2021 CPT Code Reference Guide

1 Code Reference Guide20212 | 2021 CaryOberlinFuquay-VarinaBlue RidgeKnightdaleWake ForestClaytonNumbers to KnowRaleigh Radiology Locations Blue Ridge 3200 Blue Ridge Road, Suite 100 Raleigh, NC 27612 Cary 150 Parkway Office Court, Suite 100 Cary, NC 27518 Clayton 11618 US 70 Business Clayton, NC 27520 Fuquay-Varina 601 Attain Street, Suite 100 Fuquay-Varina, NC 27526 Knightdale 1101 Great Falls Court, Suite 100 Knightdale, NC 27545 Oberlin 505 Oberlin Road, Suite 110 Raleigh, NC 27605 Wake Forest 11640 Northpark Drive, Suite 110 Wake Forest, NC 27587 Adult (phone) (fax) and Vascular Center (phone) (fax)Pediatric (phone) (fax)24/7 Radiologist Hotline Consult | 3 Breast Imaging & DEXABody PartCPT CodeReason for ExamIV w/ Contrast?

2 Procedure Required to PrecertBreast77049 Newly Diagnosed CancerPersonal History of BCBRCA 1 or 2 GeneHigh Risk ScreeningImplant Integrity, RuptureEvaluate Response to ChemoDense BreastsPalpable Lump w/Abnormal US or Mammographic FindingsYe sMRI Breast Bilateral W/ and W/O77048Ye sUnilateral W/ and W/OBreast MRIP rocedureCPT CodeNotesScreening mammography , 3D770633D mammography ScreeningScreening mammography , 2D770672D mammography ScreeningDiagnostic mammography , 3D, Bilateral or UnilateralG02793D MammographyDiagnostic mammography ; 2D, Bilateral770662D MammographyDiagnostic mammography ; 2D, Unilateral770652D MammographyMammographyProcedureCPT CodeNotesAspiration of Cyst of Breast19000 Breast Biopsy; Stereotactic Guidance19081 Breast Biopsy; ultrasound Guidance19083 BiopsiesProcedureCPT CodeNotesBone Densitometry With Vertebral Fracture Assessment77085 Bone Densitometry Without Vertebral Fracture Assessment77080 Bone Density (DEXA)ProcedureCPT CodeNotesBreast, Unilateral - Limited76642 Breast Ultrasound4 | 2021 Body PartCPT CodeReason for ExamIV w/ Contrast?

3 Procedure Required to PrecertBrain(Cranium only)70450 TraumaHeadachesC VAStroke, BleedAlzheimer sMemory Loss, ConfusionFacial DroopLoss of BalanceShunt CheckHydrocephalusTIAC hange in Mental StatusDizziness, VertigoSyncopeTinnitusNoCT Head W/O70470 Mass, TumorInfection, AbscessMeningiomaMetastatic StagingHIVYe sCT Head W/O & W(MR Brain may be preferred if patient is able)Orbits70480 TraumaFractureForeign BodyBony AbnormalitiesNoCT Orbits W/O70481 Graves DiseaseMass, SwellingPainAbscessCellulitisYe sCT Orbits w/ contrastSinus70486 SinusitisMassPainForeign BodyCongestionNasal PolypsDeviated SeptumSinus HeadacheNoCT Sinus W/OFace(From above frontal sinuses through mandible)70486 TraumaPainFractureBony AbnormalitiesNoCT Maxillofacial W/O70487 TumorSwelling, Mass in FaceInfectionAbscessYe sCT Maxillofacial W/ ContrastTemporal Bones/Mastoids70480 Congenital Hearing LossTinnitusTraumaCholesteatomaTinnitusM ass in EarNoCT Temporal Bones W/ONeck(From above frontal sinus through the aortic arch)70491 Focal MassLymphadenopathyLymphomaDysphagiaGoit erEsophageal CancerYe sCT Soft Tissue Neck W/70490 Salivary Gland StoneNoCT Soft Tissue Neck W/OCT Head & NeckHead & Neck2021 | 5 Body PartCPT CodeReason for ExamIV w/ Contrast?

