procedure code and description

74177 – Ct abd & pelv w/contrast – average fee payment – $320- $330

Procedure code changes

In 2011, the Procedure code editorial panel created three new codes for CT of abdominal and pelvis:

* Code 74176, CT, abdomen and pelvis; without contrast material

* Code 74177, CT, abdomen and pelvis; with contrast material(s)

* Code 74178, CT, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions


Radiology – 5 New Codes


– CT Angioplasty Abdomen/Pelvis

• Without Contrast – 74176
• With Contrast – 74177
• Without Contrast 1+ Body Regions – 74178
– Ultrasound Extremity Non-Vascular
• Complete – 76881
• Limited – 76882




CPT 74177 


** Abdominal Pain (upper and lower quadrants)
** Inflammatory Bowel Disease (including Crohns, Ulcerative Colitis)
** Appendicitis
** Abscess
** Hernia (ventral, umbilical, inguinal)
** CT Enterography



Indications


Evaluation of abdominal or pelvic pain.

Evaluation of known or suspected abdominal or pelvic masses or fluid collections, primary or metastatic malignancies, abdominal or pelvic inflammatory processes, and abnormalities of abdominal or pelvic vascular structures.

Evaluation of abdominal or pelvic trauma.

Clarification of findings from other imaging studies or laboratory abnormalities.

Evaluation of known or suspected congenital abnormalities of abdominal or pelvic organs.

Treatment planning for radiation therapy.


Limitations



Three dimension reconstruction of CT of Abdomen and Pelvis (CPT code 76376 or 76377) is not expected to be utilized routinely. CPT code 76376 or 76377 are not an appropriate part of every CT examination.






CT abdomen (abd) CPT codes 74176, 74177, 74178



Coverage Indications, Limitations, and/or Medical Necessity

    CT of the abdomen includes the area between the dome of the diaphragm and the iliac crests, which also includes the base of the lungs. CT of the abdomen is generally indicated when only upper abdominal organs are of interest. A typical CT of the abdomen should include transaxial images from the dome of the diaphragm to the iliac crest with up to 10mm slice thickness. Pelvic CT includes the area between the iliac crests and the perineum. A typical CT of the pelvis would extend from the iliac crest to the ischial tuberosities with up to 10 mm slice thickness. If the patient has a suspected disease that may spread through the peritoneal cavity or by lymphatics, then the pelvic scan should also be performed. In some clinical situations, it may be medically necessary to perform complete CT scans of the abdomen and pelvis on the same date of service. These situations include but are not limited to the evaluation of inflammatory disease, staging of neoplasms and the evaluation of trauma.

    Suggested indications for abdominal CT or pelvic CT examinations include, but are NOT LIMITED to the following:

    · Evaluation of pain

    Abdomen

    a. Upper abdominal pain if ultrasound is normal (*Note: Ultrasound does not work well in obese patients)

    b. Unexplained abdominal pain in patients older than 75 years or very frail

    c. Suspected diverticulitis or appendicitis

    Pelvis

    a. Lower abdominal pain, if ultrasound is normal and clearly not a bowel problem

    b. Evaluation of pelvic fractures or bony tumors

    c. Bilateral hips for avascular necrosis as the femurs will be visualized on a pelvic study

    d. Inguinal hernia suspect incarceration

    · Evaluation of known or suspected abdominal or pelvic masses or fluid collections, primary or metastatic malignancies, abdominal or pelvic inflammatory processes, and abnormalities of abdominal or pelvic vascular structures (Note – CT Scans utilized initially for suspected malignancies)

    Abdomen

    a. Jaundice or abnormal liver function tests if ultrasound is normal or not indicated

    b. Possible renal tumor (often will have ultrasound first)

    c. Persistent unresolved symptoms not explained by initial imaging

    d. Follow-up metastasis (i.e., breast, lung cancer, etc.)

    Pelvis

    a. Endometriosis follow-up of abnormal ultrasound

    b. Inflammatory bowel disease, Crohns’s or colitis

    c. Evaluation of bladder, cervical, ovarian, prostate or rectal cancer

    d. Follow-up metastasis (i.e., breast, lung cancer, etc.)

