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931 Brain Imaging CPT, HCPCS and Diagnoses Codes

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Medical Policy Brain Imaging CPT, HCPCS and Diagnoses Codes Policy Number: 931 BCBSA Reference Number: N/A NCD/LCD: N/A Related Policies • Medicare Advantage: Advanced Imaging/Radiology and Sleep Disorder Management Clinical and Utilization Guidance Redirect, #923 • Advanced Imaging/Radiology CPT and HCPCS Codes, #900 • Advanced Imaging/Radiology, #968 • Oncologic Imaging CPT, HCPCS and Diagnoses Codes, #929 • Abdomen and Pelvic Imaging CPT, HCPCS and Diagnoses Codes, #930 • Chest Imaging CPT, HCPCS and Diagnoses Codes, #932 • Extremity Imaging CPT, HCPCS and Diagnoses Codes, #933 • Head and Neck Imaging CPT, HCPCS and Diagnoses Codes, #934 • Spine Imaging CPT, HCPCS and Diagnoses Codes, #935 • Vascular Imaging CPT, HCPCS and Diagnoses Codes, #936 Table of Contents Commercial Products .................................................................................................................................... 1 Medicare Advantage Products ...................................................................................................................... 2 CPT Codes / HCPCS Codes / ICD Codes .................................................................................................... 2 CPT Codes: 70450, 70460, 70470 CT head/brain ....................................................................................... 2 CPT codes: 70551, 70552, 70553 MRI brain............................................................................................ 115 CPT codes: 70554, 70555 MRI brain functional ....................................................................................... 178 CPT codes: 78608, 78609 Brain imaging PET ......................................................................................... 179 CPT codes: 70480, 70481, 70482 CT of orbit .......................................................................................... 182 Policy History ............................................................................................................................................ 226 Disclaimer:................................................................................................................................................. 227 Commercial Products The following CPT and HCPCS codes are in-scope under the AIM Advanced Imaging/Radiology Management Program for Commercial Managed Care (HMO and POS) and Commercial PPO and EPO. For medical necessity criteria, see AIM Clinical Appropriateness Guidelines for Advanced Imaging/Radiology. 1 Medicare Advantage Products The following CPT and HCPCS codes are in-scope under the AIM Advanced Imaging/Radiology Management Program for Medicare HMO and PPO. For medical necessity criteria, see AIM Clinical Appropriateness Guidelines for Advanced Imaging/Radiology. CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member. Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable. The following codes are included below for informational purposes only; this is not an all-inclusive list. CPT Codes: 70450, 70460, 70470 CT head/brain CPT codes Code Description 70450 CT head/brain, without contrast 70460 CT head/brain, with contrast 70470 CT head/brain, without contrast, followed by re-imaging with contrast ICD-10 Codes ICD-10 Code Description A17.0 Tuberculous meningitis A17.1 Meningeal tuberculoma A17.81 Tuberculoma of brain and spinal cord A17.82 Tuberculous meningoencephalitis A17.83 Tuberculous neuritis A17.89 Other tuberculosis of nervous system A41.9 Sepsis, unspecified organism A42.81 Actinomycotic meningitis A42.82 Actinomycotic encephalitis A50.40 Late congenital neurosyphilis, unspecified A50.41 Late congenital syphilitic meningitis A50.42 Late congenital syphilitic encephalitis A50.43 Late congenital syphilitic polyneuropathy A50.45 Juvenile general paresis A50.49 Other late congenital neurosyphilis A52.10 Symptomatic neurosyphilis, unspecified A52.11 Tabes dorsalis A52.12 Other cerebrospinal syphilis A52.13 Late syphilitic meningitis A52.14 Late syphilitic encephalitis A52.15 Late syphilitic neuropathy A52.16 Charcot's arthropathy (tabetic) A52.17 General paresis A52.19 Other symptomatic neurosyphilis 2 A52.2 Asymptomatic neurosyphilis A52.3 Neurosyphilis, unspecified A81.00 Creutzfeldt-Jakob Disease, Unspecified A81.01 Variant Creutzfeldt-Jakob Disease A81.09 Other Creutzfeldt-Jakob Disease A81.2 Progressive multifocal leukoencephalopathy A81.89 Other atypical virus infections of central nervous system A81.9 Atypical virus infection of central nervous system, unspecified A82.0 Sylvatic rabies A82.1 Urban