Horizon NJ Health Pre-Authorization Codes Managed by eviCore

Tikka Attach





Horizon NJ Medicaid and FIDE-SNP
Radiology and Cardiology Code list

Code Code Description







33214


Upgrade of implanted pacemaker system, conversion of single
chamber system to dual chamber system (includes removal of
previously placed pulse generator, testing of existing lead,
insertion of new lead, insertion of new generator)


33221

Insertion of pacemaker pulse generator only; with existing
multiple leads








33224

Insertion of pacing electrode, cardiac venous system, for left
ventricular pacing, with attachment to previously placed
pacemaker or pacing cardioverter-defibrillator pulse generator
(including revision of pocket, removal, insertion, and/or
replacement of existing generator)









33225


Insertion of pacing electrode, cardiac venous system, for left
ventricular pacing, at time of insertion of pacing cardioverter-
defibrillator or pacemaker pulse generator (including upgrade
to dual chamber system and pocket revision) (list separately in
addition to code for primary procedure)





33227


Removal of permanent pacemaker pulse generator with
replacement of pacemaker pulse generator; single lead system





33228


Removal of permanent pacemaker pulse generator with
replacement of pacemaker pulse generator; dual lead system





33229

Removal of permanent pacemaker pulse generator with
replacement of pacemaker pulse generator; multiple lead
system


33230

Insertion of pacing cardioverter-defibrillator pulse generator
only; with existing dual leads


33231

Insertion of pacing cardioverter-defibrillator pulse generator
only; with existing multiple leads


33240

Insertion of pacing cardioverter-defibrillator pulse generator
only; with existing single lead





33249

Insertion or replacement of permanent pacing cardioverter-
defibrillator system with transvenous lead(s), single or dual
chamber





33262

Removal of pacing cardioverter-defibrillator pulse generator
with replacement of pacing cardioverter-defibrillator pulse
generator; single lead system





33263

Removal of pacing cardioverter-defibrillator pulse generator
with replacement of pacing cardioverter-defibrillator pulse
generator; dual lead system




Code Code Description




33264

Removal of pacing cardioverter-defibrillator pulse generator
with replacement of pacing cardioverter-defibrillator pulse
generator; multiple lead system












33270

Insertion or replacement of permanent subcutaneous
implantable defibrillator system, with subcutaneous electrode,
including defibrillation
threshold evaluation, induction of arrhythmia, evaluation of
sensing for
arrhythmia termination, and programming or reprogramming
of sensing
or therapeutic parameters, when performed

72275 Epidurography, radiological supervision and interpretation


72285
Discography, cervical or thoracic, radiological supervision and
interpretation


72295

Discography, lumbar, radiological supervision and
interpretation


74261

Computed tomographic (CT) colonography, diagnostic,
including image postprocessing; without contrast material





74262

Computed tomographic (CT) colonography, diagnostic,
including image postprocessing; with contrast material(s)
including non-contrast images, if performed


74263

Computed tomographic (CT) colonography, screening,
including image postprocessing


78499


Unlisted cardiovascular procedure, diagnostic nuclear medicine


78699

Unlisted nervous system procedure, diagnostic nuclear
medicine


78999


Unlisted miscellaneous procedure, diagnostic nuclear medicine






0042T

Cerebral perfusion analysis using computed tomography with
contrast administration, including post-processing of
parametric maps with determination of cerebral blood flow,
cerebral blood volume, and mean transit time
















0501T


Noninvasive estimated coronary fractional flow reserve (FFR)
derived from coronary computed tomography angiography
data using computation fluid dynamics physiologic simulation
software
analysis of functional data to assess the severity of coronary
artery disease; data preparation and transmission, analysis of
fluid dynamics and simulated maximal coronary hyperemia,
generation of estimated FFR model, with anatomical data
review in comparison with estimated FFR model to reconcile
discordant data, interpretation and report




Code Code Description








0502T


Noninvasive estimated coronary fractional flow reserve (FFR)
derived from coronary computed tomography angiography
data using computation fluid dynamics physiologic simulation
software analysis of functional data to assess the severity of
coronary artery disease; data preparation and transmission











0503T

Noninvasive estimated coronary fractional flow reserve (FFR)
derived from coronary computed tomography angiography
data using computation fluid dynamics physiologic simulation
software analysis of functional data to assess the severity of
coronary artery disease; analysis of fluid dynamics and
simulated maximal coronary hyperemia, and generation of
estimated FFR model












0504T


Noninvasive estimated coronary fractional flow reserve (FFR)
derived from coronary computed tomography angiography
data using computation fluid dynamics physiologic simulation
software analysis of functional data to assess the severity of
coronary artery disease; anatomical data review in comparison
with estimated FFR model to reconcile discordant data,
interpretation and report


C8921

Transthoracic echocardiography with contrast for congenital
cardiac anomalies; complete


C8922

Transthoracic echocardiography with contrast for congenital
cardiac anomalies; follow-up or limited study





C8923

Transthoracic echocardiography with contrast, real-time with
image documentation (2d) with or without m-mode
recording;complete





C8924

Transthoracic echocardiography with contrast, real-time with
image documentation (2d) with or without m-mode recording;
follow-up or limited study






C8925

Transeophageal echocardiography (tee) with contrast, real
time with image documentation (2d) (with or without m-mode
recording); including probe placement, image acquistion,
interpretation and report





C8926

Transeophageal echocardiography (tee) with contrast for
congenital cardiac anomalies; including probe placement,
image acquistion, interpretation and report








C8928

Transthoracic echocardiography with contrast, real-time with
image documentation (2d), with or without m-mode recording,
during rest and cariovascular stress test using treadmill, bicycle
exercise and/or pharmacologically induced stress, with
interpretati




Code Code Description







C8929

Transthoracic echocardiography, with contrast, or without
contrast followed by with contrast, real-time with image
documentation (2d), includes m-mode recording, when
performed, complete, with spectral doppler echocardiography,
and with color flow doppler








C8930

Transthoracic echocardiography, with contrast, or without
contrast followed by with contrast, real-time with image
documentation (2d), includes m-mode recording, when
performed, during rest and cardiovascular stress test using
treadmill, bicycle exercise

