Download Contrast Policy Update 080210 - Horizon Blue Cross Blue Shield

Horizon Blue Cross and Blue Shield of New Jersey
Title: Contrast Media for Diagnostic Imaging
Section:
Owner:
Reimbursement
Radiology/Specialty Contracting
Effective Date:
Revision Dates:
9/7/2009
8/2/2010
Distribution:
Supersedes:
Next Review Date:
Policy # 047
Purpose:
This publication serves as clarification to the policy presented on March 25, 2009. This policy provides
guidelines for the reimbursement of contrast agents used with X-rays (including but not limited to fluoroscopy
and interventional procedures), CT, CTA, CCTA, MRI, MRA and Ultrasound/Echocardiography when billed by
participating and nonparticipating providers.
Products:
This policy is applicable to both Insured and ASO accounts for all products, with the exception of the
following:
•
•
•
•
•
•
COB, when Horizon BCBSNJ is secondary (which includes secondary to Traditional Medicare claims).
Federal Employee Program (FEP).
ITS Home.
ITS Host Medicare Advantage.
Horizon NJ Health.
Medigap.
Policy:
This policy describes Horizon BCBSNJ’s reimbursement policy for contrast materials for both office and facility
(Hospital, Ambulatory Surgery Center and Skilled Nursing Facility) settings. This policy is applicable to the
codes listed below and applies to the code globally. Horizon BCBSNJ will not provide reimbursement to a
physician or other health care professional for contrast materials submitted with HCPCS codes with an office
or facility place of service.
All codes are subject to quarterly and yearly updates as dictated by the HCPCS and AMA CPT reference
source.
Attachment A: Imaging CPT Code List
Attachment B: Contrast Code List
Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:
•
•
•
•
Group benefit.
Provider contract.
Routine claim editing logic, including but not limited to incidental or mutually exclusive logic and
medical necessity.
Mandated or legislative required criteria will always supersede.
Procedure:
Deny claim lines containing contrast materials listed in Attachment B, submitted with an office or facility place
of service.
1
Attachment A – Imaging CPT Code List:
Code Code Description
Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula);
initial access with complete radiological evaluation of dialysis access, including fluoroscopy,
image documentation and report (includes access of shunt, injection[s] of contrast, and all necessary
imaging from the arterial anastomosis and adjacent artery through entire venous outflow, including
36147 the inferior or superior vena cava)
Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); additional
36148 access for therapeutic intervention (List separately in addition to code for primary procedure)
70010 Myelography, posterior fossa, radiological supervision and interpretation
70015 Cisternography, positive contrast, radiological supervision and interpretation
70170 Dacryocystography, nasolacrimal duct, radiological supervision and interpretation
70332 Temporomandibular joint arthrography, radiological supervision and interpretation
70336 Magnetic resonance (e.g., proton) imaging, temporomandibular joint(s)
70370 Radiologic examination; pharynx or larynx, including fluoroscopy and/or magnification technique
70373 Laryngography, contrast, radiological supervision and interpretation
70460 Computed tomography, head or brain; with contrast material(s)
Computed tomography, head or brain; without contrast material, followed by contrast material(s)
70470 and further sections
Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast
70481 material(s)
Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast
70482 material, followed by contrast material(s) and further sections
70487 Computed tomography, maxillofacial area; with contrast material(s)
Computed tomography, maxillofacial area; without contrast material, followed by contrast material(s)
70488 and further sections
70491 Computed tomography, soft tissue neck; with contrast material(s)
Computed tomography, soft tissue neck; without contrast material followed by contrast material(s)
70492 and further sections
Computed tomographic angiography, head, with contrast material(s), including noncontrast images,
70496 if performed, and image postprocessing
Computed tomographic angiography, neck, with contrast material(s), including noncontrast images,
70498 if performed, and image postprocessing
70542 Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; with contrast material(s)
Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s),
70543 followed by contrast material(s) and further sequences
2
Code Code Description
70545 Magnetic resonance angiography, head; with contrast material(s)
Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s)
70546 and further sequences
70548 Magnetic resonance angiography, neck; with contrast material(s)
Magnetic resonance angiography, neck; without contrast material(s), followed by contrast material(s)
70549 and further sequences
70552 Magnetic resonance (e.g., proton) imaging, brain (including brain stem); with contrast material(s)
Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material,
70553 followed by contrast material(s) and further sequences
Magnetic resonance imaging, brain, functional MRI; including test selection and administration of
repetitive body part movement and/or visual stimulation, not requiring physician or psychologist
70554 administration
Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration
70555 of entire neurofunctional testing
Magnetic resonance (e.g., proton) imaging, brain (including brain stem and skull base), during open