    · Evaluation of known or suspected primary breast cancer metastasis

    · Evaluation of abdominal or pelvic trauma

    Abdomen/Pelvis Combination

    a. Blunt trauma – splenic laceration , trauma to the kidneys, suspicion of intra-abdominal fluid collections related to trauma

    · Clarification of findings from other imaging studies or laboratory abnormalities

    Abdomen

    a. Delineation of known or suspected renal calculi

    b. Pancreatitis, psyedocyst

    c. Splenomegaly

    d. Ascites

    e. Hematuria or blood in urine (consider obtaining both abdomen and pelvis)

    f. Hydronephrosis

    Abdomen/Pelvis Combination

    a. Fever and elevated white count, suspected abscess

    b. Infection, unexpected weight loss

    · Evaluation of known or suspected congenital abnormalities of abdominal or pelvic organs

    · Guidance for interventional, diagnostic, or therapeutic procedures within the abdomen or pelvis

    · Treatment planning for radiation therapy

    Pelvis

    a. Prostate tumor – staging for regional adenopathy, as part of radiation treatment planning

    b. Follow-up of known mass, abscess or tumor

    Abdomen/Pelvis Combination

    a. Staging of known tumors or history of malignance

    b. Assessment of response to chemotherapy and radiation therapy in individuals undergoing treatment

    c. Lymphadenopathy, assessment of lymphomas

    d. Presence or suspicion of abdominal mass/cancer

    There are no absolute contraindications to abdominal CT or pelvic CT examinations. As with all procedures, the relative benefits and risks of the procedure should be evaluated prior to the performance of iodinated contrast-enhanced abdominal CT and pelvic CT. Appropriate precautions should be taken to minimize patient risk.

    CT scans performed by mobile CT scan services are eligible for reimbursement only as specified in the Medicare National Coverage Determinations Manual Chapter 1-220.1.

    CT scans performed on mobile units are subject to the same Medicare coverage requirements applicable to scans performed on stationary units, as well as certain health and safety requirements recommended by Health Resources and Services Administration (HRSA). As with scans performed on stationary units, the scans must be determined medically necessary for the individual patient. The scans must be performed on types of CT scanning equipment that have been approved for use as stationary units and must be in compliance with applicable State laws and regulations for control of radiation.



CPT/HCPCS Codes

72192 Ct pelvis w/o dye
72193 Ct pelvis w/dye
72194 Ct pelvis w/o & w/dye
74150 Ct abdomen w/o dye
74160 Ct abdomen w/dye
74170 Ct abdomen w/o & w/dye
74176 Ct abd & pelvis w/o contrast
74177 Ct abd & pelv w/contrast
74178 Ct abd & pelv 1/> regns



Abdomen & Pelvis

Renal Stone (wo) – 74176
Urogram (w/wo) – 74178
CT Angio (w/wo) – 74174
CT Enterography – 74177
Abd wo/Pelvis (wo) – 74176
Abd wo/Pelvis (w) – 74178
Abd wo/Pelvis (w/wo) – 74178
Abd w/Pelvis (wo) – 74178
Abd w/Pelvis (w) – 74177
Abd w/Pelvis (w/wo) – 74178
Abd w/wo/Pelvis (wo) –  74178
Abd w/wo/Pelvis (w) – 74178
Abd w/wo/Pelvis (w/wo) – 74178

Payment for Multiple Imaging Composite APCs

Effective for services furnished on or after January 1, 2009, multiple imaging procedures performed during asingle session using the same imaging modality are paid by applying a composite APC payment methodology.

The services are paid with one composite APC payment each time a hospital bills for second and subsequent imaging procedures described by the HCPCS codes in one imaging family on a single date of service. The I/OCE logic determines the assignment of the composite APCs for payment. Prior to January 1, 2009, hospitals received a full APC payment for each imaging service on a claim, regardless of how many procedures were performed during a single session.

The composite APC payment methodology for multiple imaging services utilizes three imaging families (Ultrasound, CT and CTA, and MRI and MRA) and five composite APCs: APC 8004 (Ultrasound Composite); APC 8005 (CT and CTA without Contrast Composite); APC 8006 (CT and CTA with Contrast Composite); APC 8007 (MRI and MRA without Contrast Composite); and APC 8008 (MRI and MRA with Contrast Composite). When a procedure is performed with contrast during the same session as a procedure without contrast, and the two procedures are within the same family, the “with contrast” composite APC (either APC8006 or 8008) is assigned.

CMS has updated the list of specified HCPCS codes within the three imaging families and five composite APCs to reflect HCPCS coding changes. Specifically, CMS added Procedure  code 74176 (Computed tomography, abdomen and pelvis; without contrast material), Procedure  code 74177 (Computed tomography, abdomen and pelvis; with contrast material(s)), and Procedure  code 74178 (Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions) to the CT and CTA family.

