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Attachment A- Codes with GT modifier
Procedure Description
37766 - STAB PHLEBECTOMY OF VARICOSE VEINS, ONE EXTREMITY; MORE THAN 20 INCISIONS
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
Attachment A- Codes with GT modifier
Procedure DescriptionProcedure Code
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
Attachment A- Codes with GT modifier
Procedure DescriptionProcedure Code
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
Attachment A- Codes with GT modifier
Procedure DescriptionProcedure Code
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
Attachment A- Codes with GT modifier
Procedure DescriptionProcedure Code
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
Attachment A- Codes with GT modifier
Procedure DescriptionProcedure Code
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
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
Attachment A-Codes with the GQ modifier 1/20/11
Procedure DescriptionProcedure Code
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
Attachment A-Codes with the GQ modifier 1/20/11
Procedure DescriptionProcedure Code
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
Attachment A-Codes with the GQ modifier 1/20/11
Procedure DescriptionProcedure Code
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
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
AHCCCS TELE-HEALTH TELE-MEDICINE
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
AHCCCS TELE-HEALTH TELE-MEDICINE
TELE-COMMUNICATIONS Radiological Global Services 70481 With contrast material(s) 26
TC
70482 Without contrast material, followed by contrast material(s) and further sections
26 TC
70486 Computed tomography, maxillofacial area; without contrast material
26 TC
70487 With contrast material(s) 26 TC
70488 Without contrast material, followed by contrast material(s) and further sections
26 TC
70490 Computed tomography, soft tissue neck; without contrast material
26 TC
70491 With contrast material(s) 26 TC
70492 Without contrast material, followed by contrast material(s) and further sections
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
70542 With 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
70545 With contrast material(s) 26 TC
70546 Without contrast material, followed by contrast material(s) and further sequences
26 TC
70547 Magnetic resonance angiography, neck; without contrast material(s)
26 TC
70548 With contrast material(s) 26 TC
70549 Without contrast material, followed by contrast material(s) and further sequences
26 TC
August 2011 3
AHCCCS TELE-HEALTH TELE-MEDICINE
TELE-COMMUNICATIONS Radiological Global Services 70551 Magnetic resonance (eg, proton)
imaging, brain (including brain stem); without contrast material
26 TC
70552 With contrast material(s) 26 TC
70553 Without contrast material, followed by contrast material(s) and further sequences
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
70558 With contrast material(s) 26 TC
70559 Without contrast material, followed by contrast material(s) and further sequences
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;
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
71551 with 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
AHCCCS TELE-HEALTH TELE-MEDICINE
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
72125 Computed tomography, cervical spine; without contrast material
26 TC
72126 with contrast material 26 TC
72127 Without contrast material, followed by contrast material(s) and further sections
26 TC
72128 Computed tomography, thoracic spine; without contrast material
26 TC
72129 with 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
72132 with contrast material 26 TC
72133 without contrast material, followed by contrast material(s) and further sections
26 TC
August 2011 6
AHCCCS TELE-HEALTH TELE-MEDICINE
TELE-COMMUNICATIONS Radiological Global Services 72141 Magnetic resonance (eg. Proton)
imaging, spinal canal and contents, cervical; without contrast material
26 TC
72142 with contrast material(s) 26 TC
72146 Magnetic resonance (eg. Proton) imaging, spinal canal and contents, thoracic; without contrast material
26 TC
72147 with contrast material(s) 26 TC
72148 Magnetic resonance (eg. Proton) imaging, spinal canal and contents, lumbar; without contrast material
26 TC
72149 with contrast material(s) 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
72193 with contrast material(s) 26 TC
72194 without contrast material, followed by contrast material(s) and further sections
26 TC
72195 Magnetic resonance (eg. Proton) imaging, pelvis; without contrast material(s)
26 TC
August 2011 7
AHCCCS TELE-HEALTH TELE-MEDICINE
TELE-COMMUNICATIONS Radiological Global Services 72196 with contrast material(s) 26
TC
72197 without contrast material(s), followed by contrast material(s) and further sequences
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
AHCCCS TELE-HEALTH TELE-MEDICINE
TELE-COMMUNICATIONS Radiological Global Services 73020 Radiologic examination, shoulder; 1
view 26 TC
73030 complete, minimum of 2 views 26 TC
73040 Radiologic examination, shoulder, arthrography, radiological supervision and interpretation
26 TC
73050 Radiologic examination; acromioclavicular joints, bilateral, with or without weighted distraction
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
73701 with contrast material(s) 26 TC
