ct exam cpt code reference tumor/mets yes body ct abdomen & pelvis: enterography ct abdomen...

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STUDY CPT DESCRIPTION CPT CODE INDICATION FOR EXAM OR STUDY CONTRAST REQUIRED? SPECIALTY CT HEAD CT Head or brain without contrast 70450 Trauma Headaches CVA Stroke/Bleed Alzheimer’s Memory loss/Confusion Shunt check Hydrocephalus TIA Change in mental status Dizziness/Vertigo No Neuro CT Head or brain with and without contrast Note: MRI Brain with/without contrast is preferred. 70470 Metastases/Known cancer HIV Intracranial infection Note: CT can be used if there are contraindications for MRI. Yes Neuro CTA HEAD Circle of Willis CTA Head with and without contrast Note: MRA Brain without contrast is preferred. 70496 Aneurysm 3rd nerve palsy Family history of aneurysm Vascular malformation Note: CT can be used if there are contraindications for MRI. Yes Neuro CT ORBITS CT Orbits/Sella/Posterior Fossa or ear without contrast 70480 Trauma Foreign body Fracture Bony abnormalities No Neuro CT Orbits/Sella/Posterior Fossa or ear with and without contrast 70482 Infection Pain Abscess/Cellulitis Mass/Tumor/Cancer Yes Neuro CT SINUS CT Maxillofacial without contrast 70486 Sinusitis Congestion Mass Nasal polyps Pain Deviated septum Foreign body Sinus headache No Neuro CT FACE From orbits to mandible CT Maxillofacial without contrast 70486 Trauma Fracture Pain Bony abnormality No Neuro CT Maxillofacial with contrast 70487 Tumor Infection Swelling/Mass in face Abscess Yes Neuro CT TEMPORAL BONES/MASTOIDS CT Orbits/Sella/Posterior Fossa or ear without contrast 70480 Conductive hearing loss Drainage in ear Tinnitus (ringing in ears) Mass Cholesteatoma Fracture No Neuro CT Orbits/Sella/Posterior Fossa or ear with and without contrast Note: MRI Brain is usually preferred. 70482 Acoustic neuroma/Sensorineural hearing loss Note: CT can be used if there are contraindications for MRI. As Determined by Radiologist Neuro CT NECK CT Soft tissue neck with contrast 70491 Focal mass Dysphagia Swollen lymph nodes Goiter Lymphoma Esophageal cancer Yes Neuro CT Soft tissue neck with and without contrast 70492 Salivary gland stone As Determined by Radiologist Neuro CTA NECK ARTERIES CT Angiography neck with and without contrast 70498 Carotid stenosis Bruit Stroke/CVA/TIA Abnormal carotid sonogram Yes Neuro CT SPINE CT Cervical without contrast CT Thoracic without contrast CT Lumbar without contrast 72125 72128 72131 Pain Fracture Trauma Post-op/Fusion Degenerative disc disease No Neuro CT ABDOMEN: General CT Abdomen with contrast 74160 Upper abdominal pain Mass RUQ or LUQ pain Unexplained weight loss Abnormal abdominal US Hernia Neoplasm Trauma Yes Body CT ABDOMEN: LIVER CT Abdomen with and without contrast Note: MRI Abdomen may be preferred in some circumstances. Consult the radiologist. 74170 Increased LFTs Hepatoma RUQ pain Hemachromatosis Abnormal abdominal US Hemangioma Jaundice Hepatitis History of liver cancer Cirrhosis Liver transplant Yes Body CT ABDOMEN & PELVIS: General From lung bases to pubis CT Abdomen & Pelvis; with contrast 74177 Generalized abdominal pain/Pelvic pain Mass Unexplained weight loss RLQ or LLQ pain Trauma Appendicitis Rectal bleeding Lymphoma Constipation/Obstruction Nausea/Vomiting/Diarrhea Inflammatory bowel disease Ventral hernia METS Bloody stool Diverticulitis Ovarian cancer staging Diverticulosis Neoplasm Peritoneal infection/Abscess Prostate/Colon cancer staging Abnormal lower abdomen/Pelvic US All cancer staging except melanoma or carcinoid Yes Body CT Abdomen & Pelvis; without contrast 1 or both with contrast 1 or both 74178 Cancer staging for melanoma or carcinoid Yes Body CT PELVIS: Soft Tissue From iliac crest to pubis CT Pelvis with contrast Note: MRI Pelvis is generally preferred for gynecological indications. Consult the radiologist. 