Semi-Private Room

Automated urinalysis test [CPT 81003]

A urinalysis is performed by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, and/or urobilinogen. Urinalysis can quickly screen for conditions that do not immediately produce symptoms such as diabetes mellitus, kidney disease, or urinary tract infection. A dip stick allows qualitative and semi-quantitative analysis using a paper or plastic stick with color strips for each agent being tested. The stick is dipped in the urine specimen and the color strips are then compared to a color chart to determine the presence or absence and/or a rough estimate of the concentration of each agent tested. Reagent tablets use an absorbent mat with a few drops of urine placed on the mat followed by a reagent tablet. A drop of distilled, deionized water is then placed on the tablet and the color change is observed. Bilirubin is a byproduct of the breakdown of red blood cells by the liver. Normally bilirubin is excreted through the bowel, but in patients with liver disease, bilirubin is filtered by the kidneys and excreted in the urine. Glucose is a sugar that is normally filtered by the glomerulus and excreted only in small quantities in the urine. Excess sugar in the urine (glycosuria) is indicative of diabetes mellitus. The peroxidase activity of erythrocytes is used to detect hemoglobin in the urine which may be indicative of hematuria, myoglobinuria, or hemoglobinuria. Ketones in the urine are the result of diabetic ketoacidosis or calorie deprivation (starvation). A leukocyte esterase test identifies the presence of white blood cells in the urine. The presence of nitrites in the urine is indicative of bacteria. The pH identifies the acid-base levels in the urine. The presence of excessive amounts of protein (proteinuria) may be indicative of nephrotic syndrome. Specific gravity measures urine density and is indicative of the kidneys' ability to concentrate and dilute urine. Following dip stick or reagent testing, the urine sample may be examined under a microscope. The urine sample is placed in a test tube and centrifuged. The sediment is resuspended. A drop of the resuspended sediment is then placed on a glass slide, cover-slipped, and examined under a microscope for crystals, casts, squamous cells, blood (white, red) cells, and bacteria.

Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope [CPT 43239]

An upper gastrointestinal (UGI) endoscopic examination, also referred to as an esophagogastroduodenoscopy (EGD), is performed on the esophagus, stomach, duodenum and/or jejunum with biopsy(s). The mouth and throat are numbed using an anesthetic spray. A hollow mouthpiece is placed in the mouth. The flexible fiberoptic endoscope is then inserted and advanced as it is swallowed by the patient. Once the endoscope has been advanced beyond the cricopharyngeal region, it is guided using direct visualization. The esophagus is inspected and any abnormalities are noted. The endoscope is then advanced beyond the gastroesophageal junction into the stomach and the stomach is insufflated with air. The cardia, fundus, greater and lesser curvature, and antrum are inspected and any abnormalities are noted. The tip of the endoscope is then advanced through the pylorus and into the duodenum and/or jejunum where mucosal surfaces are inspected for any abnormalities. Single or multiple samples of suspect tissue are taken through the scope. The endoscope is withdrawn and mucosal surfaces are again inspected for ulcerations, varices, bleeding sites, lesions, strictures, or other abnormalities.

Biopsy of the large bowel using an endoscope (colonoscopy) [CPT 45380]

A flexible colonoscopy is performed with single or multiple biopsies. The colonoscope is inserted into the rectum and advanced through the colon to the cecum or a point within the terminal ileum, using air insufflation to separate the mucosal folds for better visualization. Mucosal surfaces of the colon are inspected and any abnormalities are noted. The endoscope is then withdrawn and mucosal surfaces are again inspected for ulcerations, varices, bleeding sites, lesions, strictures, or other abnormalities. Any suspect site(s) to be biopsied is identified and biopsy forceps are placed through the biopsy channel in the endoscope. The forceps are opened, the tissue is spiked, and the forceps are closed. The biopsied tissue is then removed through the endoscope. One or more tissue samples may be obtained and are sent for separately reportable laboratory analysis.

Blood test, basic group of blood chemicals (Calcium, total) [CPT 80048]

A basic metabolic blood panel is obtained that includes ionized calcium levels along with carbon dioxide (bicarbonate) (CO2), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN). A basic metabolic panel with measurement of ionized calcium may be used to screen for or monitor overall metabolic function or identify imbalances. Ionized or free calcium flows freely in the blood, is not attached to any proteins, and represents the amount of calcium available to support metabolic processes such as heart function, muscle contraction, nerve function, and blood clotting. Total carbon dioxide (bicarbonate) (CO2) level is composed of CO2, bicarbonate (HCO3-), and carbonic acid (H2CO3) with the primary constituent being bicarbonate, a negatively charged electrolyte that works in conjunction with other electrolytes, such as potassium, sodium, and chloride, to maintain proper acid-base balance and electrical neutrality at the cellular level. Chloride is also a negatively charged electrolyte that helps regulate body fluid and maintain proper acid-base balance. Creatinine is a waste product excreted by the kidneys that is produced in the muscles while breaking down creatine, a compound used by the muscles to create energy. Blood levels of creatinine provide a good measurement of renal function. Glucose is a simple sugar and the main source of energy for the body, regulated by insulin. When more glucose is available than is required, it is stored in the liver as glycogen or stored in adipose tissue as fat. Glucose measurement determines whether the glucose/insulin metabolic process is functioning properly. Both potassium and sodium are positively charged electrolytes that work in conjunction with other electrolytes to regulate body fluid, stimulate muscle contraction, and maintain proper acid-base balance and both are essential for maintaining normal metabolic processes. Urea is a waste product produced in the liver by the breakdown of protein from a sequence of chemical reactions referred to as the urea or Krebs-Henseleit cycle. Urea is taken up by the kidneys and excreted in the urine. Blood urea nitrogen, BUN, is a measure of renal function, and helps monitor renal disease and the effectiveness of dialysis.

Blood test, clotting time [CPT 85610]

Prothrombin time (PT) measures how long it takes for blood to clot. Prothrombin, also called factor II, is one of the clotting factors made by the liver and adequate levels of vitamin K are needed for the liver to produce sufficient prothrombin. Prothrombin time is used to help identify the cause of abnormal bleeding or bruising; to check whether blood thinning medication, such as warfarin (Coumadin), is working; to check for low levels of blood clotting factors I, II, V, VII, and X; to check for low levels of vitamin K; to check liver function, to see how quickly the body is using up its clotting factors. The test is performed using electromagnetic mechanical clot detection. If prothrombin time is elevated and the patient is not on a blood thinning medication, a second prothrombin time using substitution plasma fractions, also referred to as a prothrombin time mixing study, may be performed. This is performed by mixing patient plasma with normal plasma using a 1:1 mix. The mixture is incubated and the clotting time is again measured. If the result does not correct, it may be indicative that the patient has an inhibitor, such as lupus anticoagulant. If the result does correct, the patient may have a coagulation factor deficiency.

Blood test, comprehensive group of blood chemicals [CPT 80053]

A comprehensive metabolic panel is obtained that includes albumin, bilirubin, total calcium, carbon dioxide, chloride, creatinine, glucose, alkaline phosphatase, potassium, total protein, sodium, alanine amino transferase (ALT) (SGPT), aspartate amino transferase (AST) (SGOT), and urea nitrogen (BUN). This test is used to evaluate electrolytes and fluid balance as well as liver and kidney function. It is also used to help rule out conditions such as diabetes. Tests related to electrolytes and fluid balance include: carbon dioxide, chloride, potassium, and sodium. Tests specific to liver function include: albumin, bilirubin, alkaline phosphatase, ALT, AST, and total protein. Tests specific to kidney function include: BUN and creatinine. Calcium is needed to support metabolic processes such as heart function, muscle contraction, nerve function, and blood clotting. Glucose is the main source of energy for the body and is regulated by insulin. Glucose measurement determines whether the glucose/insulin metabolic process is functioning properly.

Blood test, lipids (cholesterol and triglycerides) [CPT 80061]

"A lipid panel is obtained to assess the risk for cardiovascular disease and to monitor appropriate treatment. Lipids are comprised of cholesterol, protein, and triglycerides. They are stored in cells and circulate in the blood. Lipids are important for cell health and as an energy source. A lipid panel should include a measurement of triglycerides and total serum cholesterol and then calculate to find the measurement of high density lipoprotein (HDL-C), low density lipoprotein (LDL-C) and very low density lipoprotein (VLDL-C). HDL contains the highest ratio of cholesterol and is often referred to as ""good cholesterol"" because it is capable of transporting excess cholesterol in the blood to the liver for removal. LDL contains the highest ratio of protein and is considered ""bad cholesterol"" because it transports and deposits cholesterol in the walls of blood vessels. VLDL contains the highest ratio of triglycerides and high levels are also considered ""bad"" because it converts to LDL after depositing triglyceride molecules in the walls of blood vessels. A blood sample is obtained by separately reportable venipuncture or finger stick. Serum/plasma is tested using quantitative enzymatic method."

Blood test, thyroid stimulating hormone (TSH) [CPT 84443]

A blood test is performed to determine levels of thyroid stimulating hormone (TSH). TSH is produced in the pituitary and helps to regulate two other thyroid hormones, triiodothyronine (T3) and thyroxin (T4), which in turn help regulate the body's metabolic processes. TSH levels are tested to determine whether the thyroid is functioning properly. Patients with symptoms of weight gain, tiredness, dry skin, constipation, or menstrual irregularities may have an underactive thyroid (hypothyroidism). Patients with symptoms of weight loss, rapid heart rate, nervousness, diarrhea, feeling of being too hot, or menstrual irregularities may have an overactive thyroid (hypothyroidism). TSH levels are also periodically tested in individuals on thyroid medications. The test is performed by electrochemiluminescent immunoassay.

CT scan head or brain [CPT 70450]

Computerized tomography, also referred to as a CT scan, uses special x-ray equipment and computer technology to produce multiple cross-sectional images of the region being studied. In this study, CT scan of the head or brain is performed. The patient is positioned on the CT examination table. An initial pass is made through the CT scanner to determine the starting position of the scans after which the CT scan is performed. As the table moves slowly through the scanner, numerous x-ray beams and electronic x-ray detectors rotate around the body region being examined. The amount of radiation being absorbed is measured. As the beams and detectors rotate around the body, the table is moved through the scanner. A computer program processes the data and renders the data in two-dimensional cross-sectional images of the body region being examined. This data is displayed on a monitor. The physician reviews the data as it is being obtained and may request additional sections to provide more detail of areas of interest.