G0297 Low dose cancer screening


70336
Magnetic resonance (eg, proton) imaging, temporomandibular
joint(s)


70450

Computed tomography, head or brain; without contrast
material


70460

Computed tomography, head or brain; with contrast
material(s)





70470


Computed tomography, head or brain; without contrast
material, followed by contrast material(s) and further sections


70480

Computed tomography, orbit, sella, or posterior fossa or outer,
middle, or inner ear; without contrast material


70481

Computed tomography, orbit, sella, or posterior fossa or outer,
middle, or inner ear; with contrast material(s)





70482

Computed tomography, orbit, sella, or posterior fossa or outer,
middle, or inner ear; without contrast material, followed by
contrast material(s) and further sections


70486

Computed tomography, maxillofacial area; without contrast
material


70487

Computed tomography, maxillofacial area; with contrast
material(s)





70488


Computed tomography, maxillofacial area; without contrast
material, followed by contrast material(s) and further sections


70490

Computed tomography, soft tissue neck; without contrast
material


70491

Computed tomography, soft tissue neck; with contrast
material(s)





70492


Computed tomography, soft tissue neck; without contrast
material followed by contrast material(s) and further sections





70496

Computed tomographic angiography, head, with contrast
material(s), including noncontrast images, if performed, and
image postprocessing




Code Code Description




70498

Computed tomographic angiography, neck, with contrast
material(s), including noncontrast images, if performed, and
image postprocessing


70540

Magnetic resonance (eg, proton) imaging, orbit, face, and/or
neck; without contrast material(s)


70542

Magnetic resonance (eg, proton) imaging, orbit, face, and/or
neck; with contrast material(s)





70543

Magnetic resonance (eg, proton) imaging, orbit, face, and/or
neck; without contrast material(s), followed by contrast
material(s) and further sequences


70544

Magnetic resonance angiography, head; without contrast
material(s)


70545

Magnetic resonance angiography, head; with contrast
material(s)





70546

Magnetic resonance angiography, head; without contrast
material(s), followed by contrast material(s) and further
sequences


70547

Magnetic resonance angiography, neck; without contrast
material(s)


70548

Magnetic resonance angiography, neck; with contrast
material(s)





70549

Magnetic resonance angiography, neck; without contrast
material(s), followed by contrast material(s) and further
sequences


70551

Magnetic resonance (eg, proton) imaging, brain (including
brain stem); without contrast material


70552

Magnetic resonance (eg, proton) imaging, brain (including
brain stem); with contrast material(s)





70553

Magnetic resonance (eg, proton) imaging, brain (including
brain stem); without contrast material, followed by contrast
material(s) and further sequences






70554

Magnetic resonance imaging, brain, functional MRI; including
test selection and administration of repetitive body part
movement and/or visual stimulation, not requiring physician or
psychologist administration





70555

Magnetic resonance imaging, brain, functional MRI; requiring
physician or psychologist administration of entire
neurofunctional testing

71250 Computed tomography, thorax; without contrast material
71260 Computed tomography, thorax; with contrast material(s)


71270

Computed tomography, thorax; without contrast material,
followed by contrast material(s) and further sections





71275

Computed tomographic angiography, chest (noncoronary),
with contrast material(s), including noncontrast images, if
performed, and image postprocessing




Code Code Description




71550

Magnetic resonance (eg, proton) imaging, chest (eg, for
evaluation of hilar and mediastinal lymphadenopathy); without
contrast material(s)





71551

Magnetic resonance (eg, proton) imaging, chest (eg, for
evaluation of hilar and mediastinal lymphadenopathy); with
contrast material(s)






71552

Magnetic resonance (eg, proton) imaging, chest (eg, for
evaluation of hilar and mediastinal lymphadenopathy); without
contrast material(s), followed by contrast material(s) and
further sequences


71555

Magnetic resonance angiography, chest (excluding
myocardium), with or without contrast material(s)


72125

Computed tomography, cervical spine; without contrast
material


72126


Computed tomography, cervical spine; with contrast material





72127


Computed tomography, cervical spine; without contrast
material, followed by contrast material(s) and further sections


72128

Computed tomography, thoracic spine; without contrast
material


72129


Computed tomography, thoracic spine; with contrast material





72130


Computed tomography, thoracic spine; without contrast
material, followed by contrast material(s) and further sections


72131

Computed tomography, lumbar spine; without contrast
material

72132 Computed tomography, lumbar spine; with contrast material




72133


Computed tomography, lumbar spine; without contrast
material, followed by contrast material(s) and further sections


72141

Magnetic resonance (eg, proton) imaging, spinal canal and
contents, cervical; without contrast material


72142

Magnetic resonance (eg, proton) imaging, spinal canal and
contents, cervical; with contrast material(s)


72146

Magnetic resonance (eg, proton) imaging, spinal canal and
contents, thoracic; without contrast material


72147

Magnetic resonance (eg, proton) imaging, spinal canal and
contents, thoracic; with contrast material(s)


72148

Magnetic resonance (eg, proton) imaging, spinal canal and
contents, lumbar; without contrast material


72149

Magnetic resonance (eg, proton) imaging, spinal canal and
contents, lumbar; with contrast material(s)




Code Code Description




72156

Magnetic resonance (eg, proton) imaging, spinal canal and
contents, without contrast material, followed by contrast
material(s) and further sequences; cervical





72157

Magnetic resonance (eg, proton) imaging, spinal canal and
contents, without contrast material, followed by contrast
material(s) and further sequences; thoracic





72158

Magnetic resonance (eg, proton) imaging, spinal canal and
contents, without contrast material, followed by contrast
material(s) and further sequences; lumbar


72159

Magnetic resonance angiography, spinal canal and contents,
with or without contrast material(s)





72191

Computed tomographic angiography, pelvis, with contrast
material(s), including noncontrast images, if performed, and
image postprocessing

72192 Computed tomography, pelvis; without contrast material
72193 Computed tomography, pelvis; with contrast material(s)


72194

Computed tomography, pelvis; without contrast material,
followed by contrast material(s) and further sections


72195

Magnetic resonance (eg, proton) imaging, pelvis; without
contrast material(s)


72196

Magnetic resonance (eg, proton) imaging, pelvis; with contrast
material(s)