72193 LLQ or RLQ Pain Ovarian cancer Pelvic pain Umbilical/Lower ventral hernia Groin pain Trauma Abnormal pelvic US Adnexal mass Pelvic mass Soft tissue mass infection Cellulitis Abscess Tumor/Mets Yes Body CT ABDOMEN & PELVIS: ENTEROGRAPHY CT Abdomen & Pelvis; with contrast 74177 Crohn’s disease Suspected small bowel tumors Mesenteric/Intestinal bleeding Suspected GI bleeding Evaluation of bowel patency Yes Body CT CHEST: General CT Chest with contrast 71260 Abnormal CXR Neoplasm Adenopathy Abscess Pneumonia Pulmonary nodule Cough Enlarged aortic arch Hemoptysis Lung lesion Sarcoidosis Lymphadenopathy Hilar abnormality Asbestos exposure Hx Cancer/Tumor/Mets Shortness of breath Chest pain Abdominal aortic aneurysm Pulmonary embolism Thoracic aneurysm Aortic dissection Chest wall pain/Mass Yes Body CT CHEST: HIGH RESOLUTION CT Chest without contrast, high resolution 71250 Interstitial disease COPD/Emphysema Fibrosis Asbestos exposure Bronchiectasis Lung nodule Hypersensitivity lung disease As Determined by Radiologist Body CT ABDOMEN & PELVIS: RENAL STONE PROTOCOL CT Abdomen & Pelvis without contrast 74176 Hematuria Stone Flank plain Prostatitis Low back pain Dysuria Urinary frequency No Body CT ABDOMEN: TRI-PHASE RENAL CT Abdomen with and without contrast 74170 Hematuria Renal Failure/Mass/Transplant Flank Pain Hypertension Hydronephrosis History of renal cancer Low back pain History of stones Abnormal US Polycystic kidney disease Yes Body CT ABDOMEN & PELVIS: UROGRAM Urinary System, kidneys to bladder CT Abdomen & Pelvis; without contrast 1 or both with contrast 1 or both 74178 Abnormal cystogram History of renal cancer Painless hematuria Abnormal renal US Bladder mass or tumor Suspected renal mass Yes Body CT ABDOMEN: ADRENAL CT Abdomen with and without contrast 74170 Adrenal mass Yes Body CT ANGIOGRAPHY ABDOMEN CT Angiography Abdomen, with contrast including non-contrast images if performed and image post-processing Note: Some indications also require CTA Pelvis to fully evaluate condition. 74175 Renal artery stenosis Trauma Mesenteric ischemia Yes Body CT ANGIOGRAPHY ABDOMEN & PELVIS CT Angiography Abdomen and Pelvis, with contrast including non-contrast images if performed and image post-processing 74174 Dissection Pre-stent grafting Retroperitoneal bleed Abnormal US Abdominal aortic aneurysm (AAA) Yes Body CT ANGIOGRAPHY RUNOFF: ABDOMEN & BILATERAL LOWER EXTREMITIES CT Angiography Abdominal aorta and bilat- eral iliofemoral lower extremity runoff, with contrast including non-contrast images if performed and image post-processing Note: Some indications may be better visualized with MRI or ultrasound. 75635 Claudication Preop for aortoiliac occlusion PVD Vasculitis Pre/post ops for stent grafts Venous thrombosis (not clear on other imaging) Yes Body CT EXTREMITIY: Upper hand, wrist, elbow, radius/ulna, humerus, shoulder, SC joint Lower foot, ankle, knee, hip, tibia/fibula, femur CT Extremity with contrast: Upper Extremity with contrast Lower Extremity with contrast 73201 73701 Infection Tumor/Mass/Cancer/Mets Note: MRI is more sensitive Yes Ortho CT Extremity without contrast Upper Extremity Lower Extremity 73200 73700 Pain Fusion Arthritis Malunion Fracture No Ortho CT PELVIS: BONY HIPS ACETABULUM CT Pelvis without contrast Note: MRI Pelvis may be preferred study in some circumstances. Consult the radiologist. 72192 Pain Arthritis Fracture Bone lesions Cancer/Mets No Ortho CT EXAM CPT CODE REFERENCE Use this reference to quickly determine the correct exam for your patients based on the indications described herein and the CPT for the order. Please include creatinine levels for patients over 60 years or with history of renal failure. If not available, Creatinine levels can be obtained prior to contrasted studies, if needed, at all Wake Radiology locations. Call if you have any questions 919-232-4700.