intracranial procedure (e.g., to assess for residual tumor or residual vascular malformation); with
70558 contrast material(s)
Magnetic resonance (e.g., proton) imaging, brain (including brain stem and skull base), during open
intracranial procedure (e.g., to assess for residual tumor or residual vascular malformation); without
70559 contrast material(s), followed by contrast material(s) a
71040 Bronchography, unilateral, radiological supervision and interpretation
71060 Bronchography, bilateral, radiological supervision and interpretation
71090 Insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation
71260 Computed tomography, thorax; with contrast material(s)
Computed tomography, thorax; without contrast material, followed by contrast material(s) and further
71270 sections
Computed tomographic angiography, chest (noncoronary), with contrast material(s), including
71275 noncontrast images, if performed, and image postprocessing
Magnetic resonance (e.g., proton) imaging, chest (e.g., for evaluation of hilar and mediastinal
71551 lymphadenopathy); with contrast material(s)
Magnetic resonance (e.g., proton) imaging, chest (e.g., for evaluation of hilar and mediastinal
71552 lymphadenopathy); without contrast material(s), followed by contrast material(s) and further sequences
71555 Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s)
72126 Computed tomography, cervical spine; with contrast material
3
Code Code Description
Computed tomography, cervical spine; without contrast material, followed by contrast material(s) and
72127 further sections
72129 Computed tomography, thoracic spine; with contrast material
Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and
72130 further sections
72132 Computed tomography, lumbar spine; with contrast material
Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and
72133 further sections
Magnetic resonance (e.g., proton) imaging, spinal canal and contents, cervical; with contrast
72142 material(s)
Magnetic resonance (e.g., proton) imaging, spinal canal and contents, thoracic; with contrast
72147 material(s)
72149 Magnetic resonance (e.g., proton) imaging, spinal canal and contents, lumbar; with contrast material(s)
Magnetic resonance (e.g., proton) imaging, spinal canal and contents, without contrast material,
72156 followed by contrast material(s) and further sequences; cervical
Magnetic resonance (e.g., proton) imaging, spinal canal and contents, without contrast material,
72157 followed by contrast material(s) and further sequences; thoracic
Magnetic resonance (e.g., proton) imaging, spinal canal and contents, without contrast material,
72158 followed by contrast material(s) and further sequences; lumbar
72159 Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s)
Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if
72191 performed, and image postprocessing
72193 Computed tomography, pelvis; with contrast material(s)
Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further
72194 sections
72196 Magnetic resonance (e.g., proton) imaging, pelvis; with contrast material(s)
Magnetic resonance (e.g., proton) imaging, pelvis; without contrast material(s), followed by contrast
72197 material(s) and further sequences
72198 Magnetic resonance angiography, pelvis, with or without contrast material(s)
72240 Myelography, cervical, radiological supervision and interpretation
72255 Myelography, thoracic, radiological supervision and interpretation
72265 Myelography, lumbosacral, radiological supervision and interpretation
Myelography, 2 or more regions (e.g., lumbar/thoracic, cervical/thoracic, lumbar/cervical,
72270 lumbar/thoracic/cervical), radiological supervision and interpretation
72275 Epidurography, radiological supervision and interpretation
72285 Discography, cervical or thoracic, radiological supervision and interpretation
4
Code Code Description
Radiological supervision and interpretation, percutaneous vertebroplasty, vertebral augmentation,
or sacral augmentation (sacroplasty), including cavity creation, per vertebral body or sacrum; under
72291 fluoroscopic guidance
Radiological supervision and interpretation, percutaneous vertebroplasty, vertebral augmentation,
or sacral augmentation (sacroplasty), including cavity creation, per vertebral body or sacrum; under
72292 CT guidance
72295 Discography, lumbar, radiological supervision and interpretation
73040 Radiologic examination, shoulder, arthrography, radiological supervision and interpretation
73085 Radiologic examination, elbow, arthrography, radiological supervision and interpretation
73115 Radiologic examination, wrist, arthrography, radiological supervision and interpretation
73201 Computed tomography, upper extremity; with contrast material(s)
Computed tomography, upper extremity; without contrast material, followed by contrast material(s)
73202 and further sections
Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast
73206 images, if performed, and image postprocessing
73219 Magnetic resonance (e.g., proton) imaging, upper extremity, other than joint; with contrast material(s)
Magnetic resonance (e.g., proton) imaging, upper extremity, other than joint; without contrast
73220 material(s), followed by contrast material(s) and further sequences
73222 Magnetic resonance (e.g., proton) imaging, any joint of upper extremity; with contrast material(s)
Magnetic resonance (e.g., proton) imaging, any joint of upper extremity; without contrast material(s),
73223 followed by contrast material(s) and further sequences
73225 Magnetic resonance angiography, upper extremity, with or without contrast material(s)
73525 Radiologic examination, hip, arthrography, radiological supervision and interpretation