4 Procedure Required to PrecertCTA Head70496 AneurysmAV MalformationStenosisOcclusionThrombosisD issectionCongenital AbnormalitiesVascular InjuryPre-Op Evaluation for Tumor Blood SupplyYe sCTA Head W/ and W/OCTA Neck70498 AneurysmAV MalformationStenosisOcclusionThrombosisD issectionCongenital AbnormalitiesVascular InjuryPre-Op Evaluation for Tumor Blood SupplyPost-Op Carotid Endarterectomy, Post Carotid StentingYe sCTA Neck W/ and W/OCTA Chest71275 Pulmonary EmbolismChest PainAneurysmShortness of BreathAortic DissectionYe sCTA Chest W/ and W/OCTA Abdomen(From Lung Bases to Iliac Crest)74175 Abdominal Aortic AneurysmRenal Artery StenosisTraumaAbnormal USPost Stent GraftingMesenteric IschemiaYe sCTA Abdomen W/ and W/OCTA Abdomen and Pelvis(From Lung Bases to Pubis)74174 Abdominal Aortic AneurysmRenal Artery StenosisDissectionTraumaAbnormal USPost Stent GraftingMesenteric IschemiaYe sCTA Abdomen and Pelvis W and W/OCT AngiographyC TABody PartCPT CodeReason for ExamIV w/ Contrast?

5 Procedure Required to PrecertFrom Diaphragm to Toes75635 Occlusion of VesselsAbsence of PulseVascular AssessmentPeripheral Artery DiseaseYe sCTA, Abdominal Aorta and Bilateral Iliofemoral Lower Extremity Runoff. (NOTE: Some indications may be better visualized with MRI or US)CTA Runoff: Abdomen & Bilateral Lower Extremities6 | 2021 Body PartCPT CodeReason for ExamIV w/ Contrast?Procedure Required to PrecertLiver74170 Liver CancerCirrhosisHepatitisHemachromatosisH epatomaJaundiceYe sCT Abdomen W/ and W/OPancreas74160 Pancreatic lesionYe sCT Abdomen W/Renal Stone74176 HematuriaFlank PainUrinary FrequencyRenal StoneDysuriaRetroperitoneal BleedNoCT Abdomen and Pelvis W/ORenal74170 Renal Mass Work-UpComplex Renal CystAbnormal USHematuriaYe sCT Abdomen W/ and W/OCT Urogram(Urinary System)(Kidneys to Bladder)

6 74178 HematuriaAbnormal CystogramBladder MassYe sCT Abdomen and Pelvis W/ and W/OAdrenal74170 Adrenal MassYe sCT AbdomenContrast as Medically Indicated(A CT Abdomen W/ may be added at the discretion of the radiologist in cases where mass measurement result from the W/O scan are abnormal)Abdominal OrgansCT Abdominal Organs2021 | 7 Body PartCPT CodeReason for ExamIV w/ Contrast?Procedure Required to PrecertGeneral Chest71260 Abnormal CXRP neumonia, CoughHemoptysisSarcoidosisHilar AbnormalityHx Cancer, Tumor, Mets, Chest PainTraumaNeoplasm, MassAbscessEnlarged Aortic ArchLymphadenopathyAsbestos or Asbestos ExposureShortness of Breath (not concerned for PE)Ye sCT Chest W/71275*If ruling out PE, use CTA ChestYe sCTA Chest71250 Lung Nodule follow-upBony AbnormalityRib Fractures, TraumaChronic CoughNoCT Chest W/OHi-Resolution Chest71250 Interstitial DiseaseFibrosisBronchiectasisCOPD, EmphysemaAsbestos ExposureNoCT Chest W/OLung Screening7127150-80 years old with 20+ pack/year smoking historyAsbestos Exposure or Obstructive Airway DiseasePatients with Smoking History and Additional Risk Factors such as radon gas exposure, certain occupational exposure, COPD, and Pulmonary FibrosisNoCT Lung ScreeningBody PartCPT CodeReason for ExamIV w/ Contrast?

7 Procedure Required to PrecertAbdomen: General(From Lung Bases to Iliac Crest)74160 Abdominal PainAbnormal USNeoplasm, MassWeight LossHernia TraumaElevated LFTP ancreatitisYe sCT Abdomen W/Abdomen & Pelvis: General(Lung bases to Pubis)74177 Mass, Abdominal PainPelvic PainAppendicitisLymphomaNausea, Vomiting, DiarrheaBloody StoolsDiverticulitisDiverticulosisAbnorm al USNeoplasmFever, Elevated WBCW eight LossHernia, TraumaConstipation, ObstructionIBD, MetastasisAll Cancer Staging except melanoma or carcinoidYe sCT Abdomen and Pelvis W/Pelvis: General(Iliac Crest to Pubis)72193 Pelvic Pain, Groin PainAbnormal Pelvic USPelvic Mass, AbscessHernia, TraumaAdnexal MassInfection, CellulitisYe sCT Pelvis W/CT Abd/PelvisEnterography74177 Crohn s Disease orsuspected Crohn s DiseaseSmall Bowel TumorsGI Bleeding (chronic)Ye sCT Abdomen and Pelvis W/CT Chest, Abdomen and PelvisChestAbdomen & Pelvis8 | 2021 Body PartCPT CodeReason for ExamIV w/ Contrast?