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STUDY CPT DeSCriPTion CPT CoDe inDiCaTion for exam or STUDY ConTraST

reqUireD? SPeCialTY

CT HeaD CT Head or brain without contrast 70450 TraumaHeadachesCVAStroke/BleedAlzheimer’sMemory loss/Confusion

Shunt checkHydrocephalusTIAChange in mental statusDizziness/Vertigo

No

neuro

CT Head or brain with and without contrastNote: MRI Brain with/without contrast is preferred.

70470 Metastases/Known cancer HIVIntracranial infectionNote: CT can be used if there are contraindications for MRI.

Yesneuro

CTa HeaD Circle of Willis

CTA Head with and without contrastNote: MRA Brain without contrast is preferred.

70496 Aneurysm 3rd nerve palsyFamily history of aneurysm Vascular malformationNote: CT can be used if there are contraindications for MRI.

Yesneuro

CT orbiTS CT Orbits/Sella/Posterior Fossa or ear without contrast

70480 Trauma Foreign bodyFracture Bony abnormalities

No neuro

CT Orbits/Sella/Posterior Fossa or ear with and without contrast

70482 Infection PainAbscess/Cellulitis Mass/Tumor/Cancer

Yesneuro

CT SinUS CT Maxillofacial without contrast 70486 Sinusitis CongestionMass Nasal polypsPain Deviated septumForeign body Sinus headache

No

neuro

CT faCe From orbits to mandible

CT Maxillofacial without contrast 70486 Trauma FracturePain Bony abnormality

Noneuro

CT Maxillofacial with contrast 70487 Tumor InfectionSwelling/Mass in face Abscess

Yesneuro

CT TemPoral boneS/maSToiDS

CT Orbits/Sella/Posterior Fossa or ear without contrast

70480 Conductive hearing loss Drainage in earTinnitus (ringing in ears) MassCholesteatoma Fracture

Noneuro

CT Orbits/Sella/Posterior Fossa or ear with and without contrast Note: MRI Brain is usually preferred.

70482 Acoustic neuroma/Sensorineural hearing lossNote: CT can be used if there are contraindications for MRI.

As Determined by Radiologist neuro

CT neCk CT Soft tissue neck with contrast 70491 Focal mass DysphagiaSwollen lymph nodes GoiterLymphoma Esophageal cancer

Yesneuro

CT Soft tissue neck with and without contrast

70492 Salivary gland stone As Determined by Radiologist neuro

CTa neCk arTerieS

CT Angiography neck with and without contrast

70498 Carotid stenosis BruitStroke/CVA/TIA Abnormal carotid sonogram

Yesneuro

CT SPine CT Cervical without contrastCT Thoracic without contrastCT Lumbar without contrast

721257212872131

Pain FractureTrauma Post-op/FusionDegenerative disc disease

No

neuro

CT abDomen: General

CT Abdomen with contrast 74160 Upper abdominal pain MassRUQ or LUQ pain Unexplained weight lossAbnormal abdominal US HerniaNeoplasm Trauma

Yes

body

CT abDomen: liver

CT Abdomen with and without contrastNote: MRI Abdomen may be preferred in some circumstances. Consult the radiologist.

74170 Increased LFTs HepatomaRUQ pain HemachromatosisAbnormal abdominal US HemangiomaJaundice HepatitisHistory of liver cancer Cirrhosis Liver transplant

Yes

body

CT abDomen & PelviS: GeneralFrom lung bases to pubis

CT Abdomen & Pelvis; with contrast74177

Generalized abdominal pain/Pelvic painMass Unexplained weight lossRLQ or LLQ pain TraumaAppendicitis Rectal bleedingLymphoma Constipation/ObstructionNausea/Vomiting/Diarrhea Inflammatory bowel disease Ventral hernia METSBloody stool Diverticulitis Ovarian cancer staging Diverticulosis Neoplasm Peritoneal infection/AbscessProstate/Colon cancer stagingAbnormal lower abdomen/Pelvic US All cancer staging except melanoma or carcinoid

Yes

body

CT Abdomen & Pelvis;without contrast 1 or bothwith contrast 1 or both

74178Cancer staging for melanoma or carcinoid Yes

body

CT PelviS: Soft Tissue From iliac crest to pubis

CT Pelvis with contrast

Note: MRI Pelvis is generally preferred for gynecological indications. Consult the radiologist.