CT scan of abdomen and pelvis with contrast [CPT 74177]

Computerized tomography, also referred to as a CT scan, uses special x-ray equipment and computer technology to produce multiple cross-sectional images of the abdomen and pelvis. The patient is positioned on the CT examination table. An initial pass is made through the CT scanner to determine the starting position of the scans. The CT scan is then performed. As the table moves slowly through the scanner, numerous x-ray beams and electronic x-ray detectors rotate around the abdomen and pelvis. The amount of radiation being absorbed is measured. As the beams and detectors rotate around the body, the table is moved through the scanner. A computer program processes the data which is then displayed on the monitor as two-dimensional cross-sectional images of the abdomen or pelvis. The physician reviews the data and images as they are obtained and may request additional sections to provide more detail on areas of interest.

CT scan pelvis with contrast [CPT 72193]

Diagnostic computed tomography (CT) is done on the pelvis to provide detailed visualization of the organs and structures within or near the pelvis, such as kidneys, bladder, prostate, uterus, cervix, vagina, lymph nodes, and pelvic bones. CT uses multiple, narrow x-ray beams aimed around a single rotational axis, taking a series of 2D images of the target structure from multiple angles. Contrast material is used to enhance the images. Computer software processes the data and produces several images of thin, cross-sectional 2D slices of the targeted organ or area. Three-dimensional models of organs within the pelvis can be created by stacking multiple, individual 2D slices together. The patient is placed inside the CT scanner on the table and images are obtained of the pelvis area. The physician reviews the images to gather information for specified purposes such as diagnosing or monitoring cancer, evaluating the pelvic bones for fractures or other injury following trauma, locating abscesses or masses found during physical exam, finding the cause of pelvic pain, providing more detailed information before surgery, and evaluating the patient after surgery.

Cervical spinal fusion without complications

Coagulation assessment blood test, plasma or whole blood [CPT 85730]

This test may also be referred to as an activated PTT or aPTT. PTT may be performed to diagnose the cause of bleeding or as a screening test prior to surgery to rule-out coagulation defects. A silica and synthetic phospholipid PTT reagent is mixed with the patient plasma. The silica provides a negatively-charged particulate surface that activates the contact pathway for coagulation. Clot formation is initiated by adding calcium chloride to the mixture. Clotting time is measured photo-optically.

Complete blood cell count (red cells, white blood cell, platelets), automated test [CPT 85027]

An automated complete blood count (CBC) is performed with or without automated differential white blood cell (WBC) count. A CBC is used as a screening test to evaluate overall health and symptoms such as fatigue, bruising, bleeding, and inflammation, or to help diagnose infection. A CBC includes measurement of hemoglobin (Hgb) and hematocrit (Hct), red blood cell (RBC) count, white blood cell (WBC) count with or without differential, and platelet count. Hgb measures the amount of oxygen-carrying protein in the blood. Hct refers to the volume of red blood cells (erythrocytes) in a given volume of blood and is usually expressed as a percentage of total blood volume. RBC count is the number of red blood cells (erythrocytes) in a specific volume of blood. WBC count is the number of white blood cells (leukocytes) in a specific volume of blood. There are five types of WBCs: neutrophils, eosinophils, basophils, monocytes, and lymphocytes. If a differential is performed, each of the five types is counted separately. Platelet count is the number of platelets (thrombocytes) in the blood. Platelets are responsible for blood clotting. The CBC is performed with an automated blood cell counting instrument that can also be programmed to provide an automated WBC differential count.

Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count [CPT 85025]

An automated complete blood count (CBC) is performed with or without automated differential white blood cell (WBC) count. A CBC is used as a screening test to evaluate overall health and symptoms such as fatigue, bruising, bleeding, and inflammation, or to help diagnose infection. A CBC includes measurement of hemoglobin (Hgb) and hematocrit (Hct), red blood cell (RBC) count, white blood cell (WBC) count with or without differential, and platelet count. Hgb measures the amount of oxygen-carrying protein in the blood. Hct refers to the volume of red blood cells (erythrocytes) in a given volume of blood and is usually expressed as a percentage of total blood volume. RBC count is the number of red blood cells (erythrocytes) in a specific volume of blood. WBC count is the number of white blood cells (leukocytes) in a specific volume of blood. There are five types of WBCs: neutrophils, eosinophils, basophils, monocytes, and lymphocytes. If a differential is performed, each of the five types is counted separately. Platelet count is the number of platelets (thrombocytes) in the blood. Platelets are responsible for blood clotting. The CBC is performed with an automated blood cell counting instrument that can also be programmed to provide an automated WBC differential count.

Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope [CPT 43235]

A diagnostic upper gastrointestinal (UGI) endoscopic examination is performed of the esophagus, stomach, duodenum and/or jejunum with or without collection of specimens by brushing or washing. This procedure may also be referred to as an esophagogastroduodenoscopy (EGD). The mouth and throat are numbed using an anesthetic spray. A hollow mouthpiece is placed in the mouth. The flexible fiberoptic endoscope is then inserted and advanced as it is swallowed by the patient. Once the endoscope has been advanced beyond the cricopharyngeal region, it is guided using direct visualization. The esophagus is inspected and any abnormalities are noted. The endoscope is then advanced beyond the gastroesophageal junction into the stomach and the stomach is insufflated with air. The cardia, fundus, greater and lesser curvature, and antrum of the stomach are inspected and any abnormalities are noted. The tip of the endoscope is then advanced through the pylorus and into the duodenum and/or jejunum. Mucosal surfaces of the duodenum and/or jejunum are inspected and any abnormalities are noted. The endoscope is then withdrawn and mucosal surfaces are again inspected for ulcerations, varices, bleeding sites, lesions, strictures, or other abnormalities. Cytology samples may be obtained by cell brushing or washing.

Diagnostic examination of the colon (large bowel) using an endoscope(colonoscopy); high risk [CPT 45378]

A flexible colonoscopy is performed with or without collection of specimens by brushing or washing. The colonoscope is inserted into the rectum and advanced through the colon to the cecum or a point within the terminal ileum, using air insufflation to separate the mucosal folds for better visualization. Mucosal surfaces of the colon are inspected and any abnormalities are noted. The endoscope is then withdrawn as mucosal surfaces are again inspected for ulcerations, varices, bleeding sites, lesions, strictures, or other abnormalities. Cytology (cell) samples may be obtained using a brush introduced through the endoscope. Alternatively, sterile water may be introduced to wash the mucosal lining and the fluid aspirated to obtain cell samples. Cytology samples are sent for separately reportable laboratory analysis.

Diagnostic mammography of both breasts [CPT 77066]

These codes report diagnostic mammography of one breast or both breasts with computer-aided lesion detection (CAD), when performed. Mammography is the radiographic imaging of the breast using low-dose ionizing radiation. The x-rays used in mammography have a longer wavelength that those typically used for bone imaging. The test is done to detect tumors or cysts in women who have symptoms of breast disease or a palpable mass. The breast is compressed between planes on a machine dedicated strictly to mammography. This evens out the dense tissue and holds the breast still for a better quality image. Computer-aided detection uses algorithm analysis of the image data obtained from the mammographic films, with or without digitization of the radiographic images. The mammographic picture of the breast is used by scanning the x-ray film with a laser beam, usually converting the scanned image of the analog film into digital data for the computer first, then employing a methodical, step-by-step pattern of analyzing the data on video display for unusual or suspicious areas.

Diagnostic mammography of one breast [CPT 77065]

These codes report diagnostic mammography of one breast or both breasts with computer-aided lesion detection (CAD), when performed. Mammography is the radiographic imaging of the breast using low-dose ionizing radiation. The x-rays used in mammography have a longer wavelength that those typically used for bone imaging. The test is done to detect tumors or cysts in women who have symptoms of breast disease or a palpable mass. The breast is compressed between planes on a machine dedicated strictly to mammography. This evens out the dense tissue and holds the breast still for a better quality image. Computer-aided detection uses algorithm analysis of the image data obtained from the mammographic films, with or without digitization of the radiographic images. The mammographic picture of the breast is used by scanning the x-ray film with a laser beam, usually converting the scanned image of the analog film into digital data for the computer first, then employing a methodical, step-by-step pattern of analyzing the data on video display for unusual or suspicious areas.

Injection of substance into spinal canal of lower back or sacrum using imaging guidance [CPT 62323]

Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance, single level [CPT 64483]

Kidney function blood test panel [CPT 80069]

A renal panel is obtained for routine health screening and to monitor conditions such as diabetes, renal disease, liver disease, nutritional disorders, thyroid and parathyroid function, and interventional drug therapies. Tests in a renal panel include glucose or blood sugar; electrolytes and minerals as sodium, potassium, chloride, total calcium, and phosphorus; the waste products blood urea nitrogen (BUN) and creatinine; a protein called albumin; and bicarbonate (carbon dioxide, CO2) responsible for acid base balance. Glucose is the main source of energy for the body and is regulated by insulin. High levels may indicate diabetes or impaired kidney function. Sodium is found primarily outside cells and maintains water balance in the tissues, as well as nerve and muscle function. Potassium is primarily found inside cells and affects heart rhythm, cell metabolism, and muscle function. Chloride moves freely in and out of cells to regulate fluid levels and help maintain electrical neutrality. Calcium is needed to support metabolic processes, heart and nerve function, muscle contraction, and blood clotting. Phosphorus is essential for energy production, nerve and muscle function, and bone growth. Blood urea nitrogen (BUN) and creatinine are waste products from tissue breakdown that circulate in the blood and are filtered out by the kidneys. Albumin, a protein made by the liver, helps to nourish tissue and transport hormones, vitamins, drugs, and calcium throughout the body. Bicarbonate (HCO3) may also be referred to as carbon dioxide (CO2) maintains body pH or the acid/base balance. A specimen is obtained by separately reportable venipuncture. Serum/plasma is tested using quantitative chemiluminescent immunoassay or quantitative enzyme-linked immunosorbent assay.

Liver function blood test panel [CPT 80076]

A hepatic function panel is obtained to diagnose acute and chronic liver disease, inflammation, or scarring and to monitor hepatic function while taking certain medications. Tests in a hepatic function panel should include albumin (ALB), total and direct bilirubin, alkaline phosphatase (ALP), total protein (TP), alanine aminotransferase (ALT, SGPT), and aspartate aminotransferase (AST, SGOT). Albumin (ALB) is a protein made by the liver that helps to nourish tissue and transport hormones, vitamins, drugs, and calcium throughout the body. Bilirubin, a waste product from the breakdown of red blood cells, is removed by the liver in a conjugated state. Bilirubin is measured as total (all the bilirubin circulating in the blood) and direct (the conjugated amount only) to determine how well the liver is performing. Alkaline phosphatase (ALP) is an enzyme produced by the liver and other organs of the body. In the liver, cells along the bile duct produce ALP. Blockage of these ducts can cause elevated levels of ALP, whereas cirrhosis, cancer, and toxic drugs will decrease ALP levels. Circulating blood proteins include albumin (60% of total) and globulins (40% of total). By measuring total protein (TP) and albumin (ALB), the albumin/globulin (A/G) ratio can be determined and monitored. TP may decrease with malnutrition, congestive heart failure, hepatic disease, and renal disease and increase with inflammation and dehydration. Alanine aminotransferase (ALT, SGPT) is an enzyme produced primarily in the liver and kidneys. In healthy individuals ALT is normally low. ALT is released when the liver is damaged, especially with exposure to toxic substances such as drugs and alcohol. Aspartate aminotransferase (AST, SGOT) is an enzyme produced by the liver, heart, kidneys, and muscles. In healthy individuals AST is normally low. An AST/ALT ratio is often performed to determine if elevated levels are due to liver injury or damage to the heart or skeletal muscles. A specimen is obtained by separately reportable venipuncture. Serum/plasma is tested using quantitative enzymatic method or quantitative spectrophotometry.