rabies A82.9 Rabies, unspecified A83.0 Japanese encephalitis A83.1 Western equine encephalitis A83.2 Eastern equine encephalitis A83.3 St Louis encephalitis A83.4 Australian encephalitis A83.5 California encephalitis A83.6 Rocio virus disease A83.8 Other mosquito-borne viral encephalitis A83.9 Mosquito-borne viral encephalitis, unspecified A85.0 Enteroviral encephalitis A85.1 Adenoviral encephalitis A85.2 Arthropod-borne viral encephalitis, unspecified A85.8 Other specified viral encephalitis A86 Unspecified viral encephalitis A87.0 Enteroviral meningitis A87.1 Adenoviral meningitis A87.2 Lymphocytic choriomeningitis A87.8 Other viral meningitis A87.9 Viral meningitis, unspecified A88.8 Other specified viral infections of central nervous system A89 Unspecified viral infection of central nervous system B00.3 Herpesviral meningitis B01.11 Varicella encephalitis and encephalomyelitis B02.29 Other postherpetic nervous system involvement B05.0 Measles complicated by encephalitis B06.01 Rubella encephalitis B06.81 Rubella pneumonia B06.89 Other rubella complications B20 Human immunodeficiency virus [HIV] disease B25.0 Cytomegaloviral pneumonitis B25.1 Cytomegaloviral hepatitis B25.2 Cytomegaloviral pancreatitis 3 B25.8 Other cytomegaloviral diseases B25.9 Cytomegaloviral disease, unspecified B26.2 Mumps encephalitis B37.5 Candidal meningitis B38.4 Coccidioidomycosis meningitis B44.0 Invasive pulmonary aspergillosis B44.1 Other pulmonary aspergillosis B44.2 Tonsillar aspergillosis B44.7 Disseminated aspergillosis B44.89 Other forms of aspergillosis B44.9 Aspergillosis, unspecified B45.0 Pulmonary cryptococcosis B45.1 Cerebral cryptococcosis B45.2 Cutaneous cryptococcosis B45.3 Osseous cryptococcosis B45.7 Disseminated cryptococcosis B45.8 Other forms of cryptococcosis B45.9 Cryptococcosis, unspecified B48.4 Penicillosis B48.8 Other specified mycoses B58.2 Toxoplasma meningoencephalitis B64 Unspecified protozoal disease B69.0 Cysticercosis of central nervous system B69.1 Cysticercosis of eye B69.81 Myositis in cysticercosis B69.89 Cysticercosis of other sites B69.9 Cysticercosis, unspecified B75 Trichinellosis B89 Unspecified parasitic disease B90.0 Sequelae of central nervous system tuberculosis B94.1 Sequelae of viral encephalitis B97.10 Unspecified enterovirus as the cause of diseases classified elsewhere B97.33 Human T-cell lymphotrophic virus, type I [HTLV-I] as the cause of diseases classified elsewhere B97.89 Other viral agents as the cause of diseases classified elsewhere B99.9 Unspecified infectious disease D45 Polycythemia vera D47.01 Cutaneous mastocytosis D47.02 Systemic mastocytosis D47.09 Other mast cell neoplasms of uncertain behavior D47.3 Essential (hemorrhagic) thrombocythemia D56.0 Alpha Thalassemia D56.1 Beta Thalassemia 4 D56.2 Delta-Beta Thalassemia D56.3 Thalassemia Minor D56.5 Hemoglobin E-Beta Thalassemia D56.8 Other Thalassemias D56.9 Thalassemia, Unspecified D57.00 Hb-SS disease with crisis, unspecified D57.01 Hb-SS disease with acute chest syndrome D57.02 Hb-SS disease with splenic sequestration D57.03 Hb-SS disease with cerebral vascular involvement D57.09 Hb-SS disease with crisis with other specified complication D57.1 Sickle-cell disease without crisis D57.20 Sickle-cell/Hb-C disease without crisis D57.211 Sickle-cell/Hb-C disease with acute chest syndrome D57.212 Sickle-cell/Hb-C disease with splenic sequestration D57.213 Sickle-cell/Hb-C disease with cerebral vascular involvement D57.218 Sickle-cell/Hb-C disease with crisis with other specified complication D57.219 Sickle-cell/Hb-C disease with crisis, unspecified D57.3 Sickle-cell trait D57.40 Sickle-Cell Thalassemia Without Crisis D57.413 Sickle-cell thalassemia, unspecified, with cerebral vascular involvement D57.418 Sickle-cell thalassemia, unspecified, with crisis with other specified complication D57.419 Sickle-Cell Thalassemia With Crisis, Unspecified D57.42 Sickle-cell thalassemia beta zero without crisis D57.431 Sickle-cell thalassemia beta zero with acute chest syndrome D57.432 Sickle-cell thalassemia beta zero with splenic sequestration D57.433 Sickle-cell thalassemia beta zero with cerebral vascular involvement D57.438 Sickle-cell thalassemia beta zero with crisis with other specified complication D57.439 Sickle-cell thalassemia beta zero with crisis, unspecified D57.44 Sickle-cell thalassemia beta plus without crisis D57.451 Sickle-cell thalassemia beta plus with acute chest syndrome D57.452 Sickle-cell thalassemia beta plus with splenic sequestration D57.453 Sickle-cell thalassemia beta plus with cerebral vascular involvement D57.458 Sickle-cell thalassemia beta plus with crisis with other specified complication
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