72197

Magnetic resonance (eg, proton) imaging, pelvis; without
contrast material(s), followed by contrast material(s) and
further sequences


72198

Magnetic resonance angiography, pelvis, with or without
contrast material(s)


73200

Computed tomography, upper extremity; without contrast
material


73201

Computed tomography, upper extremity; with contrast
material(s)





73202


Computed tomography, upper extremity; without contrast
material, followed by contrast material(s) and further sections





73206

Computed tomographic angiography, upper extremity, with
contrast material(s), including noncontrast images, if
performed, and image postprocessing


73218

Magnetic resonance (eg, proton) imaging, upper extremity,
other than joint; without contrast material(s)


73219

Magnetic resonance (eg, proton) imaging, upper extremity,
other than joint; with contrast material(s)





73220

Magnetic resonance (eg, proton) imaging, upper extremity,
other than joint; without contrast material(s), followed by
contrast material(s) and further sequences


73221

Magnetic resonance (eg, proton) imaging, any joint of upper
extremity; without contrast material(s)




Code Code Description


73222
Magnetic resonance (eg, proton) imaging, any joint of upper
extremity; with contrast material(s)





73223

Magnetic resonance (eg, proton) imaging, any joint of upper
extremity; without contrast material(s), followed by contrast
material(s) and further sequences


73225

Magnetic resonance angiography, upper extremity, with or
without contrast material(s)


73700

Computed tomography, lower extremity; without contrast
material


73701

Computed tomography, lower extremity; with contrast
material(s)





73702


Computed tomography, lower extremity; without contrast
material, followed by contrast material(s) and further sections





73706

Computed tomographic angiography, lower extremity, with
contrast material(s), including noncontrast images, if
performed, and image postprocessing


73718

Magnetic resonance (eg, proton) imaging, lower extremity
other than joint; without contrast material(s)


73719

Magnetic resonance (eg, proton) imaging, lower extremity
other than joint; with contrast material(s)





73720

Magnetic resonance (eg, proton) imaging, lower extremity
other than joint; without contrast material(s), followed by
contrast material(s) and further sequences


73721

Magnetic resonance (eg, proton) imaging, any joint of lower
extremity; without contrast material


73722

Magnetic resonance (eg, proton) imaging, any joint of lower
extremity; with contrast material(s)





73723

Magnetic resonance (eg, proton) imaging, any joint of lower
extremity; without contrast material(s), followed by contrast
material(s) and further sequences


73725

Magnetic resonance angiography, lower extremity, with or
without contrast material(s)


74150


Computed tomography, abdomen; without contrast material

74160 Computed tomography, abdomen; with contrast material(s)




74170


Computed tomography, abdomen; without contrast material,
followed by contrast material(s) and further sections





74174

Computed tomographic angiography, abdomen and pelvis,
with contrast material(s), including noncontrast images, if
performed, and image postprocessing





74175

Computed tomographic angiography, abdomen, with contrast
material(s), including noncontrast images, if performed, and
image postprocessing




Code Code Description


74176
Computed Tomography, Abdomen And Pelvis; Without
Contrast Material


74177

Computed Tomography, Abdomen And Pelvis; With Contrast
Material(S)






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


74181

Magnetic resonance (eg, proton) imaging, abdomen; without
contrast material(s)


74182

Magnetic resonance (eg, proton) imaging, abdomen; with
contrast material(s)





74183

Magnetic resonance (eg, proton) imaging, abdomen; without
contrast material(s), followed by with contrast material(s) and
further sequences


74185

Magnetic resonance angiography, abdomen, with or without
contrast material(s)

74712 MRI Fetal single/first gestation
74713 MRI Fetal each additional gestation


75557

Cardiac magnetic resonance imaging for morphology and
function without contrast material;


75559

Cardiac magnetic resonance imaging for morphology and
function without contrast material; with stress imaging





75561

Cardiac magnetic resonance imaging for morphology and
function without contrast material(s), followed by contrast
material(s) and further sequences;





75563

Cardiac magnetic resonance imaging for morphology and
function without contrast material(s), followed by contrast
material(s) and further sequences; with stress imaging





75571

COMPUTED TOMOGRAPHY, HEART, WITHOUT CONTRAST
MATERIAL, WITH QUANTITIVE EVALUATION OF CORONARY
CALCIUM

75572 CARDIAC CT FOR MORPHOLOGY
75573 CARDIAC CT FOR CONGENITAL HD
75574 CORONARY CTA






75635

Computed tomographic angiography, abdominal aorta and
bilateral iliofemoral lower extremity runoff, with contrast
material(s), including noncontrast images, if performed, and
image postprocessing






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




Code Code Description





76377

3D rendering with interpretation and reporting of computed
tomography, magnetic resonance imaging, ultrasound, or
other tomographic modality; requiring image postprocessing
on an independent workstation

76380 Computed tomography, limited or localized follow-up study
76390 Magnetic resonance spectroscopy
76391 Magnetic resonance (eg, vibration) elastography


76497

Unlisted computed tomography procedure (eg, diagnostic,
interventional)


76498

Unlisted magnetic resonance procedure (eg, diagnostic,
interventional)






77021


Magnetic resonance imaging guidance for needle placement
(eg, for biopsy, needle aspiration, injection, or placement of
localization device) radiological supervision and interpretation


77022

Magnetic resonance imaging guidance for, and monitoring of,
parenchymal tissue ablation


77046

Magnetic resonance imaging, breast, without contrast
material; unilateral


77047

Magnetic resonance imaging, breast, without contrast
material; bilateral









77048

Magnetic resonance imaging, breast, without and with contrast
material(s),
including computer-aided detection (CAD real-time lesion
detection,
characterization and pharmacokinetic analysis), when
performed; unilateral









77049

Magnetic resonance imaging, breast, without and with contrast
material(s),
including computer-aided detection (CAD real-time lesion
detection,
characterization and pharmacokinetic analysis), when
performed; bilateral


77078

Computed tomography, bone mineral density study, 1 or more
sites; axial skeleton (eg, hips, pelvis, spine)


77084

Magnetic resonance (eg, proton) imaging, bone marrow blood
supply






78012

THYROID UPTAKE, SINGLE RO MULTIPLEQUANTITATIVE
MEASUREMENT(S) (INCLUDING
STIMULATION,SUPPRESSION,OR DISCHARGE, WHEN
PERFORMED)