73542 Radiologic examination, sacroiliac joint arthrography, radiological supervision and interpretation
73580 Radiologic examination, knee, arthrography, radiological supervision and interpretation
73615 Radiologic examination, ankle, arthrography, radiological supervision and interpretation
73701 Computed tomography, lower extremity; with contrast material(s)
Computed tomography, lower extremity; without contrast material, followed by contrast material(s)
73702 and further sections
Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast
73706 images, if performed, and image postprocessing
73719 Magnetic resonance (e.g., proton) imaging, lower extremity other than joint; with contrast material(s)
5
Code Code Description
Magnetic resonance (e.g., proton) imaging, lower extremity other than joint; without contrast
73720 material(s), followed by contrast material(s) and further sequences
73722 Magnetic resonance (e.g., proton) imaging, any joint of lower extremity; with contrast material(s)
Magnetic resonance (e.g., proton) imaging, any joint of lower extremity; without contrast material(s),
73723 followed by contrast material(s) and further sequences
73725 Magnetic resonance angiography, lower extremity, with or without contrast material(s)
74160 Computed tomography, abdomen; with contrast material(s)
Computed tomography, abdomen; without contrast material, followed by contrast material(s) and
74170 further sections
Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast
74175 images, if performed, and image postprocessing
74182 Magnetic resonance (e.g., proton) imaging, abdomen; with contrast material(s)
Magnetic resonance (e.g., proton) imaging, abdomen; without contrast material(s), followed by with
74183 contrast material(s) and further sequences
74185 Magnetic resonance angiography, abdomen, with or without contrast material(s)
74190 Peritoneogram (e.g., after injection of air or contrast), radiological supervision and interpretation
74260 Duodenography, hypotonic
Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast
74262 material(s) including non-contrast images, if performed
Therapeutic enema, contrast or air, for reduction of intussusception or other intraluminal obstruction
74283 (e.g., meconium ileus)
Cholangiography and/or pancreatography; through existing catheter, radiological supervision and
74305 interpretation
74320 Cholangiography, percutaneous, transhepatic, radiological supervision and interpretation
74400 Urography (pyelography), intravenous, with or without KUB, with or without tomography
74410 Urography, infusion, drip technique and/or bolus technique;
74415 Urography, infusion, drip technique and/or bolus technique; with nephrotomography
74420 Urography, retrograde, with or without KUB
Urography , antegrade, (pyelostogram, nephrostogram, loopogram), radiological supervision and
74425 interpretation
74430 Cystography, minimum of three views, radiological supervision and interpretation
74440 Vasography, vesiculography, or epididymography, radiological supervision and interpretation
74445 Corpora cavernosography, radiological supervision and interpretation
74450 Urethrocystography, retrograde, radiological supervision and interpretation
6
Code Code Description
74455 Urethrocystography, voiding, radiological supervision and interpretation
Radiologic examination, renal cyst study, translumbar, contrast visualization, radiological supervision
74470 and interpretation
Introduction of ureteral catheter or stent into ureter through renal pelvis for drainage and/or injection,
74480 percutaneous, radiological supervision and interpretation
74740 Hysterosalpingography, radiological supervision and interpretation
74742 Transcervical catheterization of fallopian tube, radiological supervision and interpretation
74775 Perineogram (e.g., vaginogram, for sex determination or extent of anomalies)
Cardiac magnetic resonance imaging for morphology and function without contrast material(s),
75561 followed by contrast material(s) and further sequences;
Cardiac magnetic resonance imaging for morphology and function without contrast material(s),
75563 followed by contrast material(s) and further sequences; with stress imaging
Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for
75565 primary procedure)
Computed tomography, heart, with contrast material, for evaluation of cardiac structure and
morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of
75572 venous structures, if performed)
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
75573 of LV cardiac function, RV structure and function and evaluation of venous structures, if performed)
Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with
contrast material, including 3D image postprocessing (including evaluation of cardiac structure and
75574 morphology, assessment of cardiac function, and evaluation of venous structures, if performed)
75600 Aortography, thoracic, without serialography, radiological supervision and interpretation
75605 Aortography, thoracic, by serialography, radiological supervision and interpretation
75625 Aortography, abdominal, by serialography, radiological supervision and interpretation
Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography,
75630 radiological supervision and interpretation
Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff,
75635 with contrast material(s), including noncontrast images, if performed, and image postprocessing
Angiography, cervicocerebral, catheter, including vessel origin, radiological supervision and
75650 interpretation
75658 Angiography, brachial, retrograde, radiological supervision and interpretation
