CT Contrast Guide

Revised 02.09

Body - CT Scan Scheduling Guidelines

Without signs or symptoms written on an order, a NORMAL study will NOT be covered by insurance.

Key: W-With WO-Without WO&W-Without & With
CPT CODE CHEST CT (x-ray is almost always required) SIGNS/SYMPTOMS IV ORAL
71250 Nodules Abnormal cxr, ancillary finding, f/u study WO No
71250 Interstitial lung disease, i.e. asbestosis, sarcoidosis,TB Breathlessness during exercise, dry cough, f/u WO No
71260 Suspected pulmonary embolus Chest pain, cough, rapid heart rate, sob, dyspnea W No
71260 Persistent unresolved cough of at least 2 weeks w normal x ray Cough W No
71260 Unresolved pneumonia documented after antibiotics (4 weeks) Chest pain, cough W No
71260 Suspected/known tumor/mass –evaluation, staging, restaging Weight loss, abnormal tumor marker, pain, f/u W No
71260 Unexplained abnormalities on chest x ray Abnormal cxr, ancillary finding, f/u study W No
71260 Aortic Root Dilation SOB, fatigue, weakness, fainting W No
71295 Pulmonary Vein Stenosis-Pre/Post Ablation SOB, fatigue, rapid heartbeat, fainting, A-fib WO&W No
         
CPT CODE ABDOMEN CT (Superior to diaphragm to the level of the iliac bifurcation) SIGNS/SYMPTOMS IV ORAL
74150 Adrenal mass High blood pressure, low potassium, palpitations WO No
74170 Cirrhosis Vomiting blood, jaundice, confusion, incr. LFTs WO&W Yes
74170 Renal Mass; abn ancillary findings Blood in urine, LBP, unexplained weight loss WO&W Yes
74170 Hemangioma; ONLY if MRI cannot be performed Abn. LFTs, F/U liver mass WO&W Yes
         
CPT Code ABDOMEN/ PELVIS CT (Superior to diaphragm through the symphysis-pubis) SIGNS/SYMPTOMS IV ORAL
74176 Suspected retroperitoneal hematoma/hemorrhage Abdominal pain; hypotension, anemia WO No
74176 Suspected stone in kidneys, bladder and ureters Abdominal pain; flank pain, hematuria WO No
74177 Clinical signs suggestive of diverticulitis, colitis, Crohn's, IBD Abdominal pain, diarrhea W Yes
74177 Clinical signs suggestive of appendicitis Abdominal pain, nausea, vomiting, fever W Yes
74177 Lymphadenopathy, assessment of lymphomas Swollen enlarged lymph nodes W Yes
74177 F/U of complication/medical treatment of abdominal/pelvic (bowel obstruction) Abdominal pain, distension, vomiting, fecal vomiting W Yes
74178 Pancreatitis, suspected necrosis or pseudocyst Severe abdominal pain, nausea, vomiting WO&W Yes
74178 Hematuria Blood in urine WO&W Yes
74178 Hydronephrosis Raised creatinine,electrolyte imbalance WO&W Yes
74178 Abdominal Aortic Aneurysm (Stent-Graph Protocol) Abdomen pain, rapid heart rate, abdominal rigidity WO&W No
         

Neuro - CT Scan Scheduling Guidelines

Without signs or symptoms written on an order, a NORMAL study will NOT be covered by an insurance carrier.

Key: W-With WO-Without WO&W-Without & With
CPT Code BRAIN CT SIGNS/SYMPTOMS IV ORAL
70450 Headache; new, sudden, severe Headache WO No
70450 Stroke or TIA Numbness, weakness, dizziness, trouble speaking WO No
70450 Visual Disturbance As stated WO No
70450 Hydrocephalus i.e. shunt revision Headache, vomiting, blurred vision WO No
70450 Trauma for depressed fracture Pain at site WO No
70470 Primary or metastatic tumor, new or follow up
ONLY if MRI is contraindicated!!!!!!!!
Blurred vision, chronic headaches, R/O mets WO&W No
         
CPT Code ORBITS SIGNS/SYMPTOMS IV ORAL
70480 Trauma Facial/eye pain WO No
70481 No Trauma; specific localized facial pain Localized orbital pain, swelling, inflamation W No
         
