gt modifier codes2011 - azahcccs.gov€¦ · attachment a- codes with gt modifier procedure...

Attachment A- Codes with GT modifier

Procedure Description

37766 - STAB PHLEBECTOMY OF VARICOSE VEINS, ONE EXTREMITY; MORE THAN 20 INCISIONS

90801 - PSYCHIATRIC DIAGNOSTIC INTERVIEW EXAMINATION

90804 - INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE

90805 - INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR





90810 - INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, L90811 - INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, 90812 - INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, 90813 - INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, 90814 - INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, 90815 - INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, 90816 - INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE



90817 GT

90818 GT

90815 GT

90816 GT

90813 GT

90814 GT

90811 GT

90812 GT

90809 GT

90810 GT

90807 GT

90808 GT

90805 GT

90806 GT

90801 GT

90804 GT

Procedure Code

Procedure Modifier

37766 GT


Procedure DescriptionProcedure Code

Procedure Modifier




90845 - PSYCHOANALYSIS

90846 - FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT PRESENT)

90847 - FAMILY PSYCHOTHERAPY (CONJOINT PSYCHOTHERAPY) (WITH PATIENT PRESENT)

90862 - PHARMACOLOGIC MANAGEMENT, INCLUDING PRESCRIPTION, USE, AND REVIEW OF MEDICATION 90882 - ENVIRONMENTAL INTERVENTION FOR MEDICAL MANAGEMENT PURPOSES ON A PSYCHIATRIC

90887 - INTERPRETATION OR EXPLANATION OF RESULTS OF PSYCHIATRIC, OTHER MEDICAL

93018 - CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREADMILL OR BICYCLE 93303 - TRANSTHORACIC ECHOCARDIOGRAPHY FOR CONGENIAL CARDIAC ANOMALIES; COMPLETE

93306 - Echocardiography, transthoracic real-time with image documentation (2D), includi

93307 - ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUD93320 - DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND/OR CONTINUOUS WAVE WITH SPECTRAL 93321 - DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND/OR CONTINUOUS WAVE WITH SPECTRAL 93325 - DOPPLER ECHOCARDIOGRAPHY COLOR FLOW VELOCITY MAPPING (LIST SEPARATELY IN

93351 - Echocardiography, transthoracic, real-time with image documentation (2D), with o93351 GT

93321 GT

93325 GT

93307 GT

93320 GT

93303 GT

93306 GT

90887 GT

93018 GT

90862 GT

90882 GT

90846 GT

90847 GT

90822 GT

90845 GT

90819 GT

90821 GT



Procedure Modifier

93352 - Use of echocardiographic contrast agent during stress echocardiography (List sep

94774 - PEDIATRIC HOME APNEA MONITORING EVENT RECORDING INCLUDING RESPIRATORY RATE, PATT96100 - PSYCHOLOGICAL TESTING (INCLUDES PSYCHODIAGNOSTIC ASSESSMENT OF PERSONALITY, PSYC96101 - PSYCHOLOGICAL TESTING (INCLUDES PSYCHODIAGNOSTIC ASSESSMENT OF EMOTIONALITY, INT96102 - PSYCHOLOGICAL TESTING (INCLUDES PSYCHODIAGNOSTIC ASSESSMENT OF EMOTIONALITY, INT96103 - PSYCHOLOGICAL TESTING (INCLUDES PSYCHODIAGNOSTIC ASSESSMENT OF EMOTIONALITY, INT96115 - NEUROBEHAVIORAL STATUS EXAM (CLINICAL ASSESSMENT OF THINKING, REASONING AND 96116 - NEUROBEHAVIORAL STATUS EXAM (CLINICAL ASSESSMENT OF THINKING, REASONING AND JUDG96118 - NEUROPSYCHOLOGICAL TESTING (EG, HALSTEAD-REITAN NEUROPSYCHOLOGICAL BATTERY, WECH96119 - NEUROPSYCHOLOGICAL TESTING (EG, HALSTEAD-REITAN NEUROPSYCHOLOGICAL BATTERY, WECH96120 - NEUROPSYCHOLOGICAL TESTING (EG, WISCONSIN CARD SORTING TEST), ADMINISTERED BY A 96125 - STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG, ROSS INFORMATION PROCESSING ASSE96153 - HEALTH AND BEHAVIOR INTERVENTION, EACH 15 MINUTES, FACE-TO-FACE; GROUP (2 OR 96154 - HEALTH AND BEHAVIOR INTERVENTION, EACH 15 MINUTES, FACE-TO-FACE; FAMILY (WITH 97802 - MEDICAL NUTRITION THERAPY; INITIAL ASSESSMENT AND INTERVENTION, INDIVIDUAL, FACE

97803 - MEDICAL NUTRITION THERAPY; RE-ASSESSMENT AND INTERVENTION, INDIVIDUAL,

97804 - MEDICAL NUTRITION THERAPY; GROUP (2 OR MORE INDIVIDUAL(S)), EACH 30 MINUTES

97803 GT

97804 GT

96154 GT

97802 GT

96125 GT

96153 GT

96119 GT

96120 GT

96116 GT

96118 GT

96103 GT

96115 GT

96101 GT

96102 GT

94774 GT

96100 GT

93352 GT



Procedure Modifier

99201 - OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATI99202 - OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW 99203 - OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW 99204 - OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW 99205 - OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW 99211 - OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLI99212 - OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN 99213 - OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN 99214 - OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN 99215 - OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN 99231 - SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIEN99232 - SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A 99233 - SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A 99241 - OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE THREE99242 - OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE 99243 - OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE 99244 - OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE

99244 GT

99242 GT

99243 GT

99233 GT

99241 GT

99231 GT

99232 GT

99214 GT

99215 GT

99212 GT

99213 GT

99205 GT

99211 GT

99203 GT

99204 GT

99201 GT

99202 GT



Procedure Modifier

99245 - OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE 99251 - INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE TH99252 - INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE TH99253 - INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE TH99254 - INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE TH99255 - INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE TH99261 - FOLLOW-UP INPATIENT CONSULTATION FOR AN ESTABLISHED PATIENT, WHICH REQUIRES AT L99262 - FOLLOW-UP INPATIENT CONSULTATION FOR AN ESTABLISHED PATIENT WHICH REQUIRES AT 99263 - FOLLOW-UP INPATIENT CONSULTATION FOR AN ESTABLISHED PATIENT WHICH REQUIRES AT 99271 - CONFIRMATORY CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE99272 - CONFIRMATORY CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES 99273 - CONFIRMATORY CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES 99274 - CONFIRMATORY CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES 99275 - CONFIRMATORY CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES 99307 - SUBSEQUENT NURSING FACILITY CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF 99308 - SUBSEQUENT NURSING FACILITY CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF 99309 - SUBSEQUENT NURSING FACILITY CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF

99308 GT

99309 GT

99275 GT

99307 GT

99273 GT

99274 GT

99271 GT

99272 GT

99262 GT

99263 GT

99255 GT

99261 GT

99253 GT

99254 GT

99251 GT

99252 GT

99245 GT



Procedure Modifier

99310 - SUBSEQUENT NURSING FACILITY CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF 99321 - DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIEN99354 - PROLONGED PHYSICIAN SERVICE IN THE OFFICE OR OTHER OUTPATIENT SETTING REQUIRING 99355 - EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PROLONGED PH99358 - PROLONGED EVALUATION AND MANAGEMENT SERVICE BEFORE AND/ OR AFTER DIRECT (FACE-TO99359 - PROLONGED EVALUATION AND MANAGEMENT SERVICE BEFORE AND/ OR AFTER DIRECT (FACE-TO99361 - MEDICAL CONFERENCE BY A PHYSICIAN WITH INTERDISCIPLINARY TEAM OF HEALTH PROFESSI99362 - MEDICAL CONFERENCE BY A PHYSICIAN WITH INTERDISCIPLINARY TEAM OF HEALTH G0108 - DIABETES OUTPATIENT SELF-MANAGEMENT TRAINING SERVICES, INDIVIDUAL, PER 30 G0109 - DIABETES OUTPATIENT SELF-MANAGEMENT TRAINING SERVICES, GROUP SESSION (2 OR G0308 - END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT, G0309 - END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT G0311 - END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT, G0312 - END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT,

G0314 - END STAGE RENAL DISEASE (ESRD) RELATED SERVICES, DURING THE COURSE OF

G0315 - END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT, G0317 - END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT,

G0317 GT

G0314 GT

G0315 GT

G0311 GT

G0312 GT

G0308 GT

G0309 GT

G0108 GT

G0109 GT

99361 GT

99362 GT

99358 GT

99359 GT

99354 GT

99355 GT

99310 GT

99321 GT



Procedure Modifier

G0318 - END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT, G0420 - FACE-TO-FACE EDUCATIONAL SERVICES RELATED TO THE CARE OF CHRONIC KIDNEY DISEASE;G0421 - FACE-TO-FACE EDUCATIONAL SERVICES RELATED TO THE CARE OF CHRONIC KIDNEY DISEASE;G0425 - INITIAL INPATIENT TELEHEALTH CONSULTATION, TYPICALLY 30 MINUTES COMMUNICATING WIG0426 - INITIAL INPATIENT TELEHEALTH CONSULTATION, TYPICALLY 50 MINUTES COMMUNICATING WIG0427 - INITIAL INPATIENT TELEHEALTH CONSULTATION, TYPICALLY 70 MINUTES OR MORE COMMUNICG0428 - COLLAGEN MENISCUS IMPLANT PROC FOR FILING MEMISCAL DEFECTS (E.G. CMI, COLLAGEN SG0429 - DERMAL FILLER INJECTIONS(S) FOR THE TREATMENT OF FACIAL LIPODYSTROPHY SYNDROME H0002 - BEHAVIORAL HEALTH SCREENING TO DETERMINE ELIGIBILITY FOR ADMISSION TO TREATMENT

