CPT Code Guidelines for X-Ray, CT and MRI

1 CPT code Guidelines for X-Ray, CT and MRI. MRI Head and Neck (soft tissue) CT Head & Neck 70540 MRI Orbit, Face, Neck, Sella w/o 70450 CT Brain w/o Contrast 70543 MRI Orbit, Face, Neck, Sella w/wo 70470 CT Brain w/wo Contrast 70551 MRI Brain w/o 70486 CT Sinus w/o 70553 MRI Brain w/wo 70486 CT Facial Bones w/o Contrast 70553 MRI Brain IAC w/wo 70487 CT Facial Bones with Contrast 70553 MRI Brain Pituitary w/wo 70488 CT Facial Bones w/wo Contrast 70480 CT Orbits w/o Contrast MRI Breast 70481 CT Orbits with Contrast 77059 MRI Bilateral Breast w/wo 70482 CT Orbits w/wo Contrast 70480 CT Temporal Bones w/o Contrast MRI Spine 70481 CT Temporal Bones with Contrast 72141 MRI Cervical Spine w/o 70482 CT Temporal Bones w/wo Contrast 72156 MRI Cervical Spine w/wo 70490

2 CT Soft Tissue Neck w/o Contrast 72146 MRI Thoracic Spine w/o 70491 CT Soft Tissue Neck with Contrast 72157 MRI Thoracic Spine w/wo 70492 CT Soft Tissue Neck w/wo Contrast 72148 MRI Lumbar Spine w/o 72158 MRI Lumbar Spine w/wo CT Chest 72195 MRI Sacrum & Coccyx w/o 71250 CT Chest w/o Contrast 72197 MRI Sacrum & Coccyx w/wo 71260 CT Chest with Contrast 75571 CT Calcium Scoring MRI Upper Extremity 71250 CT Low Dose Lung Screening 73218 MRI Upper Extremity, No Joint, w/o 73220 MRI Upper Extremity, No Joint w/wo CT Extremity (Humerus/Forearm/Hand) 73200 CT Upper Extremity w/o 73221 MRI Upper Extremity Joint w/o (Shoulder/Humerus/Elbow/.)

3 73223 MRI Upper Extremity Joint w/wo Forearm/Wrist/Hand). (Shoulder/Elbow/Wrist) 73700 CT Lower Extremity w/o (Hip/Femur/Knee/Tib/Fib/. MRI Abdomen & Pelvis Ankle/Foot). 74181 MRI Abdomen w/o . 74181 MRCP w/o CT Spine 74183 MRI Abdomen w/wo 72125 Cervical Spine w/o Contrast 74183 MRI Abdomen w/wo Eovist 72128 Thoracic Spine w/o Contrast 72195 MRI Pelvis w/o 72131 Lumbar Spine w/o Contrast 72197 MRI Pelvis w/wo CT Abdomen & Pelvis MRI Lower Extremity 74176 CT Abdomen & Pelvis w/o 73718 MRI Lower Extremity, No Joint, w/o 74177 CT Abdomen & Pelvis with 73720 MRI Lower Extremity, No Joint, w/wo 74178 CT Abdomen & Pelvis w/wo (Femur/Tib/Fib/Foot)

4 74261 Virtual Colonoscopy Diagnostic 73721 MRI Lower Extremity Joint w/o 74263 Virtual Colonoscopy Screening 73723 MRI Lower Extremity Joint w/wo (Hip/Knee/Ankle) CT Angiography 70496 CTA Head w/wo MR Angiography 70496/70498 CTA Carotids w/wo 70544 MRA Head/COW w/o 71275 CTA Chest/Thoracic Aorta w/wo 70546 MRA Head/COW w/wo 71275 CTA Pulmonary Arteries (PE) w/wo 70547 MRA Neck w/o 75572 CTA Cardiac - Lt Atrium &. 70549 MRA Neck w/wo Pulmonary Vein w/wo 74185 MRA Abdomen w/o or w/wo 75574 CTA Coronary Arteries with Calcium Score w/wo 75635 CTA Abdominal Aorta with Runoff w/wo Digital X-Ray Head and Neck 74174 CTA Abdomen & Pelvis w/wo 70110 Mandible Complete 70140 Facial Bones Less than3 views Digital X-Ray Spine 70150 Facial Bones Complete 72040 Cervical Spine 2-3 Views 70160 Nasal Bones Complete 72050 Cervical Spine Complete Digital X-Ray Abdomen 70200 Orbits Complete 4 Views Minimum 72072 Thoracic Spine 3 Views 74000 Abdomen/KUB Single View 70210 Sinus Less than 3 Views 72100 Lumbar