MRI scan of brain before and after contrast [CPT 70553]

Magnetic resonance imaging is done on the brain. MRI is a noninvasive, non-radiating imaging technique that uses the magnetic properties of hydrogen atoms in the body. The patient is placed on a motorized table within a large MRI tunnel scanner that contains the magnet. The powerful magnetic field forces the hydrogen atoms to line up. Radiowaves are then transmitted within the strong magnetic field. Protons in the nuclei of different types of tissues emit a specific radiofrequency signal that bounces back to the computer, which processes the signals and converts the data into tomographic, 3D images with very high resolution. MRI of the brain provides reliable information for diagnosing the presence, location, and extent of tumors, cysts, or other masses; swelling and infection; vascular disorders or malformations, such as aneurysms and intracranial hemorrhage; disease of the pituitary gland; stroke; developmental and structural anomalies of the brain; hydrocephalus; and chronic conditions and diseases affecting the central nervous system such as headaches and multiple sclerosis.

MRI scan of leg joint [CPT 73721]

Magnetic resonance imaging is done on a joint of the upper or lower leg. Magnetic resonance is a noninvasive, non-radiating imaging technique that uses the magnetic properties of hydrogen atoms in the body. The patient is placed on a motorized table within a large MRI tunnel scanner that contains the magnet. The powerful magnetic field forces the hydrogen atoms to line up. Radiowaves are then transmitted within the strong magnetic field. Protons in the nuclei of different types of tissues emit a specific radiofrequency signal that bounces back to the computer, which processes the signals and converts the data into tomographic, 3D images with very high resolution. The patient is placed on a motorized table within a large MRI tunnel scanner that contains the magnet. Small coils that help transmit and receive the radiowaves may be placed around the joint. MRI scans on joints of the lower extremity are often done for injury, trauma, unexplained pain, redness, or swelling, and freezing of a joint with loss of motion. MRI scans provide clear images of areas that may be difficult to see on CT. The physician reviews the images to look for information that may correlate to the patient's signs or symptoms. MRI provides reliable information on the presence and extent of tumors, masses, or lesions within the joint; infection, inflammation, and swelling of soft tissue; muscle atrophy and other anomalous muscular development; and joint effusion and vascular necrosis.

MRI scan of lower spinal canal [CPT 72148]

Magnetic resonance imaging (MRI) is done on the lumbar spinal canal and contents. MRI is a noninvasive, non-radiating imaging technique that uses the magnetic properties of nuclei within hydrogen atoms of the body. The powerful magnetic field forces the hydrogen atoms to line up. Radiowaves are then transmitted within the strong magnetic field. Protons in the nuclei of different types of tissues emit a specific radiofrequency signal that bounces back to the computer, which records the images. The computer processes the signals and coverts the data into tomographic, 3D, sectional images in slices with very high resolution. The patient is placed on a motorized table within a large MRI tunnel scanner that contains the magnet. MRI scans of the spine are often done when conservative treatment of back pain is unsuccessful and more aggressive treatments are considered or following surgery. The physician reviews the images to look for specific information that may correlate to the patient's symptoms, such as abnormal spinal alignment; disease or injury of vertebral bodies; intervertebral disc herniation, degeneration, or dehydration; the size of the spinal canal to accommodate the cord and nerve roots; pinched or inflamed nerves; or any changes since surgery.

Manual urinalysis test with examination using microscope, automated [CPT 81001]

A urinalysis is performed by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, and/or urobilinogen. Urinalysis can quickly screen for conditions that do not immediately produce symptoms such as diabetes mellitus, kidney disease, or urinary tract infection. A dip stick allows qualitative and semi-quantitative analysis using a paper or plastic stick with color strips for each agent being tested. The stick is dipped in the urine specimen and the color strips are then compared to a color chart to determine the presence or absence and/or a rough estimate of the concentration of each agent tested. Reagent tablets use an absorbent mat with a few drops of urine placed on the mat followed by a reagent tablet. A drop of distilled, deionized water is then placed on the tablet and the color change is observed. Bilirubin is a byproduct of the breakdown of red blood cells by the liver. Normally bilirubin is excreted through the bowel, but in patients with liver disease, bilirubin is filtered by the kidneys and excreted in the urine. Glucose is a sugar that is normally filtered by the glomerulus and excreted only in small quantities in the urine. Excess sugar in the urine (glycosuria) is indicative of diabetes mellitus. The peroxidase activity of erythrocytes is used to detect hemoglobin in the urine which may be indicative of hematuria, myoglobinuria, or hemoglobinuria. Ketones in the urine are the result of diabetic ketoacidosis or calorie deprivation (starvation). A leukocyte esterase test identifies the presence of white blood cells in the urine. The presence of nitrites in the urine is indicative of bacteria. The pH identifies the acid-base levels in the urine. The presence of excessive amounts of protein (proteinuria) may be indicative of nephrotic syndrome. Specific gravity measures urine density and is indicative of the kidneys' ability to concentrate and dilute urine. Following dip stick or reagent testing, the urine sample may be examined under a microscope. The urine sample is placed in a test tube and centrifuged. The sediment is resuspended. A drop of the resuspended sediment is then placed on a glass slide, cover-slipped, and examined under a microscope for crystals, casts, squamous cells, blood (white, red) cells, and bacteria.

PSA (prostate specific antigen) measurement, free [CPT 84154]

Prostate specific antigen (PSA) is measured. PSA is a protein produced by normal prostate cells found in serum and exists in both free form and complexed with other proteins. In 84154, free PSA is measured, often in conjunction with total PSA, to provide an indirect measurement of complexed PSA.

PSA (prostate specific antigen) measurement, total [CPT 84153]

Prostate specific antigen (PSA) is measured. PSA is a protein produced by normal prostate cells found in serum and exists in both free form and complexed with other proteins. Total PSA is measured ad the total amount of both free and complexed forms. Total PSA levels are higher in men with benign prostatic hyperplasia (BPH), acute bacterial prostatitis, or prostate cancer. Total PSA is used to screen for prostate cancer and evaluate the response to treatment in those with prostate cancer, but cannot be used by itself to definitively diagnose prostate cancer.

Removal of cataract with insertion of lens, simple [CPT 66984]

Removal of gallbladder using an endoscope [CPT 47562]

The gallbladder is removed by laparoscopic technique. A small portal incision is made at the navel and a trocar is inserted. The scope and video camera are then inserted at this site. The abdomen is inflated with carbon dioxide. Two to three additional abdominal portal incisions are made and trocars are inserted for placing surgical instruments. The gallbladder is identified. If the gallbladder is distended, a needle may be used to drain bile from the gallbladder. Grasper clamps are applied. The Hartmann's pouch is identified and retracted, exposing the triangle of Calot. The cystic artery and cystic duct are identified. The cystic duct is dissected free and transected. The cystic artery is dissected free, ligated, and doubly divided. Electrocautery is used to dissect the gallbladder off the liver bed. The gallbladder is placed in an extraction sac and removed from the abdomen through one of the small incisions.

Removal of one knee cartilage using an endoscope [CPT 29881]

Removal of polyps or growths in large bowel using an endoscope (colonoscopy) using a mechanical snare [CPT 45385]

A flexible colonoscopy is performed with removal of tumors, polyps, or other lesions by hot biopsy forceps or snare technique. The colonoscope is inserted into the rectum and advanced through the colon to the cecum or a point within the terminal ileum, using air insufflation to separate the mucosal folds for better visualization. Mucosal surfaces of the colon are inspected and any abnormalities are noted. The tumor, polyp, or other lesion is identified. Hot biopsy method uses insulated monopolar forceps to remove and electrocoagulate (cauterize) tissue simultaneously. Hot biopsy forceps are used primarily for removal of small polyps and treatment of vascular ectasias. A wire snare loop is placed around the lesion. The loop is heated to shave off and cauterize the lesion. Lesions may be removed en bloc with one placement of the snare or in a piecemeal fashion which requires multiple applications of the snare. The endoscope is withdrawn and mucosal surfaces are again inspected for ulcerations, bleeding sites, lesions, strictures, or other abnormalities.

Repair of groin hernia patient age 5 years or older [CPT 49505]

An initial inguinal hernia repair is performed on a patient who is five years or older. An inguinal hernia is a condition where structures protrude through a weakness in the abdominal wall in the groin area. Incarcerated hernia tissue cannot be pushed back into its normal position. Strangulated hernias are those in which circulation is compromised. An incision is made over the internal ring. The skin, fat, and subcutaneous fascia are incised down to the aponeurosis of the external oblique muscle. The external ring is identified and the external oblique aponeurosis is slit. The internal ring is opened and the inguinal canal is exposed. In males, the spermatic cord and its covering are mobilized and the covering is removed. The hernia sac is dissected free into the retroperitoneum, opened, and inspected for the presence of bowel or bladder wall. Any bowel or bladder content is reduced (pushed back into the abdominal cavity) and the hernia sac is transected and inverted into the abdominal cavity. A mesh plug may be placed to reinforce the repair. In women, the sac is inspected for the ovary. If the ovary is present, it is returned to the abdomen. The sac is then resected together with the round ligament. The internal ring is closed and the posterior wall of the inguinal canal is repaired.

Screening mammography of both breasts [CPT 77067]

Bilateral screening mammography is done with computer-aided lesion detection (CAD), when performed. Mammography is the radiographic imaging of the breast using low-dose ionizing radiation. The x-rays used in mammography have a longer wavelength than those typically used for bone imaging. A screening mammogram is done on asymptomatic women for early breast cancer detection when there are no known palpable masses. This is done on both breasts with two views taken on each side. The breast is compressed between planes on a machine dedicated strictly to mammography. This evens out the dense tissue and holds the breast still for a better quality image. Computer-aided detection uses algorithm analysis of the image data obtained from the mammographic films, with or without digitization of the radiographic images. The mammographic picture of the breast is used by scanning the x-ray film with a laser beam, usually converting the scanned image of the analog film into digital data for the computer first, then employing a methodical, step-by-step pattern of analyzing the data on video display for unusual or suspicious areas.