H0004 - BEHAVIORAL HEALTH COUNSELING AND THERAPY, PER 15 MINUTES (GROUP)

H0031 - MENTAL HEALTH ASSESSMENT, BY NON-PHYSICIAN

H0034 - MEDICATION TRAINING AND SUPPORT, PER 15 MINUTES

H2000 - COMPREHENSIVE MULTIDISCIPLINARY EVALUATION

S0215 - NON-EMERGENCY TRANSPORTATION; MILEAGE, PER MILE

S0625 - RETINAL TELESCREENING BY DIGITAL IMAGING

T1016 - CASE MANAGEMENT, EACH 15 MINUTES T1016 GT

S0215 GT

S0625 GT

H0034 GT

H2000 GT

H0004 GT

H0031 GT

G0429 GT

H0002 GT

G0427 GT

G0428 GT

G0425 GT

G0426 GT

G0420 GT

G0421 GT

G0318 GT

Attachment A-Codes with the GQ modifier 1/20/11

Procedure Description

90804 - INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE






90862 - PHARMACOLOGIC MANAGEMENT, INCLUDING PRESCRIPTION, USE, AND REVIEW OF MEDICATION 93228 - EXTERNAL MOBILE CARDIOVASCULAR TELEMETRY WITH ELECTROCARDIOGRAPHIC RECORDING, CO93229 - EXTERNAL MOBILE CARDIOVASCULAR TELEMETRY WITH ELECTROCARDIOGRAPHIC RECORDING, CO94774 - PEDIATRIC HOME APNEA MONITORING EVENT RECORDING INCLUDING RESPIRATORY RATE, PATT94776 - PEDIATRIC HOME APNEA MONITORING EVENT RECORDING INCLUDING RESPIRATORY RATE, PATT96116 - NEUROBEHAVIORAL STATUS EXAM (CLINICAL ASSESSMENT OF THINKING, REASONING AND JUDG96153 - HEALTH AND BEHAVIOR INTERVENTION, EACH 15 MINUTES, FACE-TO-FACE; GROUP (2 OR 96154 - HEALTH AND BEHAVIOR INTERVENTION, EACH 15 MINUTES, FACE-TO-FACE; FAMILY (WITH

97804 - MEDICAL NUTRITION THERAPY; GROUP (2 OR MORE INDIVIDUAL(S)), EACH 30 MINUTES

99201 - OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATI99202 - OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW 99203 - OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW

99203 GQ

99201 GQ

99202 GQ

96154 GQ

97804 GQ

96116 GQ

96153 GQ

94774 GQ

94776 GQ

93228 GQ

93229 GQ

90809 GQ

90862 GQ

90807 GQ

90808 GQ

90805 GQ

90806 GQ

Procedure Code

Procedure Modifier

90804 GQ



Procedure Modifier

99204 - OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW 99205 - OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW 99211 - OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLI99212 - OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN 99213 - OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN 99214 - OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN 99215 - OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN 99231 - SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIEN99232 - SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A 99233 - SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A 99241 - OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE THREE99242 - OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE 99243 - OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE 99244 - OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE 99245 - OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE 99251 - INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE TH99252 - INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE TH99253 - INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE TH

99253 GQ

99251 GQ

99252 GQ

99244 GQ

99245 GQ

99242 GQ

99243 GQ

99233 GQ

99241 GQ

99231 GQ

99232 GQ

99214 GQ

99215 GQ

99212 GQ

99213 GQ

99205 GQ

99211 GQ

99204 GQ



Procedure Modifier

99254 - INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE TH99255 - INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE TH99307 - SUBSEQUENT NURSING FACILITY CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF 99308 - SUBSEQUENT NURSING FACILITY CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF 99309 - SUBSEQUENT NURSING FACILITY CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF 99310 - SUBSEQUENT NURSING FACILITY CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF G0108 - DIABETES OUTPATIENT SELF-MANAGEMENT TRAINING SERVICES, INDIVIDUAL, PER 30 G0109 - DIABETES OUTPATIENT SELF-MANAGEMENT TRAINING SERVICES, GROUP SESSION (2 OR G0308 - END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT, G0309 - END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT G0311 - END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT, G0312 - END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT,

G0314 - END STAGE RENAL DISEASE (ESRD) RELATED SERVICES, DURING THE COURSE OF

G0315 - END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT, G0317 - END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT, G0318 - END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT, G0347 - INTRAVENOUS INFUSION, FOR THERAPEUTIC/DIAGNOSTIC (SPECIFY SUBSTANCE OR DRUG); G0420 - FACE-TO-FACE EDUCATIONAL SERVICES RELATED TO THE CARE OF CHRONIC KIDNEY DISEASE;

G0420 GQ

G0318 GQ

G0347 GQ

G0315 GQ

G0317 GQ

G0312 GQ

G0314 GQ

G0309 GQ

G0311 GQ

G0109 GQ

G0308 GQ

99310 GQ

G0108 GQ

99308 GQ

99309 GQ

99255 GQ

99307 GQ

99254 GQ



Procedure Modifier

G0421 - FACE-TO-FACE EDUCATIONAL SERVICES RELATED TO THE CARE OF CHRONIC KIDNEY DISEASE;G0425 - INITIAL INPATIENT TELEHEALTH CONSULTATION, TYPICALLY 30 MINUTES COMMUNICATING WIG0426 - INITIAL INPATIENT TELEHEALTH CONSULTATION, TYPICALLY 50 MINUTES COMMUNICATING WIG0427 - INITIAL INPATIENT TELEHEALTH CONSULTATION, TYPICALLY 70 MINUTES OR MORE COMMUNICG0428 - COLLAGEN MENISCUS IMPLANT PROC FOR FILING MEMISCAL DEFECTS (E.G. CMI, COLLAGEN SG0429 - DERMAL FILLER INJECTIONS(S) FOR THE TREATMENT OF FACIAL LIPODYSTROPHY SYNDROME

H0004 - BEHAVIORAL HEALTH COUNSELING AND THERAPY, PER 15 MINUTES (GROUP)

S0215 - NON-EMERGENCY TRANSPORTATION; MILEAGE, PER MILE S0215 GQ

G0429 GQ

H0004 GQ

G0427 GQ

G0428 GQ

G0425 GQ

G0426 GQ

G0421 GQ

AHCCCS TELE-HEALTH TELE-MEDICINE

TELE-COMMUNICATIONS

Radiological Global Services (May be submitted with 26 or TC whichever is appropriate)

70010 Myelography, posterior fossa, radiological supervision and interpretation

26 TC

70015 Cisternography, positive contrast, radiological supervision and interpretation

26 TC

70030 Radiologic examination, eye for detection of foreign body

26 TC

70100 Radiologic examination, mandible; partial, less than 4 views

26 TC

70110 Complete, minimum of 4 views 26 TC

70120 Radiologic examination, mastoids; less than 3 views per side

26 TC

70130 Complete, minimum of 3 views per side 26 TC

70134 Radiologic examination, internal auditory meati, complete

26 TC

70140 Radiologic examination, facial vones; less than 3 views

26 TC

70150 Complete, minimum of 3 views 26 TC

70160 Radiologic examination, nasal vones, complete, minimum of 3 views

26 TC

70170 Dacryocystography, nasolacrimal duct, radiological supervision and interpretation

26 TC

70190 Radiologic examination; optic foramina 26 TC

70200 Orbits, complete, minimum of 4 views 26 TC

70210 Radiologic examination, sinuses, paranasal, complete, minimum of 3 views

26 TC

70220 Radiologic examination, sinuses, paranasal, complete, minimum of 3 views

26 TC

70240 Radiologic examination, sella turcica 26 TC

70250 Radiologic examination, skull; less than 4 views

26 TC

August 2011 1


TELE-COMMUNICATIONS Radiological Global Services 70260 Complete, minimum of 4 views 26

TC

70300 Radiologic examination, teeth; single view

26 TC

70310 Partial examination, less than full mouth 26 TC

70320 Complete, full mouth 26 TC

70328 Radiologic examination, temporomandibular joint, open and closed mouth; unilateral

26 TC

70330 Bilateral 26 TC

70332 Temporomandibular joint arthrography, radiological supervision and interpretation

26 TC

70336 Magnetic resonance (eg proton) imaging, temporomandibular joint(s)

26 TC

70350 Cephalogram, orthodontic 26 TC

70355 Orthopantogram 26 TC

70360 Radiologic examination; neck, soft tissue

26 TC

70370 Pharynx orlarynx, including fluoroscopy and/pr magnification technique

26 TC

70371 Complex dynamic pharyngeal and speech evaluation by cine or video recording

26 TC

70373 Laryngography, contrast, radiological supervision and interpretation

26 TC

70380 Radiologic examination, salivary gland for calculus

26 TC

70390 Sialography, radiological supervision and interpretation

26 TC

70450 Computed tomography, head or brain; without contrast material

26 TC

70460 With contrast material(s) 26 TC

70470 Without contrast material, followed by contrast material(s) and further sections

26 TC

70480 Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material

26 TC

August 2011 2


TELE-COMMUNICATIONS Radiological Global Services 70481 With contrast material(s) 26

