933 Extremity Imaging CPT, HCPCS and Diagnoses Codes

[Pages:680]Medical Policy Extremity Imaging CPT, HCPCS and Diagnoses Codes

Policy Number: 933

BCBSA Reference Number: N/A NCD/LCD: N/A

Related Policies

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Table of Contents

Commercial Products .................................................................................................................................... 1 Medicare Advantage Products ...................................................................................................................... 2 CPT Codes / HCPCS Codes / ICD Codes .................................................................................................... 2 CPT Codes: 73200, 73201, 73202 CT upper extremity; 73221, 73222, 73223, 73218, 73219, 73220 MRI upper extremity ............................................................................................................................................. 2 CPT Codes: 73700, 73701, 73702 CT lower extremity; 73718, 73719, 73720, 73721 ............................ 339 73722, 73723 MRI lower extremity ........................................................................................................... 339 CPT Codes: 78811, 78812, 78813, 78814, 78815, 78816 PET imaging ................................................ 680 Policy History ............................................................................................................................................ 680 Disclaimer:................................................................................................................................................. 680

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.

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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.

CPT Codes: 73200, 73201, 73202 CT upper extremity; 73221, 73222, 73223, 73218,

73219, 73220 MRI upper extremity

CPT codes Code Description

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

73221

MRI upper extremity any joint, without contrast

73222

MRI upper extremity any joint, with contrast

73223

MRI upper extremity any joint, without contrast, followed by re-imaging with contrast

73218

MRI upper extremity non-joint, without contrast

73219

MRI upper extremity non-joint, with contrast

73220

MRI upper extremity non-joint, without contrast, followed by re-imaging with contrast

ICD Diagnoses Codes

ICD-10

Code Description

G54.0

Brachial plexus disorders

G54.5

Neuralgic amyotrophy

G54.8

Other nerve root and plexus disorders

G54.9

Nerve root and plexus disorder, unspecified

G56.00

Carpal tunnel syndrome, unspecified upper limb

G56.01

Carpal tunnel syndrome, right upper limb

G56.02

Carpal tunnel syndrome, left upper limb

G56.10

Other lesions of median nerve, unspecified upper limb

G56.11

Other lesions of median nerve, right upper limb

G56.12

Other lesions of median nerve, left upper limb

G56.20

Lesion of ulnar nerve, unspecified upper limb

G56.21

Lesion of ulnar nerve, right upper limb

G56.22

Lesion of ulnar nerve, left upper limb

G58.9

Mononeuropathy, unspecified

L02.411

Cutaneous abscess of right axilla

L02.412

Cutaneous abscess of left axilla

L02.413

Cutaneous abscess of right upper limb

L02.414

Cutaneous abscess of left upper limb

L02.419

Cutaneous abscess of limb, unspecified

M00.80

Arthritis due to other bacteria, unspecified joint

M00.811

Arthritis due to other bacteria, right shoulder

M00.812

Arthritis due to other bacteria, left shoulder

M00.819

Arthritis due to other bacteria, unspecified shoulder

M00.821

Arthritis due to other bacteria, right elbow

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M00.822 M00.829 M00.831 M00.832 M00.839 M00.841 M00.842 M00.849 M06.011 M06.012 M06.019 M06.021 M06.022 M06.029 M06.031 M06.032 M06.039 M06.041 M06.042 M06.049 M06.211 M06.212 M06.219 M06.221 M06.222 M06.229 M06.231 M06.232 M06.239 M06.241 M06.242 M06.249 M06.311 M06.312 M06.319 M06.321 M06.322 M06.329 M06.331 M06.332 M06.339 M06.341 M06.342 M06.349 M06.80 M06.811 M06.812 M06.819 M06.821 M06.822 M06.829 M06.831 M06.832