These codes are new for CY 2011. CMS also added HCPCS codes C8931 (Magnetic resonance angiography with contrast, spinal canal and contents), C8932 (Magnetic resonance angiography without contrast, spinal canal and contents), C8933 (Magnetic resonance angiography without contrast followed by with contrast, spinal canal and contents), C8934 (Magnetic resonance angiography with contrast, upper extremity), C8935 (Magnetic resonance angiography without contrast, upper extremity), and C8936 (Magnetic resonance angiography without contrast followed by with contrast, upper extremity), to the MRI and MRA family. These codes were recognized for OPPS payment in the October 2010 OPPS Update

The Creation of New Bundled Codes


Under the Affordable Care Act, it is mandated that the Secretary of Health and Human Services (HHS) periodically identify physician services under the Medicare Physician Fee Schedule (MPFS) that are potentially misvalued and make appropriate adjustments(Sec. 3134 of H.R. 3590). Medicare has also been working with the RVS Update Committee (RUC) on other screens to identify codes billed together 95%, 90%, and 75% of the time, site of service anomalies, different performing
specialty from the specialty surveyed (eg, radiology surveyed but procedure also frequently performed by cardiology and/ or vascular surgery), and Harvard-valued codes with utilization over 100,000. As a result, beginning in 2010, new bundled  codes were developed and implemented with new relative values. Once the bundled codes have been developed and accepted by Medicare, they must also be assigned an ambulatory payment category (APC) for payment to hospitals under the Hospital Outpatient Prospective Payment System (HOPPS).

Since then, the ACR has been working with CMS to help determine where the new bundled codes should be placed in the APC. Medicare’s data and methodology are used for the recommendations. When CMS assigns the new bundled code placements, they initially use historical data from the codes that were previously used to report the service(s). CMS then gives hospitals about a year to begin to use these new codes with the expectation that the facility will accurately report actual charges and costs. CMS then converts to using the most recent bundled code data from hospitals to price the bundled codes in their APCs. The ACR has been monitoring the pricing and has observed that the new bundled code payments are falling short of the payment levels of the predecessor codes and value. See Table 1 for the new bundled codes for CT of the abdomen and pelvis for 2013. Although these codes have been established for two years now, the pricing is still coming in low and even dropping.

It seems that many hospitals are not accurately pricing the combined codes to ensure that all charges are captured in the new bundled code charges. For example, on your hospital’s Charge Description Master (CDM) do these new codes include all the charges of the individual CT codes?

74176 = 72192 (CT Pelvis w/o contrast) + 74150 (CT abdomen w/o contrast)

74177 = 72193 (CT Pelvis w/contrast) + 74160 (CT abdomen w/contrast) 74178 = 72194 (CT Pelvis w/o & w/contrast) + 74150 (CT abdomen w/o & w/contrast)



Rationale for Edit:

Anthem Central Region bundles 74150 and 72192 and creates a new code 74176; bundles 74150 as incidental to 74176; bundles 72192 as incidental to 74176; bundles 74150-26 and 72192-26 and creates a new code 74176-26; bundles 74150-26 as incidental to 74176-26; bundles 74150-TC and 72192-TC and creates a new code 74176-TC; bundles 74150-TC as incidental to 74176-TC and bundles 72192-TC as incidental 74176-TC. Based on the 2011 Procedure  code manual codes 74150 and 72192 are listed as codes that create 74176. Based on the National Correct Coding Initiative Edits, codes 74150 and 72192 are listed as a component codes to code 74176. Therefore if 74150 and 72192 are submitted together they bundleand create a new code 74176 and this code reimburses; if 74150 is submitted with 74176—only 74176 reimburses; if 72192 is submitted with 74176—only 74176 reimburses; if 74150-26 is submitted with 72192-26 they bundle and create a new code 74176-26 and only this code reimburses; if 74150-26 is submitted with 74176-26—only 74176-26 reimburses; if 72192-26 is submitted with 74176-26—only 74176-26 reimburses; if 74150-TC is submitted with 72192-TC they bundle and create a new code— 74176-TC and only this code reimburses; and if 74150-TC is submitted with 747176-TC—only 74176- TC reimburses and if 72192-TC is submitted with 74176-TC—only 74176-TC reimburses

Inclusive Edit

74150 (Computed tomography, abdomen; without contrast material) bundles with 72192 (Computed tomography, pelvis; without contrast material) and creates a new code 74176 (Computed tomography, abdomen and pelvis, without contrast material).