TC


26 TC

70486 Computed tomography, maxillofacial area; without contrast material

26 TC



26 TC

70490 Computed tomography, soft tissue neck; without contrast material

26 TC



26 TC

70496 Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing

26 TC

70498 Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing

26 TC

70540 MRI orbit, face and or neck; without contrast material(s)

26 TC


70543 Without contrast material, followed by contrast material(s) and further sequences

26 TC

70544 Magnetic resonance angiography, head; withour contrast material(s)

26 TC



26 TC

70547 Magnetic resonance angiography, neck; without contrast material(s)

26 TC



26 TC

August 2011 3


TELE-COMMUNICATIONS Radiological Global Services 70551 Magnetic resonance (eg, proton)

imaging, brain (including brain stem); without contrast material

26 TC



26 TC

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

26 TC

70555 Requiring physician or psychologist administration of entire neurofunctional testing

26 TC

70557 MRI, brain (including brain stem an skull base), during open intracranial procedure (eg, to assess for residual tumor or residual vascular malformation); without contrast material

26 TC



26 TC

71010 Radiologic examination, chest; single view, frontal

26 TC

71015 Stereo, frontal 26 TC

71020 Radiologic examination, chest, 2 views, frontal and lateral;

26 TC

71022 With oblique projections 26 TC

71023 With fluoroscopy 26 TC

71030 Radiologic examination, chest, complete, minimum of 4 views;

26 TC

71034 With fluoroscopy 26 TC

71035 Radiologic examination, chest, special views (eg, lateral decubitus, Bucky studies)

26 TC

71040 Bronchography, unilateral, radiological supervision and interpretation

26 TC

August 2011 4


TELE-COMMUNICATIONS Radiological Global Services 71060 Bronchography, bilateral, radiological

supervision and interpretation 26 TC

71090 Insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation

26 TC

71100 Radiologic examination, ribs, unilateral; 2 views

26 TC

71101 including posteroanterior chest, minimum of 3 views

26 TC

71110 Radiologic examination, ribs, bilateral; 3 views

26 TC

71111 including posteroanterior chest, minimum of 4 views

26 TC

71120 Radiologic examination; sternum, minimum of 2 views

26 TC

71130 sternoclavicular joint or joints, minimum of 3 views

26 TC

71250 Computed tomography, thorax; without contrast material

26 TC

71260 with contrast material(s) 26 TC

71270 without contrast material, follows by contrast material(s) and further sections

26 TC

71275 Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing

26 TC

71550 Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s)

26 TC


71552 without contrast material(s), followed by contrast material(s) and further sequences

26 TC

71555 Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s)

26 TC

72010 Radiologic examination, spine, entire, survey study, anteroposterior and lateral

26 TC

72020 Radiologic examination, spine, single view, specify level

26 TC

August 2011 5


TELE-COMMUNICATIONS Radiological Global Services 72040 Radiologic examination, spine, cervical;

2 or 3 views 26 TC

72050 minimum of 4 views 26 TC

72052 complete, including oblique and flexion and/or extension studies

26 TC

72069 Radiologic examination, spine, thoracolumbar, standing (scoliosis)

26 TC

72070 Radiologic examination, spine; thoracic, 2 views

26 TC

72072 thoracic, 3 views 26 TC

72074 thoracic, minimum 4 views 26 TC

72080 thoracolumbar, 2 views 26 TC

72090 scoliosis study, including supine and erect studies

26 TC

72100 Radiologic examination, spine, lumbosacral; 2 or 3 views

26 TC


72114 complete, including bending views 26 TC

72120 Radiologic examination, spine, lumbosacral, bending views only, minimum of 4 views

26 TC

72125 Computed tomography, cervical spine; without contrast material

26 TC

72126 with contrast material 26 TC


26 TC

72128 Computed tomography, thoracic spine; without contrast material

26 TC


72130 without contrast material, followed by contrast material(s) and further sections

26 TC

72131 Computed tomography, lumbar spine; without contrast material

26 TC



26 TC

August 2011 6


TELE-COMMUNICATIONS Radiological Global Services 72141 Magnetic resonance (eg. Proton)

imaging, spinal canal and contents, cervical; without contrast material

26 TC


72146 Magnetic resonance (eg. Proton) imaging, spinal canal and contents, thoracic; without contrast material

26 TC


72148 Magnetic resonance (eg. Proton) imaging, spinal canal and contents, lumbar; without contrast material

26 TC


72156 Magnetic resonance (eg. Proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical

26 TC

72157 thoracic 26 TC

72158 lumbar 26 TC

72159 Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s)

26 TC

72170 Radiologic examination, pelvis; 1 or 2 views

26 TC

72190 complete, minimum of 3 views 26 TC

72191 Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing

26 TC

72192 Computed tomography, pelvis; without contrast material

26 TC



26 TC

72195 Magnetic resonance (eg. Proton) imaging, pelvis; without contrast material(s)

26 TC

August 2011 7


TELE-COMMUNICATIONS Radiological Global Services 72196 with contrast material(s) 26

TC


26 TC

72198 Magnetic resonance angiography, pelvis, with or without contrast material(s)

26 TC

72200 Radiologic examination, sacroiliac joints; less than 3 views

26 TC

72202 3 or more views 26 TC

72220 Radiologic examination, sacrum and coccyx, minimum of 2 views

26 TC

72240 Myelography, cervical, radiological supervision and interpretation

26 TC

72255 Myelography, thoracic, radiological supervision and interpretation

26 TC

72265 Myelography, lumbosacral, radiological supervision and interpretation

26 TC

72270 Myelography, 2 or more regions (eg. lumbar/thoracic, cervical/thoracic, lumbar/cervical, lumbar/thoracic/cervical), radiological supervision and interpretation

26 TC

72275 Epidurography, radiological supervision and interpretation

26 TC

72285 Discography, cervical or thoracic, radiological supervision and interpretation

26 TC

72291 Radiological supervision and interpretation, percutaneous vertebroplasty, vertebral augmentation, or sacral augmentation (sacroplasty), including cavity creation, per vertebral body or sacrum; under fluoroscopic guidance

26 TC

72292 under CT guidance 26 TC

72295 Discography, lumbar, radiological supervision and interpretation

26 TC

73000 Radiologic examination; clavicle, complete

26 TC

73010 scapula, complete 26 TC

August 2011 8


TELE-COMMUNICATIONS Radiological Global Services 73020 Radiologic examination, shoulder; 1

view 26 TC


73040 Radiologic examination, shoulder, arthrography, radiological supervision and interpretation

26 TC

73050 Radiologic examination; acromioclavicular joints, bilateral, with or without weighted distraction

26 TC

73060 Humerus, minimum of 2 views 26 TC

73070 Radiologic examination, elbow; 2 views 26 TC


73085 Radiologic examination, elbow, arthrography, radiological supervision and interpretation

26 TC

73090 Radiologic examination; forearm, 2 views

26 TC

73092 upper extremity, infant, minimum of 2 views

26 TC

73100 Radiologic examination, wrist; 2 views 26 TC


73115 Radiologic examination, wrist, arthrography, radiological supervision and interpretation

26 TC

73120 Radiologic examination, hand; 2 views 26 TC


73140 Radiologic examination, finger(s), minimum of 2 views

26 TC

73200 Computed tomography, upper extremity; without contrast material

26 TC

73201 with contract material(s) 26 TC


26 TC

August 2011 9


TELE-COMMUNICATIONS Radiological Global Services 73206 Computed tomographic angiography,

upper extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing

26 TC

73218 Magnetic resonance (eg. Proton) imaging, upper extremity, other than joint; without contrast material(s)

26 TC



26 TC

73221 Magnetic resonance (eg. proton) imaging, any joint of upper extremity; without contrast material(s)

26 TC



26 TC

73225 Magnetic resonance angiography, upper extremity, with or without contrast material(s)

26 TC

73500 Radiologic examination, hip, unilateral; 1 view

26 TC


73520 Radiologic examination, hips, bilateral, minimum of 2 views of each hip, inhcluding anteroposterior view of pelvis

26 TC

73525 Radiologic examination, hip, arthrography, radiological supervision and interpretation

26 TC

73542 X-ray exam, sacroiliac joint 26 TC

73540 Radiologic examination, pelvis and hips, infant or child

26 TC

73542 Radiological examination, sacroiliac joint arthrography, radiological supervision and interpretation

26 TC

73550 Radiologic examination, femur, 2 views 26 TC

August 2011 10


TELE-COMMUNICATIONS Radiological Global Services 73560 Radiologic examination, knee; 1 or 2

views 26 TC

73562 3 views 26 TC

73564 complete, 4 or more views 26 TC

73565 both knees, standing, anteroposterior 26 TC

73580 Radiologic examination, knee, arthrography, radiological supervision and interpretation

26 TC

73590 Radiologic examination; tibia and fibula, 2 views

26 TC

73592 lower extremity, infant, minimum of 2 views

26 TC

73600 Radiologic examination, ankle; 2 views 26 TC


73615 Radiologic examination, ankle, arthrography, radiological supervision and interpretation

26 TC

73620 Radiologic examination, foot; 2 views 26 TC

73630 complete, minimum of views 26 TC

73650 Radiologic examination; calcaneus, minimum of 2 views

26 TC

73660 toe(s), minimum of 2 views 26 TC

73700 Computed tomography, lower extremity; without contrast material

26 TC



26 TC

73706 Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing

26 TC

73718 Magnetic resonance (eg. proton) imaging, lower extremity other than joint; without contrast material(s)

26 TC

August 2011 11


TELE-COMMUNICATIONS Radiological Global Services 73719 with contrast material(s) 26

