935 Spine Imaging CPT, HCPCS and Diagnoses Codes

Medical Policy Spine Imaging CPT, HCPCS and Diagnoses Codes

Policy Number: 935

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 ? Brain Imaging CPT, HCPCS and Diagnoses Codes, #931 ? 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 ? Vascular Imaging CPT, HCPCS and Diagnoses Codes, #936

Table of Contents

Commercial Products .................................................................................................................................... 2 Medicare Advantage Products ...................................................................................................................... 2 CPT Codes / HCPCS Codes / ICD Codes .................................................................................................... 2 CPT Codes: 72125, 72126, 72127 CT cervical spine................................................................................... 2 CPT Codes: 72128, 72129, 72130 CT thoracic spine ................................................................................ 40 CPT Codes: 72131, 72132, 72133 CT lumbar spine .................................................................................. 73 CPT Codes: 72141, 72142 MR (eg, proton) imaging, spinal canal and contents, cervical; 72156 MR (eg, proton) imaging, spinal canal and contents .............................................................................................. 104 CPT Codes: 72146, 72147, 72157 MRI of thoracic spine ........................................................................ 188 CPT Codes: 72148, 72149, 72158 MR (eg, proton) imaging, spinal canal and contents, lumbar .......... 269 CPT Codes: 77078 CT bone mineral density study, 1 or more sites, axial skeleton; 78811, 78812, 78813, 78814, 78815, 78816 PET imaging .......................................................................................................... 351 Policy History ............................................................................................................................................ 351 Disclaimer:................................................................................................................................................. 351

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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.

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: 72125, 72126, 72127 CT cervical spine

CPT codes Code Description

72125

CT cervical spine, without contrast

72126

CT cervical spine, with contrast

72127

CT cervical spine, without contrast, followed by reimaging with contrast

ICD-10 Diagnoses Codes

ICD-10

Code Description

A18.01

Tuberculosis of spine

A52.15

Late syphilitic neuropathy

E75.23

Krabbe disease

E75.25

Metachromatic leukodystrophy

E75.26

Sulfatase deficiency

E75.29

Other sphingolipidosis

E76.01

Hurler's syndrome

E76.02

Hurler-Scheie syndrome

E76.03

Scheie's syndrome

E76.1

Mucopolysaccharidosis, type II

E76.210

Morquio A mucopolysaccharidoses

E76.211

Morquio B mucopolysaccharidoses

E76.219

Morquio mucopolysaccharidoses, unspecified

E76.22

Sanfilippo mucopolysaccharidoses

E76.29

Other mucopolysaccharidoses

E76.3

Mucopolysaccharidosis, unspecified

E76.8

Other disorders of glucosaminoglycan metabolism

E76.9

Glucosaminoglycan metabolism disorder, unspecified

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E78.71 E78.72 G03.0 G03.1 G03.8 G03.9 G04.00 G04.01

G04.02 G04.1 G04.30 G04.31 G04.32 G04.39 G04.81 G04.89 G04.90 G04.91 G05.3 G05.4 G06.1 G11.3 G11.8 G11.9 G13.0 G13.1 G20 G21.4 G25.70 G25.71 G25.79 G25.89 G25.9 G26 G32.0 G35 G36.0 G36.1 G36.8 G36.9 G37.0 G37.1

Barth syndrome Smith-Lemli-Opitz syndrome Nonpyogenic meningitis Chronic meningitis Meningitis due to other specified causes Meningitis, unspecified Acute disseminated encephalitis and encephalomyelitis, unspecified Postinfectious acute disseminated encephalitis and encephalomyelitis (postinfectious ADEM) Postimmunization acute disseminated encephalitis, myelitis and encephalomyelitis Tropical spastic paraplegia Acute necrotizing hemorrhagic encephalopathy, unspecified Postinfectious acute necrotizing hemorrhagic encephalopathy Postimmunization acute necrotizing hemorrhagic encephalopathy Other acute necrotizing hemorrhagic encephalopathy Other encephalitis and encephalomyelitis Other myelitis Encephalitis and encephalomyelitis, unspecified Myelitis, unspecified Encephalitis and encephalomyelitis in diseases classified elsewhere Myelitis in diseases classified elsewhere Intraspinal abscess and granuloma Cerebellar ataxia with defective DNA repair Other hereditary ataxias Hereditary ataxia, unspecified Paraneoplastic neuromyopathy and neuropathy Other systemic atrophy primarily affecting central nervous system in neoplastic disease Parkinson's disease Vascular parkinsonism Drug induced movement disorder, unspecified Drug induced akathisia Other drug induced movement disorders Other specified extrapyramidal and movement disorders Extrapyramidal and movement disorder, unspecified Extrapyramidal and movement disorders in diseases classified elsewhere Subacute combined degeneration of spinal cord in diseases classified elsewhere Multiple sclerosis Neuromyelitis optica [Devic] Acute and subacute hemorrhagic leukoencephalitis [Hurst] Other specified acute disseminated demyelination Acute disseminated demyelination, unspecified Diffuse sclerosis of central nervous system Central demyelination of corpus callosum