Shaving of shoulder bone using an endoscope [CPT 29826]

Sleep monitoring of patient (6 years or older) in sleep lab [CPT 95810]

Spinal fusion other than the neck without major complications

Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes [CPT 97110]

Therapeutic exercise is the application of careful, graduated force to the body to increase strength, endurance, range of motion, and flexibility. Increased muscle strength is achieved by the deliberate overloading of a targeted muscle or muscle group and improved endurance is achieved by raising the intensity of the strengthening exercise to the targeted area(s) over a prolonged period of time. To maintain range of motion (ROM) and flexibility requires the careful movement and stretching of contractile and non-contractile tissue that may tighten with injury or neurological disease, causing weakness and/or spasticity. Therapeutic exercise can increase blood flow to the targeted area, reduce pain and inflammation, reduce the risk of blood clots from venous stasis, decrease muscle atrophy and improve coordination and motor control. Therapeutic exercise may be prescribed following acute illness or injury and for chronic conditions that affect physical activity or function.

Total Knee or Hip Replacement

Ultrasound of abdomen, complete [CPT 76700]

A real time abdominal ultrasound is performed with image documentation. The patient is placed supine. Acoustic coupling gel is applied to the skin of the abdomen. The transducer is pressed firmly against the skin and swept back and forth over the abdomen and images obtained. The ultrasonic wave pulses directed at the abdomen are imaged by recording the ultrasound echoes. Any abnormalities are evaluated to identify characteristics that might provide a definitive diagnosis. The physician reviews the ultrasound images of the abdomen and provides a written interpretation.

Ultrasound pelvis through vagina [CPT 76830]

A transvaginal ultrasound is performed to evaluate the non-pregnant uterus and other pelvic structures. Conditions that may be evaluated by transvaginal ultrasound include infertility, abnormal bleeding, unexplained pain, congenital anomalies of the ovaries and uterus, ovarian cysts and tumors, pelvic inflammatory disease, bladder abnormalities, and intrauterine device (IUD) location. The patient is asked to empty the bladder and then lies back with the feet in stirrups. A protective cover is placed over the transducer and acoustic coupling gel is applied. The transducer is inserted into the vagina. Images of the uterus, ovaries, and surrounding pelvic structures are obtained from different orientations of the transducer. The ultrasonic wave pulses directed at the pelvic structures are imaged by recording the ultrasound echoes. The uterus is examined and endometrial thickness is determined. The ovaries are examined and any ovarian masses are carefully evaluated. The bladder and other pelvic structures are examined and any abnormalities are noted. The physician reviews the transvaginal ultrasound images and provides a written interpretation.

Urinalysis, manual test [CPT 81002]

A urinalysis is performed by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, and/or urobilinogen. Urinalysis can quickly screen for conditions that do not immediately produce symptoms such as diabetes mellitus, kidney disease, or urinary tract infection. A dip stick allows qualitative and semi-quantitative analysis using a paper or plastic stick with color strips for each agent being tested. The stick is dipped in the urine specimen and the color strips are then compared to a color chart to determine the presence or absence and/or a rough estimate of the concentration of each agent tested. Reagent tablets use an absorbent mat with a few drops of urine placed on the mat followed by a reagent tablet. A drop of distilled, deionized water is then placed on the tablet and the color change is observed. Bilirubin is a byproduct of the breakdown of red blood cells by the liver. Normally bilirubin is excreted through the bowel, but in patients with liver disease, bilirubin is filtered by the kidneys and excreted in the urine. Glucose is a sugar that is normally filtered by the glomerulus and excreted only in small quantities in the urine. Excess sugar in the urine (glycosuria) is indicative of diabetes mellitus. The peroxidase activity of erythrocytes is used to detect hemoglobin in the urine which may be indicative of hematuria, myoglobinuria, or hemoglobinuria. Ketones in the urine are the result of diabetic ketoacidosis or calorie deprivation (starvation). A leukocyte esterase test identifies the presence of white blood cells in the urine. The presence of nitrites in the urine is indicative of bacteria. The pH identifies the acid-base levels in the urine. The presence of excessive amounts of protein (proteinuria) may be indicative of nephrotic syndrome. Specific gravity measures urine density and is indicative of the kidneys' ability to concentrate and dilute urine. Following dip stick or reagent testing, the urine sample may be examined under a microscope. The urine sample is placed in a test tube and centrifuged. The sediment is resuspended. A drop of the resuspended sediment is then placed on a glass slide, cover-slipped, and examined under a microscope for crystals, casts, squamous cells, blood (white, red) cells, and bacteria.

X-ray of lower and sacral spine, minimum of 4 views [CPT 72110]

A radiologic exam is done of the lumbosacral spine. Frontal, posteroanterior, and lateral views are the most common projections taken. X-ray uses indirect ionizing radiation to take pictures inside the body. X-rays work on non-uniform material, such as human tissue, because of the different density and composition of the object, which allows some of the x-rays to be absorbed and some to pass through and be captured behind the object on a detector. This produces a 2D image of the structures.

Hospital outpt clinic visit [HCPCS G0463]

Hospital outpatient clinic visit for assessment and management of a patient

Critical care delivery critically ill or injured patient, first 30-74 minutes [CPT 99291]

Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes

Emergency department visit, low to moderately severe problem [CPT 99282]

Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity.

Emergency department visit, moderately severe problem [CPT 99283]

Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity.

Emergency department visit, problem of high severity [CPT 99284]

Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function.

Emergency department visit, problem with significant threat to life or function [CPT 99285]

Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function.

Acute hepatitis panel [CPT 80074]

An acute hepatitis panel is obtained to detect and diagnose acute or chronic viral liver infections. Hepatitis A virus (HAV) is highly contagious but usually causes only a mild illness. HAV is found in contaminated food and water but may also be spread person to person by close physical contact. It does not cause a chronic infection and a vaccine is available. Hepatitis B virus (HBV) is found in blood and body fluids and is the most common hepatitis virus contracted. It is a chronic infection and a vaccine is available against HBV. Hepatitis C virus is also found in blood and body fluids, and is chronic, however no vaccine is yet available to protect against this virus. Tests in an acute hepatitis panel should include Hepatitis A antibody, IgM antibody (HAAb IgM Ab), Hepatitis B core antibody, IgM antibody (HBcAb IgM Ab), Hepatitis B surface antigen (HBsAg), and Hepatitis C antibody (by CIA or Interp). Hepatitis A Virus antibody, IgM develops 2-3 weeks post exposure and remains elevated for 2-6 months. Hepatitis B Virus core antibody, IgM is produced in response to the presence of Hepatitis B core antigen. It will be elevated with acute initial infection and during flare up of disease activity in chronic infection. Hepatitis B Virus surface antigen is a protein located on the surface of HBV. Elevated levels of HBsAg may be an early sign of exposure to the virus or indicate an acute or chronic infection. When testing for Hepatitis C antibody, it is not possible to distinguish whether elevated levels are due to active acute infection or a chronic disease state unless differentiated by further testing. A specimen is obtained by separately reportable venipuncture. Serum/plasma is tested using quantitative chemiluminescent immunoassay.

Adrenocorticotropic hormone (ACTH) level [CPT 82024]

Alpha-fetoprotein (AFP) level, serum [CPT 82105]

Alpha-fetoprotein (AFP) is measured in serum or amniotic fluid during pregnancy to screen for neural tube defects such as spina bifida and anencephaly, chromosomal abnormalities such as Down syndrome or Edwards syndrome, and omphalocele. AFP is a protein produced by the yolk sac of the fetus in early gestation and then later by the liver and gastrointestinal tract of the fetus. A blood sample is obtained by separately reportable venipuncture between 14 and 22 weeks gestation. The blood (serum) test screens for high and low levels of AFP. High levels are associated with neural tube defects while low levels are associated with chromosomal abnormalities.

Analgesics levels, 1 or 2 [CPT 80329]

Analysis of substance using immunoassay technique, multiple step method [CPT 83516]

An immunoassay is performed to detect a chemical substance (analyte) other than an antigen or antibody produced by the body in response to an infectious agent. There are dozens of immunoassays for non-infectious antigens and antibodies that are reported with these codes. Examples of non-infectious diseases and disorders that may be worked up using these tests include: celiac disease, motor and sensory neuropathy, Crohn's disease or other inflammatory bowel disease, liver disease, thyroid disease. Examples of specific antigens and antibodies reported with these codes include: Asialo IgG and IgM, ganglioside IgG and IgM, gliadin IgA and IgG. Codes are reported for each immunoglobulin class or subclass tested using this technique, so for example when testing for gliadin IgA and IgG by immunoassay, the code would be reported twice. Qualitative or semiquantitative testing is performed. Qualitative tests detect only the presence or absence of the specific substance. Semiquantitative tests provide a rough estimate of the amount of the substance being tested.

Bacterial blood culture [CPT 87040]

A blood sample is drawn and placed in a medium conducive to the growth of bacteria. Any bacteria present in the blood sample will then reveal themselves.

Bacterial culture for aerobic isolates [CPT 87077]

Used if further testing is required from an anaerobic bacterial tissue culture in order to verify the results.

Bacterial culture, any other source except urine, blood or stool, aerobic [CPT 87070]

A tissue sample besides blood, urine, or stool is collected and placed in a medium conducive to the growth of bacteria. The culture is examined for the growth of bacteria.

Bacterial culture, any source, except blood, anaerobic [CPT 87075]

A tissue sample is collected and placed in a medium conducive to the growth of bacteria. The culture is examined for the growth of bacteria that can survive without oxygen.

Bilirubin level, total [CPT 82247]

A laboratory test is performed to measure total or direct bilirubin. Bilirubin is a pigmented waste product normally produced when red blood cells (RBCs) break down. Non-water soluble (unconjugated) bilirubin is carried on albumin to the liver where it attaches to sugar molecules to become conjugated. Conjugated (direct) bilirubin is water soluble and able to pass from the liver to the small intestine. Further breakdown of bilirubin occurs in the small intestine and it is eventually eliminated in the feces in the form of stercobilin. Total bilirubin is the sum of conjugated (direct) and unconjugated bilirubin. A test for either conjugated or direct bilirubin or total bilirubin may be ordered to diagnose and monitor liver disorders, hemolytic anemia, and newborn (physiologic) jaundice. A blood sample is obtained by separately reportable venipuncture or heel stick. Other body fluids, including cerebral spinal fluid, may be collected and tested for total bilirubin. Serum/plasma is tested using quantitative spectrophotometry.