74150 (Computed tomography, abdomen; without contrast material) bundles with 74176 (Computed tomography, abdomen and pelvis, without contrast material).

72192 (Computed tomography, pelvis; without contrast material) bundles with 74176 (Computed tomography, abdomen and pelvis, without contrast material).

• Pathology & Laboratory–15 New & 13 Deleted

Medicine – 40 New & 41 Deleted
– New Codes
• Immunization Administration thru 18 years
– First Vaccine/Toxoid – 90460
– Each Additional – 90461
• H1N1 Immunization Administration, including counseling – 90470
• Meningococcal Vaccine, 2-15 months – 90644
• Influenza Virus Vaccine
– Intranasal – 90664
– Intramuscular, Preservative Free – 90666
– Intramuscular, Split Virus, Adjuvanted – 90667
– Intramuscular, Split Virus – 90668

New Codes


• Therapeutic repetitive transcranial magnetic stimulation treatment; planning – 90867
– Delivery and management, per session – 90868
• Esophageal Motility (Add-On Code) – 91013
• Sleep Study 95800 – 95801
– Deleted Codes
• Immunization Administration – 90465 – 90468
• Esophageal/Gastric Intubation/Motility – 91000-91105
• Telephonic Transmission of Post-Symptom EKG strips
– 93012 & 93014
• Holter Monitors
– 93230 – 93233
– 93235 – 93237

CY 2011 APC 8005 (CT and CTA without Contrast Composite)*

70450 Ct head/brain w/o dye
70480 Ct orbit/ear/fossa w/o dye
70486 Ct maxillofacial w/o dye
70490 Ct soft tissue neck w/o dye
71250 Ct thorax w/o dye
72125 Ct neck spine w/o dye
72128 Ct chest spine w/o dye
72131 Ct lumbar spine w/o dye
72192 Ct pelvis w/o dye
73200 Ct upper extremity w/o dye
73700 Ct lower extremity w/o dye
74150 Ct abdomen w/o dye
74261 Ct colonography, w/o dye
74176 Ct angio abd & pelvis

CY 2011 APC 8006 (CT and CTA with Contrast Composite)

70487 Ct maxillofacial w/dye
70460 Ct head/brain w/dye
70470 Ct head/brain w/o & w/dye
70481 Ct orbit/ear/fossa w/dye
70482 Ct orbit/ear/fossa w/o&w/dye
70488 Ct maxillofacial w/o & w/dye
70491 Ct soft tissue neck w/dye
70492 Ct sft tsue nck w/o & w/dye
70496 Ct angiography, head
70498 Ct angiography, neck
71260 Ct thorax w/dye
71270 Ct thorax w/o & w/dye
71275 Ct angiography, chest
72126 Ct neck spine w/dye
72127 Ct neck spine w/o & w/dye
72129 Ct chest spine w/dye
72130 Ct chest spine w/o & w/dye
72132 Ct lumbar spine w/dye
72133 Ct lumbar spine w/o & w/dye
72191 Ct angiograph pelv w/o&w/dye
72193 Ct pelvis w/dye
72194 Ct pelvis w/o & w/dye
73201 Ct upper extremity w/dye
73202 Ct uppr extremity w/o&w/dye
73206 Ct angio upr extrm w/o&w/dye
73701 Ct lower extremity w/dye
73702 Ct lwr extremity w/o&w/dye
73706 Ct angio lwr extr w/o&w/dye
74160 Ct abdomen w/dye
74170 Ct abdomen w/o & w/dye
74175 Ct angio abdom w/o & w/dye
74262 Ct colonography, w/dye
75635 Ct angio abdominal arteries
74177 Ct angio abd&pelv w/contrast
74178 Ct angio abd & pelv 1+ regns



Radiology Coverage Restriction

EPNI will not reimburse for many imaging services when billed by a chiropractor. This policy applies to all High Tech Diagnostic Imaging (HTDI) procedures, including CT Scans and MRI services, in addition to the procedures below. This will allow EPNI to better manage these high-cost radiology services. These claims will be denied as provider liability

71260 71550 72192 72193 72194 73221 73721 74150 74160 74170 74183 76140 76496 76536 76800 76856 76870 76977 77057 77080

EPNI will continue to allow chiropractors to order Medically Necessary radiology services, as permitted by the provider’s scope of practice.