TC


26 TC

73721 Magnetic resonance (eg. proton) imaging, any joint of lower extremity; without contrast material

26 TC



26 TC

73725 Magnetic resonance angiography, lower extremity, with or without contrast material(s)

26 TC

74000 Radiologic examination, abdoment; single anteroposterior view

26 TC

74010 anteroposterior and additional oblique and cone views

26 TC

74020 complete, including decubitus and/or erect views

26 TC

74022 Complete acute abdomen series, including supine, erect, and/or decubitus views, single view chest

26 TC

74150 Computed tomography, abdomen; without contrast material

26 TC


74170 without contrast material, followed by contrast material(s) and further sectionds

26 TC

74175 Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing

26 TC

74176 Computed tomography, abdomen and pelvis; without contrast material

26 TC


74178 without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions

26 TC

August 2011 12


TELE-COMMUNICATIONS Radiological Global Services 74181 Magnetic resonance (eg. proton)

imaging, abdomen; without contrast material(s)

26 TC


74183 without contrast material(s), followed by with contrast material(s) and further sequences

26 TC

74185 Magnetic resonance angiography, abdomen, with or without contrast material(s)

26 TC

74190 Peritoneogram (eg. after injection of air or contrast), radiological supervision and interpretation

26 TC

74210 Radiologic examination; pharynx and/or cervical esophagus

26 TC

74220 esophagus 26 TC

74230 Swallowing function, with cineradiography/videoradiography

26 TC

74235 Removal of foreign body(s), esophageal, with use of balloon catheter, radiological supervision and interpretation

26 TC

74240 Radiologic examination, gastrointestinal tract, upper; with or without delayed films, without KUB

26 TC

74241 with or without delayed films, with KUB

26 TC

74245 with small intestine, includes multiple serial films

26 TC

74246 Radiological examination, gastrointestinal tract, upper, air contrast, with specific high density barium, effervescent agent, with or without glucagon; with or without delayed films, without KUB

26 TC

74247 with or without delayed films, with KUB

26 TC

74249 with small intestine follow-through 26 TC

74250 Radiologic examination, small intestine, includes multiple serial films;

26 TC

74251 via enteroclysis tube 26 TC

August 2011 13


TELE-COMMUNICATIONS Radiological Global Services 74260 Duodenography, hypotonic 26

TC

74261 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material

26 TC

74262 with contrast material(s) including non-contrast images, if performed

26 TC

74263 Computed tomographic (CT) colonography, screening, including image postprocessing

26 TC

74270 Radiologic examination, colon; contrast (eg. barium) enema, with or without KUB

26 TC

74280 air contrast with specific high density barium, with or without glucagon

26 TC

74283 Therapeutic enema, contrast or air, for reduction of intussusception or other intraluminal obstruction (eg. meconium ileus)

26 TC

74290 Cholecystography, oral contrast; 26 TC

74291 additional or repeat examination or multiple day examination

26 TC

74300 Cholangiography and/or pancreatography; intraoperative, radiological supervision and interpretation

26 TC

+74301 additional set intraoperative, radiological supervision and interpretation (List separately in addition to code for primary procedure)

26 TC

74305 through existing catheter, radiological supervision and interpretation

26 TC

74320 Cholangiography, percutaneous, transhepatic, radiological supervision and interpretation

26 TC

74327 Postoperative biliary duct calculus removal, percutaneous via T-tube tract, basket, or snare (eg. Burhenne technique), radiological supervision and interpretation

26 TC

74328 Endoscopic catheterization of the biliary ductal system, radiological supervision and interpretation

26 TC

August 2011 14


TELE-COMMUNICATIONS Radiological Global Services 74329 Endoscopic catheterization of the

pancreatic ductal system, radiological supervision and interpretation

26 TC

74330 Combined endoscopic catheterization of the biliary and pancreatic ductal systems, radiological supervision and interpretation

26 TC

74340 Introduction of long gastrointestinal tube (eg. Miller-Abbott), including multiple fluoroscopies and films, radiological supervision and interpretation

26 TC

74355 Percutaneous placement of enteroclysis tube, radiological supervision and interpretation

26 TC

74360 Intraluminal dilation of strictures and/or obstructions (eg. esophagus), radiological supervision and interpretation

26 TC

74363 Percutaneous transhepatic dilation of biliary duct, stricture with or without placement of stent, radiological supervision and interpretation

26 TC

74400 Urography (pyelography), intravenous, with or without KUB, with or without tomography

26 TC

74410 Urography, infusion, drip technique and/or bolus technique;

26 TC

74415 with nephrotomography 26 TC

74420 Urography, retrograde, with or without KUB

26 TC

74425 Urography, antegrade (pyelostogram, nephrostogram, loopogram), radiological supervision and interpretation

26 TC

74430 Cystography, minimum of 3 views, radiological supervision and interpretation

26 TC

74440 Vasagraphy, vesiculography, or epididymography, radiological supervision and interpretation

26 TC

74445 Corpora cavenosography, radiological supervision and interpretation

26 TC

August 2011 15


TELE-COMMUNICATIONS Radiological Global Services 74450 Urethrocystography, retrograde,

radiological supervision and interpretation

26 TC

74455 Urethrocystography, voiding, radiological supervision and interpretation

26 TC

74470 Radiologic examination, renal cyst study, translumbar, contrast visualization, radiological supervision and interpretaton

26 TC

74475 Introduction of intracatheter or catheter into renal pelvis for drainage and/or injection, percutaneous, radiological supervision and interpretation

26 TC

74480 Introduction of ureteral catheter or stent into ureter through renal pelvis for drainage and/or injection, percutaneous, radiological supervision and interpretation

26 TC

74485 Dilation of nephrostomy, ureters, or urethra, radiological supervision and interpretation

26 TC

74710 Pelvimetry, with or without placental localization

26 TC

74740 Hysterosalpingography, radiological supervision and interpretation

26 TC

74742 Transcervical catheterization of fallopian tube, radiological supervision and interpretation

26 TC

74775 Perineogram (eg. vaginogram, for sex determination or extent of anomalies)

26 TC

75553 Heart mri for morph w/dye 26 TC

75557 Cardiac magnetic resonance imaging for morphology and function without contrast material;

26 TC

75559 with stress imaging 26 TC

75561 Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences;

26 TC

75563 with stress imaging 26 TC

August 2011 16


TELE-COMMUNICATIONS Radiological Global Services +75565 Cardiac magnetic resonance imaging for

velocity flow mapping (List separately in addition to code for primary procedure)

26 TC

75571 Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium

26 TC

75572 Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed)

26 TC

75573 Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, assessment of LV cardiac function, RV structure and function and evaluation of venous structures, if performed)

26 TC

75574 Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed)

26 TC

75600 Aortography, thoracic, without serialography, radiological supervision and interpretation

26 TC

75605 Aortography, thoracic, by serialography, radiological supervision and interpretation

26 TC

75625 Aortography, abdominal, by serialography, radiological supervision and interpretation

26 TC

75630 Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision and interpretation

26 TC

August 2011 17


TELE-COMMUNICATIONS Radiological Global Services 75635 Computed tomographic angiography,

abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including noncontrast images, if performed, and image postprocessing

26 TC

75650 Angiography, cervicocerebral, catheter, including vessel origin, radiological supervision and interpretation

26 TC

75658 Angiography, brachial, retrograde, radiological supervision and interpretation

26 TC

75660 Angiography, external carotid, unilateral, selective, radiological supervision and interpretation

26 TC

75662 Angiography, external carotid, bilateral, selective, radiological supervision and interpretation

26 TC

75665 Angiography, carotid, cerebral, unilateral, radiological supervision and interpretation

26 TC

75671 Angiography, carotid, cerebral, bilateral, radiological supervision and interpretation

26 TC

75676 Angiography, carotid, cervical, unilateral, radiological supervision and interpretation

26 TC

75680 Angiography, carotid, cervical, bilateral, radiological supervision and interpretation

26 TC

75685 Angiography, vertebral, cervical, and/or intracranial, radiological supervision and interpretation

26 TC

75705 Angiography, spinal, selective, radiological supervision and interpretation

26 TC

75710 Angiography, extremity, unilateral, radiological supervision and interpretation

26 TC

75716 Angiography, extremity, bilateral, radiological supervision and interpretation

26 TC

75722 Angiography, renal, unilateral, selective (including flush aortogram), radiological supervision and interpretation

26 TC

August 2011 18


TELE-COMMUNICATIONS Radiological Global Services 75724 Angiography, renal, bilateral, selective

(including flush aortogram), radiological supervision and interpretation

26 TC

75726 Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision and interpretation

26 TC

75731 Angiography, adrenal, unilateral, selective, radiological supervision and interpretation

26 TC

75733 Angiography, adrenal, bilateral, selective, radiological supervision and interpretation

26 TC

75736 Angiography, pelvic, selective or supraselective, radiological supervision and interpretation

26 TC

75741 Angiography, pulmonary, unilateral, selective, radiological supervision and interpretation

26 TC

75743 Angiography, pulmonary, bilateral, selective, radiological supervision and interpretation

26 TC

75746 Angiography, pulmonary, by nonselective catheter or venous injection, radiological supervision and interpretation

26 TC

75756 Angiography, internal mammary, radiological supervision and interpretation

26 TC

+ 75774 Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation (List separately in addition to code for primary procedures)