Blood count, hemoglobin [CPT 85018]

A blood test is performed to determine hemoglobin (Hgb) which is a measurement of the amount of oxygen-carrying protein in the blood. Hgb is measured to determine the severity of anemia or polycythemia, monitor response to treatment for these conditions, or determine the need for blood transfusion. A blood sample is collected by separately reportable venipuncture or finger, heel, or ear stick. The sample may be sent to the lab or a rapid testing system may be used in the physician's office. Systems consist of a portable photometer and pipettes that contain reagent. The pipette is used to collect the blood sample from a capillary stick and the blood is automatically mixed with the reagent in the pipette. The photometer is then used to read the result which is displayed on the photometer device.

Blood gases measurement [CPT 82803]

A laboratory test is performed to measure one or more components of blood gases. The homeostatic acid-base balance is measured as blood pHùthe number of hydrogen ions (H+) dissolved in the blood. Partial pressure of carbon dioxide (pCO2) is the amount of carbon dioxide dissolved in the blood and reflects how well the lungs can move CO2 out of the body. Partial pressure of oxygen (pO2) is the level of oxygen dissolved in the blood and reflects the exchange of oxygen molecules in the alveoli. Bicarbonate (HCO3) is calculated from pH and pCO2 and is the metabolic component of acid-base balance reflecting the kidney's response to changes in pH. Oxygen saturation (O2 Sat) is the percent of hemoglobin that is carrying oxygen. Calculated O2 saturation uses a mathematical model to determine the percentage of hemoglobin that is carrying oxygen based on the level of pO2. Blood gas monitoring may be performed to evaluate lung function; detect an acid-base imbalance; monitor metabolic, respiratory, and kidney disorders; and evaluate the effectiveness of treatment. A blood sample is obtained by separately reportable venipuncture, heelstick, arterial, or umbilical cord draw.

Blood glucose (sugar) measurement using reagent strip [CPT 82948]

Blood group typing (ABO) [CPT 86900]

A blood specimen is tested to determine blood type (ABO) or Rh(D). Blood is grouped using an ABO blood typing system which identifies four blood types: type A, B, AB, or O. The blood sample is mixed with antibodies against Type A and B blood and then checked to determine if the blood cells agglutinate, or stick together. Type A blood has anti-B antibodies; type B blood has anti-A antibodies; type O blood has antibodies to both A and B; and type AB blood does not have anti-A or anti-B antibodies. Type A blood agglutinates when type B antibodies are introduced. Type B blood agglutinates when type A antibodies are introduced. Type O blood agglutinates when type A or B antibodies are introduced. Type AB blood does not agglutinate when type A or B antibodies are introduced. The blood is then back typed. Blood serum is mixed with blood that is known to be type A or B.

Blood typing for Rh (D) antigen [CPT 86901]

A blood specimen is tested to determine blood type (ABO) or Rh(D). In Rh(D), blood is tested for Rh factor, which is an antigen on red blood cells. Blood is Rh+ if the antigen is present or Rh- if the antigen is absent. Blood is tested by mixing the blood sample with antibodies against Rh factor and then checking for agglutination. If agglutination occurs, the blood is Rh+. If the blood does not agglutinate, it is Rh-.

Blood unit compatibility test, electronic [CPT 86923]

Carcinoembryonic antigen (CEA) protein level [CPT 82378]

A laboratory test is obtained to measure carcinoembryonic antigen (CEA) levels in blood and body fluids. CEA is a protein normally present at high levels during fetal development but is low or absent after birth. Elevated levels of CEA may occur with colorectal, breast, lung, pancreatic, prostate, ovarian, and medullary thyroid cancers. CEA testing can help determine tumor size, stage, and metastasis. A baseline level is usually obtained following a cancer diagnosis. Serial testing is done to monitor treatment and response to therapy. Elevated levels of CEA have also been noted in smokers and in patients diagnosed with inflammatory disorders, cirrhosis, peptic ulcer, ulcerative colitis, rectal polyps, emphysema, and benign breast disease. CEA testing should not be used for screening in the general population. A blood sample is obtained by separately reportable venipuncture. Cerebral spinal fluid (CSF) is obtained by separately reportable lumbar puncture. Pleural and peritoneal fluids are obtained by needle aspiration. Serum/plasma and body fluids are tested using quantitative electrochemiluminescent immunoassay.

Chemical analysis using chromatography technique [CPT 82542]

Cortisol (hormone) measurement, total [CPT 82533]

Cortisol is a glucocorticoid (steroid hormone) produced by the adrenal gland in response to stress. The hormone causes an elevation in blood glucose levels, a decrease in immune system function and aids in the metabolism of fats, proteins and carbohydrates. The test may be used to diagnose Cushing syndrome (elevated cortisol levels) or Addison disease (decreased cortisol levels). A blood or saliva test is performed to measure total cortisol (hydrocortisone) levels. A blood sample is obtained by separately reportable venipuncture. Serum or plasma is tested using quantitative chemiluminescent immunoassay or quantitative liquid chromatography-tandom mass spectrometry. A saliva sample is obtained by separately reportable oral swab using a saliva collection device. Saliva is tested using quantitative enzyme immunoassay.

Creatinine level to test for kidney function or muscle injury [CPT 82570]

A sample other than blood is taken to measure creatinine levels. Creatinine is a waste product produced by the muscles in the breakdown of creatine, which is a compound used by the muscles to create energy for contraction. The waste product, creatinine, is excreted by the kidneys and blood levels provide a good measurement of renal function. Creatinine may be checked to screen for or monitor treatment of renal disease. Creatinine levels may also be monitored in patients with acute or chronic illnesses that may impair renal function and in patients on medications that affect renal function. Creatinine clearance, also known as urea or urea nitrogen clearance tests both blood and urine samples for a calculation of creatinine content adjusted for urine volume and physical size as a general indicator of glomerular filtration function.

Cyanocobalamin (vitamin B-12) level [CPT 82607]

Cyanocobalamin is a vitamer of the B-12 vitamin family and plays an important role in metabolism, red blood cell production and nervous system function. Blood levels of cyanocobalamin are measured. Blood levels may be reduced with pernicious and other forms of anemia, and in individuals who follow a strict vegan diet, have chronic infections (such as HIV) and during pregnancy. A blood sample is obtained by separately reportable venipuncture. Serum is tested using quantitative chemiluminescent immunoassay.

Detection test by immunoassay technique for clostridium difficile toxins (stool pathogen) [CPT 87324]

Detection test by nucleic acid for Chlamydia pneumoniae, amplified probe technique [CPT 87486]

Detection test by nucleic acid for Mycoplasma pneumoniae (bacteria), amplified probe technique [CPT 87581]

Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique [CPT 87641]

Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique [CPT 87660]

Detection test by nucleic acid for clostridium difficile, amplified probe technique [CPT 87493]

Detection test by nucleic acid for multiple organisms, amplified probe(s) technique [CPT 87801]

Detection test by nucleic acid for multiple types influenza virus [CPT 87502]

Detection test by nucleic acid for organism, amplified probe technique [CPT 87798]

Detection test for candida species (yeast), direct probe technique [CPT 87480]

Detection test for gardnerella vaginalis (bacteria), direct probe technique [CPT 87510]

Folic acid level, serum [CPT 82746]

A blood test is performed to measure folic acid (folate) levels in serum or red blood cells (RBC). Folic acid (folate) may also be referred to as Vitamin B9 and is essential for the growth, division and repair of cells, especially fetal growth during pregnancy and in early infancy. It is also necessary for the production of healthy red blood cells and to prevent anemia at all ages. The test may be used to diagnose anemia or certain neuropathies and to monitor the effectiveness of treatment for these conditions. A blood sample is obtained by separately reportable venipuncture.

Gammaglobulin (immune system protein) measurement [CPT 82784]

A test is performed to measure immunoglobin levels in the blood or other body fluids, such as saliva or cerebral spinal fluid. Immunoglobins, also referred to as antibodies, are evaluated to help diagnose a variety of conditions including autoimmune diseases, allergies, or malignant neoplasms such as multiple myeloma or macroglobulinemia. In addition, immunoglobulin levels may be evaluated in patients with frequent infections to determine if there is a low level of immunoglobulin IgG. Immunoglobulins are also evaluated in patients with cancer or H. pylori infection to determine the effectiveness of treatment. There are five major types of antibodies. IgA antibodies are found in the nose, respiratory and digestive tracts, ears, eyes, and vagina. IgA protects the body surfaces from outside foreign substances. IgD is found in tissues lining the abdominal and thoracic cavity. IgE is found in the lungs, skin, and mucous membranes and reacts to substances commonly associated with allergies, such as food, pollen, dander, dust, fungus spores, etc. High levels of IgE are associated with allergies. IgG is found in all body fluids and is important in fighting bacterial and viral infections. There are four subclasses of IgG, designated as IgG1, IgG2, IgG3, and IgG4. These different subclasses protect against different types of infection. For example IgG1 is particularly effective in protecting the body from viral proteins, whereas IgG2 is more effective against certain types of bacterial infections. Individuals may have selective IgG subclass deficiencies characterized by low levels of one or two IgG subclasses with normal total IgG. IgM is found in blood and lymph and is important in fighting infection. A blood specimen is obtained by separately reportable venipuncture, a CSF sample is obtained by separately reportable spinal puncture, or saliva is collected. The methodology used to test immunoglobulin levels is dependent on the type of specimen and the immunoglobulin being tested.

Gonadotropin (reproductive hormone) analysis [CPT 84703]

A specimen is tested for chorionic gonadotropin (hCG). A qualitative test is performed to test for the presence of absence of hCG only. This test may be performed on blood or urine. Qualitative hCG testing is performed to confirm pregnancy.

HLA class II typing low resolution one locus [CPT 81376]

Hemoglobin A1C level [CPT 83036]

A blood test is performed to measure glycosylated hemoglobin (HbA1C) levels. Plasma glucose binds to hemoglobin and the HbA1C test measures the average plasma glucose concentration over the life of red blood cells (approximately 90-120 days). HbA1C levels may be used as a diagnostic reference for patients with suspected diabetes mellitus (DM) and to monitor blood glucose control in patients with known DM. HbA1C levels should be monitored at least every 6 months in patients with DM and more frequently when the level is >7.0%. A blood sample is obtained by separately reportable venipuncture. Whole blood is tested using quantitative high performance liquid chromatography/boronate affinity.

Hepatitis B surface antibody measurement [CPT 86706]

A blood sample is tested for hepatitis B surface antibody (HBsAB). Hepatitis B is an inflammation of the liver caused by the hepatitis B virus (HBV). HBsAB testing is performed to identify previous exposure to HBV without current acute or chronic infection, to determine the need for vaccination, and whether or not a previously administered vaccination has been successful. Individuals with a positive HBsAB test have been exposed to the virus but no longer carry an active form of the virus, cannot pass it on to others, and are immune from future HBV infection. HBsAB is tested using chemiluminescent assay.