Services billed for consultation on X-ray exams performed elsewhere (CPT 76140) will not be payable, as EPNI already reimburses for both the professional and technical component of most radiology services. Re-interpretation of a film is a duplication of these other components.

EPNI will continue to allow chiropractors to perform, bill and be reimbursed for most traditional X-ray films based on the Subscriber’s benefits

ICD-10 CODE DESCRIPTION

A06.2 – A06.6 – Opens in a new window Amebic nondysenteric colitis – Amebic brain abscess
A06.81 – A06.89 – Opens in a new window Amebic cystitis – Other amebic infections
A18.10 – A18.18 – Opens in a new window Tuberculosis of genitourinary system, unspecified – Tuberculosis of other female genital organs
A18.31 – A18.39 – Opens in a new window Tuberculous peritonitis – Retroperitoneal tuberculosis
A18.7 Tuberculosis of adrenal glands
A18.83 Tuberculosis of digestive tract organs, not elsewhere classified
A18.85 Tuberculosis of spleen
A31.0 Pulmonary mycobacterial infection
A31.2 Disseminated mycobacterium avium-intracellulare complex (DMAC)
A34 Obstetrical tetanus
A39.1 Waterhouse-Friderichsen syndrome
A40.0 – A41.9 – Opens in a new window Sepsis due to streptococcus, group A – Sepsis, unspecified organism
A42.7 Actinomycotic sepsis
A50.04 Early congenital syphilitic pneumonia
A50.06 – A50.09 – Opens in a new window Early cutaneous congenital syphilis – Other early congenital syphilis, symptomatic
A51.49 Other secondary syphilitic conditions
A52.74 – A52.75 – Opens in a new window Syphilis of liver and other viscera – Syphilis of kidney and ureter
A56.11 Chlamydial female pelvic inflammatory disease
B15.0 – B19.9 – Opens in a new window Hepatitis A with hepatic coma – Unspecified viral hepatitis without hepatic coma
B25.1 – B25.2 – Opens in a new window Cytomegaloviral hepatitis – Cytomegaloviral pancreatitis
B37.7 Candidal sepsis
B65.0 – B65.9 – Opens in a new window Schistosomiasis due to Schistosoma haematobium [urinary schistosomiasis] – Schistosomiasis, unspecified
B67.0 Echinococcus granulosus infection of liver
B67.5 Echinococcus multilocularis infection of liver
B67.8 – B67.99 – Opens in a new window Echinococcosis, unspecified, of liver – Other echinococcosis
C00.0 – C43.9 – Opens in a new window Malignant neoplasm of external upper lip – Malignant melanoma of skin, unspecified
C4A.0 – C4A.9 – Opens in a new window Merkel cell carcinoma of lip – Merkel cell carcinoma, unspecified
C44.00 – C49.9 – Opens in a new window Unspecified malignant neoplasm of skin of lip – Malignant neoplasm of connective and soft tissue, unspecified
C50.011 – C75.9 – Opens in a new window Malignant neoplasm of nipple and areola, right female breast – Malignant neoplasm of endocrine gland, unspecified
C7A.00 – C7B.8 – Opens in a new window Malignant carcinoid tumor of unspecified site – Other secondary neuroendocrine tumors
C76.0 – C79.9 – Opens in a new window Malignant neoplasm of head, face and neck – Secondary malignant neoplasm of unspecified site
C80.0 – C84.79 – Opens in a new window Disseminated malignant neoplasm, unspecified – Anaplastic large cell lymphoma, ALK-negative, extranodal and solid organ sites
C84.A0 – C84.Z9 – Opens in a new window Cutaneous T-cell lymphoma, unspecified, unspecified site – Other mature T/NK-cell lymphomas, extranodal and solid organ sites
C84.90 – C84.99 – Opens in a new window Mature T/NK-cell lymphomas, unspecified, unspecified site – Mature T/NK-cell lymphomas, unspecified, extranodal and solid organ sites
C85.10 – C86.6 – Opens in a new window Unspecified B-cell lymphoma, unspecified site – Primary cutaneous CD30-positive T-cell proliferations
C88.2 – C91.62 – Opens in a new window Heavy chain disease – Prolymphocytic leukemia of T-cell type, in relapse
C91.A0 – C91.Z2 – Opens in a new window Mature B-cell leukemia Burkitt-type not having achieved remission – Other lymphoid leukemia, in relapse
C91.90 – C91.92 – Opens in a new window Lymphoid leukemia, unspecified not having achieved remission – Lymphoid leukemia, unspecified, in relapse
C92.00 – C92.62 – Opens in a new window Acute myeloblastic leukemia, not having achieved remission – Acute myeloid leukemia with 11q23-abnormality in relapse
C92.A0 – C92.Z2 – Opens in a new window Acute myeloid leukemia with multilineage dysplasia, not having achieved remission – Other myeloid leukemia, in relapse
C92.90 – C92.92 – Opens in a new window Myeloid leukemia, unspecified, not having achieved remission – Myeloid leukemia, unspecified in relapse
C93.00 – C93.32 – Opens in a new window Acute monoblastic/monocytic leukemia, not having achieved remission – Juvenile myelomonocytic leukemia, in relapse
C93.Z0 – C93.Z2 – Opens in a new window Other monocytic leukemia, not having achieved remission – Other monocytic leukemia, in relapse
C93.90 – C93.92 – Opens in a new window Monocytic leukemia, unspecified, not having achieved remission – Monocytic leukemia, unspecified in relapse
C94.00 – C94.32 – Opens in a new window Acute erythroid leukemia, not having achieved remission – Mast cell leukemia, in relapse
C94.80 – C96.4 – Opens in a new window Other specified leukemias not having achieved remission – Sarcoma of dendritic cells (accessory cells)
C96.A – C96.Z – Opens in a new window Histiocytic sarcoma – Other specified malignant neoplasms of lymphoid, hematopoietic and related tissue
C96.9 Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified
D00.1 – D01.9 – Opens in a new window Carcinoma in situ of esophagus – Carcinoma in situ of digestive organ, unspecified
D03.0 – D03.9 – Opens in a new window Melanoma in situ of lip – Melanoma in situ, unspecified
D06.0 – D09.19 – Opens in a new window Carcinoma in situ of endocervix – Carcinoma in situ of other urinary organs
D12.0 – D12.9 – Opens in a new window Benign neoplasm of cecum – Benign neoplasm of anus and anal canal
D13.1 – D13.9 – Opens in a new window Benign neoplasm of stomach – Benign neoplasm of ill-defined sites within the digestive system
D16.8 Benign neoplasm of pelvic bones, sacrum and coccyx
D17.5 Benign lipomatous neoplasm of intra-abdominal organs
D17.71 Benign lipomatous neoplasm of kidney
D18.03 Hemangioma of intra-abdominal structures
D18.1 Lymphangioma, any site
D19.1 Benign neoplasm of mesothelial tissue of peritoneum
D20.0 – D20.1 – Opens in a new window Benign neoplasm of soft tissue of retroperitoneum – Benign neoplasm of soft tissue of peritoneum
D21.20 – D21.22 – Opens in a new window Benign neoplasm of connective and other soft tissue of unspecified lower limb, including hip – Benign neoplasm of connective and other soft tissue of left lower limb, including hip
D21.4 – D21.5 – Opens in a new window Benign neoplasm of connective and other soft tissue of abdomen – Benign neoplasm of connective and other soft tissue of pelvis
D25.0 – D28.9 – Opens in a new window Submucous leiomyoma of uterus – Benign neoplasm of female genital organ, unspecified
D30.00 – D30.9 – Opens in a new window Benign neoplasm of unspecified kidney – Benign neoplasm of urinary organ, unspecified
D35.00 – D35.02 – Opens in a new window Benign neoplasm of unspecified adrenal gland – Benign neoplasm of left adrenal gland
D35.6 Benign neoplasm of aortic body and other paraganglia
D3A.00 – D3A.8 – Opens in a new window Benign carcinoid tumor of unspecified site – Other benign neuroendocrine tumors
D37.1 – D37.9 – Opens in a new window Neoplasm of uncertain behavior of stomach – Neoplasm of uncertain behavior of digestive organ, unspecified
D39.0 – D39.9 – Opens in a new window Neoplasm of uncertain behavior of uterus – Neoplasm of uncertain behavior of female genital organ, unspecified
D40.0 – D41.9 – Opens in a new window Neoplasm of uncertain behavior of prostate – Neoplasm of uncertain behavior of unspecified urinary organ
D44.10 – D44.12 – Opens in a new window Neoplasm of uncertain behavior of unspecified adrenal gland – Neoplasm of uncertain behavior of left adrenal gland
D44.6 – D44.7 – Opens in a new window Neoplasm of uncertain behavior of carotid body – Neoplasm of uncertain behavior of aortic body and other paraganglia
D45 Polycythemia vera
D48.3 – D48.4 – Opens in a new window Neoplasm of uncertain behavior of retroperitoneum – Neoplasm of uncertain behavior of peritoneum
D49.0 Neoplasm of unspecified behavior of digestive system
D57.02 Hb-SS disease with splenic sequestration
D57.212 Sickle-cell/Hb-C disease with splenic sequestration
D57.412 Sickle-cell thalassemia with splenic sequestration
D57.812 Other sickle-cell disorders with splenic sequestration
D73.1 – D73.2 – Opens in a new window Hypersplenism – Chronic congestive splenomegaly
D73.81 Neutropenic splenomegaly
D75.0 – D75.1 – Opens in a new window Familial erythrocytosis – Secondary polycythemia
D78.01 – D78.22 – Opens in a new window Intraoperative hemorrhage and hematoma of the spleen complicating a procedure on the spleen – Postprocedural hemorrhage of the spleen following other procedure
D86.0 – D86.2 – Opens in a new window Sarcoidosis of lung – Sarcoidosis of lung with sarcoidosis of lymph nodes
D86.84 Sarcoid pyelonephritis
D86.89 – D86.9 – Opens in a new window Sarcoidosis of other sites – Sarcoidosis, unspecified
E08.51 – E08.52 – Opens in a new window Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy without gangrene – Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene
E09.51 – E09.52 – Opens in a new window Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy without gangrene – Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene
E10.51 – E10.52 – Opens in a new window Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene – Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E11.51 – E11.52 – Opens in a new window Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene – Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E13.51 – E13.52 – Opens in a new window Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene – Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene
E16.3 – E16.8 – Opens in a new window Increased secretion of glucagon – Other specified disorders of pancreatic internal secretion
E24.0 Pituitary-dependent Cushing’s disease
E24.2 – E27.9 – Opens in a new window Drug-induced Cushing’s syndrome – Disorder of adrenal gland, unspecified
E28.2 Polycystic ovarian syndrome
E35 – E36.12 – Opens in a new window Disorders of endocrine glands in diseases classified elsewhere – Accidental puncture and laceration of an endocrine system organ or structure during other procedure
E74.00 – E74.09 – Opens in a new window Glycogen storage disease, unspecified – Other glycogen storage disease
E83.10 – E83.19 – Opens in a new window Disorder of iron metabolism, unspecified – Other disorders of iron metabolism
E84.0 – E85.9 – Opens in a new window Cystic fibrosis with pulmonary manifestations – Amyloidosis, unspecified
E89.6 Postprocedural adrenocortical (-medullary) hypofunction