78013

THYROID IMAGING, (INCLUDING VASCULAR FLOW,WHEN
PERFORMED)




Code Code Description







78014

THYROID IMAGING, (INCLUDING VASCULAR FLOW,WHEN
PERFORMED); WITH SINGLE OR MULTIPLE UPTAKE(S)
QUANTITATIVE MEASUREMENT(S) (INCLUDING
STIMULATION,SUPPRESSION, OR DISCHARGE, WHEN
PERFORMED)


78015

Thyroid carcinoma metastases imaging; limited area (eg, neck
and chest only)


78016

Thyroid carcinoma metastases imaging; with additional studies
(eg, urinary recovery)

78018 Thyroid carcinoma metastases imaging; whole body


78020
Thyroid carcinoma metastases uptake (List separately in
addition to code for primary procedure)

78070 Parathyroid imaging




78071

PARATHYROID PLANAR IMAGING (INCLUDING
SEBTRACTION,WHEN PERFORMED); WITH TOMOGRAPHIC
(SPECT)








78072

PARATHYROID PLANAR IMAGING (INCLUDING
SEBTRACTION,WHEN PERFORMED); WITH TOMOGRAPHIC
(SPECT), AND CONCURRENTLY ACQUIRED
COMPUTEDTOMOGRPAHY (CT) FOR ANATOMICAL
LOCALIZATION.

78075 Adrenal imaging, cortex and/or medulla
78102 Bone marrow imaging; limited area
78103 Bone marrow imaging; multiple areas
78104 Bone marrow imaging; whole body
78185 Spleen imaging only, with or without vascular flow
78195 Lymphatics and lymph nodes imaging
78201 Liver imaging; static only
78202 Liver imaging; with vascular flow




78215 Liver and spleen imaging; static only
78216 Liver and spleen imaging; with vascular flow


78226

Hepatobiliary system imaging, including gallbladder when
present;





78227

Hepatobiliary system imaging, including gallbladder when
present; with pharmacologic intervention, including
quantitative measurement(s) when performed

78230 Salivary gland imaging;
78231 Salivary gland imaging; with serial images
78232 Salivary gland function study
78258 Esophageal motility
78261 Gastric mucosa imaging
78262 Gastroesophageal reflux study
78264 Gastric emptying imaging study (eg, solid, liquid, or both)
78265 Gastric emptying imaging study




Code Code Description
78266 Gastric emptying imaging study
78278 Acute gastrointestinal blood loss imaging


78290

Intestine imaging (eg, ectopic gastric mucosa, Meckel's
localization, volvulus)


78291

Peritoneal-venous shunt patency test (eg, for LeVeen, Denver
shunt)

78300 Bone and/or joint imaging; limited area
78305 Bone and/or joint imaging; multiple areas
78306 Bone and/or joint imaging; whole body
78315 Bone and/or joint imaging; three phase study


78429 Myocardial imaging, positron emission tomography (PET),

metabolic evaluation study (including ventricular wall motion[s]
and/or ejection fraction[s], when performed), single study; with
concurrently acquired computed tomography transmission scan

78430 Myocardial imaging, positron emission tomography (PET),
perfusion study (including ventricular wall motion[s] and/or
ejection fraction[s], when performed); single study, at rest or
stress (exercise or pharmacologic), with concurrently acquired
computed tomography transmission scan

78431 Myocardial imaging, positron emission tomography (PET),
perfusion study (including ventricular wall motion[s] and/or
ejection fraction[s], when performed); multiple studies at rest
and stress (exercise or pharmacologic), with concurrently
acquired computed tomography transmission scan

78432 Myocardial imaging, positron emission tomography (PET),
combined perfusion with metabolic evaluation study (including
ventricular wall motion[s] and/or ejection fraction[s], when
performed), dual radiotracer (eg, myocardial viability);

78433 Myocardial imaging, positron emission tomography (PET),
combined perfusion with metabolic evaluation study (including
ventricular wall motion[s] and/or ejection fraction[s], when
performed), dual radiotracer (eg, myocardial viability); with
concurrently acquired computed tomography transmission scan

78434 Absolute quantitation of myocardial blood flow (AQMBF),
positron emission tomography (PET), rest and pharmacologic
stress (List separately in addition to code for primary
procedure)






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
determinations

78428 Cardiac shunt detection


78445
Non-cardiac vascular flow imaging (ie, angiography,
venography)

78451 MPI, SPECT, SINGLE REST OR STRESS



78452 MPI, SPECT, MULTIPLE, REST OR STRESS
78453 MPI, PLANAR, SINGLE REST OR STRESS
78454 MPI, PLANAR, MULTIPLE, REST OR STRESS
78456 Acute venous thrombosis imaging, peptide
78457 Venous thrombosis imaging, venogram; unilateral
78458 Venous thrombosis imaging, venogram; bilateral


78459

Myocardial imaging, positron emission tomography (PET),
metabolic evaluation study (including ventricular wall
motion[s] and/or ejection fraction[s], when performed), single
study


78466

Myocardial imaging, infarct avid, planar; qualitative or
quantitative


78468

Myocardial imaging, infarct avid, planar; with ejection fraction
by first pass technique


78469

Myocardial imaging, infarct avid, planar; tomographic SPECT
with or without quantification






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






78473

Cardiac blood pool imaging, gated equilibrium; multiple
studies, wall motion study plus ejection fraction, at rest and
stress (exercise and/or pharmacologic), with or without
additional quantification






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




Code Code Description





78483

Cardiac blood pool imaging, (planar), first pass technique;
multiple studies, at rest and with stress (exercise and/ or
pharmacologic), wall motion study plus ejection fraction, with
or without quantification


78491

Myocardial imaging, positron emission tomography (PET), perfusion
study(including ventricular wall motion[s] and/or ejection fraction[s], when
performed); single study, at rest or stress (exercise or pharmacologic)




78492

Myocardial imaging, positron emission tomography (PET), perfusion
study(including ventricular wall motion[s] and/or ejection fraction[s], when
performed); multiple studies at rest and/or stress (exercise or pharmacologic)







