Provider Manual

Chapter 19: Radiology Program

This chapter contains information about our diagnostic imaging management program for outpatient radiology services, including prior approval and radiology scheduling procedures, for all members.

The EmblemHealth Radiology Program, developed with eviCore, provides diagnostic imaging management for outpatient radiology services. Services targeted for utilization management depend on the EmblemHealth benefit plan. eviCore also conducts clinical standard and expedited appeals (excluding members with Medicare plans).

 

Assessment and Certification

All radiologists and non-radiologists participating in our radiology programs undergo a comprehensive site visit, as well as evaluation of equipment, technical staff credentials, continuing education, equipment maintenance records and operating policies. They may also be required to complete the appropriate assessment and certification forms. This process is based on nationally recognized requirements of the American Institute of Ultrasound in Medicine, the American College of Radiology and The Joint Commission.

 

Film Review

Practitioners' film images must comply with the high standards of the American College of Radiology. At least once every two years, practitioners may be required to provide EmblemHealth and/or eviCore with requested materials for an independent review and professional interpretation of films. For this review, we randomly select a sampling of patient studies. At least two board-certified radiologists then assess these studies for technical quality and diagnostic interpretation.

As of January 1, 2018, ACPNY members are no longer exempt from the EmblemHealth Radiology Program. eviCore now provides utilization management (prior approval) for ACPNY radiology services. The referring provider will need to contact eviCore to get the prior approval.

 

As of August 20, 2018, members assigned to a PCP affiliated with St. Barnabas Hospital are no longer exempt from the EmblemHealth Radiology Program. eviCore now provides utilization management (prior approval) for these members. The referring provider will need to contact eviCore to get the prior approval.

 

While most of our members’ covered radiology services are managed by eviCore, the following exceptions apply:

  • Members whose care is managed by Montefiore Medical Group (CMO) or HealthCare Partners (HCP) must contact the applicable organization for prior approval. Check the member’s ID card or eligibility information on emblemhealth.com to determine whether HIP, CMO, or HCP is the managing entity responsible for managing a member’s care; if HIP is the managing entity, then eviCore is the organization to contact for prior approval.
  • Effective January 1, 2018, this exemption no longer applies for:
    • Members who selected a PCP assigned to ACPNY. The prior approval request must be entered on emblemhealth.com.
  • Effective August 20, 2018, this exemption no longer applies for:
    • Members who selected a physician affiliated with the St. Barnabas Hospital System. The prior approval request must be entered on emblemhealth.com.

Services Requiring Prior Approval

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:

 

HIP, EmblemHealth CompreHealth EPO (Retired August 1, 2018), EmblemHealth Medicare HMO and Vytra EmblemHealth EPO/PPO and EmblemHealth Medicare PPO
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 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.

For MRI, General Use Clinical Certification Request Form
For CT Scan, CT/CTA Clinical Certification Request Form
For PET Scan, PET Scan Clinical Certification Request Form
For MR/MRAs, MR/MRA Clinical Certification Request Form

 

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 (Retired August 1, 2018) 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

evicore.com cannot be used for expedited approval requests. These requests must be processed through the call center. Call 1-866-417-2345 for GHI HMO, HIP, EmblemHealth CompreHealth EPO (Retired August 1, 2018), 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 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. evicore.com cannot be used for urgent approval requests. These requests must be processed through the call center. Call 1-866-417-2345for GHI HMO, HIP, EmblemHealth CompreHealth EPO (Retired August 1, 2018), 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.

 

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, the 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 evicore.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 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 (Retired August 1, 2018), EmblemHealth Medicare HMO and Vytra plan members. Call 1-800-835-7064 for 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 (Retired August 1, 2018), EmblemHealth Medicare HMO and Vytra plans. Call 1-800-835-7064 for 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 HIP, EmblemHealth CompreHealth EPO (Retired August 1, 2018), EmblemHealth Medicare HMO and Vytra

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 EmblemHealth 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

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

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)

 

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.

