST; UNILATERAL (crosswalked to 77058)

    C8902

    MRA WITH AND WITHOUT CONTRAST, ABDOMEN (crosswalked to 74185)

    C8901

    MRA WITHOUT CONTRAST, ABDOMEN (crosswalked to 74185)

    C8900

    MRA WITH CONTRAST, ABDOMEN (crosswalked to 74185)

    0175T

    COMPUTER-AIDED DETECTION (CAD), INCLUDING COMPUTER ALGORITHM ANALYSIS OF DIGITAL IMAGE DATA FOR LESION DETECTION, WITH FURTHER PHYSICIAN REVIEW FOR INTERPRETATION AND REPORT, WITH OR WITHOUT DIGITIZATION OF FILM RADIOGRAPHIC IMAGES, CHEST RADIOGRAPH(S) PERFORMED REMOTE FROM PRIMARY INTERPRETATION

    0174T

    COMPUTER-AIDED DETECTION (CAD), INCLUDING COMPUTER ALGORITHM ANALYSIS OF DIGITAL IMAGE DATA FOR LESION DETECTION, WITH FURTHER PHYSICIAN REVIEW FOR INTERPRETATION AND REPORT, WITH OR WITHOUT DIGITIZATION OF FILM RADIOGRAPHIC IMAGES, CHEST RADIOGRAPH(S) PERFORMED CONCURRENT WITH PRIMARY INTERPRETATION

    78816

    POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; WHOLE BODY

    78815

    POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; SKULL BASE TO MID-THIGH

    78814

    POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; LIMITED AREA (E.G., CHEST, HEAD/NECK)

    78813

    POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; WHOLE BODY

    78812

    POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; SKULL BASE TO MID-THIGH

    78811

    POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; LIMITED AREA (E.G., CHEST, HEAD/NECK)

    78807

    RADIOPHARM LOCALIZATION OF ABSCESS, SPECT

    78806

    RADIOPHARM LOCALIZATION OF ABSCESS, WHOLE BODY

    78805

    RADIOPHARM LOCALIZATION OF ABSCESS, LIMITED AREA

    78804

    RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR OR DISTRIBUTION OF RADIOPHARMACEUTICAL AGENT(S); WHOLE BODY, REQUIRING 2 OR MORE DAYS IMAGING

    78803

    RADIOPHARM LOCALIZATION OF TUMOR, SPECT

    78802

    RADIOPHARM LOCALIZATION OF TUMOR, WHOLE BODY

    78801

    RADIOPHARM LOCALIZATION OF TUMOR, MULTI AREAS

    78800

    RADIOPHARM LOCALIZATION OF TUMOR, LIMITED AREA

    78761

    TESTICULAR IMAGING W/ VASCULAR FLOW

    78740

    URETERAL REFLUX STUDY

    78730

    URINARY BLADDER RESIDUAL STUDY

    78725

    KIDNEY FUNCTION STUDY, NON-IMAGE RADIOISOTROPIC

    78710

    KIDNEY IMAGING, SPECT

    78709

    KIDNEY IMAGING MORPHOLOGY W/ VASCULAR FLOW, MULTI, W/O AND W/ PHARM INTERVENTION

    78708

    KIDNEY IMAGING MORPHOLOGY W/ VASCULAR FLOW AND FUNCTION, SINGLE W/ PHARM INTERVENTION

    78707

    KIDNEY IMAGING MORPHOLOGY W/ VASCULAR FLOW AND FUNCTION STUDY

    78701

    KIDNEY IMAGING MORPHOLOGY W/ VASCULAR FLOW

    78700

    KIDNEY IMAGING MORPHOLOGY

    78660

    RADIOPHARMACEUTICAL DACRYOCYSTORGRAPHY

    78650

    CSF LEAKAGE DETECTION AND LOCALIZATION

    78647

    CEREBROSPINAL FLUID SCAN SPECT

    78645

    CSF SHUNT EVALUATION

    78635

    CEREBROSPINAL VENTRICULOGRAPHY

    78630

    CISTERNOGRAM (Cerebrospinal fluid flow)

    78610

    BRAIN FLOW IMAGING ONLY

    78609

    BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION EVALUATION

    78608

    BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), METABOLIC EVALUATION

    78607

    BRAIN IMAGING SPECT

    78606

    BRAIN IMAGING COMPLETE W/ FLOW

    78605

    BRAIN IMAGING COMPLETE

    78601

    BRAIN LTD IMAGING AND FLOW

    78600

    BRAIN IMAGING LTD STATIC

    78598

    QUANTITATIVE DIFFERENTIAL PULMONARY PERFUSION AND VENTILATION (E.G., AEROSOL OR GAS), INCLUDING IMAGING WHEN PERFORMED

    78597

    QUANTITATIVE DIFFERENTIAL PULMONARY PERFUSION, INCLUDING IMAGING WHEN PERFORMED

    78582

    PULMONARY VENTILATION (E.G., AEROSOL OR GAS) AND PERFUSION IMAGING

    78579

    PULMONARY VENTILATION IMAGING (E.G., AEROSOL OR GAS)

    78496

    CARDIAC BLOOD POOL IMAGING, SINGLE AT REST (Use with 78472)

    78494

    CARDIAC BLOOD POOL IMAGING, SPECT

    78492

    MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION; MULTIPLE STUDIES AT REST OR STRESS

    78491

    MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION; SINGLE STUDY AT REST OR STRESS