7
Code Code Description
75660 Angiography, external carotid, unilateral, selective, radiological supervision and interpretation
75662 Angiography, external carotid, bilateral, selective, radiological supervision and interpretation
75665 Angiography, carotid, cerebral, unilateral, radiological supervision and interpretation
75671 Angiography, carotid, cerebral , bilateral, radiological supervision and interpretation
75676 Angiography, carotid, cervical, unilateral, radiological supervision and interpretation
75680 Angiography, carotid, cervical, bilateral, radiological supervision and interpretation
75685 Angiography, vertebral, cervical, and/or intracranial, radiological supervision and interpretation
75705 Angiography, spinal, selective, radiological supervision and interpretation
75710 Angiography, extremity, unilateral, radiological supervision and interpretation
75716 Angiography, extremity, bilateral, radiological supervision and interpretation
Angiography, renal, unilateral, selective (including flush aortogram), radiological supervision and
75722 interpretation
Angiography, renal, bilateral, selective (including flush aortogram), radiological supervision and
75724 interpretation
Angiography, visceral, selective or supraselective, (with or without flush aortogram), radiological
75726 supervision and interpretation
75731 Angiography, adrenal, unilateral, selective, radiological supervision and interpretation
75733 Angiography, adrenal, bilateral, selective, radiological supervision and interpretation
75736 Angiography, pelvic, selective or supraselective, radiological supervision and interpretation
75741 Angiography, pulmonary, unilateral, selective, radiological supervision and interpretation
75743 Angiography, pulmonary, bilateral, selective, radiological supervision and interpretation
Angiography, pulmonary, by nonselective catheter or venous injection, radiological supervision and
75746 interpretation
75756 Angiography, internal mammary, radiological supervision and interpretation
Angiography, selective, each additional vessel studied after basic examination, radiological
75774 supervision and interpretation (List separately in addition to code for primary procedure)
Angiography, arteriovenous shunt (e.g., 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,
75791 including the inferior or superior vena cava), radiological supervision and interpretation
75810 Splenoportography, radiological supervision and interpretation
8
Code Code Description
75820 Venography, extremity, unilateral, radiological supervision and interpretation
75822 Venography, extremity, bilateral, radiological supervision and interpretation
75825 Venography, caval, inferior, with serialography, radiological supervision and interpretation
75827 Venography, caval, superior, with serialography, radiological supervision and interpretation
75831 Venography, renal, unilateral, selective, radiological supervision and interpretation
75833 Venography, renal, bilateral, selective, radiological supervision and interpretation
75840 Venography, adrenal, unilateral, selective, radiological supervision and interpretation
75842 Venography, adrenal, bilateral, selective, radiological supervision and interpretation
Venography, venous sinus (e.g., petrosal and inferior sagittal) or jugular, catheter, radiological
75860 supervision and interpretation
75870 Venography, superior sagittal sinus, radiological supervision and interpretation
75872 Venography, epidural, radiological supervision and interpretation
75880 Venography, orbital, radiological supervision and interpretation
Percutaneous transhepatic portography with hemodynamic evaluation, radiological supervision and
75885 interpretation
Percutaneous transhepatic portography without hemodynamic evaluation, radiological supervision and
75887 interpretation
Hepatic venography, wedged or free, with hemodynamic evaluation, radiological supervision and
75889 interpretation
Hepatic venography, wedged or free, without hemodynamic evaluation, radiological supervision and
75891 interpretation
75894 Transcatheter therapy, embolization, any method, radiological supervision and interpretation
Angiography through existing catheter for follow-up study for transcatheter therapy, embolization or
75898 infusion
Exchange of a previously placed intravascular catheter during thrombolytic therapy with contrast
75900 monitoring, radiological supervision and interpretation
Mechanical removal of pericatheter obstructive material (e.g., fibrin sheath) from central venous device
75901 via separate venous access, radiologic supervision and interpretation
Mechanical removal of intraluminal (intracatheter) obstructive material from central venous device
75902 through device lumen, radiologic supervision and interpretation
75940 Percutaneous placement of IVC filter, radiological supervision and interpretation
Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal aortic or
75953 iliac artery aneurysm, pseudoaneurysm, or dissection, radiological supervision and interpretation
Endovascular repair of iliac artery aneurysm, pseudoaneurysm, arteriovenous malformation, or
75954 trauma, radiological supervision and interpretation
9
Code Code Description
Endovascular repair of descending thoracic aorta (e.g., aneurysm, pseudoaneurysm, dissection,
penetrating ulcer, intramural hematoma, or traumatic disruption); involving coverage of left subclavian
artery origin, initial endoprosthesis plus descending thoracic aortic extension(s), if required, to level of
75956 celiac artery origin, radiological supervision and interpretation.