Arthritis due to other bacteria, left elbow Arthritis due to other bacteria, unspecified elbow Arthritis due to other bacteria, right wrist Arthritis due to other bacteria, left wrist Arthritis due to other bacteria, unspecified wrist Arthritis due to other bacteria, right hand Arthritis due to other bacteria, left hand Arthritis due to other bacteria, unspecified hand Rheumatoid arthritis without rheumatoid factor, right shoulder Rheumatoid arthritis without rheumatoid factor, left shoulder Rheumatoid arthritis without rheumatoid factor, unspecified shoulder Rheumatoid arthritis without rheumatoid factor, right elbow Rheumatoid arthritis without rheumatoid factor, left elbow Rheumatoid arthritis without rheumatoid factor, unspecified elbow Rheumatoid arthritis without rheumatoid factor, right wrist Rheumatoid arthritis without rheumatoid factor, left wrist Rheumatoid arthritis without rheumatoid factor, unspecified wrist Rheumatoid arthritis without rheumatoid factor, right hand Rheumatoid arthritis without rheumatoid factor, left hand Rheumatoid arthritis without rheumatoid factor, unspecified hand Rheumatoid bursitis, right shoulder Rheumatoid bursitis, left shoulder Rheumatoid bursitis, unspecified shoulder Rheumatoid bursitis, right elbow Rheumatoid bursitis, left elbow Rheumatoid bursitis, unspecified elbow Rheumatoid bursitis, right wrist Rheumatoid bursitis, left wrist Rheumatoid bursitis, unspecified wrist Rheumatoid bursitis, right hand Rheumatoid bursitis, left hand Rheumatoid bursitis, unspecified hand Rheumatoid nodule, right shoulder Rheumatoid nodule, left shoulder Rheumatoid nodule, unspecified shoulder Rheumatoid nodule, right elbow Rheumatoid nodule, left elbow Rheumatoid nodule, unspecified elbow Rheumatoid nodule, right wrist Rheumatoid nodule, left wrist Rheumatoid nodule, unspecified wrist Rheumatoid nodule, right hand Rheumatoid nodule, left hand Rheumatoid nodule, unspecified hand Other specified rheumatoid arthritis, unspecified site Other specified rheumatoid arthritis, right shoulder Other specified rheumatoid arthritis, left shoulder Other specified rheumatoid arthritis, unspecified shoulder Other specified rheumatoid arthritis, right elbow Other specified rheumatoid arthritis, left elbow Other specified rheumatoid arthritis, unspecified elbow Other specified rheumatoid arthritis, right wrist Other specified rheumatoid arthritis, left wrist

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M06.839 M06.841 M06.842 M06.849 M06.9 M12.211 M12.212 M12.219 M12.221 M12.222 M12.229 M12.231 M12.232 M12.239 M12.241 M12.242 M12.249 M14.60 M14.611 M14.612 M14.619 M14.621 M14.622 M14.629 M14.631 M14.632 M14.639 M14.641 M14.642 M14.649 M18.0 M18.10 M18.11 M18.12 M18.2 M18.30 M18.31 M18.32 M18.4 M18.50 M18.51 M18.52 M18.9 M19.011 M19.012 M19.019 M19.021 M19.022 M19.029 M19.031 M19.032 M19.039 M19.041