    78483

    CARDIAC BLOOD POOL IMAGING, MULTI

    78481

    HEART FIRST PASS SINGLE

    78473

    CARDIAC BLOOD POOL MUGA SCAN

    78472

    GATED HEART, REST OR STRESS

    78469

    HEART INFARCT IMAGE SPECT

    78468

    HEART INFARCT IMAGE EF

    78466

    MYOCARDIAL INFARCTION SCAN

    78459

    MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) METABOLIC EVAL

    78458

    VENOUS THROMBOSIS IMAGING BILATERAL

    78457

    VENOUS THROMBOSIS IMAGING UNILATERAL

    78456

    ACUTE VENOUS THROMBOSIS IMAGING

    78454

    MPI, PLANAR, MULTIPLE, REST OR STRESS

    78453

    MPI, PLANAR, SINGLE REST OR STRESS

    78452

    MPI, SPECT, MULTIPLE, REST OR STRESS

    78451

    MPI, SPECT, SINGLE REST OR STRESS

    78445

    RADIONUCLIDE VENOGRAM NON-CARDIAC

    78428

    CARDIAC SHUNT IMAGING

    78414

    NON-IMAGING HEART FUNCTION

    78320

    BONE JOINT IMAGING TOMO TEST SPECT

    78315

    BONE AND/OR JOINT IMAGING; 3 PHASE STUDY

    78306

    BONE SCAN WHOLE BODY

    78305

    BONE OR JOINT IMAGING MULTIPLE

    78300

    BONE OR JOINT IMAGING LTD

    78291

    LEVEEN SHUNT PATENCY EXAM

    78290

    MECKEL'S DIVERTICULUM IMAGING

    78282

    GI PROTEIN LOSS EXAM

    78278

    GI BLEEDER SCAN

    78264

    GASTRIC EMPTYING STUDY

    78262

    GASTROESOPHAGEAL REFLUX EXAM

    78261

    GASTRIC MUCOSA IMAGING

    78258

    ESOPHAGUS MOTILITY STUDY

    78232

    SALIVARY GLAND FUNCTION TEST

    78231

    SERIAL SALIVARY GLAND

    78230

    SALIVARY GLAND IMAGING

    78227

    HIDA SCAN

    78226

    LIVER FUNCTION STUDY

    78223

    HIDA SCAN

    78220

    LIVER FUNCTION STUDY

    78216

    LIVER AND SPLEEN IMAGING W/ FLOW

    78215

    LIVER AND SPLEEN IMAGING

    78206

    LIVER IMAGING SPECT W/ VASCULAR FLOW

    78205

    LIVER IMAGING SPECT

    78202

    LIVER IMAGING W/ FLOW

    78201

    LIVER IMAGING

    78195

    LYMPH SYSTEM IMAGING

    78191

    PLATELET SURVIVAL

    78190

    PLATELET SURVIVAL, KINETICS

    78185

    SPLEEN IMAGING W/ OR W/O VASCULAR FLOW

    78140

    LABELED RED CELL SEQUESTRATION

    78104

    BONE MARROW IMAGING, WHOLE BODY

    78103

    BONE MARROW IMAGING, MULTIPLE

    78102

    BONE MARROW IMAGING, LIMITED

    78075

    ADRENAL NUCLEAR IMAGING

    78070

    PARATHYROID NUCLEAR IMAGING

    78020

    THYROID CARCINOMA METASTASES UPTAKE (add on code - use w/ code 78018 only)

    78018

    THYROID SCAN WHOLE BODY

    78016

    THYROID MET IMAGING WITH ADDITIONAL STUDIES

    78015

    THYROID MET IMAGING

    78011

    THYROID IMAGING W/ FLOW

    78010

    THYROID SCAN ONLY

    78007

    THYROID IMAGE, MULTIPLE UPTAKES

    78006

    THYROID UPTAKE AND SCAN

    78003

    THYROID SUPPRESS OR STIMULATION

    78001

    THYROID MULTIPLE UPTAKE

    78000

    THYROID RAI UPTAKE

    77084

    MRI BONE MARROW BLOOD SUPPLY

    77059

    MRI BREAST BILATERAL

    77058

    MRI BREAST W/ AND/OR W/O CONTRAST; UNILATERAL

    77021

    MRI GUIDANCE FOR NEEDLE PLACEMENT

    76390

    MRI SPECTROSCOPY

    76380

    CT LIMITED OR LOCALIZED FOLLOW-UP STUDY

    76377

    3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND, OR OTHER TOMOGRAPHIC MODALITY; REQUIRING IMAGE POSTPROCESSING ON AN INDEPENDENT WORKSTATION

    76376

    3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND, OR OTHER TOMOGRAPHIC MODALITY; NOT REQUIRING IMAGE POSTPROCESSING ON AN INDEPENDENT WORKSTATION

    75635

    CT ANGIOGRAPHY ABDOMINAL AORTA

    75574

    CORONARY CTA

    75573

    CARDIAC CT FOR CONGENITAL HD

    75572

    CARDIAC CT FOR MORPHOLOGY

    75563

    CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; WITH STRESS IMAGING

    75561

    CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES

    75559

    CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL; WITH STRESS IMAGING

    75557

    CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL

    74263

    COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY, SCREENING, INCLUDING IMAGE POSTPROCESSING

    74262

    COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY, DIAGNOSTIC, INCLUDING IMAGE POSTPROCESSING; WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED

    74261

    COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY, DIAGNOSTIC, INCLUDING IMAGE POSTPROCESSING; WITHOUT CONTRAST MATERIAL

    74185

    MRA ABDOMEN W/ OR W/O CONTRAST

    74183

    MRI ABDOMEN W/ & W/O CONTRAST

    74182

    MRI ABDOMEN W/ CONTRAST

    74181

    MRI ABDOMEN W/O CONTRAST

    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

    74177

    COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL(S)

    74176

    COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL

    74175

    CT ANGIOGRAPHY ABDOMEN

    74174

    CT ANGIOGRAPHY, ABDOMEN AND PELVIS, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING

    74170

    CT ABDOMEN W/O & W/ CONTRAST

    74160

    CT ABDOMEN W/ CONTRAST

    74150

    CT ABDOMEN W/O CONTRAST

    73725

    MRA LOWER EXTREMITY W/ OR W/O CONTRAST

    73723

    MRI LOWER EXTREMITY JOINT W/ & W/O CONTRAST

    73722

    MRI LOWER EXTREMITY JOINT W/ CONTRAST

    73721

    MRI LOWER EXTREMITY JOINT W/O CONTRAST

    73720

    MRI LOWER EXTREMITY W/ & W/O CONTRAST

    73719

    MRI LOWER EXTREMITY W/ CONTRAST

    73718

    MRI LOWER EXTREMITY W/O CONTRAST

    73706

    CT ANGIOGRAPHY LOWER EXTREMITY

    73702

    CT LOWER EXTREMITY W/O & W/ CONTRAST

    73701

    CT LOWER EXTREMITY W/ CONTRAST

    73700

    CT LOWER EXTREMITY W/O CONTRAST

    73225

    MRA UPPER EXTREMITY W/ OR W/O CONTRAST

    73223

    MRI UPPER EXTREMITY JOINT W/ & W/O CONTRAST

    73222

    MRI UPPER EXTREMITY JOINT W/ CONTRAST

    73221

    MRI UPPER EXTREMITY JOINT W/O CONTRAST

    73220

    MRI UPPER EXTREMITY W/ & W/O CONTRAST

    73219

    MRI UPPER EXTREMITY W/ CONTRAST

    73218

    MRI UPPER EXTREMITY W/O CONTRAST

    73206

    CT ANGIOGRAPHY UPPER EXTREMITY

    73202

    CT UPPER EXTREMITY W/O & W/ CONTRAST

    73201

    CT UPPER EXTREMITY W/ CONTRAST

    73200

    CT UPPER EXTREMITY W/O CONTRAST

    72198

    MRA PELVIS W/ OR W/O CONTRAST

    72197

    MRI PELVIS W/ & W/O CONTRAST

    72196

    MRI PELVIS W/ CONTRAST

    72195

    MRI PELVIS W/O CONTRAST

    72194

    CT PELVIS W/O & W/ CONTRAST

    72193

    CT PELVIS W/ CONTRAST

    72192

    CT PELVIS W/O CONTRAST

    72191

    CT ANGIOGRAPHY PELVIS

    72159

    MRA SPINAL CANAL W/ OR W/O CONTRAST

    72158

    MRI L SPINE W/ & W/O CONTRAST

    72157

    MRI T SPINE W/ & W/O CONTRAST

    72156

    MRI C SPINE W/ & W/O CONTRAST

    72149

    MRI LUMBAR SPINE W/ CONTRAST

    72148

    MRI LUMBAR SPINE W/O CONTRAST

    72147

    MRI THORACIC SPINE W/ CONTRAST

    72146

    MRI THORACIC SPINE W/O CONTRAST

    72142

    MRI CERVICAL SPINE W/ CONTRAST

    72141

    MRI CERVICAL SPINE W/O CONTRAST

    72133

    CT L SPINE W/O & W/ CONTRAST

    72132

    CT L SPINE W/ CONTRAST

    72131

    CT L SPINE W/O CONTRAST

    72130

    CT T SPINE W/O & W/ CONTRAST

    72129

    CT T SPINE W/ CONTRAST

    72128

    CT T SPINE W/O CONTRAST

    72127

    CT C SPINE W/O & W/ CONTRAST

    72126

    CT C SPINE W/ CONTRAST

    72125

    CT C SPINE W/O CONTRAST

    71555

    MRA CHEST (EXC MYOCARDIUM) W/ OR W/O CONTRAST

    71552

    MRI CHEST W/ & W/O CONTRAST

    71551

    MRI CHEST W/ CONTRAST

    71550

    MRI CHEST W/O CONTRAST

    71275

    CT ANGIOGRAPHY CHEST, NON-CORONARY

    71270

    CT THORAX W/O & W/ CONTRAST

    71260

    CT THORAX W/ CONTRAST

    71250

    CT THORAX W/O CONTRAST

    70555

    MRI, BRAIN, FUNCTIONAL MRI; REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION OF ENTIRE NEUROFUNCTIONAL TESTING

    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

    70553

    MRI HEAD W/ & W/O CONTRAST

    70552

    MRI HEAD W/ CONTRAST

    70551

    MRI HEAD W/O CONTRAST

    70549

    MRA NECK W/ & W/O CONTRAST

    70548

    MRA NECK W/ CONTRAST

    70547

    MRA NECK W/O CONTRAST

    70546

    MRA HEAD W/ & W/O CONTRAST

    70545

    MRA HEAD W/ CONTRAST

    70544

    MRA HEAD W/O CONTRAST

    70543

    MRI FACE, ORBIT, NECK W/ & W/O CONTRAST

    70542

    MRI FACE, ORBIT, NECK W/ CONTRAST

    70540

    MRI FACE, ORBIT, NECK W/O CONTRAST

    70498

    CT ANGIOGRAPHY NECK

    70496

    CT ANGIOGRAPHY HEAD

    70492

    CT SOFT TISSUE NECK W/O & W/ CONTRAST

    70491

    CT SOFT TISSUE NECK W/ CONTRAST

    70490

    CT SOFT TISSUE NECK W/O CONTRAST

    70488

    CT MAXLLFCL W/O & W/ CONTRAST

    70487

    CT MAXLLFCL W/ CONTRAST

    70486

    CT MAXLLFCL W/O CONTRAST

    70482

    CT ORBIT W/O & W/ CONTRAST

    70481

    CT ORBIT W/ CONTRAST

    70480

    CT ORBIT W/O CONTRAST

    70470

    CT HEAD/BRAIN W/O & W/ CONTRAST

    70460

    CT HEAD/BRAIN W/ CONTRAST

    70450

    CT HEAD/BRAIN W/O CONTRAST

    70336

    MRI TMJ

    Radiology Program Prior Approval Code List For GHI HMO - RETIRED

    Radiology Program Prior Approval Code List For GHI HMO - RETIRED

    Effective October 1, 2012 until December 31, 2015
    Radiology CPT Code Procedure Description