26 TC

75791 Angiography, arteriovenous shunt (eg. dialysis patient fistula/graft), complete evaluation of dialysis access, including fluoroscopy, image documentation and report (includes injections of contrast and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava), radiological supervision and interpretation

26 TC

August 2011 19


TELE-COMMUNICATIONS Radiological Global Services 75801 Lymphangiography, extremity only,

unilateral, radiological supervision and interpretation

26 TC

75803 Lymphangiography, extremity only, bilateral, radiological supervision and interpretation

26 TC

75805 Lymphangiography, pelvic/abdominal, unilateral, radiological supervision and interpretation

26 TC

75807 Lymphangiography, pelvic/abdominal, bilateral, radiological supervision and interpretation

26 TC

75809 Shuntogram for investigation of previously placed indwelling nonvascular shunt (eg. LeVeen shunt, ventriculoperitoneal shunt, indwelling unfusion pump), radiological supervision and interpretation

26 TC

75810 Splenoportography, radiological supervision and interpretation

26 TC

75820 Venography, extremity, unilateral, radiological supervision and interpretation

26 TC

75822 Venography, extremity, bilateral, radiological supervision and interpretation

26 TC

75825 Venography, caval, inferior, with serialography, radiological supervision and interpretation

26 TC

75827 Venography, caval, superior, with serialography, radiological supervision and interpretation

26 TC

75831 Venography, renal, unilateral, selective, radiological supervision and interpretation

26 TC

75833 Venography, renal, bilateral, selective, radiological supervision and interpretation

26 TC

75840 Venography, adrenal, unilateral, selective, radiological supervision and interpretation

26 TC

75842 Venography, adrenal, bilateral, selective, radiological supervision and interpretation

26 TC

August 2011 20


TELE-COMMUNICATIONS Radiological Global Services 75860 Venography, venous sinus (eg. petrosal

and inferior sagittal) or jugular, catheter, radiological supervision and interpretation

26 TC

75870 Venography, superior sagittal sinus, radiological supervision and interpretation

26 TC

75872 Venography, epidural, radiological supervision and interpretation

26 TC

75880 Venography, orbital, radiological supervision and interpretation

26 TC

75885 Percutaneous transhepatic portography with hemodynamic evaluation, radiological supervision and interpretation

26 TC

75887 Percutaneous transhepatic portography without hemodynamic evaluation, radiological supervision and interpretation

26 TC

75889 Hepatic venography, wedged or free, with hemodynamic evaluation, radiological supervision and interpretation

26 TC

75891 Hepatic venography, wedged or free, without hemodynamic evaluation, radiological supervision and interpretation

26 TC

75893 Venous sampling through catheter, with or without angiography (eg. for parathyroid hormone, rennin), radiological supervision and interpretation

26 TC

75894 Transcatheter therapy, embolization, any method, radiological supervision and interpretation

26 TC

75896 Transcatheter therapy, infusion, any method (eg. thrombolysis other than coronary), radiological supervision and interpretation

26 TC

75898 Angiography through existing catheter for follow-up study for transcatheter therapy, embolization or infusion

26 TC

August 2011 21


TELE-COMMUNICATIONS Radiological Global Services 75900 Exchange of a previously placed

intravascular catheter during thrombolytic therapy with contrast monitoring, radiological supervision and interpretation

26 TC

75901 Mechanical removal of pericatheter, obstructive material (eg. fibrin sheath) from central venous device via separate venous access, radiologic supervision and interpretation

26 TC

75902 Mechanical removal of intraluminal (intracatheter) obstructive material from central venous device through device lumen, radiologic supervision and interpretation

26 TC

75940 Percutaneous placement of IVC filter, radiological supervision and interpretation

26 TC

75945 Intravascular ultrasound (non-coronary vessel), radiological supervision and interpretation; initial vessel

26 TC

+ 75946 each additional non-coronary vessel (List separately in addition to code for primary procedure)

26 TC

75952 Endovascular repair of infrarenal abdominal aortic aneurysm or dissection, radiological supervision and interpretation

26 TC

75953 Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal aortic or iliac artery aneurysm, pseudoaneurysm, or dissection, radiological supervision and interpretation

26 TC

75954 Endovascular repair of iliac artery aneurysm, pseudoaneurysm, arteriovenous malformation, or trauma, using ilio-iliac tube endoprosthesis, radiological supervision and interpretation

26 TC

August 2011 22


TELE-COMMUNICATIONS Radiological Global Services 75956 Endovascular repair of descending

thoracic aorta (eg. aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hemotoma, or traumatic disruption); involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension(s), if required, to level of celiac artery origin, radiological supervision and interpretation

26 TC

75957 non involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension(s), if required, to level of celiac artery origin, radiological supervision and interpretation

26 TC

75958 Placement of proximal extension prosthesis for endovascular repair of descending thoracic aorta (eg. aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption), radiological supervision and interpretation

26 TC

75959 Placement of distal extension prosthesis(s) (delayed) after endovascular repair of descending thoracic aorta, as needed, to level of celiac origin, radiological supervision and interpretation

26 TC

75960 Transcatheter introduction of intravascular stent(s) (except coronary, carotid, vertebral, iliac, and lower estremity artery), percutaneous and/or open, radiological supervision and interpretation, each vessel

26 TC

75961 Transcatheter retrieval, percutaneous, of intravascular foreign body (eg. fractured venous or arterial catheter), radiological supervision and interpretation

26 TC

75962 Transluminal balloon angioplasty, peripheral artery other than cervical carotid, renal or other visceral artery, iliac or lower extremity, radiological supervision and interpretation

26 TC

August 2011 23


TELE-COMMUNICATIONS Radiological Global Services 75964 Transluminal balloon angioplasty, each

addit6ional peripheral artery other than cervical carotid, renal or other visceral artery, iliac and lower extremity, radiological supervision and interpretation (List separately in addition to code for primary procedure)

26 TC

75966 Transluminal balloon angioplasty, renal or other visceral artery, radiological supervision and interpretation

26 TC

75968 Transluminal balloon angioplasty, each additional visceral artery, radiological supervision and interpretation (List separately in addition to code for primary procedure)

26 TC

75970 Transcatheter biopsy, radiological supervision and interpretation

26 TC

75978 Transluminal balloon angioplasty, venous (eg. subclavian stenosis), radiological supervision and interpretation

26 TC

75980 Percutaneous transhepatic biliary drainage with contract contrast monitoring, radiological supervision and interpretation

26 TC

75982 Percutaneous placement of drainage catheter for combined internal and external biliary drainage or of a drainage stent for internal biliary drainage in patients with an inoperable mechanical biliary obstruction, radiological supervision and interpretation

26 TC

75984 Change of percutaneous tube or drainage catheter with contrast monitoring (eg. genitourinary system, abscess), radiological supervision and interpretation

26 TC

75989 Radiological guidance (ie, fluoroscopy, ultrasound, or computed tomography), for percutaneous drainage (eg, abscess, specimen collection), with placement of catheter, radiological supervision and interpretation

26 TC

76000 Fluoroscopy (separate procedure), up to 1 hour physician time, other than 71023 or 71034 (eg, cardiac fluoroscopy)

26 TC

August 2011 24


TELE-COMMUNICATIONS Radiological Global Services 76001 Fluoroscopy, physician time more than

1 hour, assisting a nonradiologic physician (eg. nephrostolithotomy, ERCP, bronchoscopy, transbronchial biobsy)

26 TC

76010 Radiologic examination from nose to rectum for foreign body, single view, child

26 TC

76070 Ct bone density, axial 26 TC

76076 Dxa bone density/peripheral 26 TC

76080 Radiologic examination, abscess, fistula or sinus tract study, radiological supervision and interpretation

26 TC

76098 Radiological examination, surgical specimen

26 TC

76100 Radiologic examination, single plane body section (eg. tomography), other than with urography

26 TC

76101 Radiologic examination, complex motion (ie, hypercycloidal) body section (eg. mastoid polytomorgraphy), other than with urography; unilateral

26 TC

76102 Complex body section x-rays 26 TC

76120 Cineradiography/videoradiography, except where specifically included

26 TC

76125 Cineradiography/videoradiography to completion routine examination (List separately in addition to code for primary procedure)

26 TC

76140 Consultation on X-ray examination made elsewhere, written report

26 TC

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

26 TC

76377 requiring image postprocessing on an independent workstation

26 TC

76380 Computed tomography, limited or localized follow-up study

26 TC

August 2011 25


TELE-COMMUNICATIONS Radiological Global Services 76390 Magnetic resonance spectroscopy 26

TC

76496 Unlisted fluoroscopic procedure (eg. diagnostic, interventional)

26 TC

76497 Unlisted computed tomography procedure (eg. diagnostic, interventional)

26 TC

76498 Unlisted magnetic resonance procedure (eg, diagnostic, interventional)

26 TC

76499 Unlisted diagnostic radiographic procedure

26 TC

76506 Echoencephalography, real time with image documentation (gray scale) (for determination of ventricular size, delineation of cerebral contents, and detection of fluid masses or other intracranial abnormalities), including A-mode encephalography as secondary component where indicated