78494

Cardiac blood pool imaging, gated equilibrium, SPECT, at rest,
wall motion study plus ejection fraction, with or without
quantitative processing






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)

78579 Pulmonary ventilation imaging (eg, aerosol or gas)
78580 Pulmonary perfusion imaging, particulate


78582

Pulmonary ventilation (eg, aerosol or gas) and perfusion
imaging


78597

Quantitative differential pulmonary perfusion, including
imaging when performed





78598


Quantitative differential pulmonary perfusion and ventilation
(eg, aerosol or gas), including imaging when performed

78600 Brain imaging, less than 4 static views;
78601 Brain imaging, less than 4 static views; with vascular flow
78605 Brain imaging, minimum 4 static views;
78606 Brain imaging, minimum 4 static views; with vascular flow




78608
Brain imaging, positron emission tomography (PET); metabolic
evaluation


78609

Brain imaging, positron emission tomography (PET); perfusion
evaluation

78610 Brain imaging, vascular flow only


78630
Cerebrospinal fluid flow, imaging (not including introduction of
material); cisternography


78635

Cerebrospinal fluid flow, imaging (not including introduction of
material); ventriculography


78645

Cerebrospinal fluid flow, imaging (not including introduction of
material); shunt evaluation








78650 Cerebrospinal fluid leakage detection and localization
78660 Radiopharmaceutical dacryocystography
78700 Kidney imaging morphology;
78701 Kidney imaging morphology; with vascular flow




Code Code Description


78707
Kidney imaging morphology; with vascular flow and function,
single study without pharmacological intervention





78708

Kidney imaging morphology; with vascular flow and function,
single study, with pharmacological intervention (eg,
angiotensin converting enzyme inhibitor and/or diuretic)






78709

Kidney imaging morphology; with vascular flow and function,
multiple studies, with and without pharmacological
intervention (eg, angiotensin converting enzyme inhibitor
and/or diuretic)


78725 Kidney function study, non-imaging radioisotopic study


78730

Urinary bladder residual study (List separately in addition to
code for primary procedure)


78740


Ureteral reflux study (radiopharmaceutical voiding cystogram)

78761 Testicular imaging with vascular flow


78800
Radiopharmaceutical localization of tumor, inflammatory process or distribution
of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging,
when performed); planar, single limited area (includes vascular flow and blood
pool imaging, when performed); planar, single (includes vascular flow and blood
pool imaging, when performed); planar, single




78801

Radiopharmaceutical localization of tumor, inflammatory process or distribution
of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging,
when performed); planar, 2 or more mulitple areas (eg, abdomen and pelvis,
head and chest), 1 or more days imaging or single area imaging over 2 or more
days







78802


Radiopharmaceutical localization of tumor, inflammatory process or distribution
of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging,
when performed); planar, whole body, single day imaging




78803

Radiopharmaceutical localization of tumor, inflammatory process or distribution
of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging,
when performed); tomographic (SPECT) , single area (eg, head, neck, chest,
pelvis), single day imaging







78804

Radiopharmaceutical localization of tumor, inflammatory process or distribution
of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging,
when performed); planar, whole body, requiring 2 or more days imaging





















78811

Positron emission tomography (PET) imaging; limited area (eg,
chest, head/neck)


78812

Positron emission tomography (PET) imaging; skull base to mid-
thigh

78813 Positron emission tomography (PET) imaging; whole body





78814

Positron emission tomography (PET) with concurrently
acquired computed tomography (CT) for attenuation
correction and anatomical localization imaging; limited area
(eg, chest, head/neck)




Code Code Description





78815

Positron emission tomography (PET) with concurrently
acquired computed tomography (CT) for attenuation
correction and anatomical localization imaging; skull base to
mid-thigh





78816

Positron emission tomography (PET) with concurrently
acquired computed tomography (CT) for attenuation
correction and anatomical localization imaging; whole body

78830 Radiopharmaceutical localization of tumor, inflammatory
process or distribution of radiopharmaceutical agent(s)
(includes vascular flow and blood pool imaging, when
performed); tomographic (SPECT) with concurrently acquired
computed tomography (CT) transmission scan for anatomical
review, localization and determination/detection of pathology,
single area (eg, head, neck, chest, pelvis), single day imaging

78831 Radiopharmaceutical localization of tumor, inflammatory
process or distribution of radiopharmaceutical agent(s)
(includes vascular flow and blood pool imaging, when
performed); tomographic (SPECT), minimum 2 areas (eg, pelvis
and knees, abdomen and pelvis), single day imaging, or single
area imaging over 2 or more days

78832 Radiopharmaceutical localization of tumor, inflammatory
process or distribution of radiopharmaceutical agent(s)
(includes vascular flow and blood pool imaging, when
performed); tomographic (SPECT) with concurrently acquired
computed tomography (CT) transmission scan for anatomical
review, localization and determination/detection of pathology,
minimum 2 areas (eg, pelvis and knees, abdomen and pelvis),
single day imaging, or single area imaging over 2 or more days


93303

Transthoracic echocardiography for congenital cardiac
anomalies; complete


93304

Transthoracic echocardiography for congenital cardiac
anomalies; follow-up or limited study








93306


Echocardiography, transthoracic, real-time with image
documentation (2D), includes M-mode recording, when
performed, complete, with spectral Doppler echocardiography,
and with color flow Doppler echocardiography






93307

Echocardiography, transthoracic, real-time with image
documentation (2D), includes M-mode recording, when
performed, complete, without spectral or color Doppler
echocardiography





93308

Echocardiography, transthoracic, real-time with image
documentation (2D), includes M-mode recording, when
performed, follow-up or limited study

93313 Echocardiography, transesophageal, placement of probe
93314 Echocardiography, transesophageal, image acquisition
93315 Transesophageal, echocardiography
93316 Transesophageal, echocardiography, placement of probe
93317 Transesophageal, echocardiography, image acquistion










93350

Echocardiography, transthoracic, real-time with image
documentation (2D), includes M-mode recording, when
performed, during rest and cardiovascular stress test using
treadmill, bicycle exercise and/or pharmacologically induced
stress, with interpretation