    70336

    MRI TMJ

    70450

    CT HEAD/BRAIN W/O CONTRAST

    70460

    CT HEAD/BRAIN W/ CONTRAST

    70470

    CT HEAD/BRAIN W/O & W/ CONTRAST

    70480

    CT ORBIT W/O CONTRAST

    70481

    CT ORBIT W/ CONTRAST

    70482

    CT ORBIT W/O & W/ CONTRAST

    70486

    CT MAXLLFCL W/O CONTRAST

    70487

    CT MAXLLFCL W/ CONTRAST

    70488

    CT MAXLLFCL W/O & W/ CONTRAST

    70490

    CT SOFT TISSUE NECK W/O CONTRAST

    70491

    CT SOFT TISSUE NECK W/ CONTRAST

    70492

    CT SOFT TISSUE NECK W/O & W/ CONTRAST

    70496

    CT ANGIOGRAPHY HEAD

    70498

    CT ANGIOGRAPHY NECK

    70540

    MRI FACE, ORBIT, NECK W/O CONTRAST

    70542

    MRI FACE, ORBIT, NECK W/ CONTRAST

    70543

    MRI FACE, ORBIT, NECK W/ & W/O CONTRAST

    70544

    MRA HEAD W/O CONTRAST

    70545

    MRA HEAD W/ CONTRAST

    70546

    MRA HEAD W/ & W/O CONTRAST

    70547

    MRA NECK W/O CONTRAST

    70548

    MRA NECK W/ CONTRAST

    70549

    MRA NECK W/ & W/O CONTRAST

    70551

    MRI HEAD W/O CONTRAST

    70552

    MRI HEAD W/ CONTRAST

    70553

    MRI HEAD W/ & W/O CONTRAST

    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

    70555

    MRI, BRAIN, FUNCTIONAL MRI; REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION OF ENTIRE NEUROFUNCTIONAL TESTING

    71250

    CT THORAX W/O CONTRAST

    71260

    CT THORAX W/ CONTRAST

    71270

    CT THORAX W/O & W/ CONTRAST

    71275

    CT ANGIOGRAPHY CHEST, NON-CORONARY

    71550

    MRI CHEST W/O CONTRAST

    71551

    MRI CHEST W/ CONTRAST

    71552

    MRI CHEST W/ & W/O CONTRAST

    71555

    MRA CHEST (EXC MYOCARDIUM) W/ OR W/O CONTRAST

    72125

    CT C SPINE W/O CONTRAST

    72126

    CT C SPINE W/ CONTRAST

    72127

    CT C SPINE W/O & W/ CONTRAST

    72128

    CT T SPINE W/O CONTRAST

    72129

    CT T SPINE W/ CONTRAST

    72130

    CT T SPINE W/O & W/ CONTRAST

    72131

    CT L SPINE W/O CONTRAST

    72132

    CT L SPINE W/ CONTRAST

    72133

    CT L SPINE W/O & W/ CONTRAST

    72141

    MRI CERVICAL SPINE W/O CONTRAST

    72142

    MRI CERVICAL SPINE W/ CONTRAST

    72146

    MRI THORACIC SPINE W/O CONTRAST

    72147

    MRI THORACIC SPINE W/ CONTRAST

    72148

    MRI LUMBAR SPINE W/O CONTRAST

    72149

    MRI LUMBAR SPINE W/ CONTRAST

    72156

    MRI C SPINE W/ & W/O CONTRAST

    72157

    MRI T SPINE W/ & W/O CONTRAST

    72158

    MRI L SPINE W/ & W/O CONTRAST

    72159

    MRA SPINAL CANAL W/ OR W/O CONTRAST

    72191

    CT ANGIOGRAPHY PELVIS

    72192

    CT PELVIS W/O CONTRAST

    72193

    CT PELVIS W/ CONTRAST

    72194

    CT PELVIS W/O & W/ CONTRAST

    72195

    MRI PELVIS W/O CONTRAST

    72196

    MRI PELVIS W/ CONTRAST

    72197

    MRI PELVIS W/ & W/O CONTRAST

    72198

    MRA PELVIS W/ OR W/O CONTRAST

    73200

    CT UPPER EXTREMITY W/O CONTRAST

    73201

    CT UPPER EXTREMITY W/ CONTRAST

    73202

    CT UPPER EXTREMITY W/O & W/ CONTRAST

    73206

    CT ANGIOGRAPHY UPPER EXTREMITY

    73218

    MRI UPPER EXTREMITY W/O CONTRAST

    73219

    MRI UPPER EXTREMITY W/ CONTRAST

    73220

    MRI UPPER EXTREMITY W/ & W/O CONTRAST

    73221

    MRI UPPER EXTREMITY JOINT W/O CONTRAST

    73222

    MRI UPPER EXTREMITY JOINT W/ CONTRAST

    73223

    MRI UPPER EXTREMITY JOINT W/ & W/O CONTRAST

    73225

    MRA UPPER EXTREMITY W/ OR W/O CONTRAST

    73700

    CT LOWER EXTREMITY W/O CONTRAST

    73701

    CT LOWER EXTREMITY W/ CONTRAST

    73702

    CT LOWER EXTREMITY W/O & W/ CONTRAST

    73706

    CT ANGIOGRAPHY LOWER EXTREMITY

    73718

    MRI LOWER EXTREMITY W/O CONTRAST

    73719

    MRI LOWER EXTREMITY W/ CONTRAST

    73720

    MRI LOWER EXTREMITY W/ & W/O CONTRAST

    73721

    MRI LOWER EXTREMITY JOINT W/O CONTRAST

    73722

    MRI LOWER EXTREMITY JOINT W/ CONTRAST

    73723

    MRI LOWER EXTREMITY JOINT W/ & W/O CONTRAST

    73725

    MRA LOWER EXTREMITY W/ OR W/O CONTRAST

    74150

    CT ABDOMEN W/O CONTRAST

    74160

    CT ABDOMEN W/ CONTRAST

    74170

    CT ABDOMEN W/O & W/ CONTRAST

    74174

    CT ANGIOGRAPHY, ABDOMEN AND PELVIS, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING

    74175

    CT ANGIOGRAPHY ABDOMEN

    74176

    COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL

    74177

    COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL(S)

    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

    74181

    MRI ABDOMEN W/O CONTRAST

    74182

    MRI ABDOMEN W/ CONTRAST

    74183

    MRI ABDOMEN W/ & W/O CONTRAST

    74185

    MRA ABDOMEN W/ OR W/O CONTRAST

    74261

    COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY, DIAGNOSTIC, INCLUDING IMAGE POSTPROCESSING; WITHOUT CONTRAST MATERIAL

    74262

    COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY, DIAGNOSTIC, INCLUDING IMAGE POSTPROCESSING; WITH CONTRAST MATERIAL(S) INCLUDING NON-CONTRAST IMAGES, IF PERFORMED

    74263

    COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY, SCREENING, INCLUDING IMAGE POSTPROCESSING

    75557

    CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL

    75559

    CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL; WITH STRESS IMAGING

    75561

    CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES

    75563

    CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; WITH STRESS IMAGING

    75572

    CARDIAC CT FOR MORPHOLOGY

    75573

    CARDIAC CT FOR CONGENITAL HD

    75574

    CORONARY CTA

    75635

    CT ANGIOGRAPHY ABDOMINAL AORTA

    76376

    3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND OR OTHER TOMOGRAPHIC MODALITY; NOT REQUIRING IMAGE POSTPROCESSING ON AN INDEPENDENT WORKSTATION

    76377

    3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND OR OTHER TOMOGRAPHIC MODALITY; REQUIRING IMAGE POSTPROCESSING ON AN INDEPENDENT WORKSTATION

    76380

    CT LIMITED OR LOCALIZED FOLLOW-UP STUDY

    76390

    MRI SPECTROSCOPY

    76801

    U/S OB PELVIS, PREGNANT UTERUS, FIRST TRIMESTER <14 WEEKS SINGLE OR FIRST GESTATION

    76802

    U/S OB PELVIS, PREGNANT UTERUS, FIRST TRIMESTER <14 WEEKS EACH ADDITIONAL GESTATION

    76805

    U/S OB PELVIS, PREGNANT UTERUS, B-SCAN (Allowed once per gestation)

    76810

    U/S OB PELVIS COMPLETE, MULTIPLE GESTATION AFTER 1ST TRIMESTER (Allowed once for each additional fetus per gestation; must be billed with 76805)

    76811

    U/S 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)

    76812

    U/S 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)

    76813

    ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FIRST TRIMESTER FETAL NUCHAL TRANSLUCENCY MEASUREMENT, TRANSABDOMINAL OR TRANSVAGINAL APPROACH; SINGLE OR FIRST GESTATION (Allowed once per gestation)

    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

    76816

    U/S OB PELVIS FOLLOW-UP OR REPEAT

    76817

    U/S PREGNANT UTERUS TRANSVAGINAL

    76818

    FETAL BIOPHYSICAL PROFILE

    76819

    FETAL BIOPHYSICAL PROFILE W/O STRESS NON STRESS

    76820

    DOPPLER VELOCIMETRY, FETAL; UMBILICAL ARTERY

    76821

    DOPPLER VELOCIMETRY, FETAL; MIDDLE CEREBRAL ARTERY

    76825

    U/S OB ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM

    76826

    FOLLOW-UP OR REPEAT STUDY

    76827

    DOPPLER ECHOCARDIOGRAPHY FETAL COMPLETE

    76828

    FOLLOW-UP OR REPEAT STUDY

    77021

    MRI GUIDANCE FOR NEEDLE PLACEMENT

    77058

    MRI BREAST W/ AND/OR W/O CONTRAST; UNILATERAL

    77059

    MRI BREAST BILATERAL

    77084

    MRI BONE MARROW BLOOD SUPPLY

    78000

    THYROID RAI UPTAKE

    78001

    THYROID MULTIPLE UPTAKE

    78003

    THYROID SUPPRESS OR STIMULATION

    78006

    THYROID UPTAKE AND SCAN

    78007

    THYROID IMAGE, MULTIPLE UPTAKES

    78010

    THYROID SCAN ONLY

    78011

    THYROID IMAGING W/ FLOW

    78015

    THYROID MET IMAGING

    78016

    THYROID MET IMAGING WITH ADDITIONAL STUDIES

    78018

    THYROID SCAN WHOLE BODY

    78020

    THYROID CARCINOMA METASTASES UPTAKE (add on code - use w/ code 78018 only)