26 TC

76510 Ophthalmic ultrasound, diagnostic; B-scan and quantitative A-scan performed during the same patient encounter

26 TC

76511 quantitative A-scan only 26 TC

76512 B-scan (with or without superimposed non-quantitative A-scan)

26 TC

76513 anterior segment ultrasound, immersion (water bath) B-scan or high resolution biomicroscopy

26 TC

76514 corneal pachymetry, unilateral or bilateral (determination of corneal thickness)

26 TC

76516 Ophthalmic biometry by ultrasound echography, A-scan;

26 TC

76519 with intraocular lens power calculation 26 TC

76529 Ophthalmic ultrasonic foreign body localization

26 TC

76536 Ultrasound, soft tissues of head and neck (eg. thyroid, parathyroid, paratid), real time with image documentation

26 TC

76604 Ultrasound, chest (includes mediastinum), real time with image documentation

26 TC

August 2011 26


TELE-COMMUNICATIONS Radiological Global Services 76645 Ultrasound, breast(s) (unilateral or

bilateral), real time with image documentation

26 TC

76700 Ultrasound, abdominal, real time with image documentation; complete

26 TC

76705 limited (eg, single organ, quadrant, follow-up)

26 TC

76770 Ultrasound, retroperitoneal (eg. renal, aorta, nodes), real time with image documentation; complete

26 TC

76775 limited 26 TC

76776 Ultrasound, transplanted kidney, real time and duplex Doppler with image documentation

26 TC

76801 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (<14 weeks 0 day), transabdominal approach; single or first gestation

26 TC

76802 each additional gestation (List separately in addition to code for primary procedure)

26 TC

76805 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation

26 TC


26 TC

76811 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; sing or first gestation

26 TC


26 TC

76813 Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation

26 TC

August 2011 27


TELE-COMMUNICATIONS Radiological Global Services 76814 each additional gestation (List

separately in addition to code for primary procedure)

26 TC

76815 Ultrasound, pregnant uterus, real time with image documentation, limited (eg. fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses

26 TC

76816 Ultrasound, pregnan6t uterus, real time with image documentation, follow-up (eg. re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus

26 TC

76817 Ultrasound, pregnant uterus, real time with image documentation, transvaginal

26 TC

76818 Fetal biophysical profile; with non-stress test

26 TC

76819 without non-stress testing 26 TC

76820 Doppler velocimetry, fetal; umbilical artery

26 TC

76821 middle cerebral artery 26 TC

76825 Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording);

26 TC

76826 follow-up or repeat study 26 TC

76827 Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; complete

26 TC

76828 follow-up or repeat study 26 TC

76830 Ultrasound, transvaginal 26 TC

76831 Saline infusion sonohysterography (SIS), including color flow Doppler, when performed

26 TC

August 2011 28


TELE-COMMUNICATIONS Radiological Global Services 76856 Ultrasound, pelvic (nonobstetric), real

time with image documentation; complete

26 TC

76857 limited or follow-up (eg, for follicles) 26 TC

76870 Ultrasound, scrotum and contents 26 TC

76872 Ultrasound, transrectal; 26 TC

76873 prostate volume study for brachytherapy treatment planning (separate procedure)

26 TC

76882 limited, anatomic specific 26 TC

76885 Ultrasound, infant hips, real time with imaging documentation; dynamic (requiring physician manipulation)

26 TC

76886 limited, static (not requiring physician manipulation)

26 TC

76930 Ultrasonic guidance for pericardiocentesis, imaging supervision and interpretation

26 TC

76932 Ultrasonic guidance for endomyocardial biopsy, imaging supervision and interpretation

26 TC

76936 Ultrasound guided compression repair of arterial pseudoaneurysm or arteriovenous fistulae (includes diagnostic ultrasound evaluation, compression of lesion and imaging)

26 TC

76937 Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure)

26 TC

76940 Ultrasound guidance for, and monitoring of, parenchymal tissue ablation

26 TC

76941 Ultrasonic guidance for intrauterine fetal transfusion or cordocentesis, imaging supervision and interpretation

26 TC

August 2011 29


TELE-COMMUNICATIONS Radiological Global Services 76942 Ultrasonic guidance for needle

placement (eg. biopsy, aspiration, injection, localization device), imaging supervision and interpretation

26 TC

76945 Ultrasonic guidance for chorionic villus sampling, imaging supervision and interpretation

26 TC

76946 Ultrasonic guidance for amniocentesis, imaging supervision and interpretation

26 TC

76948 Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation

26 TC

76950 Ultrasonic guidance for placement of radiation therapy fields

26 TC

76965 Ultrasonic guidance for interstitial radioelement application

26 TC

76970 Ultrasound study follow-up (specify) 26 TC

76975 Gastrointestinal endoscopic ultrasound, supervision and interpretation

26 TC

76977 Ultrasound bone density measurement and interpretation, peripheral site(s), any method

26 TC

76998 Ultrasonic guidance, intraoperative 26 TC

76999 Unlisted ultrasound procedure (eg, diagnostic, interventional)

26 TC

77001 Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position) (List separately in addition to code for primary procedure)

26 TC

77002 Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device)

26 TC

August 2011 30


TELE-COMMUNICATIONS Radiological Global Services 77003 Fluoroscopic guidance and localization

of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, subarachnoid, or sacroiliac joint), including neurolytic agent destruction

26 TC

77011 Computed tomography guidance for sterotactic localization

26 TC

77012 Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation

26 TC

77013 Computed tomography guidance for, and monitoring of, parenchymal tissue ablation

26 TC

77014 Computed tomography guidance for placement of radiation therapy fields

26 TC

77021 Magnetic resonance guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation

26 TC

77022 Magnetic resonance guidance for, and monitoring of, parenchymal tissue ablation

26 TC

77031 Stereotactic localization guidance for breast biopsy or needle placement (eg, for wire localization or for injection), each lesion, radiological supervision and interpretation

26 TC

77032 Mammographic guidance for needle placement, breast (eg, for wire localization or for injection), each lesion, radiological supervision and interpretation

26 TC

77051 Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; diagnostic mammography (List separately in addition to code for primary procedure)

26 TC

August 2011 31


TELE-COMMUNICATIONS Radiological Global Services 77052 screening mammography (List

separately in addition to code for primary procedure)

26 TC

77053 Mammary ductogram or galactogram, multiple duct, radiological supervision and interpretation

26 TC

77054 Mammary ductogram or galactogram, multiple ducts, radiological supervision and interpretation

26 TC

77055 Mammography, unilateral 26 TC

77056 bilateral 26 TC

77057 Screening mammography, bilateral (2-view film study of each breast)

26 TC

77058 Magnetic resonance imaging, breast, without and/or with contrast material(s); unilateral

26 TC


77071 Manual application of stress performed by physician for joint radiography, including contralateral joint if indicated

26 TC

77072 Bone age studies 26 TC

77073 Bone length studies (orthoroentgenogram, scanogram)

26 TC

77074 Radiologic examination, osseous survey; limited (eg, for metastases)

26 TC

77075 complete (axial and appendicular skeleton)

26 TC

77076 Radiologic examination, osseous survey, infant

26 TC

77077 Joint survey, single view, 2 or more joints (specify)

26 TC

77078 Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine)

26 TC

77079 appendicular skeleton (peripheral) (eg, radius, wrist, heel)

26 TC

77080 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spinie)

26 TC

August 2011 32


TELE-COMMUNICATIONS Radiological Global Services 77081 appendicular skeleton (peripheral) (eg,

radius, wrist, heel) 26 TC

77082 vertebral facture assessment 26 TC

77083 Radiographic absorptiometry (eg, photodensitometry, radiogrammetry), 1 or more sites

26 TC

77084 Magnetic resonance (eg, proton) imaging, bone marrow blood supply

26 TC

Radiation Oncology 77261 Therapeutic radiology treatment planning; simple

26 TC

77262 intermediate 26 TC

77263 complex 26 TC

77280 Therapeutic radiology simulation-aided field setting; simple

26 TC


77290 complex 26 TC

77295 3-dimensional 26 TC

77299 Unlisted procedure, therapeutic radiology clinical treatment planning

26 TC

77300 Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician

26 TC

77301 Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications

26 TC

77305 Teletherapy, isidose plan (whether hand or computer calculated); simple (1 or 2 parallel opposed unmodified ports directed to a single area of interest)

26 TC

77310 intermediate (3 or more treatment ports directed to a single area of interest)

26 TC

August 2011 33


TELE-COMMUNICATIONS Radiation Oncology 77315 complex (mantle or inverted Y,

tangential ports, the use of wedges, compensators, complex blocking, rotational beam, or special beam considerations)

26 TC

77321 Special teletherapy port plan, particles, hemibody, total body

26 TC

77326 Brachytherapy isodose plan; simple (calculation made from single plan, 1 to 4 sources/ribbon application, remote afterloading brachytherapy, 1 to 8 sources)

26 TC

77327 intermediate (multiplane dosage calculations, application involving 5 to 10 sources/ribbons, remote afterloading brachytherapy, 9 to 12 sources)

26 TC

77328 complex (multiplane isodose plan, volume implant calculations, over 10 sources/ribbons used, special spatial reconstruction, remote afterloading brachytherapy, over 12 sourcesP

26 TC

77331 Special dosimetry (eg, TLD, microdosimetry) (specify), only when prescribed by the treating physicial

26 TC

77332 Treatment devices, design and construction; simple (simple block, simple bolus)

26 TC

77333 intermediate (multiple blocks, stents, bite blocks, special bolus)