93351

Echocardiography, transthoracic, real-time with image
documentation (2D), includes M-mode recording, when
performed, during rest and cardiovascular stress test using
treadmill, bicycle exercise and/or pharmacologically induced
stress, with interpretation






93452


LEFT HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR LEFT VENTRICULOGRAPHY, IMAGING
SUPERVISION AND INTERPRETATION, WHEN PERFORMED






93453

COMBINED RIGHT AND LEFT HEART CATHETERIZATION
INCLUDING INTRAPROCEDURAL INJECTION(S) FOR LEFT
VENTRICULOGRAPHY, IMAGING SUPERVISION AND
INTERPRETATION, WHEN PERFORMED

93356 Myocardial strain imaging using speckle tracking-derived
assessment of myocardial mechanics (List separately in addition
to codes for echocardiography imaging)




Code Code Description







93454


CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING
SUPERVISION AND INTERPRETATION;












93455

CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING
SUPERVISION AND INTERPRETATION; WITH CATHETER
PLACEMENT(S) IN BYPASS GRAFT(S) (INTERNAL MAMMARY,
FREE ARTERIAL VENOUS GRAFTS) INCLUDING
INTRAPROCEDURAL INJECTION(S) FOR BYPASS GRAFT
ANGIOGRAPHY








93456

CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING
SUPERVISION AND INTERPRETATION; WITH RIGHT HEART
CATHETERIZATION















93457


CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING
SUPERVISION AND INTERPRETATION; WITH CATHETER
PLACEMENT(S) IN BYPASS GRAFT(S) (INTERNAL MAMMARY,
FREE ARTERIAL, VENOUS GRAFTS) INCLUDING
INTRAPROCEDURAL INJECTION(S) FOR BYPASS GRAFT
ANGIOGRAPHY AND RIGHT HEART CATHETERIZATION











93458

CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING
SUPERVISION AND INTERPRETATION; WITH LEFT HEART
CATHETERIZATION INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN
PERFORMED















93459


CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING
SUPERVISION AND INTERPRETATION; WITH LEFT HEART
CATHETERIZATION INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN
PERFORMED, CATHETER PLACEMENT(S) IN BYPASS GRAFT(S)
(INTERNAL MAMMARY, FREE ARTERIAL, VENOUS GRAFTS)
WITH BYPASS GRAFT ANGIOGRAPHY




Code Code Description











93460


CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING
SUPERVISION AND INTERPRETATION; WITH RIGHT AND LEFT
HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN
PERFORMED















93461


CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING
SUPERVISION AND INTERPRETATION; WITH RIGHT AND LEFT
HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN
PERFORMED, CATHETER PLACEMENT(S) IN BYPASS GRAFT(S)
(INTERNAL MAMMARY, FREE ARTERIAL, VENOUS GRAFTS)
WITH BYPASS GRAFT ANGIOGRAPHY





93462

Left heart catheterization by trans septal puncture through
intact septum or by trans apical puncture (List separately in
addition to code for primary procedure)

C8900 Magnetic resonance angiography with contrast, abdomen


C8901

Magnetic resonance angiography without contrast, abdomen


C8902

Magnetic resonance angiography without contrast followed by
with contrast, abdomen

C8903 Magnetic resonance imaging with contrast, breast; unilateral


C8905
Magnetic resonance imaging without contrast followed by with
contrast, breast; unilateral

C8906 Magnetic resonance imaging with contrast, breast; bilateral


C8908
Magnetic resonance imaging without contrast followed by with
contrast, breast; bilateral


C8909

Magnetic resonance angiography with contrast, chest
(excluding myocardium)


C8910

Magnetic resonance angiography without contrast, chest
(excluding myocardium)


C8911

Magnetic resonance angiography without contrast followed by
with contrast, chest (excluding myocardium)


C8912

Magnetic resonance angiography with contrast, lower
extremity


C8913

Magnetic resonance angiography without contrast, lower
extremity


C8914

Magnetic resonance angiography without contrast followed by
with contrast, lower extremity

C8918 Magnetic resonance angiography with contrast, pelvis
C8919 Magnetic resonance angiography without contrast, pelvis
















Code Code Description


C8920
Magnetic resonance angiography without contrast followed by
with contrast, pelvis


C8931

MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST,
SPINAL CANAL AND CONTENTS (crosswalk to 72159)





C8932


MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST,
SPINAL CANAL AND CONTENTS (crosswalk to 72159)





C8933

MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST
FOLLOWED BY WITH CONTRAST, SPINAL CANAL AND
CONTENTS (crosswalk to 72159)


C8934

MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST,
UPPER EXTREMITY (crosswalk to 73225)


C8935

MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST,
UPPER EXTREMITY (crosswalk to 73225)





C8936

MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST
FOLLOWED BY WITH CONTRAST, UPPER EXTREMITY (crosswalk
to 73225)


G0219

PET imaging whole body; melanoma for non-covered
indications

G0235 PET imaging, any site, not otherwise specified




G0252

PET imaging, full and partial-ring pet scanners only, for initial
diagnosis of breast cancer and/or surgical planning for breast
cancer (e.g., initial staging of axillary lymph nodes)

S8037 Magnetic resonance cholangiopancreatography (mrcp)
S8042 Magnetic resonance imaging (MRI), low-field


S8085

Fluorine-18 fluorodeoxyglucose (f-18 fdg) imaging using dual-
head coincidence detection system (non-dedicated pet scan)











Horizon NJ Medicaid and FIDE-SNP
Radiation Therapy Code List

Code Code Description







19294


Preparation of tumor cavity, with placement of
radiation therapy applicator for intraoperative

radiation therapy (IORT), concurrent with partial
mastectomy









19296

Placement of radiotherapy afterloading
expandable catheter (single or multichannel)
into the breast for interstitial radioelement
application following partial mastectomy,

includes imaging guidance; on date separate
from partial mastectomy











19297

Placement of radiotherapy afterloading
expandable catheter (single or multichannel)
into the breast for interstitial radioelement
application following partial mastectomy,

includes imaging guidance; concurrent with
partial mastectomy (List separately in addition

to code for primary procedure)