72193 LLQ or RLQ Pain Ovarian cancerPelvic pain Umbilical/Lower ventral herniaGroin pain TraumaAbnormal pelvic US Adnexal massPelvic mass Soft tissue massinfection CellulitisAbscess Tumor/Mets

Yes

body

CT abDomen & PelviS: enTerograPHY

CT Abdomen & Pelvis; with contrast74177

Crohn’s diseaseSuspected small bowel tumorsMesenteric/Intestinal bleedingSuspected GI bleedingEvaluation of bowel patency

Yes

body

CT CHeST: General

CT Chest with contrast 71260 Abnormal CXR NeoplasmAdenopathy AbscessPneumonia Pulmonary noduleCough Enlarged aortic archHemoptysis Lung lesionSarcoidosis LymphadenopathyHilar abnormality Asbestos exposureHx Cancer/Tumor/Mets Shortness of breathChest pain Abdominal aortic aneurysmPulmonary embolism Thoracic aneurysmAortic dissection Chest wall pain/Mass

Yes

body

CT CHeST: HigH reSolUTion

CT Chest without contrast, high resolution 71250 Interstitial disease COPD/EmphysemaFibrosis Asbestos exposureBronchiectasis Lung noduleHypersensitivity lung disease

As Determined by Radiologist body

CT abDomen & PelviS: renal STone ProToCol

CT Abdomen & Pelvis without contrast 74176 Hematuria StoneFlank plain ProstatitisLow back pain DysuriaUrinary frequency

No

body

CT abDomen: Tri-PHaSe renal

CT Abdomen with and without contrast 74170 Hematuria Renal Failure/Mass/TransplantFlank Pain HypertensionHydronephrosis History of renal cancerLow back pain History of stonesAbnormal US Polycystic kidney disease

Yes

body

CT abDomen & PelviS: UrogramUrinary System, kidneys to bladder

CT Abdomen & Pelvis;without contrast 1 or bothwith contrast 1 or both

74178 Abnormal cystogram History of renal cancerPainless hematuria Abnormal renal USBladder mass or tumor Suspected renal mass

Yes

body

CT abDomen: aDrenal

CT Abdomen with and without contrast 74170 Adrenal mass Yes body

CT angiograPHY abDomen

CT Angiography Abdomen, with contrast including non-contrast images if performed and image post-processingNote: Some indications also require CTA Pelvis to fully evaluate condition.

74175 Renal artery stenosis TraumaMesenteric ischemia

Yes

body

CT angiograPHY abDomen & PelviS

CT Angiography Abdomen and Pelvis, with contrast including non-contrast images if performed and image post-processing

74174 Dissection Pre-stent graftingRetroperitoneal bleed Abnormal USAbdominal aortic aneurysm (AAA)

Yesbody

CT angiograPHY rUnoff: abDomen & bilaTeral loWer exTremiTieS

CT Angiography Abdominal aorta and bilat-eral iliofemoral lower extremity runoff, with contrast including non-contrast images if performed and image post-processingNote: Some indications may be better visualized with MRI or ultrasound.

75635 Claudication Preop for aortoiliac occlusionPVD VasculitisPre/post ops for stent graftsVenous thrombosis (not clear on other imaging)

Yes

body

CT exTremiTiY:Upperhand, wrist, elbow, radius/ulna, humerus, shoulder, SC joint

lowerfoot, ankle, knee, hip, tibia/fibula, femur

CT Extremity with contrast:Upper Extremity with contrastLower Extremity with contrast

7320173701

InfectionTumor/Mass/Cancer/Mets

Note: MRI is more sensitive

Yes

ortho

CT Extremity without contrastUpper Extremity Lower Extremity

7320073700

Pain FusionArthritis MalunionFracture

Noortho

CT PelviS:bonY HiPSaCeTabUlUm

CT Pelvis without contrast

Note: MRI Pelvis may be preferred study in some circumstances. Consult the radiologist.

72192 Pain ArthritisFracture Bone lesionsCancer/Mets

No

ortho

CT EXAM CPT CODE REFERENCEUse this reference to quickly determine the correct exam for your patients based on the indications described herein and the CPT for the order.

Please include creatinine levels for patients over 60 years or with history of renal failure. If not available, Creatinine levels can be obtained prior tocontrasted studies, if needed, at all Wake Radiology locations. Call if you have any questions 919-232-4700.