26 TC

77334 complex (irregular blocks, special shields, compensators, wedges, molds or casts)

26 TC

77336 Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy

26 TC

77338 Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan

26 TC

77370 Special medical radiation physics consultation

26 TC

August 2011 34


TELE-COMMUNICATIONS Radiation Oncology 77371 Radiation treatment delivery, sterotactic

radiosurgey (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based

26 TC

77372 linear accelerator based 26 TC

77373 Sterotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions

26 TC

77399 Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services

26 TC

77401 Radiation treatment delivery, superficial and/or ortho voltage

26 TC

77402 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; up to 5 MeV

26 TC

77403 6-10 MeV 26 TC

77404 11-19 MeV 26 TC

77406 20 MeV or greater 26 TC

77407 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks; up to 5 MeV

26 TC

77408 6-10 MeV 26 TC

77409 11-19 MeV 26 TC

77411 20 MeV or greater 26 TC

77412 Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5 MeV

26 TC

77413 6-10 MeV 26 TC

77414 11-19 MeV 26 TC

August 2011 35


TELE-COMMUNICATIONS Radiation Oncology 77416 20 MeV or greater 26

TC

77417 Therapeutic radiology port film(s) 26 TC

77418 Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session

26 TC

77421 Steroscopic X-ray guidance for localization of target volume for the delivery of radiation therapy

26 TC

77422 High energy meutron radiation treatment delivery; single treatment area using a single port or parallel-opposed ports with no blocks or simple blocking

26 TC

77423 1 or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s)

26 TC

77427 Radiation treatment management, 5 treatments

26 TC

77431 Radiation therapy management with complete course of therapy consisting of 1 or 2 fractions only

26 TC

77432 Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)

26 TC

77435 Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions

26 TC

77470 Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral, endocavitary or intraoperative cone irradiation)

26 TC

77499 Unlisted procedure, therapeutic radiology treatment management

26 TC

77520 Proton treatment delivery; simple, without compensation

26 TC

77522 simple, with compensation 26 TC


August 2011 36


TELE-COMMUNICATIONS Radiology Services 77525 complex 26

TC

77600 Hyperthermia, externally generated; superficial (ie, heating to a depth of 4 cm or less)

26 TC

77605 deep (ie, heating to depths greater than 4 cm)

26 TC

77610 Hyperthermia generated by interstitial probe(s); 5 or few interstitial applicators

26 TC

77615 more than 5 interstitial applicators 26 TC

77620 Hyperthermia generated by intracavitary probe(s)

26 TC

77750 Infusion or instillation of radioelement solution (includes 3-month follow-up care)

26 TC

77761 Intracavitary radiation source application; simple

26 TC


77763 complex 26 TC

77776 Interstitial radiation source application; simple

26 TC


77778 complex 26 TC

77781 High intensity brachytherapy 26 TC

77784 High intensity brachytherapy 26 TC

77785 Remote afterloading high dose rate radionuclide brachytherapy; 1 channel

26 TC

77786 2-12 channels 26 TC

77787 over 12 channels 26 TC

77789 Surface application of radiation source 26 TC

77790 Supervision, handling, loading of radiation source

26 TC

77799 Unlisted procedure, clinical brachytherapy

26 TC

August 2011 37


TELE-COMMUNICATIONS Radiology Services 78000 Thyroid uptake; single determination 26

TC

78001 multiple determinations 26 TC

78003 stimulation, suppression or discharge (not including initial uptake studies)

26 TC

78006 Thyroid imaging, with uptake; single determination

26 TC

78007 multiple determinations 26 TC

78010 Thyroid imaging; only 26 TC

78011 with vascular flow 26 TC

78015 Thyroid carcinoma metastases imaging; limited area (eg, neck and chest only)

26 TC

78016 with additional studies (eg, urinary recovery)

26 TC

78018 whole body 26 TC

78020 Thyroid carcinoma metastases uptake (List separately in addition to code for primary procedure)

26 TC

78070 Parathyroid imaging 26 TC

78075 Adrenal imaging, cortex and/or medulla 26 TC

78099 Unlisted endocrine procedure, diagnostic nuclear medicine

26 TC

78102 Bone marrow imaging, limited area 26 TC

78103 multiple areas 26 TC


78110 Plasma volume, radiopharmaceutical volume-dilution technique (separate procedure); single sampling

26 TC

78111 multiple samplings 26 TC

78120 Red cell volume determination (separate procedure); single sampling

26 TC

78121 multiple samplings 26 TC

August 2011 38


TELE-COMMUNICATIONS Radiology Services 78122 Whole blood volume determination,

including separate measurement of plasma volume and red cell volume (radiopharmaceutical volume-dilution technique)

26 TC

78f130 Red cell survival study; 26 TC

78135 differential organ/tissue kinetics (eg, splenic, and/or hepatic sequestration)

26 TC

78140 Labeled red cell sequestration, differential organ/tissue (eg, splenic and/or hepatic)

26 TC

78185 Spleen imaging only, with or without vascular flow

26 TC

78190 Kinetics, study of platelet survival, with or without differential organ/tissue localization

26 TC

78191 Platelet survival study 26 TC

78195 Lymphatics and lymph nodes imaging 26 TC

78199 Unlisted hematopoietic, reticuloendothelial and lymphatic procedure, diagnostic nuclear medicine

26 TC

78201 Liver imaging; static only 26 TC


78205 Liver imaging (SPECT) 26 TC


78215 Liver and spleen imaging; static only 26 TC


78220 Liver function study with hepatobiliary agents, with serial images

26 TC

78223 Hepatobiliary ductal system imaging, including gallbladder, with or without pharmacologic intervention, with or without quantitative measurement of gallbladder function

26 TC

78230 Salivary gland imaging; 26 TC

August 2011 39


TELE-COMMUNICATIONS Radiology Services 78231 with serial images 26

TC

78232 Salivary gland function study 26 TC

78258 Esophageal motility 26 TC

78261 Gastric mucosa imaging 26 TC

78262 Gastroesophageal reflux study 26 TC

78264 Gastric emptying study 26 TC

78267 Urea breath test, C-14 (isotopic); acquisition for analysis

26 TC

78268 analysis 26 TC

78270 Vitamin B-12 absorption study (eg, Schilling test); without intrinsic factor

26 TC

78271 with intrinsic factor 26 TC

78272 Vitamin B-12 absorption studies combined, with and without intrinsic factor

26 TC

78278 Acute gastrointestinal blood loss imaging

26 TC

78282 Gastrointestinal protein loss 26 TC

78290 Intestine imaging (eg, ectopic gastric mucosa, Meckel’s localization, volvulus)

26 TC

78291 Peritoneal-venous shunt patency test (eg, for LeVeen, Denver shunt)

26 TC

78299 Unlisted gastrointestinal procedure, diagnostic nuclear medicine

26 TC

78300 Bone and/or joint imaging, limited area 26 TC



78315 3 phase study 26 TC

78320 tomographic (SPECT) 26 TC

August 2011 40


TELE-COMMUNICATIONS Radiology Services 78350 Bone density (bone mineral content)

study, 1 or more sites; single photon absorptiometry

26 TC

78351 dual photon absorptiometry, 1 or more sites

26 TC

78399 Unlisted musculoskeletal procedure, diagnostic nuclear medicine

26 TC

78414 Determination of central c-v hemodynamics (non-imaging) (eg, ejection fraction with probe technique) with or without pharmacologic intervention or exercise, single or multiple determination

26 TC

78428 Cardiac shunt detection 26 TC

78445 Non-cardiac vascular flow imaging (ie, angiography, venography)

26 TC

78451 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)

26 TC

78452 multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection

26 TC

78453 Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed(; single study, at rest or stress (exercise or pharmacologic)

26 TC

78454 multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection

26 TC

78456 Acute venous thrombosis imaging, peptide

26 TC

78457 Venous thrombosis imaging, venogram; unilateral

26 TC


August 2011 41


TELE-COMMUNICATIONS Radiology Services 78459 Myocardial imaging, positron emission

tomography (PET), metabolic evaluation

26 TC

78466 Myocardial imaging, infarct avid, planar; qualitative or quantitative

26 TC

78468 with ejection fraction by first pass technique

26 TC

78469 tomographic SPECT with or without quantification

26 TC

78472 Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without additional quantitative processing

26 TC

78473 multiple studies, wall motion study plus ejection fraction, at rest and stress (exercise and/or pharmacologic), with or without additional quantififcation

26 TC

78481 Cardiac blood pool imaging (planar), first pass technique; single study, at rest or with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification

26 TC

78483 multiple studies, at rest and with stress (exercise and/or pharmacologic), wall motion study plus ejection faction, with or without quantification

26 TC

78491 Myocardial imaging, positron emission tomography (PET), perfusion; single study at rest or stress

26 TC

78492 multiple studies at rest and/or stress 26 TC

78494 Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction, with or without quantitative processing

26 TC

78496 Cardiac blood pool imaging, gated equilibrium, single study, at rest, with right ventricular ejection fraction by first Pass technique (List separately in addition to code for primary procedure)