8 Procedure Required to PrecertUpper Extremities: Hand, Wrist, Elbow, Radius, Ulna, Humerus, Shoulder7320073700 PainArthritisFractureFusionMalunionNoCT W/O Upper ExtremityCT W/O Lower ExtremityLower Extremities: Foot, Ankle, Knee, Hip, Tibia, Fibula, Femur7320173701 InfectionTumor, Mass, Cancer, Mets(MRI is more sensitive)Ye sCT W/ Upper ExtremityCT W/ Lower ExtremityBody PartCPT CodeReason for ExamIV w/ Contrast?Procedure Required to PrecertSpine721257212872131 PainTraumaPre or Post SurgeryFractureFusionNoCT W/O CervicalCT W/O ThoracicCT W/O Lumbar721267212972132 InfectionTumor, Mass, Cancer, Mets(MRI is more sensitive)Disc DegenerationYe sCT W/ CervicalCT W/ ThoracicCT W/ LumbarBody PartCPT CodeReason for ExamIV w/ Contrast?

9 Procedure Required to PrecertPelvis/Hips (Bony)Acetabulum72192 PainFractureArthritisBone LesionsNoCT Pelvis W/OExtremitiesSpinePelvisCT Extremities, Spine, Pelvis2021 | 9 ProcedureCPT CodeNotesBarium Swallow74220 Chest, With Fluoroscopy 76000 Colon, Barium Enema; With Air Contrast74280 Colon, Barium Enema; Without Air Contrast74270 Cystography74430 Hysterosalpinogram (HSG) 74740 & 58435 IVP (Intravenous Pyelogram)74400 Small Bowel Study, Single Contrast74250 Upper GI; Single Contrast With/Without KUB74240 Upper GI; Double Contrast With/Without KUB74246 Upper GI, single contrast, w/ Small Bowel Follow Through74248 & 74240 Fluoroscopy10 | 2021 ProcedureCPT CodeNotesArthrocentesis, Aspiration and/or Injection; MAJOR Joint/Bursa (Shoulder, Hip, Knee)20610 Specify exact body part/joint(s) to be aspiratedArthrocentesis, Aspiration and/or Injection; MAJOR Joint/Bursa, ultrasound Guidance (Shoulder, Hip, Knee)20611 Specify exact body part/joint(s) to be aspiratedArthrocentesis, Aspiration and/or Injection; MEDIUM Joint/Bursa (Hand, Wrist, Elbow, Foot, Ankle)20605 Specify exact body part/joint(s) to be aspiratedArthrocentesis, Aspiration and/or Injection.

10 SMALL Joint/Bursa (Fingers, Toes)20600 Specify exact body part/joint(s) to be aspiratedAspiration and/or Injection of Baker's Cyst or Ganglion Cyst(s)20612 Thyroid Fine Needle Aspiration10022CT Guided Epidural Steriod Injection; Lumbar or Sacral62323 Specify spinal level(s) to be injectedCT Guided Epidural Steriod Injection; Cervical or Thoracic62321 Specify spinal level(s) to be injectedCT Guided Facet Injection; Cervical or Thoracic64490 Specify spinal level(s) to be injectedCT Guided Facet Injection; Lumbar or Sacral64493 Specify spinal level(s) to be injectedTendon/Ligament Sheath Injection20551 Injections & Biopsies2021 | 11 Body PartCPT CodeReason for ExamIV w/ Contrast?Procedure Required to PrecertBrain70551 Alzheimer sMental Status ChangeConfusionDementiaMemory LossSuspected MSStroke, CVATIAT raumaDizziness, Vertigo (CVA)HeadachesNoMRI Brain W/O70553 Tumor, Mass, CancerCranial Nerve LesionsHIVI nfectionMultiple SclerosisNeurofibromatosisHearing Loss, IAC MassPituitary LesionAcoustic NeuromaSyrinxVisual ChangeVascular Lesion (AVM)Elevated ProlactinVertigo, Dizziness (IAC)Bell s PalsyYe sMRI Brain W/ and W/OMRV Brain70544 Venous ThrombosisNoMRV W/OOrbits(includes whole brain plus thin cuts through the orbits)70540 TraumaNoMRI Orbits, Face, Neck W/O70543 Graves DiseaseExophthalmos, ProptosisVascular Lesions (Hemangioma)