73702 without contrast material, followed by contrast material(s) and further sections
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
AHCCCS TELE-HEALTH TELE-MEDICINE
TELE-COMMUNICATIONS Radiological Global Services 73719 with contrast material(s) 26
TC
73720 without contrast material(s), followed by contrast material(s) and further sequences
26 TC
73721 Magnetic resonance (eg. proton) imaging, any joint of lower extremity; without contrast material
26 TC
73722 with contrast material(s) 26 TC
73723 without contrast material(s), followed by contrast material(s) and further sequences
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
74160 with contrast material(s) 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
74177 with contrast material(s) 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
AHCCCS TELE-HEALTH TELE-MEDICINE
TELE-COMMUNICATIONS Radiological Global Services 74181 Magnetic resonance (eg. proton)
imaging, abdomen; without contrast material(s)
26 TC
74182 with 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
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
AHCCCS TELE-HEALTH TELE-MEDICINE
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
AHCCCS TELE-HEALTH TELE-MEDICINE
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
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
AHCCCS TELE-HEALTH TELE-MEDICINE
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
AHCCCS TELE-HEALTH TELE-MEDICINE
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
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
AHCCCS TELE-HEALTH TELE-MEDICINE
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
AHCCCS TELE-HEALTH TELE-MEDICINE
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
AHCCCS TELE-HEALTH TELE-MEDICINE
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
+ 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
AHCCCS TELE-HEALTH TELE-MEDICINE
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
AHCCCS TELE-HEALTH TELE-MEDICINE
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
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
AHCCCS TELE-HEALTH TELE-MEDICINE
TELE-COMMUNICATIONS Radiological Global Services 76001 Fluoroscopy, physician time more than
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
AHCCCS TELE-HEALTH TELE-MEDICINE
TELE-COMMUNICATIONS Radiological Global Services 76390 Magnetic resonance spectroscopy 26
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
AHCCCS TELE-HEALTH TELE-MEDICINE
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
76810 each additional gestation (List separately in addition to code for primary procedure)
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
76812 each additional gestation (List separately in addition to code for primary procedure)
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
AHCCCS TELE-HEALTH TELE-MEDICINE
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
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
AHCCCS TELE-HEALTH TELE-MEDICINE
TELE-COMMUNICATIONS Radiological Global Services 76942 Ultrasonic guidance for needle
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)
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
AHCCCS TELE-HEALTH TELE-MEDICINE
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
77059 bilateral 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)
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
AHCCCS TELE-HEALTH TELE-MEDICINE
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
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
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
AHCCCS TELE-HEALTH TELE-MEDICINE
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)
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)
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
78202 with vascular flow 26 TC
78205 Liver imaging (SPECT) 26 TC
78206 with vascular flow 26 TC
78215 Liver and spleen imaging; static only 26 TC
78216 with vascular flow 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
AHCCCS TELE-HEALTH TELE-MEDICINE
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
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
78305 multiple areas 26 TC
78306 whole body 26 TC
78315 3 phase study 26 TC
78320 tomographic (SPECT) 26 TC
August 2011 40
AHCCCS TELE-HEALTH TELE-MEDICINE
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
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
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
including introduction of material); cisternography
26 TC
78635 ventriculography 26 TC
78645 shunt evaluation 26 TC
78647 tomographic (SPECT) 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
78701 with vascular flow 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
78710 tomographic (SPECT) 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
AHCCCS TELE-HEALTH TELE-MEDICINE
TELE-COMMUNICATIONS Radiology Services 78800 Radiopharmaceutical localization of
tumor or distribution of radiopharmaceutical agent(s); limited area
26 TC
78801 multiple areas 26 TC
78802 whole body, single day imaging 26 TC
78803 tomographic (SPECT) 26 TC
78804 whole body, requiring 2 or more days imaging
26 TC
78805 Radiopharmaceutical localization of inflammatory process; limited area
26 TC
78806 whole body 26 TC
78807 tomographic (SPECT) 26 TC
78808 Injection procedure for radiopharmaceutical localization by non-imaging probe study, intravenous (eg, parathyroid adenoma)