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 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

2 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/. 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) 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)

3 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 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

4 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. 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.

5 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. 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.

6 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. 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).

7 INCLUDING BUT NOT LIMITED TO: INCLUDING BUT NOT LIMITED TO: ARIZONA PRIORITY CARE AHCCCS FFS. 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.