19298

Placement of radiotherapy after loading
brachytherapy catheters (multiple tube and
button type) into the breast for interstitial

radioelement application following (at the time
of or subsequent to) partial mastectomy,

includes imaging guidance





31643

Bronchoscopy, rigid or flexible, including
fluoroscopic guidance, when performed; with

placement of catheter(s) for intracavitary
radioelement application






32553

Placement of interstitial device(s) for radiation
therapy guidance (eg, fiducial markers,

dosimeter), percutaneous, intra-thoracic, single
or multiple








41019


Placement of needles, catheters, or other
device(s) into the head and/or neck region
(percutaneous, transoral, or transnasal) for

subsequent interstitial radioelement application







49411

Placement of interstitial device(s) for radiation
therapy guidance (eg, fiducial markers,

dosimeter), percutaneous, intra-abdominal,
intra-pelvic (except prostate), and/or
retroperitoneum, single or multiple




Code Code Description










49412

Placement of interstitial device(s) for radiation
therapy guidance (eg, fiducial markers,

dosimeter), open, intra-abdominal, intrapelvic,
and/or retroperitoneum, including image

guidance, if performed, single or multiple (List
separately in addition to code for primary

procedure)





55875


Transperineal placement of needles or catheters

into prostate for interstitial radioelement
application, with or without cystoscopy






55876

Placement of interstitial device(s) for radiation
therapy guidance (eg, fiducial markers,

dosimeter), prostate (via needle, any approach),
single or multiple






55920


Placement of needles or catheters into pelvic
organs and/or genitalia (except prostate) for

subsequent interstitial radioelement application


57155
Insertion of uterine tandem and/or vaginal

ovoids for clinical brachytherapy


57156
Insertion of a vaginal radiation afterloading

apparatus for clinical brachytherapy


58346
Insertion of Heyman capsules for clinical

brachytherapy




61796

Stereotactic radiosurgery (particle beam,
gamma ray, or linear accelerator); 1

simple cranial lesion







61797

Stereotactic radiosurgery (particle beam,
gamma ray, or linear accelerator); each

additional cranial lesion, simple (List separately
in addition to code for primary

procedure)




61798

Stereotactic radiosurgery (particle beam,
gamma ray, or linear accelerator); 1

complex cranial lesion







61799

Stereotactic radiosurgery (particle beam,
gamma ray, or linear accelerator); each
additional cranial lesion, complex (List

separately in addition to code for primary
procedure)






61800

Application of stereotactic headframe for
stereotactic radiosurgery (List separately

in addition to code for primary procedure)




Code Code Description




76873

Ultrasound, transrectal; prostate volume study
for brachytherapy treatment planning (separate

procedure)


76965
Ultrasonic guidance for interstitial radioelement

application


77014
Computed tomography guidance for placement

of radiation therapy fields


77261
Therapeutic radiology treatment planning;

simple


77262
Therapeutic radiology treatment planning;

intermediate


77263
Therapeutic radiology treatment planning;

complex


77280
Therapeutic radiology simulation-aided field

setting; simple


77285
Therapeutic radiology simulation-aided field

setting; intermediate


77290
Therapeutic radiology simulation-aided field

setting; complex




77293

Respiratory motion management simulation
(List separately in addition to code for primary

procedure)


77295
3-dimensional radiotherapy plan, including dose-

volume histograms













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, onl





77301


Intensity modulated radiotherapy plan, including

dose-volume histograms for target and critical
structure partial tolerance specifications






77306


Teletherapy isodose plan; simple (1 or 2

unmodified ports directed to a single area of
interest), includes basic dosimetry calculation(s)








77307

Teletherapy isodose plan; complex (multiple
treatment areas, tangential ports, the use of
wedges, blocking, rotational beam, or special

beam considerations), includes basic dosimetry
calculation(s)




Code Code Description







77316


Brachytherapy isodose plan; simple

(calculation[s] made from 1 to 4 sources, or
remote afterloading brachytherapy, 1 channel),

includes basic dosimetry calculation(s)







77317

Brachytherapy isodose plan; intermediate
(calculation[s] made from 5 to 10 sources, or

remote afterloading brachytherapy, 2-12
channels), includes basic dosimetry

calculation(s)







77318

Brachytherapy isodose plan; complex
(calculation[s] made from over 10 sources, or
remote afterloading brachytherapy, over 12

channels), includes basic dosimetry
calculation(s)


77321

Special teletherapy port plan, particles,
hemibody, total body





77331

Special dosimetry (eg, TLD, microdosimetry)
(specify), only when prescribed by the treating

physician


77332
Treatment devices, design and construction;

simple (simple block, simple bolus)




77333

Treatment devices, design and construction;
intermediate (multiple blocks, stents, bite

blocks, special bolus)




77334

Treatment devices, design and construction;
complex (irregular blocks, special shields,
compensators, wedges, molds or casts)









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




77338

Multi-leaf collimator (MLC) device(s) for
intensity modulated radiation therapy (IMRT),

design and construction per IMRT plan
77370 Special medical radiation physics consultation






77371

Radiation treatment delivery, stereotactic
radiosurgery (SRS), complete course of

treatment of cranial lesion(s) consisting of 1
session; multi-source Cobalt 60 based






77372

Radiation treatment delivery, stereotactic
radiosurgery (SRS), complete course of

treatment of cranial lesion(s) consisting of 1
session; linear accelerator based




Code Code Description





77373

Stereotactic body radiation therapy, treatment
delivery, per fraction to 1 or more lesions,

including image guidance, entire course not to
exceed 5 fractions





77385

Intensity modulated radiation treatment
delivery (IMRT), includes guidance and tracking,

when performed; simple




77386

Intensity modulated radiation treatment
delivery (IMRT), includes guidance and tracking,

when performed; complex




77387

Guidance for localization of target volume for
delivery of radiation treatment, includes
intrafraction tracking, when performed





77399

Unlisted procedure, medical radiation physics,
dosimetry and treatment devices, and special

services


77401
Radiation treatment delivery, superficial and/or

ortho voltage, per day
77402 Radiation treatment delivery, >1 MeV; simple






77407

Radiation treatment delivery; two separate
treatment areas; three or more ports on a single

treatment area; or three or more simple
blocks;>=1 MeV; intermediate









77412

Radiation treatment delivery; three or more
separate treatment areas; custom blocking;

tangential ports; wedges; rotational beam; field-
in-field or other tissue compensation that does
not meet IMRT guidelines; or electron beam;