Hepatitis C antibody measurement [CPT 86803]

A laboratory test is performed to measure Hepatitis C virus (HCV) antibodies. Hepatitis C causes acute or chronic liver inflammation and may be transmitted via blood transfusion, needle sticks or sharing of needles in occupational situations or recreational drug use, unprotected sex, placental transfer during pregnancy, or sharing personal items such as a razor or toothbrush. The test is used to screen individuals at risk for infection with HCV. A blood sample is obtained by separately reportable venipuncture. Serum is tested using qualitative chemiluminescent immunoassay. Antibodies toward HCV may not start to elevate until 2 months after exposure, so a negative test screening should be repeated if there is a strong suspicion of HCV infection.

Identification of organisms by genetic analysis, amplified probe technique [CPT 87150]

Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3 [CPT 86300]

Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9 [CPT 86301]

Iron binding capacity [CPT 83550]

A blood test is performed to measure the iron binding capacity of transferrin. Transferrin, a protein found in circulating blood is responsible for carrying iron molecules. This test measures the ability of transferrin to carry iron. A blood sample is obtained by separately reportable venipuncture. Serum or plasma is tested using quantitative spectrophotometry/calculation.

Iron level [CPT 83540]

A blood, urine or liver test is performed to measure iron levels. Iron (Fe) is an essential element that circulates in the blood attached to the protein transferrin. Iron is necessary component of hemoglobin, found in red blood cells (RBCs) and myoglobin found in muscle cells. Low iron levels may cause a decrease in red blood cells and iron deficiency anemia. High iron levels may be caused by excessive intake of iron supplements or a hereditary genetic condition such as hemochromatosis from a mutation of the RGMc gene or HAMP gene. A blood sample is obtained by separately reportable venipuncture. Serum or plasma is tested using quantitative spectrophotometry. A random voided or 24 hour urine specimen is obtained and tested using quantitative inductively coupled plasma/emission spectrometry. Patient should wait 2-4 days after receiving iodine or gadolinium contrast media to collect a urine specimen. A liver sample is obtained by a separately reportable procedure. Liver tissue is tested using quantitative inductively coupled plasma-mass spectrometry.

Lactate dehydrogenase (enzyme) level [CPT 83615]

A blood or body fluid test is performed to measure lactate dehydrogenase (LD) (LDH) levels. LDH is an enzyme present in red blood cells (RBCs) and in the tissue of heart, liver, pancreas, kidney, skeletal muscle, brain and lungs. LDH levels are used as a marker for tissue and RBC damage. Elevated blood levels can be caused by stroke, myocardial infarction, liver disease, pancreatitis, muscular dystrophy, infectious mononucleosis, hemolytic anemia and tumors/cancers such as lymphoma. Elevated cerebral spinal fluid (CSF) levels are usually indicative of bacterial meningitis. LDH levels in pleural and/or pericardial fluid can indicate if the effusion is an exudate, caused by an infection or a transudate caused by fluid pressure problem. A blood sample is obtained by separately reportable venipuncture. Cerebral spinal fluid is obtained by separately reportable lumbar puncture (spinal tap). Pericardial fluid is obtained by separately reportable pericardiocentesis. Fluid from a pleural effusion is obtained by separately reportable thoracentesis. Serum or plasma and all body fluids are tested using quantitative enzymatic methodology.

Lipase (fat enzyme) level [CPT 83690]

A test is performed on blood and body fluids to measure lipase levels. Lipase is an enzyme released by the pancreas into the small intestine and is essential for the digestion of dietary fats. Elevated levels may result from small bowel obstruction, celiac disease, cholecystitis, duodenal ulcer, severe gastroenteritis, macrolipasemia, pancreatitis, and pancreatic tumors. The test may be ordered when there is a family history of lipoprotein lipase deficiency. A blood sample is obtained by separately reportable venipuncture. Other body fluids collected by other methods. Blood and other body fluids are tested using quantitative enzymatic methodology.

Magnesium level [CPT 83735]

A blood, urine, or fecal test is performed to measure magnesium levels. Magnesium is an essential dietary mineral responsible for enzyme function, energy production, and contraction and relaxation of muscle fibers. Decreased levels may result from severe burns, metabolic disorders, certain medications, and low blood calcium levels. A blood sample is obtained by separately reportable venipuncture. Red blood cells (RBCs) are tested using quantitative inductively coupled plasma-mass spectrometry. Serum/plasma is tested using quantitative spectrophotometry. A 24-hour voided urine specimen is tested using quantitative spectrophotometry. A random or 24-hour fecal sample is tested using quantitative spectrophotometry.

Measurement C-reactive protein for detection of infection or inflammation [CPT 86140]

A blood test is performed to measure C-reactive protein (CRP) levels. This standard test has a wide value range. CRP is an acute phase protein, synthesized by the liver and released in response to inflammation and infection. The test is not diagnostic for any specific disease or condition but can be used as a marker to monitor the body's response to treatment(s) or to evaluate the need for further testing. Elevation of CRP levels may be found during pregnancy, with the use of oral contraceptives, or hormone replacement therapy. Diseases/conditions that cause an elevation of CRP include: lymphoma, arteritis/vasculitis, osteomyelitis, inflammatory bowel disease, rheumatoid arthritis, pelvic inflammatory disease (PID), systemic lupus erythematosus (SLE), acute infections, burns, surgical procedures, and organ transplants. A blood sample is obtained by separately reportable venipuncture. Serum in neonates is tested using immunoassay. Serum/plasma in all other patients is tested using quantitative immunoturbidimetric method.

Measurement of antibody (IgE) to allergic substance, crude allergen extract, each [CPT 86003]

Lab test for Allergen-specific antibodies

Measurement of antibody for rheumatoid arthritis assessment [CPT 86200]

Microscopic examination for white blood cells with manual cell count [CPT 85007]

A blood smear is performed with microscopic examination with or without a manual differential WBC count. A blood smear is typically performed following an automated test that indicates the presence of abnormal or immature blood cells. It may also be performed when the physician suspects a condition that affects blood cell production, such as anemia. A blood sample is obtained by separately reportable venipuncture. A blood smear is prepared and examined under a microscope by a technician for immature or abnormal cells. The test is performed with a manual differential white blood cell (WBC) count. The technician examines and counts each of the five types of WBCs separately. Neutrophils comprise the majority of WBCs in healthy adults and are differentiated by cytoplasm with pink or purple granules. Eosinophils normally comprise 1-3% of total WBCs and are differentiated in stained smears by their large, red-orange granules. Elevated levels of eosinophils may indicate allergy or parasitic infection. Basophils normally comprise only 1% of total WBCs and are differentiated by their large black granules. Elevated levels of basophils may be indicative of certain leukemias, varicella (chicken pox) infection, or ulcerative colitis. Monocytes are the largest WBCs and act as scavengers to ingest (phagocytize) cellular debris, bacteria, and other particles. Lymphocytes produce antibodies (immunoglobulins) and are differentiated by their homogenous cytoplasm and smooth, round nucleus.

Microscopic genetic analysis of tumor, using computer-assisted technology [CPT 88361]

Natriuretic peptide (heart and blood vessel protein) level [CPT 83880]

The level of the natriuretic peptide in the blood is measured to evaluate heart failure and to differentiate symptoms that might be indicative of heart failure from other disorders that cause similar symptoms. A separately reportable venipuncture is performed and whole blood or plasma collected using EDTA as an anticoagulant. An automated immunoassay is performed using murine monoclonal and polyclonal antibodies against natriuretic peptide. The antibodies are labeled with a fluorescent dye and immobilized on the solid phase. The specimen is placed in the sample chamber and the analysis is run. The physician reviews the results and uses them to make diagnosis and treatment decisions.

Organic acid level [CPT 83921]

Parathormone (parathyroid hormone) level [CPT 83970]

A blood or tissue test is performed to measure parathormone (parathyroid hormone, parathyrin) levels. Parathyroid hormone (PTH) is produced by chief cells in the parathyroid gland. The hormone helps to regulate blood calcium levels, absorption/excretion of phosphate by the kidneys and in Vitamin D synthesis in the body. Elevated levels (hyperparathyroidism) may be caused by parathyroid gland tumors or chronic renal failure. Decreased levels (hypoparathyroidism) may result from inadvertent removal (during thyroid gland surgery), autoimmune disorders or genetic inborn errors of metabolism. A blood sample is obtained by separately reportable venipuncture. Parathyroid gland tissue is obtained by separately reportable fine needle aspirate. Serum/plasma or tissue sample are tested using quantitative electrochemiluminescent immunoassay. Plasma is tested for parathyroid hormone, CAP (Cyclase Activating Parathyroid Hormone) using immunoradiometric assay.

Pathology examination of specimen during surgery, first tissue block [CPT 88331]

Pathology examination of tissue using a microscope, intermediate complexity [CPT 88305]

Tissue removed during a surgical procedure, such as a biopsy, excision, or resection, is examined macroscopically (gross or visual examination) and then under a microscope. The cells, tissues, or organ are transported from the surgical suite to the pathologist. The pathologist first visually examines the specimen and notes any defining characteristics. The specimen is then prepared for microscopic evaluation. The physician carefully analyzes the specimens to help establish a diagnosis, identify the presence or absence of malignant neoplasm, identify the exact type malignancy if present, examine the margins of the specimen to determine whether or not the entire diseased area was removed. A written report of findings is then prepared and a copy sent to the treating physician. Pathology services are reported based on the type of tissue examined, whether or not the tissue is expected to be normal or diseased, the difficulty of the pathology exam, and the time required to complete the exam.

Pathology examination of tissue using a microscope, moderately high complexity [CPT 88307]

Tissue removed during a surgical procedure, such as a biopsy, excision, or resection, is examined macroscopically (gross or visual examination) and then under a microscope. The cells, tissues, or organ are transported from the surgical suite to the pathologist. The pathologist first visually examines the specimen and notes any defining characteristics. The specimen is then prepared for microscopic evaluation. The physician carefully analyzes the specimens to help establish a diagnosis, identify the presence or absence of malignant neoplasm, identify the exact type malignancy if present, examine the margins of the specimen to determine whether or not the entire diseased area was removed. A written report of findings is then prepared and a copy sent to the treating physician. Pathology services are reported based on the type of tissue examined, whether or not the tissue is expected to be normal or diseased, the difficulty of the pathology exam, and the time required to complete the exam.