not 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
75957 interpretation
Placement of proximal extension prosthesis for endovascular repair of descending thoracic aorta
(e.g., aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic
75958 disruption), radiological supervision and interpretation
Placement of distal extension prosthesis(s) (delayed) after endovascular repair of descending thoracic
75959 aorta, as needed, to level of celiac origin, radiological supervision and interpretation
Transcatheter introduction of intravascular stent(s), (except coronary, carotid, and vertebral vessel),
75960 percutaneous and/or open, radiological supervision and interpretation, each vessel
Transcatheter retrieval, percutaneous, of intravascular foreign body (e.g., fractured venous or arterial
75961 catheter), radiological supervision and interpretation
75962 Transluminal balloon angioplasty, peripheral artery, radiological supervision and interpretation
Transluminal balloon angioplasty, each additional peripheral artery, radiological supervision and
75964 interpretation (List separately in addition to code for primary procedure)
Transluminal balloon angioplasty, renal or other visceral artery, radiological supervision and
75966 interpretation
Transluminal balloon angioplasty, venous (e.g., subclavian stenosis), radiological supervision and
75978 interpretation
Percutaneous transhepatic biliary drainage with contrast monitoring, radiological supervision and
75980 interpretation
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
75982 obstruction, radiological supervision and interpretation
Change of percutaneous tube or drainage catheter with contrast monitoring (e.g., genitourinary
75984 system, abscess), radiological supervision and interpretation
75992 Transluminal atherectomy, peripheral artery, radiological supervision and interpretation
75993 Transluminal atherectomy, each additional peripheral artery, radiological supervision and interpretation
75994 Transluminal atherectomy, renal, radiological supervision and interpretation
75995 Transluminal atherectomy, visceral, radiological supervision and interpretation
10
Code Code Description
75996 Transluminal atherectomy, each additional visceral artery, radiological supervision and interpretation
Fluoroscopy, physician time more than 1 hour, assisting a nonradiologic physician
76001 (e.g., nephrostolithotomy, ERCP, bronchoscopy, transbronchial biopsy)
76120 Cineradiography/videoradiography, except where specifically included
76496 Unlisted fluoroscopic procedure (e.g., diagnostic, interventional)
76497 Unlisted computed tomography procedure (e.g., diagnostic, interventional)
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
77001 supervision and interpretation, and radiographic documentation of final catheter position)
77002 Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device)
Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or
therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid, or sacroiliac joint),
77003 including neurolytic agent destruction
77011 Computed tomography guidance for stereotactic localization
Computed tomography guidance for needle placement (e.g., biopsy, aspiration, injection, localization
77012 device), radiological supervision and interpretation
77013 Computerized tomography guidance for, and monitoring of, parenchymal tissue ablation
77014 Computed tomography guidance for placement of radiation therapy fields
Magnetic resonance guidance for needle placement (e.g., for biopsy, needle aspiration, injection,
77021 or placement of localization device) radiological supervision and interpretation
77022 Magnetic resonance guidance for, and monitoring of, parenchymal tissue ablation
77053 Mammary ductogram or galactogram, single duct, radiological supervision and interpretation
77054 Mammary ductogram or galactogram, multiple ducts, radiological supervision and interpretation
77058 Magnetic resonance imaging, breast, without and/or with contrast material(s); unilateral
77059 Magnetic resonance imaging, breast, without and/or with contrast material(s); bilateral
77084 Magnetic resonance (e.g., proton) imaging, bone marrow blood supply
Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode
93308 recording, when performed, follow-up or limited study
Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode
recordingk when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise
93350 and/or pharmacologically induced stress, with interpretataion and report
11
Code Code Description
Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode
recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise
and/or pharmacologically induced stress, with interpretation and report; including performance of
93351 continuous electrocardiographic monitoring, with physician supervision
Use of echocardiographic contrast agent during stress echocardiography (List separately in addition to
93352 code for primary procedure.)
Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery;
93510 percutaneous
93526 Combined right heart catheterization and retrograde left heart catheterization
Imaging supervision, interpretation and report for injection procedure(s) during cardiac catheterization;
93555 ventricular and/or atrial angiography
Imaging supervision, interpretation and report for injection procedure(s) during cardiac catheterization;
pulmonary angiography, aortography, and/or selective coronary angiography including venous bypass
93556 grafts and arterial conduits (whether native or used in bypass)
Renal angiography, nonselective, one or both kidneys, performed at the same time as cardiac
catheterization and/or coronary angiography, includes positioning or placement of any catheter in the
abdominal aorta at or near the origins (ostia) of the renal arteries, injection of dye, flush aortogram,
production of permanent images, and radiologic supervision and interpretation (List separately in
G0275 addition to primary procedure.)
Iliac artery angiography performed at the same time of cardiac catheterization, includes catheter
placement, injection of dye, radiologic supervision and interpretation and production of images (List
G0278 separately in addition to primary procedure.)
Vessel mapping of vessels for hemodialysis access (services for preoperative vessel mapping prior to
creation of hemodialysis access using an autogenous hemodialysis conduit, including arterial inflow
G0365 and venous outflow)
S8042 Magnetic resonance imaging (MRI), low-field
S8085 Injection, iron-based magnetic resonance contrast agent, per ml
12
Attachment B – Contrast Code List (Healthcare Common Procedural Coding System [HCPCS]):
MRI Contrast Agents:
A9576 Injection, gadoteridol, (ProHance multipack)
A9577 Injection, gadobenate dimeglumine (MultiHance)
A9578 Injection, gadobenate dimeglumine (MultiHance multipack)
A9579 Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified
Q9953 Injection, iron-based magnetic resonance contrast agent, per ml
Q9954 Oral magnetic resonance contrast agent, per 100 ml
CT, X-Ray/Interventional Contrast Agents:
Q9951
Q9958
Q9960
Q9961
Q9962
Q9963
Q9964
Q9965
Q9966
Q9967
Low Osmolar Contrast Material, 400 or greater mg/ml iodine concentration, per ml
High Osmolar Contrast Material, up to 149 mg/ml iodine concentration, per ml
High Osmolar Contrast Material, 200-249 mg/ml iodine concentration, per ml
High Osmolar Contrast Material, 250-299 mg/ml iodine concentration, per ml
High Osmolar Contrast Material, 300-349 mg/ml iodine concentration, per ml
High Osmolar Contrast Material, 350-399 mg/ml iodine concentration, per ml
High Osmolar Contrast Material, 400 or greater mg/ml iodine concentration, per ml
Low Osmolar Contrast Material, 100-199 mg/ml iodine concentration. Per ml
Low Osmolar Contrast Material, 200-299 mg/ml iodine concentration, per ml
Low Osmolar Concentration Material. 300-399 mg/ml iodine concentration, per ml
Echocardiography Contrast:
A9700 – Supply of injectable contrast material for use in echocardiography, per study
Definitions
Osmolar contrast
materials
An iodinated based substance, administered intravascularly, intra-articularly or
intrathecally or orally used to enhance the visibility of structures or fluids within the
body during an imaging procedure such as: X-ray (including but not limited to
fluoroscopy and interventional procedures), CT, CTA, CCTA.
Echocardiography
contrast agents
Gas-filled microspheres (micro-bubble contrast agents) injected intravenously to
improve cardiac ultrasound scanning.
Gadolinium
Paramagnetic agent used during magnetic resonance imaging (MRI) and magnetic
resonance angiography (MRA) procedures.
Superparamagnetic
Iron Oxide and
Ultrasmall
Superparamagnetic
Iron Oxide
Iron oxide contrast agents consist of supspended colloids of iron oxide nanoparticles.
These agents are sometimes used for liver tumor enhancement.
13
Mangafodipir
Trisodium
A chelate complex of the paramagnetic metal ion manganese (Mn) and fodipir. MnDPDP is used for the T1 weighted enhancement of MR images and is sometimes used
to improve the detection of lesions of the liver and pancreas. Mn-DPDP can also be
sued in cardiac MRI.
Perflurochemical
Fluorinated organic compounds sometimes used in MRI gastrointestinal imaging as a
negative contrast agent to reduce signal in the intestine.
14