5 2-3 Views 74020 Abdomen 2 View Supine & Erect 70220 Sinus Complete 72110 Lumbar Spine Complete 70250 Skull Less than 4 Views 72114 Lumbar Complete w/Flexion & Extension Digital X-Ray Lower Extremities 70260 Skull Complete 73510 Hip Unilateral 2 Views 70360 Soft Tissue Neck Lateral Digital X-Ray Upper Extremities 73520 Hips Bilateral w/AP Pelvis 73000 Clavicle Unilateral Complete 73540 Hips/Pelvis Infant Digital X-Ray Chest 73030 Shoulder Unilateral Complete 73550 Femur 2 Views 71020 Chest; 2 Views 73050 AC Joints 2 Views 73562 Knee Unilateral Complete 71100 Ribs; Unilateral,2 Views 73060 Humerus 2 Views 73565 Bilateral Standing Knees 71101 Ribs; Bilateral, 3 Views 73080 Elbow Unilateral Complete 73590 Tibia/Fibula 2 Views 71130 Sternoclavicular Joints 73090 Forearm Unilateral 2 Views 73592 Lower Ext.

6 Infant 2 views 73110 Wrist Unilateral Complete 73610 Ankle Unilateral Complete 73130 Hand Unilateral Complete 73630 Foot Unilateral Complete To schedule an appointment Call 623-847-2000. VR 408 - 08/2015. SCHEDULING: (623) 847-2000 FAX: (623) 847-2001. AT-A-GLANCE PET/IR SCHEDULING: (623) 842-5614. INSURANCE PLANS NUCLEAR MEDICINE SCHEDULING: (623) 842-5910. DIGITAL RECORDS/PATIENT REPORTS: (623) 842-5620. IT SUPPORT LINE: (602) 521-6373. Tax ID Number: 200382536 SMIL, EVDI and Valley Radiologists are a liates of Southwest Diagnostic Imaging (SDI). All share the same Tax ID and extensive network of plans.

7 Authorization assistance is available. This At-A-Glance reference is intended to be a guide. For the full list or with questions call (623) 931-1128. AETNA (ALL PRODUCTS) INTEGRATED HEALTH PLAN. ARIZONA FOUNDATION MERITUS (HMO & PPO). BANNER HEALTH NETWORK MULTIPLAN. BEECH STREET OPTUM MEDICAL NETWORK (FORMERLY LIFEPRINT). BCBS AZ (ALL STATES) PPO NEXT. CIGNA (ALL PRODUCTS INCLUDES GREATWEST AND GWH) PRIVATE HEALTHCARE SYSTEM (PHCS). COPPERPOINT (FORMERLY SCF ARIZONA) TECH HEALTH. CORECHOICE THREE RIVERS PROVIDER NETWORK. COVENTRY HEALTH CARE (ALL PRODUCTS) TRICARE/UHC MILITARY & VETERANS SERVICES.

8 FIRST HEALTH UNITED HEALTHCARE (ALL PRODUCTS). GALAXY HEALTH UA HEALTHCARE (ALL PRODUCTS). HEALTH MANAGEMENT NETWORK AMN/RAN/HMN USA MANAGED CARE. HEALTH NET (ALL PRODUCTS) VA (DEPARTMENT OF VETERANS AFFAIRS - INCLUDES TRI-WEST VAPC3). HUMANA (ALL PRODUCTS EXCEPT HMOx) WORKERS COMPENSATION (MOST PLANS). MEDICARE AHCCCS. SDI AND AFFILIATES ARE IN NETWORK WITH A FULL SDI AND AFFILIATES ARE IN NETWORK WITH ALL. RANGE OF TRADITIONAL MEDICARE AND MEDICARE MARICOPA COUNTY AHCCCS PLANS (PLUS RELATED. ADVANTAGE PLANS. MEDICARE ADVANTAGE & ALTCS PLANS). INCLUDING BUT NOT LIMITED TO: INCLUDING BUT NOT LIMITED TO: ARIZONA PRIORITY CARE AHCCCS FFS.

9 BANNER HEALTH NETWORK BRIDGEWAY HEALTH SOLUTIONS. BLUE CROSS ADVANTAGE CARE 1ST. HEALTHCHOICE GENERATIONS EVERCARE (ALTCS PLAN). TRADITIONAL MEDICARE (FFS)/RAILROAD MEDICARE HEALTHCHOICE ARIZONA (EXCEPT ESSENTIALS). MERCYCARE ADVANTAGE INDIAN HEALTH SERVICES. ONECare MARICOPA HEALTH PLAN. PHOENIX ADVANTAGE MERCY CARE PLAN. SECURE HORIZONS/PACIFICARE PHOENIX HEALTH PLAN. UNITED HEALTHCARE AARP Medicare Complete UNITED HEALTHCARE COMMUNITY PLAN (FORMERLY APIPA). Plans we are NOT contracted with: Caremore Health Choice Essential (marketplace plan) Humana Phoenix HMOx (marketplace plan) Scan/Health Care Partners Kaiser Permanente (CA HMO plan) Out of State Medicaid Out of State Medicare Advantage Plans Health Partners SDI Patient Assistance Programs available by calling (602) 521-6203.