Pathology examination of tissue using a microscope, moderately low complexity [CPT 88304]

Tissue removed during a surgical procedure, such as a biopsy, excision, or resection, is examined macroscopically (gross or visual examination) and then under a microscope. The cells, tissues, or organ are transported from the surgical suite to the pathologist. The pathologist first visually examines the specimen and notes any defining characteristics. The specimen is then prepared for microscopic evaluation. The physician carefully analyzes the specimens to help establish a diagnosis, identify the presence or absence of malignant neoplasm, identify the exact type malignancy if present, examine the margins of the specimen to determine whether or not the entire diseased area was removed. A written report of findings is then prepared and a copy sent to the treating physician. Pathology services are reported based on the type of tissue examined, whether or not the tissue is expected to be normal or diseased, the difficulty of the pathology exam, and the time required to complete the exam.

Phosphatase (enzyme) level, alkaline [CPT 84075]

Lab test for Alkaline Phosphatase

Psa screening [HCPCS G0103]

Prostate cancer screening; prostate specific antigen test (psa)

Rbc leukocytes reduced [HCPCS P9016]

Red blood cells, leukocytes reduced, each unit

Red blood cell concentration measurement [CPT 85014]

A blood test is performed to determine hematocrit (Hct). Hematocrit refers to the volume of red blood cells (erythrocytes) in a given volume of blood and is usually expressed as a percentage of total blood volume. A blood sample is obtained by separately reportable venipuncture or finger, heel, or ear stick. Hct is calculated using an electronic cell counter.

Rheumatoid factor level [CPT 86431]

Lab test for Rheumatoid Arthritis factor

SARS-Cov-2 COVID 19 (PCR Test) [CPT 87635]

Screening test for red blood cell antibodies [CPT 86850]

A blood sample is tested for antibodies directed against red blood cell (RBC) antigens other than A and B antigens. This test may also be referred to as an indirect antiglobulin test (IAT). This test is performed as part of a blood typing and screening test when it is anticipated that a blood transfusion might be required. If an antibody is detected, then separately reportable antibody identification is performed to identify the specific antibodies present. The test may be performed using IAT methodology or another serum technique such as solid phase. If multiple serum techniques are used, each reported separately.

Special Gram or Giemsa stain for microorganism [CPT 87205]

A laboratory test is performed to identify bacteria, fungi, or cell types in pus, normally sterile body fluid(s), or aspirated material using Gram or Giemsa stain technique. Gram staining is a differential technique used to classify bacteria into gram positive (Gram +) or gram negative (Gram -) groups. Gram + bacteria have a thick layer of peptidoglycan in the cell wall which stains purple. Giemsa technique is used in cytogenetics for chromosome staining; in histopathology to detect trichomonas, some spirochetes, protozoans, malaria, and other parasites; and as a stain for peripheral blood and bone marrow to differentiate cells types such as erythrocytes, platelets, lymphocyte cytoplasm, monocyte cytoplasm, and leukocyte nuclear chromatin. A drop of suspended culture or cell material is applied in a thin layer to a slide using an inoculation hook and fixed with heat. The material is stained and the slide is examined under a microscope. The bacteria, fungi, or cells are identified, counted, and a written report of the findings is made.

Stool analysis for blood, by peroxidase activity [CPT 82272]

A fecal (stool) sample is obtained for colorectal neoplasm screening and tested for the presence of occult (hidden) blood by peroxidase activity. This test is also referred to as a fecal occult blood test (FOBT). Occult blood in a stool specimen is present in amounts too small to see with the naked eye, but becomes visible when chemical tests are performed. Guaiac is one type of chemical (reagent) test that can be performed to identify the presence of blood in the stool. If the test is performed in an office or hospital, the physician may obtain the sample during a rectal exam. If the test is performed at home, the patient is provided with a stool collection kit consisting of three cards or a single triple card. The patient obtains three consecutive stool specimens per the kit instructions. The stool specimens are then returned to the physician office or mailed to a laboratory. All three specimens are then tested using a chemical reagent for the presence of occult blood. A few drops of the chemical reagent are applied to each stool specimen. If blood is present, a color change will be detected on the card.

Stool culture, additional pathogens [CPT 87046]

Tacrolimus level [CPT 80197]

A blood test is performed to measure tacrolimus levels. Tacrolimus, also known as Prograf is an immunosuppressant drug that affects the ability of certain white blood cells in the body to recognize and respond to transplanted body organs such as kidney, liver, heart and lung. The drug is administered intravenously, either alone or in combination with other immunosuppressant drugs. Tacrolimus has a narrow therapeutic range and blood levels may be assessed daily at the start of therapy, taper to 1-2 times per week and finally to once every 1-2 months. For routine monitoring the specimen is collected as a trough level, immediately prior to a scheduled dose and at least 12 hours after the previous dose. A blood sample is obtained by a separately reportable venipuncture. Whole blood is then tested using liquid chromatography-tandem mass spectrometry. Prograf may be tested with chromatographic or immunoassay technique and the results will be somewhat different. Make note of the technique used when comparing results with previous levels.

Test for detection of gastrointestinal disease-causing organism using amplified probe [CPT 0097U]

Testing for presence of drug, read by direct observation [CPT 80305]

Testing for presence of drug, read by instrument assisted observation [CPT 80306]

Thyroid hormone, T3 measurement, free [CPT 84481]

A blood sample is tested to determine levels of total triiodothyronine (T3), free T3, or reverse T3. T3 is a hormone made by the thyroid gland that affects almost every metabolic process including body temperature, growth, and heart rate. T3 can either be produced by the thyroid or synthesized by the body from T4. Approximately 95% of T3 is bound to proteins in the blood and is inactive. The remaining 5% is free and active. T3 tests are used to help determine whether the thyroid is functioning properly, to diagnose hyperthyroidism, and to monitor patients with known thyroid disorders. In total T3, which reflects the amount of both bound and free T3, is measured. Total and free T3 are evaluated using electrochemiluminescent immunoassay.

Thyroid hormone, T3 measurement, total [CPT 84480]

A blood sample is tested to determine levels of total triiodothyronine (T3), free T3, or reverse T3. T3 is a hormone made by the thyroid gland that affects almost every metabolic process including body temperature, growth, and heart rate. T3 can either be produced by the thyroid or synthesized by the body from T4. Approximately 95% of T3 is bound to proteins in the blood and is inactive. The remaining 5% is free and active. T3 tests are used to help determine whether the thyroid is functioning properly, to diagnose hyperthyroidism, and to monitor patients with known thyroid disorders. In total T3, which reflects the amount of both bound and free T3, is measured. Total and free T3 are evaluated using electrochemiluminescent immunoassay. If the thyroid does not produce enough T3 or not enough is synthesized from T4, an inactive form of T3, referred to as reverse T3 or rT3, may be produced. Elevated levels of rT3 may be indicative of a thyroid disorder. Radioimmunoassay is used to evaluate rT3 levels.

Total protein level, blood [CPT 84155]

A blood test is performed to measure total protein levels. Total protein is often reported as a ratio of albumin to globulin (A/G ratio), and normal results will show albumin slightly greater than globulin. The test may be used to monitor nutritional status or diagnose kidney and liver disease. Elevated levels can indicate chronic inflammation, viral hepatitis, HIV infection, and multiple myeloma. Levels that are decreased may result from malnutrition or malabsorption syndromes such as celiac disease or inflammatory bowel disease. A blood sample is obtained by separately reportable venipuncture. Serum, plasma, or whole blood may be tested using quantitative spectrophotometry.

Troponin (protein) analysis, quantitative [CPT 84484]

A blood test is performed to measure troponin levels. Troponins are regulatory proteins that facilitate contraction of skeletal and smooth muscle by forming calcium bonds. Troponin T binds to tropomyosin to form a complex. Troponin I binds to actin and holds the Troponin T-tropomyosin complex together. Elevation of troponins, coupled with cardiac symptoms such as chest pain are considered diagnostic for cardiac injury. This test is commonly ordered in the Emergency Department when a patient presents with possible myocardial infarction, and is then repeated at 6 hour intervals. It may be ordered with other tests that assess cardiac biomarkers such as CK, CK-MB, and myoglobin. A blood sample is obtained by separately reportable venipuncture. Serum/plasma is tested for Troponin T using quantitative electrochemiluminescent immunoassay. Serum is tested for Troponin I using chemiluminescent immunoassay.

Vitamin D-3 level [CPT 82306]

Blood levels of 25-hydroxyvitamin D are used to primarily to determine whether a deficiency of Vitamin D or abnormal metabolism of calcium is the cause of bone weakness or malformation. Vitamin D is a fat soluble vitamin that is absorbed from the intestine like fat, and 25-hydroxyvitamin D levels are also evaluated in individuals with conditions or diseases that interfere with fat absorption, such as cystic fibrosis, Crohn's disease, or in patients who have undergone gastric bypass surgery. A blood sample is obtained. Levels of 25-hydroxyvitamin D3 and 25-hydroxyvitamin D2 are evaluated using chemiluminescent immunoassay. The test results may be the sum of Vitamin D3 and D2 or the results may include fractions of D3 and D2 as well as the sum of these values.

Hydration infusion into a vein 31 minutes to 1 hour [CPT 96360]

An intravenous infusion is administered for hydration. An intravenous line is placed into a vein, usually in the arm, and fluid is administered to provide additional fluid levels and electrolytes to counteract the effects of dehydration or supplement deficient oral fluid intake. The physician provides direct supervision of the fluid administration and is immediately available to intervene should complications arise. The physician provides periodic assessments of the patient and documentation of the patient's response to treatment.

Hydration infusion into a vein [CPT 96361]

An intravenous infusion is administered for hydration. An intravenous line is placed into a vein, usually in the arm, and fluid is administered to provide additional fluid levels and electrolytes to counteract the effects of dehydration or supplement deficient oral fluid intake. The physician provides direct supervision of the fluid administration and is immediately available to intervene should complications arise. The physician provides periodic assessments of the patient and documentation of the patient's response to treatment. Use 96360 for the initial 31 minutes to one hour of hydration. Use 96361 for each additional hour.

Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour [CPT 96365]

An intravenous infusion of a specified substance or drug is administered for therapy, prophylaxis, or diagnosis. An intravenous line is placed into a vein, usually in the arm, and the specified substance or drug is administered. The physician provides direct supervision of the administration and is immediately available to intervene should complications arise. The physician provides periodic assessments of the patient and documentation of the patient's response to treatment.

Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion [CPT 96368]

An intravenous infusion of a specified substance or drug is administered for therapy, prophylaxis, or diagnosis. An intravenous line is placed into a vein, usually in the arm, and the specified substance or drug is administered. The physician provides direct supervision of the administration and is immediately available to intervene should complications arise. The physician provides periodic assessments of the patient and documentation of the patient's response to treatment.