    78070

    PARATHYROID NUCLEAR IMAGING

    78075

    ADRENAL NUCLEAR IMAGING

    78102

    BONE MARROW IMAGING, LIMITED

    78103

    BONE MARROW IMAGING, MULTIPLE

    78104

    BONE MARROW IMAGING, WHOLE BODY

    78140

    LABELED RED CELL SEQUESTRATION

    78185

    SPLEEN IMAGING W/ OR W/O VASCULAR FLOW

    78190

    PLATELET SURVIVAL, KINETICS

    78191

    PLATELET SURVIVAL

    78195

    LYMPH SYSTEM IMAGING

    78201

    LIVER IMAGING

    78202

    LIVER IMAGING W/ FLOW

    78205

    LIVER IMAGING SPECT

    78206

    LIVER IMAGING SPECT W/ VASCULAR FLOW

    78215

    LIVER AND SPLEEN IMAGING

    78216

    LIVER AND SPLEEN IMAGING W/ FLOW

    78220

    LIVER FUNCTION STUDY

    78223

    HIDA SCAN

    78226

    LIVER FUNCTION STUDY

    78227

    HIDA SCAN

    78230

    SALIVARY GLAND IMAGING

    78231

    SERIAL SALIVARY GLAND

    78232

    SALIVARY GLAND FUNCTION TEST

    78258

    ESOPHAGUS MOTILITY STUDY

    78261

    GASTRIC MUCOSA IMAGING

    78262

    GASTROESOPHAGEAL REFLUX EXAM

    78264

    GASTRIC EMPTYING STUDY

    78278

    GI BLEEDER SCAN

    78282

    GI PROTEIN LOSS EXAM

    78290

    MECKEL'S DIVERTICULUM IMAGING

    78291

    LEVEEN SHUNT PATENCY EXAM

    78300

    BONE OR JOINT IMAGING LTD

    78305

    BONE OR JOINT IMAGING MULTIPLE

    78306

    BONE SCAN WHOLE BODY

    78315

    BONE AND/OR JOINT IMAGING; 3 PHASE STUDY

    78320

    BONE JOINT IMAGING TOMO TEST SPECT

    78414

    NON-IMAGING HEART FUNCTION

    78428

    CARDIAC SHUNT IMAGING

    78445

    RADIONUCLIDE VENOGRAM NON-CARDIAC

    78451

    MPI, SPECT, SINGLE REST OR STRESS

    78452

    MPI, SPECT, MULTIPLE, REST OR STRESS

    78453

    MPI, PLANAR, SINGLE REST OR STRESS

    78454

    MPI, PLANAR, MULTIPLE, REST OR STRESS

    78456

    ACUTE VENOUS THROMBOSIS IMAGING

    78457

    VENOUS THROMBOSIS IMAGING UNILATERAL

    78458

    VENOUS THROMBOSIS IMAGING BILATERAL

    78459

    MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) METABOLIC EVAL

    78466

    MYOCARDIAL INFARCTION SCAN

    78468

    HEART INFARCT IMAGE EF

    78469

    HEART INFARCT IMAGE SPECT

    78472

    GATED HEART, REST OR STRESS

    78473

    CARDIAC BLOOD POOL MUGA SCAN

    78481

    HEART FIRST PASS SINGLE

    78483

    CARDIAC BLOOD POOL IMAGING, MULTI

    78491

    MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION; SINGLE STUDY AT REST OR STRESS

    78492

    MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION; MULTIPLE STUDIES AT REST OR STRESS

    78494

    CARDIAC BLOOD POOL IMAGING, SPECT

    78496

    CARDIAC BLOOD POOL IMAGING, SINGLE AT REST (Use with 78472)

    78579

    PULMONARY VENTILATION IMAGING (E.G., AEROSOL OR GAS)

    78582

    PULMONARY VENTILATION (E.G., AEROSOL OR GAS) AND PERFUSION IMAGING

    78597

    QUANTITATIVE DIFFERENTIAL PULMONARY PERFUSION, INCLUDING IMAGING WHEN PERFORMED

    78598

    QUANTITATIVE DIFFERENTIAL PULMONARY PERFUSION AND VENTILATION (E.G., AEROSOL OR GAS), INCLUDING IMAGING WHEN PERFORMED

    78600

    BRAIN IMAGING LTD STATIC

    78601

    BRAIN LTD IMAGING AND FLOW

    78605

    BRAIN IMAGING COMPLETE

    78606

    BRAIN IMAGING COMPLETE W/ FLOW

    78607

    BRAIN IMAGING SPECT

    78608

    BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), METABOLIC EVALUATION

    78609

    BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION EVALUATION

    78610

    BRAIN FLOW IMAGING ONLY

    78630

    CISTERNOGRAM (Cerebrospinal fluid flow)

    78635

    CEREBROSPINAL VENTRICULOGRAPHY

    78645

    CSF SHUNT EVALUATION

    78647

    CEREBROSPINAL FLUID SCAN SPECT

    78650

    CSF LEAKAGE DETECTION AND LOCALIZATION

    78660

    RADIOPHARMACEUTICAL DACRYOCYSTORGRAPHY

    78700

    KIDNEY IMAGING MORPHOLOGY

    78701

    KIDNEY IMAGING MORPHOLOGY W/ VASCULAR FLOW

    78707

    KIDNEY IMAGING MORPHOLOGY W/ VASCULAR FLOW AND FUNCTION STUDY

    78708

    KIDNEY IMAGING MORPHOLOGY W/ VASCULAR FLOW AND FUNCTION, SINGLE W/ PHARM INTERVENTION

    78709

    KIDNEY IMAGING MORPHOLOGY W/ VASCULAR FLOW, MULTI, W/O AND W/ PHARM INTERVENTION

    78710

    KIDNEY IMAGING, SPECT

    78725

    KIDNEY FUNCTION STUDY, NON-IMAGE RADIOISOTROPIC

    78730

    URINARY BLADDER RESIDUAL STUDY

    78740

    URETERAL REFLUX STUDY

    78761

    TESTICULAR IMAGING W/ VASCULAR FLOW

    78800

    RADIOPHARM LOCALIZATION OF TUMOR, LIMITED AREA

    78801

    RADIOPHARM LOCALIZATION OF TUMOR, MULTI AREAS

    78802

    RADIOPHARM LOCALIZATION OF TUMOR, WHOLE BODY

    78803

    RADIOPHARM LOCALIZATION OF TUMOR, SPECT

    78804

    RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR OR DISTRIBUTION OF RADIOPHARMACEUTICAL AGENT(S); WHOLE BODY, REQUIRING 2 OR MORE DAYS IMAGING