>=1 MeV; complex
77417 Therapeutic radiology port image(s)






77423

High energy neutron radiation treatment
delivery; 1 or more isocenter(s) with coplanar or

non-coplanar geometry with blocking and/or
wedge, and/or compensator(s)


77424

Intraoperative radiation treatment delivery, x-
ray, single treatment session


77425

Intraoperative radiation treatment delivery,
electrons, single treatment session


77427


Radiation treatment management, 5 treatments





77431

Radiation therapy management with complete
course of therapy consisting of 1 or 2 fractions

only




77432

Stereotactic radiation treatment management
of cranial lesion(s) (complete course of

treatment consisting of 1 session)




Code Code Description







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


77469

Intraoperative radiation treatment management





77470

Special treatment procedure (eg, total body
irradiation, hemibody radiation, per oral or

endocavitary irradiation)


77499
Unlisted procedure, therapeutic radiology

treatment management


77520
Proton treatment delivery; simple, without

compensation


77522
Proton treatment delivery; simple, with

compensation
77523 Proton treatment delivery; intermediate
77525 Proton treatment delivery; complex





77600


Hyperthermia, externally generated; superficial

(ie, heating to a depth of 4 cm or less)


77605
Hyperthermia, externally generated; deep (ie,

heating to depths greater than 4 cm)


77610
Hyperthermia generated by interstitial probe(s);

5 or fewer interstitial applicators


77615
Hyperthermia generated by interstitial probe(s);

more than 5 interstitial applicators


77620
Hyperthermia generated by intracavitary

probe(s)


77750
Infusion or instillation of radioelement solution

(includes 3-month follow-up care)


77761
Intracavitary radiation source application;

simple


77762
Intracavitary radiation source application;

intermediate


77763
Intracavitary radiation source application;

complex


77767
HDR radionuclide skin surface brachytherapy;

lesion diameter up to 2.0 cm or 1 channel




77768

HDR radionuclide skin surface brachytherapy;
lesion diameter over 2.0 cm and 2 or more

channels, or multiple lesions


77770
HDR radionuclide interstitial or intracavitary

brachytherapy; 1 channel


77771
HDR radionuclide rate interstitial or

intracavitary brachytherapy; 2 to 12 channels




Code Code Description


77772
HDR radionuclide interstitial or intracavitary

brachytherapy; over 12 channels




77778

Interstitial radiation source application,
complex, includes supervision, handling, loading

of radiation source when performed


77789
Surface application of low dose rate

radionuclide source


77790
Supervision, handling, loading of radiation

source
77799 Unlisted procedure, clinical brachytherapy


79005

Radiopharmaceutical therapy, by oral
administration; used for I-131 treatment


79101

Radiopharmaceutical therapy, by intravenous
administration





79403

Radiopharmaceutical therapy, radiolabeled
monoclonal antibody by intravenous

infusion


0394T
HDR electronic brachytherapy, skin surface

application, per fraction


0395T
HDR electronic brachytherapy, interstitial or

intracavitary treatment, per fraction


A9606
Radium ra-223 dichloride, therapeutic, per

microcurie (Xofigo)


C2616
Brachytherapy source, nonstranded, yttrium-90,

per source





G0339

Image guided robotic linear accelerator-based
stereotactic radiosurgery, complete course of

therapy in one session or first session of
fractionated treatment









G0340

Image guided robotic linear accelerator-based
stereotactic radiosurgery, delivery including

collimator changes and custom plugging,
fractionated treatment, all lesions, per session,

second through fifth sessions, maximum 5
sessions per course of treatment


G6001

Ultrasonic guidance for placement of radiation
therapy fields






G6002

Stereoscopic x-ray guidance for localization of
target volume for the delivery of radiation

therapy





G6003

Radiation treatment delivery, single treatment
area,single port or parallel opposed ports,

simple blocks or no blocks: up to 5mev




Code Code Description




G6004

Radiation treatment delivery, single treatment
area,single port or parallel opposed ports,

simple blocks or no blocks: 6-10mev




G6005

Radiation treatment delivery, single treatment
area,single port or parallel opposed ports,

simple blocks or no blocks: 11-19mev




G6006

Radiation treatment delivery, single treatment
area,single port or parallel opposed ports,

simple blocks or no blocks: 20mev or greater





G6007

Radiation treatment delivery, 2 separate
treatment areas, 3 or more ports on a single
treatment area, use of multiple blocks: up to

5mev





G6008


Radiation treatment delivery, 2 separate

treatment areas, 3 or more ports on a single
treatment area, use of multiple blocks: 6-10mev






G6009

Radiation treatment delivery, 2 separate
treatment areas, 3 or more ports on a single
treatment area, use of multiple blocks: 11-

19mev





G6010

Radiation treatment delivery, 2 separate
treatment areas, 3 or more ports on a single

treatment area, use of multiple blocks: 20 mev
or greater






G6011

Radiation treatment delivery,3 or more
separate treatment areas, custom blocking,
tangential ports, wedges, rotational beam,
compensators, electron beam; up to 5mev






G6012

Radiation treatment delivery,3 or more
separate treatment areas, custom blocking,
tangential ports, wedges, rotational beam,

compensators, electron beam; 6-10mev





G6013

Radiation treatment delivery,3 or more
separate treatment areas, custom blocking,
tangential ports, wedges, rotational beam,
compensators, electron beam; 11-19mev








G6014


Radiation treatment delivery,3 or more separate

treatment areas, custom blocking, tangential
ports, wedges, rotational beam, compensators,

electron beam; 20mev or greater





G6015

Intensity modulated treatment delivery, single
or multiple fields/arcs,via narrow spatially and
temporally modulated beams, binary, dynamic

mlc, per treatment session




























Code Code Description







G6016

Compensator-based beam modulation
treatment delivery of inverse planned treatment
using 3 or more high resolution (milled or cast)

compensator, convergent beam modulated
fields, per treatment session








G6017


Intra-fraction localization and tracking of target
or patient motion during delivery of radiation
therapy (eg, 3d positional tracking, gating, 3d
surface tracking), each fraction of treatment