CPT Code SINUS SIGNS/SYMPTOMS IV ORAL
70486 Preoperative after failure of conservative treatment   WO No
70486 Sinusitis; chronic, failed several courses of antibiotic therapy Facial pain, congestion WO No
70487 Osteomyelitis Pain in infected bone, fever, chills W No
70487 Sinus-nasal tumor Nasal congestion, pain above or below eyes W No
         
CPT Code NECK SIGNS/SYMPTOMS IV ORAL
70490 R/O Calculi Pain, dry mouth, bad taste in mouth, swelling WO No
70491 Lymphadenopathy Swelling of lymph nodes W No
70491 Suspected or known tumor of larynx, pharynyx, parathyroid & parotids Dysphagia, vocal changes, aspiration W No
70491 Vocal cord lesion, hoarseness, paralysis Hoarseness, breathy sounding W No
         
CPT Code EXTREMITIES SIGNS/SYMPTOMS IV ORAL
Upper
73200 Position of known fracture Pain and swelling around area, loss of function WO No
73200 Joint Arthritis, pain WO No
73200 Arthrogram Pain, decreasing ROM WO No
Lower
73700 Position of known fracture Pain and swelling around area, loss of function WO No
73700 Joint Arthritis, pain WO No
73700 Arthrogram Pain, "clicking" WO No
73700 Leg Length Studies: Leg length Discrepancy One leg is shorter, gait problems, pain in back/legs WO No
CPT Code SPINE - Due to radiation exposure, levels must be indicated SIGNS/SYMPTOMS IV ORAL
Cervical:
72125 Fractures Pain, bruising and swelling WO No
72125 Scoliosis Curving spine, shoulders/hips are uneven, LBP WO No
72125 Tumor: if MRI is contraindicated Pain, weight loss, fatigue W No
72125 Tumor: if MRI was recently completed…eval for bone Pain, weight loss, fatigue WO No
72125 Post-op Studies Pain, f/u surgical eval WO No
Thoracic:
72128 Fractures Pain, bruising and swelling WO No
72128 Scoliosis Curving spine, shoulders/hips are uneven, LBP WO No
72129 Tumor: if MRI is contraindicated Pain, weight loss, fatigue W No
72128 Tumor: if MRI was recently completed…eval for bone Pain, weight loss, fatigue WO No
72128 Post-op Studies Pain, f/u surgical eval WO No
Lumbar:
72131 Fractures Pain, bruising and swelling WO No
72131 Scoliosis Curving spine, shoulders/hips are uneven, LBP WO No
72132 Tumor: if MRI is contraindicated Pain, weight loss, fatigue W No
72131 Tumor: if MRI was recently completed…eval for bone Pain, weight loss, fatigue WO No
72131 Post-op Studies Pain, f/u surgical eval WO No
         

CT Angiography (CTA) Scheduling Guidelines

Without signs or symptoms written on an order, a NORMAL study will NOT be covered by an insurance carrier.

Key: W-With WO-Without WO&W-Without & With
CPT Code HEAD SIGNS/SYMPTOMS IV ORAL
70496 Aneurysm Double or loss of vision, headache, eye pain WO&W No
         
CPT Code NECK SIGNS/SYMPTOMS IV ORAL
70498 Suspected Carotid Stenosis Weakness, numbness, Confusion, dizziness W No
         
CPT Code CHEST SIGNS/SYMPTOMS IV ORAL
71275 Evaluation of thoracic aortic aneurysm Most have no symptoms until the aneurysm leaks WO&W No
71260 Suspected pulmonary embolis Chest pain, cough, SOB, dyspnea W No
         
CPT Code CHEST / ABDOMEN / PELVIS SIGNS/SYMPTOMS IV ORAL
71275 + 74175 + 72191 Dissection Stabbing or sharp chest pain W&WO No
         
CPT Code ABDOMEN SIGNS/SYMPTOMS IV ORAL
74175 Renal hypertension Blood in urine, hypertension, renal insufficiency W&WO No
         
CPT Code ABDOMEN / PELVIS SIGNS/SYMPTOMS IV ORAL
74175 + 72191 Abdominal Aortic Aneurysm Constant chest/abd & back pain; pulsatile mass W&WO No
74175 + 72191 Iliac Aneurysm Lower abdominal pain, low back pain or groin pain W&WO No
         
CPT Code ABDOMINAL AORTA with RUNOFFS SIGNS/SYMPTOMS IV ORAL
75635 Lower extremity ischemia, claudication, foot ulcer Absent pulse in foot, cramping pain, rest pain W No