Other specified rheumatoid arthritis, unspecified wrist Other specified rheumatoid arthritis, right hand Other specified rheumatoid arthritis, left hand Other specified rheumatoid arthritis, unspecified hand Rheumatoid arthritis, unspecified Villonodular synovitis (pigmented), right shoulder Villonodular synovitis (pigmented), left shoulder Villonodular synovitis (pigmented), unspecified shoulder Villonodular synovitis (pigmented), right elbow Villonodular synovitis (pigmented), left elbow Villonodular synovitis (pigmented), unspecified elbow Villonodular synovitis (pigmented), right wrist Villonodular synovitis (pigmented), left wrist Villonodular synovitis (pigmented), unspecified wrist Villonodular synovitis (pigmented), right hand Villonodular synovitis (pigmented), left hand Villonodular synovitis (pigmented), unspecified hand Charcot's joint, unspecified site Charcot's joint, right shoulder Charcot's joint, left shoulder Charcot's joint, unspecified shoulder Charcot's joint, right elbow Charcot's joint, left elbow Charcot's joint, unspecified elbow Charcot's joint, right wrist Charcot's joint, left wrist Charcot's joint, unspecified wrist Charcot's joint, right hand Charcot's joint, left hand Charcot's joint, unspecified hand Bilateral primary osteoarthritis of first carpometacarpal joints Unilateral primary osteoarthritis of first carpometacarpal joint, unspecified hand Unilateral primary osteoarthritis of first carpometacarpal joint, right hand Unilateral primary osteoarthritis of first carpometacarpal joint, left hand Bilateral post-traumatic osteoarthritis of first carpometacarpal joints Unilateral post-traumatic osteoarthritis of first carpometacarpal joint, unspecified hand Unilateral post-traumatic osteoarthritis of first carpometacarpal joint, right hand Unilateral post-traumatic osteoarthritis of first carpometacarpal joint, left hand Other bilateral secondary osteoarthritis of first carpometacarpal joints Other unilateral secondary osteoarthritis of first carpometacarpal joint, unspecified hand Other unilateral secondary osteoarthritis of first carpometacarpal joint, right hand Other unilateral secondary osteoarthritis of first carpometacarpal joint, left hand Osteoarthritis of first carpometacarpal joint, unspecified Primary osteoarthritis, right shoulder Primary osteoarthritis, left shoulder Primary osteoarthritis, unspecified shoulder Primary osteoarthritis, right elbow Primary osteoarthritis, left elbow Primary osteoarthritis, unspecified elbow Primary osteoarthritis, right wrist Primary osteoarthritis, left wrist Primary osteoarthritis, unspecified wrist Primary osteoarthritis, right hand

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M19.042 M19.049 M21.021 M21.022 M21.029 M21.121 M21.122 M21.129 M21.80 M21.821 M21.822 M21.829 M21.831 M21.832 M21.839 M21.921 M21.922 M21.929 M21.931 M21.932 M21.939 M21.941 M21.942 M21.949 M24.00 M24.011 M24.012 M24.019 M24.021 M24.022 M24.029 M24.031 M24.032 M24.039 M24.041 M24.042 M24.049 M24.111 M24.112 M24.119 M24.9 M25.011 M25.012 M25.019 M25.021 M25.022 M25.029 M25.031 M25.032 M25.039 M25.041 M25.042 M25.049

Primary osteoarthritis, left hand Primary osteoarthritis, unspecified hand Valgus deformity, not elsewhere classified, right elbow Valgus deformity, not elsewhere classified, left elbow Valgus deformity, not elsewhere classified, unspecified elbow Varus deformity, not elsewhere classified, right elbow Varus deformity, not elsewhere classified, left elbow Varus deformity, not elsewhere classified, unspecified elbow Other specified acquired deformities of unspecified limb Other specified acquired deformities of right upper arm Other specified acquired deformities of left upper arm Other specified acquired deformities of unspecified upper arm Other specified acquired deformities of right forearm Other specified acquired deformities of left forearm Other specified acquired deformities of unspecified forearm Unspecified acquired deformity of right upper arm Unspecified acquired deformity of left upper arm Unspecified acquired deformity of unspecified upper arm Unspecified acquired deformity of right forearm Unspecified acquired deformity of left forearm Unspecified acquired deformity of unspecified forearm Unspecified acquired deformity of hand, right hand Unspecified acquired deformity of hand, left hand Unspecified acquired deformity of hand, unspecified hand Loose body in unspecified joint Loose body in right shoulder Loose body in left shoulder Loose body in unspecified shoulder Loose body in right elbow Loose body in left elbow Loose body in unspecified elbow Loose body in right wrist Loose body in left wrist Loose body in unspecified wrist Loose body in right finger joint(s) Loose body in left finger joint(s) Loose body in unspecified finger joint(s) Other articular cartilage disorders, right shoulder Other articular cartilage disorders, left shoulder Other articular cartilage disorders, unspecified shoulder Joint derangement, unspecified Hemarthrosis, right shoulder Hemarthrosis, left shoulder Hemarthrosis, unspecified shoulder Hemarthrosis, right elbow Hemarthrosis, left elbow Hemarthrosis, unspecified elbow Hemarthrosis, right wrist Hemarthrosis, left wrist Hemarthrosis, unspecified wrist Hemarthrosis, right hand Hemarthrosis, left hand Hemarthrosis, unspecified hand