    78805

    RADIOPHARM LOCALIZATION OF ABSCESS, LIMITED AREA

    78806

    RADIOPHARM LOCALIZATION OF ABSCESS, WHOLE BODY

    78807

    RADIOPHARM LOCALIZATION OF ABSCESS, SPECT

    78811

    POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; LIMITED AREA (E.G., CHEST, HEAD/NECK)

    78812

    POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; SKULL BASE TO MID-THIGH

    78813

    POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; WHOLE BODY

    78814

    POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; LIMITED AREA (E.G., CHEST, HEAD/NECK)

    78815

    POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; SKULL BASE TO MID-THIGH

    78816

    POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; WHOLE BODY

    0174T

    COMPUTER-AIDED DETECTION (CAD) INCLUDING COMPUTER ALGORITHM ANALYSIS OF DIGITAL IMAGE DATA FOR LESION DETECTION, WITH FURTHER PHYSICIAN REVIEW FOR INTERPRETATION AND REPORT, WITH OR WITHOUT DIGITIZATION OF FILM RADIOGRAPHIC IMAGES, CHEST RADIOGRAPH(S) PERFORMED CONCURRENT WITH PRIMARY INTERPRETATION

    0175T

    COMPUTER-AIDED DETECTION (CAD), INCLUDING COMPUTER ALGORITHM ANALYSIS OF DIGITAL IMAGE DATA FOR LESION DETECTION, WITH FURTHER PHYSICIAN REVIEW FOR INTERPRETATION AND REPORT, WITH OR WITHOUT DIGITIZATION OF FILM RADIOGRAPHIC IMAGES, CHEST RADIOGRAPH(S) PERFORMED REMOTE FROM PRIMARY INTERPRETATION

    C8900

    MRA WITH CONTRAST, ABDOMEN (crosswalked to 74185)

    C8901

    MRA WITHOUT CONTRAST, ABDOMEN (crosswalked to 74185)

    C8902

    MRA WITH AND WITHOUT CONTRAST, ABDOMEN (crosswalked to 74185)

    C8903

    MRI WITH CONTRAST, BREAST; UNILATERAL (crosswalked to 77058)

    C8904

    MRI WITHOUT CONTRAST, BREAST; UNILATERAL (crosswalked to 77058)

    C8905

    MRI WITH AND WITHOUT CONTRAST, BREAST; UNILATERAL (crosswalked to 77058)

    C8906

    MRI WITH CONTRAST, BREAST; BILATERAL (crosswalked to 77059)

    C8907

    MRI WITHOUT CONTRAST, BREAST; BILATERAL (crosswalked to 77059)

    C8908

    MRI WITH AND WITHOUT CONTRAST, BREAST; BILATERAL (crosswalked to 77059)

    C8909

    MRA WITH CONTRAST, CHEST (EXCLUDING MYOCARDIUM) (crosswalked to 71555)

    C8910

    MRA WITHOUT CONTRAST, CHEST (EXCLUDING MYOCARDIUM) (crosswalked to 71555)

    C8911

    MRA WITH AND WITHOUT CONTRAST, CHEST (EXCLUDING MYOCARDIUM) (crosswalked to 71555)

    C8912

    MRA WITH CONTRAST, LOWER EXTREMITY (crosswalked to 73725)

    C8913

    MRA WITHOUT CONTRAST, LOWER EXTREMITY (crosswalked to 73725)

    C8914

    MRA WITH AND WITHOUT CONTRAST, LOWER EXTREMITY (crosswalked to 73725)

    C8918

    MRA WITH CONTRAST, PELVIS (crosswalked to 72198)

    C8919

    MRA WITHOUT CONTRAST, PELVIS (crosswalked to 72198)

    C8920

    MRA WITH AND WITHOUT CONTRAST, PELVIS (crosswalked to 72198)

    C8931

    MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, SPINAL CANAL AND CONTENTS (crosswalked to 72159)

    C8932

    MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, SPINAL CANAL AND CONTENTS (crosswalked to 72159)

    C8933

    MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, SPINAL CANAL AND CONTENTS (crosswalked to 72159)

    C8934

    MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, UPPER EXTREMITY (crosswalked to 73225)

    C8935

    MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, UPPER EXTREMITY (crosswalked to 73225)

    C8936

    MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, UPPER EXTREMITY (crosswalked to 73225)

    Deleted EmblemHealth Radiology Program Codes

    The following codes may no longer be billed for services rendered in 2011 and 2012. Please reference these codes for older claims.