Texas Medicaid Benefit Changes

The following limitations apply to added CT and MRI procedure codes 74176, 74177, and 74178 for Texas Medicaid.

Computed tomography procedure codes 74176, 74177, and 74178 may be reimbursed as follows:

The total component may be reimbursed to NP, CNS, PA, physician, radiation treatment center, portable X-ray supplier, radiological laboratory, and physiological laboratory providers for services that are rendered in the office setting; and to radiation treatment center and hospital providers for services that are rendered in the outpatient hospital setting.

The professional interpretation component may be reimbursed to NP, CNS, PA, and physician providers for services that are rendered in the office setting; and to physician providers for services that are rendered in the inpatient hospital or outpatient hospital setting.

The technical component may be reimbursed to NP, CNS, PA, physician, radiation treatment center, portable X-ray supplier, radiological laboratory, and physiological laboratory providers for services that are rendered in the office setting; and to radiation treatment center providers for services that are rendered in the outpatient hospital setting. Prior authorization is required and must be submitted to the MedSolutions Radiology Prior Authorization Department.

For more information about authorization requirements, providers may refer to the 2011 Texas Medicaid Provider Procedures Manual, (Vol. 2) Radiology and Laboratory Services Handbook, subsection 3.2.5 “Authorization Requirements for CT, CTA, MRI, fMRI, MRA, PET, and Cardiac Nuclear Imaging Services.” One radiology procedure code may be reimbursed per day. If an additional radiology procedure is medically necessary, a second procedure code may be reimbursed the same day when it is billed with modifier 76