26 TC

78499 Unlisted cardiovascular procedure, diagnostic nuclear medicine

26 TC

August 2011 42


TELE-COMMUNICATIONS Radiology Services 78580 Pulmonary perfusion imaging,

particulate 26 TC

78584 Pulmonary perfusion imaging, particulate, with ventilation; single breath

26 TC

78585 Rebreathing and washout, with or without single breath

26 TC

78586 Pulmonary ventilation imaging, aerosol; single projection

26 TC

78587 multiple projections (eg, anterior, posterior, lateral views)

26 TC

78588 Pulmonary perfusion imaging, particulate, with ventilation imaging, aerosol, 1 or multiple projections

26 TC

78591 Pulmonary ventilation imaging, gaseous, single breath, single projection

26 TC

78593 Pulmonary ventilation imaging, gaseous, with rebreathing and washout with or without single breath; single projection

26 TC

78594 multiple projections (eg, anterior, posterior, lateral views)

26 TC

78596 Pulmonary quantitative differential function (ventilation/perfusion) study

26 TC

78599 Unlisted respiratory procedure, diagnostic nuclear medicine

26 TC

78600 Brain imaging, less than 4 static views 26 TC


78605 Brain imaging, minimum 4 static views; 26 TC


78607 Brain imaging, tomographic (SPECT) 26 TC

78608 Brain imaging, positron emission tomography (PET); metabolic evaluation

26 TC

78608 perfusion evaluation 26 TC

78610 Brain imaging, vascular flow only 26 TC

August 2011 43


TELE-COMMUNICATIONS Radiology Services 78630 Cerebrospinal fluid flow, imaging (not

including introduction of material); cisternography

26 TC

78635 ventriculography 26 TC

78645 shunt evaluation 26 TC


78650 Cerebrospinal fluid leakage detection and localization

26 TC

78660 Radiopharmaceutical dacryocystography

26 TC

78699 Unlisted nervous system procedure, diagnostic nuclear medicine

26 TC

78700 Kidney imaging morphology; 26 TC


78707 with vascular flow and function, single study without pharmacological intervention

26 TC

78708 with vascular flow and function, single study, with pharmacological intervention (eg, angiotensin converting enzyme inhibitor and/or diureticf)

26 TC

78709 with vascular flow and function, multiple studies, with and without pharmacological intervention (eg, angiotensin converting enzyme inhibitor and/or diuretic)

26 TC


78725 Kidney function study, non-imaging radioisotopic study

26 TC

78730 Urinary bladder residual study (List separately in addition to code for primary procedure)

26 TC

78740 Ureteral reflux study (radiopharmaceutical voiding cystogram)

26 TC

78761 Testicular imaging with vascular flow 26 TC

78799 Unlisted genitourinary procedure, diagnostic nuclear medicine

26 TC

August 2011 44


TELE-COMMUNICATIONS Radiology Services 78800 Radiopharmaceutical localization of

tumor or distribution of radiopharmaceutical agent(s); limited area

26 TC


78802 whole body, single day imaging 26 TC


78804 whole body, requiring 2 or more days imaging

26 TC

78805 Radiopharmaceutical localization of inflammatory process; limited area

26 TC



78808 Injection procedure for radiopharmaceutical localization by non-imaging probe study, intravenous (eg, parathyroid adenoma)

26 TC

78811 Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck)

26 TC

78812 skull base to mid-thigh 26 TC


78814 Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck)

26 TC

78815 skull base to mid-thigh 26 TC


78999 Unlisted miscellaneous procedure, diagnostic nuclear medicine

26 TC

79005 Radiopharmaceutical therapy, by oral administration

26 TC

79101 Radiopharmaceutical therapy, by intravenous administration

26 TC

August 2011 45


TELE-COMMUNICATIONS Radiology Services 79200 Radiopharmaceutical therapy, by

intracavitary administration 26 TC

79300 Radiopharmaceutical therapy, by interstitial radioactive colloid administration

26 TC

79403 Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion

26 TC

79440 Radiopharmaceutical therapy, by intra-articular administration

26 TC

79445 Radiopharmaceutical therapy, by intra-arterial particulate administration

26 TC

79999 Radiopharmaceutical therapy, unlisted procedure

26 TC

Pathology 88106 Cytopathology, fluids 26 TC

88112 Cytopath, cell enhance tech 26 TC

88161 Cytopath smear, other source 26 TC

88173 Cytopath eval, fna, report 26 TC

88300 Surgical path, gross 26 TC

88305 Tissue exam by pathologist 26 TC

88311 Decalcify tissue 26 TC

88314 Histochemical stain 26 TC

88323 Microslide consultation 26 TC

88333 Intraop cyto path consult, 1 26 TC

88346 Immunofluorescent study 26 TC

88349 Scanning electron microscopy 26 TC

88358 Analysis, tumor 26 TC

88362 Nerve teasing preparations 26 TC

88368 Insitu hybridization, manual 26 TC

August 2011 46


TELE-COMMUNICATIONS Pathology 88385 Eval molecul probes, 51-250 26

TC

Medical Tests which can be split into professional and technical components

91000 Esophageal intubation 26 TC

91012 Esophagus motility study 26 TC

91030 Acid perfusion of esophagus 26 TC

91037 Esoph imped function test 26 TC

91052 Gastric analysis test 26 TC

91065 Breath hydrogen test 26 TC

91122 Anal pressure record 26 TC

91299 Gastroenterology procedure 26 TC

Ophthalmology 92025 Computerized corneal topography, unilateral or bilateral, with interpretation and report

26 TC

92060 Sensorimotor examination with multiple measurements

26 TC

92065 Orthoptic and/or pleoptic training with continuing medical direction and eval

26 TC

92081 Visual field examination(s) 26 TC

92082 Visual field examination intermediate exam

26 TC

92083 Visual field examination extended examination

26 TC

92135 Opthalmic dx imaging 26 TC

92136 Scanning biometry by partial coherence interferometry

26 TC

92235 Fluorescein angiography with interpretation and report

26 TC

92240 Icg angiography 26 TC

92250 Fundus photography with interpretation and report

26 TC

92270 Electro-oculography 26 TC

August 2011 47


TELE-COMMUNICATIONS 92284 Dark adaptation eye exam 26

TC

92499 Eye service or procedure 26 TC

92543 Caloric vestibular test 26 TC

92546 Sinusoidal rotational test 26 TC

92587 Evoked auditory test 26 TC

Cardiovascular 92979 Intravasc us, heart add-on 26 TC

93278 ECG/signal-averaged 26 TC

93307 Echo exam of heart 26 TC

93314 Echo transesophageal 26 TC

93318 Echo transesophageal intraop 26 TC

93325 Doppler color flow add-on 26 TC

93505 Biopsy of heart lining 26 TC

93511 Left heart catheterization 26 TC

93526 Rt & Lt heart catheters 26 TC

93529 Rt & lt heart catheterization 26 TC

93532 R & l heart cath, congenital 26 TC

93556 Imaging, cardiac cath 26 TC

93571 Heart flow reserve measure 26 TC

93602 Intra-atrial recording 26 TC

93610 Intra-atrial pacing 26 TC

93616 Esophageal recording 26 TC

93620 Electrophysiology evaluation 26 TC

August 2011 48


TELE-COMMUNICATIONS 93623 Stimulation, pacing heart 26

TC

93640 Evaluation heart device 26 TC

93660 Tilt table evaluation 26 TC

93724 Analyze pacemaker system 26 TC

93733 Telephone analy, pacemaker 26 TC

93736 Telephonic analy, pacemaker 26 TC

93742 Analyze ht pace device sngl 26 TC

93745 Set-up cardiovert-defibrill 26 TC

Noninvasive Vascular Diagnostic Studies

93875 Extracranial study 26 TC

93886 Intracranial study 26 TC

93892 Tcd, emboli detect w/o inj 26 TC

93923 Extremity study 26 TC

93926 Lower extremity study 26 TC

93965 Extremity study 26 TC

93975 Vascular study 26 TC

93979 Vascular study 26 TC

93990 Doppler flow testing 26 TC

94070 Evaluation of wheezing 26 TC

94240 Residual lung capacity 26 TC

94350 Lung nitrogen washout curve 26 TC

94375 Respiratory flow volume loop 26 TC

94452 Hast w/report 26 TC

August 2011 49


TELE-COMMUNICATIONS 94621 Pulm stress test/complex 26

TC

94690 Exhaled air analysis 26 TC

94750 Pulmonary compliance study 26 TC

94799 Pulmonary service/procedure 26 TC

Neurology and Neuromuscular Procedures

95807 Sleep study, attended 26 TC

95811 Polysomnography w/cpap 26 TC

95816 EEG, awake and drowsy 26 TC

95824 EEG, cerebral death only 26 TC

95860 Muscle test, one limb 26 TC

95864 Muscle test, 4 limbs 26 TC

95867 Muscle test cran nerv unilat 26 TC

95870 Muscle test, nonparaspinal 26 TC

95874 Guide nerve destr, needle emg 26 TC

95903 Motor nerve conduction test 26 TC

95921 Autonomic nerve function test 26 TC

95925 Somatosensory testing 26 TC

95928 C motor evoked, upper limbs 26 TC

95933 Blink reflex test 26 TC

95937 Neuromuscular junction test 26 TC

95953 EEG monitoring/computer 26 TC

95956 EEG monitoring, cable/radio 26 TC

95961 Electrode stimulation, brain 26 TC

August 2011 50


TELE-COMMUNICATIONS

August 2011 51

95966 Meg, evoked, single 26 TC

gt modifier codes2011 - azahcccs.gov€¦ · attachment a- codes with gt modifier procedure...

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