    Deleted EmblemHealth Radiology Program Codes

    Applicable to All Plans in Program Procedures That Required Prior Approval, CPT-4 List

    For Reference for Claims With Dates of Service From 1/1/2011 to 12/31/2011

    Please do not use for your current (2012) claims billing.
    Nuclear Medicine
    CPT-4 Code Procedure Description Note

    78596

    LUNG DIFFERENTIAL FUNCTION

    Code deleted 1/1/12 - use 78598

    78220

    LIVER FUNCTION STUDY

    Code deleted 1/1/12 - use new code 78226

    78223

    HIDA SCAN

    Code deleted 1/1/12 - use new code 78227

    78586

    PULMONARY VENTILATION IMAGING

    Code deleted 1/1/12, use 78579

    78587

    PULMONARY VENTILATION MULTI

    Code deleted 1/1/12, use 78579

    78591

    VENT IMAGE 1 BREATH, 1 PROJECTION

    Code deleted 1/1/12, use 78579

    78593

    VENT IMAGE 1 PROJECTION, GAS

    Code deleted 1/1/12, use 78579

    78594

    VENT IMAGE MULTI PROJECTION, GAS

    Code deleted 1/1/12, use 78579

    78584

    PULMONARY PERFUSION WITH VENT SINGLE BREATH

    Code deleted 1/1/12, use 78582

    78585

    PULMONARY PERFUSION W/ WASHOUT OR W/O SINGLE BREATH

    Code deleted 1/1/12, use 78582

    78588

    PULMONARY PERFUSION IMAGING, PARTICULATE, WITH VENTILATION IMAGING, AEROSOL, 1 OR MULTIPLE PROJECTIONS

    Code deleted 1/1/12, use 78582

    Formal Dispute Resolution

    Please submit to EmblemHealth:

    • Appeals for Medicare members. Please follow EmblemHealth's standard processes for Medicare members, described in the Dispute Resolution Medicare chapter.
    • Complaints and grievances. Please refer to the Dispute Resolution chapters for Commercial/CHP and Medicaid/HARP, as applicable.

    Please submit to eviCore:

    • Expedited and standard clinical appeals for Commercial/CHP members and expedited and standard action appeals for Medicaid/HARP members. Appeals may be filed by the member, the member's delegate (including the practitioner acting as the member's delegate) or by practitioners on their own behalf. For a full description of member and practitioner rights regarding clinical and action appeals, see the Dispute Resolution chapters for Commercial/CHP and Medicaid/HARP, as applicable.

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    Glossary terms found on this page:

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    • Denial or limited authorization of a service authorization request, including the type or level of service
    • Reduction, suspension or termination of a previously authorized service
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    • Failure to provide services in a timely manner
    • Failure of EmblemHealth to act within the time frames for resolution and notification of determinations regarding complaints, action appeals and complaint appeals

    Oral or written request for EmblemHealth to review or reconsider an action by EmblemHealth or its subcontractor.

    Oral or written request from a member or their designee for EmblemHealth to review or reconsider a decision made by the plan.

    Services that have been approved for payment based on a review of EmblemHealth's policies.

    Services that have been approved for payment based on a review of EmblemHealth's policies.

    A health insurance product offered by a health plan company that is defined by the benefit contract and represents a set of covered services. Also called a health benefit plan.

    Services available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).

    A process in which an individual, an institution or educational program is evaluated and recognized as meeting certain predetermined standards. Certification usually applies to individuals; accreditation usually applies to institutions.

    An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

    Occurs when a clinical professional reviews information about a patient's health.

    Initial oral or written communication from a member or their designee or provider that expresses discontent with any aspect of their care or coverage with EmblemHealth. Specifically, it is dissatisfaction with:

    • A determination made by the plan, other than a determination of medical necessity or a determination that a service is considered experimental or investigational
    • Treatment experienced through the plan, its providers or contractors
    • Any concern with the plan, its benefits, employees or providers.

    Services rendered by a physician whose opinion or advice is requested by another physician for further evaluation or management of the patient.

    A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.

    The fixed dollar amount members must pay for certain covered services. It is generally paid to a network provider at the time the service is rendered.

    The fixed dollar amount members must pay for certain covered services. It is generally paid to a network provider at the time the service is rendered.

    An entity contracted with EmblemHealth to perform various services including utilization review, credentialing and claims processing. Also called managing entities and carve outs.

    An individual other than the subscriber who is eligible to receive health care services under the member's Certificate of Insurance. Generally, dependents are limited to the subscriber's spouse and eligible children.

    A determination of whether or not a person meets the requirements to participate in the plan and receive coverage under the plan.

    Means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (b) serious impairment to such person’s bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person.

    A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.

    A request to change an adverse determination that was based on administrative policies, procedures or guidelines.

    An organization that provides comprehensive health care coverage to its members through a network of doctors, hospitals and other health care providers. Also called a Health Maintenance Organization.

    An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:

    • Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
    • Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
    • Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
    • Maintains medical records for all patients
    • Has a requirement that every patient be under the care of a member of the medical staff
    • Provides 24-hour patient services
    • Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements

    A unique number which identifies the member's enrollment with EmblemHealth. EmblemHealth's claims are processed by this number. Also known as Member ID Number.

    Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.

    Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

    A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

    A doctor of medicine or doctor of osteopathic medicine who is duly licensed to practice medicine and is an employee of, or party to a contract with, a utilization management organization, and has responsibility for clinical oversight of the utilization management organization's utilization management, credentialing, quality management and other clinical functions.

    A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

    An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

    A unique number that identifies the member's enrollment with EmblemHealth. EmblemHealth's claims are processed by this number. Also known as ID Number.

    The physician or other provider who specifically prescribes the health care service being reviewed.

    A family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a primary care physician.

    A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

    A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

    The process of obtaining advanced approval of coverage for a health care service or medication. The request for services is reviewed to assess medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided. Also called pre-authorization or pre-certification or pre-determination.

    A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

    • Doctor of medicine
    • Doctor of osteopathy
    • Dentist
    • Chiropractor
    • Doctor of podiatric medicine
    • Physical therapist
    • Nurse midwife
    • Certified and registered psychologist
    • Certified and qualified social worker
    • Optometrist
    • Nurse anesthetist
    • Speech-language pathologist
    • Audiologist
    • Clinical laboratory
    • Screening center
    • General hospital
    • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

    A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

    A recommendation by a physician that an enrollee receive care from a specialty physician or facility.

    A formal evaluation (prospective, concurrent or retrospective) of the coverage, medical necessity, efficiency or appropriateness of health services and treatment plans. Also called Coordinated Care.

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