Plan Participation

Members with HIP as their managing entity (see the member's ID card or eligibility information on emblemhealth.com follow the Radiology Scheduling Procedure.

 

Scheduling Procedure

When a prior approval request is made, utilization review staff evaluates the requested procedure against the existing criteria and determines its medical necessity.

 

If the prior approval request is approved, a scheduling representative contacts the member to schedule the procedure at a participating location. Once the location is selected, the medical necessity determination is amended to include an authorization number.

 

Program staff attempts to contact the member for a 48-hour period. If at the end of that period the scheduling representative is unable to speak with the member, they select a participating imaging facility close to the member's home and send a letter to both the member and the referring practitioner with the contact information for the site selected.

 

Members may contact the scheduling department at 1-866-699-8131, Monday through Friday, from 7 am to 7 pm, EST, to schedule a procedure or change the procedure site before the appointment date.

Overview

Vytra HMO contracted with various groups to provide radiology services for its members. All participating Vytra PCPs designated a radiology center that their Vytra patients used exclusively. The designated radiology center appeared on the ID card of each Vytra member on the PCP's panel.

 

Designated Radiology Centers

For radiology services to be covered, Vytra plan members used the designated radiology center specified on their Vytra ID card. If no radiology center appeared on the ID card, the member was able to go to any Vytra network radiologist. Participating practitioners sent members directly, without a referral, to the designated radiologist by writing a prescription detailing the test required.

 

PCPs with more than one office location were able to select a different radiology center for each of their offices.

 

In the rare instance that the designated radiology center could not meet the member's needs, the practitioner contacted Vytra's Care Management department at 1-888-288-9872 for prior approval to send the member to another facility.

 

Guarantee Waiver Agreement for Radiology Groups

Radiology centers treating a member outside their designation called Vytra's Provider Service Line at 1-888-288-9872before rendering services. During this call, the center ensured prior approval was secured and use Vytra's Guarantee Waiver Agreement.

 

Each member seeking service outside their designated facility signed Vytra's Guarantee Waiver Agreement. This was the only waiver recognized by Vytra. At time of signing, members were advised that they would be responsible for payment of all services performed. Practitioners had the right to withhold service to any member who chose not to sign this waiver.

 

If the radiology facility rendered services without having a signed waiver, the member was reimbursed for any up-front payment and could not be balance billed. Vytra reserves the right to withhold future payment to the facility until the member was reimbursed.

 

Changing Designated Radiology Groups

PCPs were able to change their designated radiologist under the following circumstances:

  • PCP requested a change and Vytra's Provider Relations department deemed the change to be in the best interest of the PCP's patients (e.g., quality of care related, PCP location change)
  • A corporate decision allowed all PCPs to change their designated radiologist
  • Administrative purposes (e.g., correction of database)

 

Quality Issues

All quality-related issues had to be reported to Vytra at 1-888-288-9877 promptly for immediate resolution. 

 

Copies of X-Rays

Copies of X-rays were not reimbursed unless the member received a second opinion for a cancer diagnosis and the practitioner received proper approval. Eligible copies were reimbursed at the then current fee schedule.

 

Radiation Therapy

Radiation therapy required the hematologist/oncologist to obtain prior approval.

If appropriate, a Care Management representative authorized an initial series of three visits for radiation therapy. Upon completing the initial evaluation, the radiation oncologist contacted Vytra's Care Management department with the findings.

The radiologist then forwarded a copy of the proposed treatment plan to the referring hematologist/oncologist. Specialists were required to communicate with the member's PCP regarding all treatment and follow-up care provided.

 

DEXA Scans

Vytra reimbursed only radiologists for dual energy X-ray absorptiometry (DEXA) scans. PCPs and specialists other than radiologists were not reimbursed for DEXA scans, regardless of any prior arrangements with or payments from Vytra.

If the member's designated radiologist did not perform DEXAs, the referring physician called Vytra's Care Management department to authorize services at another network radiologist.