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M25.411 M25.412 M25.419 M25.421 M25.422 M25.429 M25.431 M25.432 M25.439 M25.441 M25.442 M25.449 M25.50 M25.511 M25.512 M25.519 M25.521 M25.522 M25.529 M25.531 M25.532 M25.539 M25.541 M25.542 M25.549 M60.000 M60.001 M60.002 M60.011 M60.012 M60.019 M60.021 M60.022 M60.029 M60.031 M60.032 M60.039 M60.041 M60.042 M60.043 M60.044 M60.045 M60.046 M60.111 M60.112 M60.119 M60.121 M60.122 M60.129 M60.131 M60.132 M60.139 M60.141

Effusion, right shoulder Effusion, left shoulder Effusion, unspecified shoulder Effusion, right elbow Effusion, left elbow Effusion, unspecified elbow Effusion, right wrist Effusion, left wrist Effusion, unspecified wrist Effusion, right hand Effusion, left hand Effusion, unspecified hand Pain in unspecified joint Pain in right shoulder Pain in left shoulder Pain in unspecified shoulder Pain in right elbow Pain in left elbow Pain in unspecified elbow Pain in right wrist Pain in left wrist Pain in unspecified wrist Pain in joints of right hand Pain in joints of left hand Pain in joints of unspecified hand Infective myositis, unspecified right arm Infective myositis, unspecified left arm Infective myositis, unspecified arm Infective myositis, right shoulder Infective myositis, left shoulder Infective myositis, unspecified shoulder Infective myositis, right upper arm Infective myositis, left upper arm Infective myositis, unspecified upper arm Infective myositis, right forearm Infective myositis, left forearm Infective myositis, unspecified forearm Infective myositis, right hand Infective myositis, left hand Infective myositis, unspecified hand Infective myositis, right finger(s) Infective myositis, left finger(s) Infective myositis, unspecified finger(s) Interstitial myositis, right shoulder Interstitial myositis, left shoulder Interstitial myositis, unspecified shoulder Interstitial myositis, right upper arm Interstitial myositis, left upper arm Interstitial myositis, unspecified upper arm Interstitial myositis, right forearm Interstitial myositis, left forearm Interstitial myositis, unspecified forearm Interstitial myositis, right hand

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M60.142 M60.149 M60.811 M60.812 M60.819 M60.821 M60.822 M60.829 M60.831 M60.832 M60.839 M60.841 M60.842 M60.849 M60.88 M60.9 M62.81 M65.221 M65.222 M65.229 M65.311 M65.312 M65.319 M65.331 M65.332 M65.339 M65.811 M65.812 M65.819 M65.821 M65.822 M65.829 M65.831 M65.832 M65.839 M65.841 M65.842 M65.849 M66.111 M66.112 M66.119 M66.121 M66.122 M66.129 M66.131 M66.132 M66.139 M66.141 M66.142 M66.143 M66.144 M66.145 M66.146

Interstitial myositis, left hand Interstitial myositis, unspecified hand Other myositis, right shoulder Other myositis, left shoulder Other myositis, unspecified shoulder Other myositis, right upper arm Other myositis, left upper arm Other myositis, unspecified upper arm Other myositis, right forearm Other myositis, left forearm Other myositis, unspecified forearm Other myositis, right hand Other myositis, left hand Other myositis, unspecified hand Other myositis, other site Myositis, unspecified Muscle weakness (generalized) Calcific tendinitis, right upper arm Calcific tendinitis, left upper arm Calcific tendinitis, unspecified upper arm Trigger thumb, right thumb Trigger thumb, left thumb Trigger thumb, unspecified thumb Trigger finger, right middle finger Trigger finger, left middle finger Trigger finger, unspecified middle finger Other synovitis and tenosynovitis, right shoulder Other synovitis and tenosynovitis, left shoulder Other synovitis and tenosynovitis, unspecified shoulder Other synovitis and tenosynovitis, right upper arm Other synovitis and tenosynovitis, left upper arm Other synovitis and tenosynovitis, unspecified upper arm Other synovitis and tenosynovitis, right forearm Other synovitis and tenosynovitis, left forearm Other synovitis and tenosynovitis, unspecified forearm Other synovitis and tenosynovitis, right hand Other synovitis and tenosynovitis, left hand Other synovitis and tenosynovitis, unspecified hand Rupture of synovium, right shoulder Rupture of synovium, left shoulder Rupture of synovium, unspecified shoulder Rupture of synovium, right elbow Rupture of synovium, left elbow Rupture of synovium, unspecified elbow Rupture of synovium, right wrist Rupture of synovium, left wrist Rupture of synovium, unspecified wrist Rupture of synovium, right hand Rupture of synovium, left hand Rupture of synovium, unspecified hand Rupture of synovium, right finger(s) Rupture of synovium, left finger(s) Rupture of synovium, unspecified finger(s)