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G37.2 G37.3 G37.4 G37.5 G37.8 G37.9 G45.0 G54.2 G54.4 G54.8 G55 G61.0 G61.1 G61.81 G61.89 G61.9 G62.0 G62.1 G62.2 G62.81 G62.82 G62.89 G62.9 G63 G64 G65.0 G65.1 G65.2 G81.00 G81.01 G81.02 G81.03 G81.04 G81.10 G81.11 G81.12 G81.13 G81.14 G81.90 G81.91 G81.92 G81.93 G81.94

Central pontine myelinolysis Acute transverse myelitis in demyelinating disease of central nervous system Subacute necrotizing myelitis of central nervous system Concentric sclerosis [Balo] of central nervous system Other specified demyelinating diseases of central nervous system Demyelinating disease of central nervous system, unspecified Vertebro-basilar artery syndrome Cervical root disorders, not elsewhere classified Lumbosacral root disorders, not elsewhere classified Other nerve root and plexus disorders Nerve root and plexus compressions in diseases classified elsewhere Guillain-Barre syndrome Serum neuropathy Chronic inflammatory demyelinating polyneuritis Other inflammatory polyneuropathies Inflammatory polyneuropathy, unspecified Drug-induced polyneuropathy Alcoholic polyneuropathy Polyneuropathy due to other toxic agents Critical illness polyneuropathy Radiation-induced polyneuropathy Other specified polyneuropathies Polyneuropathy, unspecified Polyneuropathy in diseases classified elsewhere Other disorders of peripheral nervous system Sequelae of Guillain-Barr syndrome Sequelae of other inflammatory polyneuropathy Sequelae of toxic polyneuropathy Flaccid hemiplegia affecting unspecified side Flaccid hemiplegia affecting right dominant side Flaccid hemiplegia affecting left dominant side Flaccid hemiplegia affecting right nondominant side Flaccid hemiplegia affecting left nondominant side Spastic hemiplegia affecting unspecified side Spastic hemiplegia affecting right dominant side Spastic hemiplegia affecting left dominant side Spastic hemiplegia affecting right nondominant side Spastic hemiplegia affecting left nondominant side Hemiplegia, unspecified affecting unspecified side Hemiplegia, unspecified affecting right dominant side Hemiplegia, unspecified affecting left dominant side Hemiplegia, unspecified affecting right nondominant side Hemiplegia, unspecified affecting left nondominant side

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G82.20 G82.21 G82.22 G82.50 G82.51 G82.52 G82.53 G82.54 G83.0 G83.10 G83.11 G83.12 G83.13 G83.14 G83.20 G83.21 G83.22 G83.23 G83.24 G83.30 G83.31 G83.32 G83.33 G83.34 G83.4 G83.5 G83.81 G83.82 G83.83 G83.84 G83.89 G83.9 G89.11 G89.21 G92 G93.0 G93.5 G93.81 G93.82 G93.89 G95.0 G95.11 G95.19

Paraplegia, unspecified Paraplegia, complete Paraplegia, incomplete Quadriplegia, unspecified Quadriplegia, C1-C4 complete Quadriplegia, C1-C4 incomplete Quadriplegia, C5-C7 complete Quadriplegia, C5-C7 incomplete Diplegia of upper limbs Monoplegia of lower limb affecting unspecified side Monoplegia of lower limb affecting right dominant side Monoplegia of lower limb affecting left dominant side Monoplegia of lower limb affecting right nondominant side Monoplegia of lower limb affecting left nondominant side Monoplegia of upper limb affecting unspecified side Monoplegia of upper limb affecting right dominant side Monoplegia of upper limb affecting left dominant side Monoplegia of upper limb affecting right nondominant side Monoplegia of upper limb affecting left nondominant side Monoplegia, unspecified affecting unspecified side Monoplegia, unspecified affecting right dominant side Monoplegia, unspecified affecting left dominant side Monoplegia, unspecified affecting right nondominant side Monoplegia, unspecified affecting left nondominant side Cauda equina syndrome Locked-in state Brown-Squard syndrome Anterior cord syndrome Posterior cord syndrome Todd's paralysis (postepileptic) Other specified paralytic syndromes Paralytic syndrome, unspecified Acute pain due to trauma Chronic pain due to trauma Toxic encephalopathy Cerebral cysts Compression of brain Temporal sclerosis Brain death Other specified disorders of brain Syringomyelia and syringobulbia Acute infarction of spinal cord (embolic) (nonembolic) Other vascular myelopathies

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