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M66.211 M66.212 M66.219 M66.221 M66.222 M66.229 M66.231 M66.232 M66.239 M66.241 M66.242 M66.249 M66.311 M66.312 M66.319 M66.321 M66.322 M66.329 M66.331 M66.332 M66.339 M66.341 M66.342 M66.349 M66.811 M66.812 M66.819 M66.821 M66.822 M66.829 M66.831 M66.832 M66.839 M66.841 M66.842 M66.849 M67.80 M67.811 M67.812 M67.813 M67.814 M67.819 M67.821 M67.822 M67.823 M67.824 M67.829 M67.831 M67.832 M67.833 M67.834 M67.839 M67.841

Spontaneous rupture of extensor tendons, right shoulder Spontaneous rupture of extensor tendons, left shoulder Spontaneous rupture of extensor tendons, unspecified shoulder Spontaneous rupture of extensor tendons, right upper arm Spontaneous rupture of extensor tendons, left upper arm Spontaneous rupture of extensor tendons, unspecified upper arm Spontaneous rupture of extensor tendons, right forearm Spontaneous rupture of extensor tendons, left forearm Spontaneous rupture of extensor tendons, unspecified forearm Spontaneous rupture of extensor tendons, right hand Spontaneous rupture of extensor tendons, left hand Spontaneous rupture of extensor tendons, unspecified hand Spontaneous rupture of flexor tendons, right shoulder Spontaneous rupture of flexor tendons, left shoulder Spontaneous rupture of flexor tendons, unspecified shoulder Spontaneous rupture of flexor tendons, right upper arm Spontaneous rupture of flexor tendons, left upper arm Spontaneous rupture of flexor tendons, unspecified upper arm Spontaneous rupture of flexor tendons, right forearm Spontaneous rupture of flexor tendons, left forearm Spontaneous rupture of flexor tendons, unspecified forearm Spontaneous rupture of flexor tendons, right hand Spontaneous rupture of flexor tendons, left hand Spontaneous rupture of flexor tendons, unspecified hand Spontaneous rupture of other tendons, right shoulder Spontaneous rupture of other tendons, left shoulder Spontaneous rupture of other tendons, unspecified shoulder Spontaneous rupture of other tendons, right upper arm Spontaneous rupture of other tendons, left upper arm Spontaneous rupture of other tendons, unspecified upper arm Spontaneous rupture of other tendons, right forearm Spontaneous rupture of other tendons, left forearm Spontaneous rupture of other tendons, unspecified forearm Spontaneous rupture of other tendons, right hand Spontaneous rupture of other tendons, left hand Spontaneous rupture of other tendons, unspecified hand Other specified disorders of synovium and tendon, unspecified site Other specified disorders of synovium, right shoulder Other specified disorders of synovium, left shoulder Other specified disorders of tendon, right shoulder Other specified disorders of tendon, left shoulder Other specified disorders of synovium and tendon, unspecified shoulder Other specified disorders of synovium, right elbow Other specified disorders of synovium, left elbow Other specified disorders of tendon, right elbow Other specified disorders of tendon, left elbow Other specified disorders of synovium and tendon, unspecified elbow Other specified disorders of synovium, right wrist Other specified disorders of synovium, left wrist Other specified disorders of tendon, right wrist Other specified disorders of tendon, left wrist Other specified disorders of synovium and tendon, unspecified forearm Other specified disorders of synovium, right hand

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