Infusion of chemotherapy into a vein [CPT 96415]

Injection beneath the skin or into muscle for therapy, diagnosis, or prevention [CPT 96372]

A subcutaneous or intramuscular injection of a therapeutic, prophylactic, or diagnostic substance or drug is given. A subcutaneous injection is administered just under the skin in the fatty tissue of the abdomen, upper arm, upper leg, or buttocks. The skin is cleansed. A two-inch fold of skin is pinched between the thumb and forefinger. The needle is inserted completely under the skin at a 45 to 90 degree angle using a quick, sharp thrust. The plunger is retracted to check for blood. If blood is present, a new site is selected. If no blood is present, the medication is injected slowly into the tissue. The needle is withdrawn and mild pressure is applied. An intramuscular injection is administered in a similar fashion deep into muscle tissue, differing only in the sites of administration and the angle of needle insertion. Common sites include the gluteal muscles of the buttocks, the vastus lateralis muscle of the thigh, or the deltoid muscle of the upper arm. The angle of insertion is 90 degrees. Intramuscular administration provides rapid systemic absorption and can be used for administration of relatively large doses of medication.

Injection of incremental dosages of allergen [CPT 95115]

Patient visit for Allergy shots, one injection

Injection of incremental dosages of allergen, 2 or more injections [CPT 95117]

Patient visit for Allergy shots, more than two injections

Medical nutrition therapy re-assessment and intervention, each 15 minutes [CPT 97803]

Needle measurement and recording of electrical activity of muscles in arm or leg or muscles in trunk or head, limited study [CPT 95870]

Physician services for outpatient heart rehabilitation with continuous EKG monitoring per session [CPT 93798]

Psychiatric diagnostic evaluation [CPT 90791]

Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube [CPT 95811]

Polysomnography is performed with sleep staging by a sleep technologist. Sleep studies are performed to evaluate and diagnose a variety of sleep disorders including sleep apnea, narcolepsy, insomnia, sleep walking, restless leg syndrome, and other periodic movements during sleep. The patient presents to the sleep study center in the evening. Sleep staging is accomplished using electroencephalography (EEG), electro-oculogram (EOG), and electromyogram (EMG). EEG is performed using one to four electrodes attached to the scalp. Electrodes are attached around the eyes and an EOG performed to monitor eye movement. A submental EMG is performed by placing an electrode under the chin to record muscle tone. One or more additional parameters of sleep are recorded and analyzed including: heart rate and rhythm; airflow; ventilation and respiratory effort; gas exchange by oximetry, transcutaneous monitoring, or end tidal gas analysis; extremity muscle activity or motor activity-movement; extended EEG monitoring; penile tumescence; gastroesophageal reflux; continuous blood pressure monitoring; snoring; and/or body position. The room is darkened and brain activity, eye and muscle movement are recorded. Other parameters of sleep are monitored and recorded as needed. The physician analyzes the recorded data obtained during the polysomnography and provides a written interpretation of the test results. If CPAP is performed a nasal mask is applied to the nose to keep the airway open during inhalation. If bi-level ventilation is performed, a ventilator is used to augment respiration while still allowing spontaneous unassisted respiration.

Therapeutic removal of whole blood to correct blood level imbalance [CPT 99195]

Vaccine for influenza for administration into muscle, 0.5 ml dosage, quadrivalent, preservation free [CPT 90686]

Flu shot for patients ages 3 and older

Vaccine for influenza for injection into muscle, split virus, preservation free [CPT 90662]

High dose flu shot preservative free

Hospital observation per hr [HCPCS G0378]

Hospital observation service, per hour

Diab manage trn per indiv [HCPCS G0108]

Epicord, per square centimeter

Epifix, per square centimeter

Gad-base mr contrast nos,1ml [HCPCS A9579]

Kcentra, per i.u. [HCPCS C9132]

Tomosynthesis, mammo [HCPCS G0279]

Abatacept injection [HCPCS J0129]

Admin influenza virus vac [HCPCS G0008]

Administration of influenza virus vaccine

Alteplase recombinant [HCPCS J2997]

Betamethasone acet&sod phosp [HCPCS J0702]

Cefazolin sodium injection [HCPCS J0690]

Injection, cefazolin sodium, 500 mg

Cefepime hcl for injection [HCPCS J0692]

Ceftriaxone sodium injection [HCPCS J0696]

Injection, ceftriaxone sodium, per 250 mg

Dexamethasone sodium phos [HCPCS J1100]

Injection, dexamethasone sodium phosphate, 1mg

Dopamine injection [HCPCS J1265]

Ertapenem injection [HCPCS J1335]

Furosemide injection [HCPCS J1940]

Injection, furosemide, up to 20 mg

Gamunex-c/gammaked [HCPCS J1561]

Garamycin gentamicin inj [HCPCS J1580]

Infliximab not biosimil 10mg [HCPCS J1745]

Infusion of chemotherapy into a vein up to 1 hour [CPT 96413]

An intravenous infusion of a chemotherapy substance or drug is administered for treatment of a malignant neoplasm. An intravenous line is placed into a vein, usually in the arm, and the specified chemotherapy agent is administered. The physician provides direct supervision of the administration of the chemotherapy agent and is immediately available to intervene should complications arise. The physician provides periodic assessments of the patient and documentation of the patient's response to treatment.

Inj ceftazidime per 500 mg [HCPCS J0713]

Inj heparin sodium per 1000u [HCPCS J1644]

Injection, heparin sodium, per 1000 units

Inj magnesium sulfate [HCPCS J3475]

Injection, magnesium sulfate, per 500 mg

Inj mepivacaine hcl/10 ml [HCPCS J0670]

Inj naloxone hydrochloride [HCPCS J2310]

Inj pantoprazole sodium, via [HCPCS C9113]

Inj potassium chloride [HCPCS J3480]

Inj, propofol, 10 mg [HCPCS J2704]

Injection of different drug or substance into a vein for therapy, diagnosis, or prevention [CPT 96375]

A therapeutic, prophylactic, or diagnostic injection is administered by intravenous push (IVP) technique. The specified substance or drug is injected using a syringe directly into an injection site of an existing intravenous line or intermittent infusion set (saline lock). The injection is given over a short period of time, usually less than 15 minutes.

Injection, ocrelizumab, 1 mg [HCPCS J2350]

Injection, rituximab, 10 mg

Insulin injection [HCPCS J1815]

Levetiracetam injection [HCPCS J1953]

Levofloxacin injection [HCPCS J1956]

Injection, levofloxacin, 250 mg

Medroxyprogesterone acetate [HCPCS J1050]

Methylprednisolone 40 mg inj [HCPCS J1030]

Omalizumab injection [HCPCS J2357]

Ondansetron hcl injection [HCPCS J2405]

Injection, ondansetron hydrochloride, per 1 mg

Piperacillin/tazobactam [HCPCS J2543]

Injection, piperacillin sodium/tazobactam sodium, 1 gram/0.125 grams (1.125 grams)

Prednisone ir or dr oral 1mg [HCPCS J7512]

Regadenoson injection [HCPCS J2785]

Succinycholine chloride inj [HCPCS J0330]

Tocilizumab injection [HCPCS J3262]

Triamcinolone acet inj nos [HCPCS J3301]

Vancomycin hcl injection [HCPCS J3370]

Injection, vancomycin hcl, 500 mg

Vitamin k phytonadione inj [HCPCS J3430]

Evaluation of occupational therapy, typically 45 minutes [CPT 97166]

An occupational therapy evaluation or re-evaluation is performed. Occupational therapy assists the patient in developing or regaining skills that allow independent functioning and enhance health and personal well-being. A patient history is taken that includes an occupational profile and medical and therapy history with review of records as well as an extensive review of physical, cognitive, or psychosocial elements related to current performance of daily activities. The occupational therapist evaluates the patient's physical functioning, mental, and/or neurobehavioral impairment and performs tests to identify functional limitations or performance deficits. Physical functioning is evaluated, including an evaluation of any musculoskeletal conditions that may impair function. The ability to perform basic activities of daily living such as dressing, bathing, mobility, and other activities for living independently, such as shopping, cooking, driving, or accessing public transportation are all assessed. Barriers in the home, school, work, and community environments are identified. The need for adaptive equipment is assessed. The occupational therapist develops a treatment plan using clinical decision making from the patient analysis, assessment data, comorbidities, and possible treatment options. During a re-evaluation, an interim history is taken; the patient's response to treatment is evaluated; and the plan of care is revised based on the patient's response to treatment, functional and medical status, and any changes in condition or environment that affect future interventions or goals.

Evaluation of physical therapy, typically 30 minutes [CPT 97162]

A physical therapy evaluation or re-evaluation is performed. The physical therapist takes a history of the current complaint including onset of symptoms, comorbidities, changes since the onset, treatment received for the symptoms or condition, medications prescribed for it, and any other medications the patient is taking. A physical examination of body systems is done to assess physical structure and function, any activities or movements that exacerbate the symptoms, limit activity, or restrict participation in movement, as well as anything that helps to relieve the symptoms. The evaluation may involve provocative maneuvers or positions that increase symptoms; tests for joint flexibility and muscle strength; assessments of general mobility, posture, and core strength; evaluation of muscle tone; and tests for restrictions of movement caused by myofascial disorders. Following the history and physical, the therapist determines the patient's clinical presentation characteristics, provides a detailed explanation of the condition, identifies physical therapy treatment options, and explains how often and how long physical therapy modalities should be applied. The physical therapist will then develop a plan of care with clinical decision making based on patient assessment and/or measurable functional outcome. The plan of care may include both physical therapy in the clinic and exercises or changes in the home environment. Upon re-evaluation, the established care plan is reviewed and an interim history is taken requiring the use of standardized tests and measures. The patient's response to treatment is evaluated and the plan of care is revised based on the patient's measurable response.

Evaluation of swallowing function [CPT 92610]

An evaluation of the oral and pharyngeal phase of the swallowing function is performed in a patient who is suspected of having oropharyngeal dysphagia. The initial evaluation is typically performed by a dysphagia specialist, usually a speech-language pathologist. This evaluation is performed to determine whether more extensive studies are warranted. Swallowing function is divided into oral, pharyngeal, and esophageal phases. The oral and pharyngeal phases are made up of oral preparation for solid foods (not required for liquids or pureed foods), oral transfer, and initiation of the swallow. Both oral and pharyngeal movements are necessary in preparing, transferring, and swallowing food. The patient is given both solids and liquids to swallow. During oral preparation of solid food the ability of the tongue to move the food from side-to-side so that the solid can be chewed and prepared for swallowing is evaluated. Once the solid food is prepared and transferred to the back of the throat, the swallowing movements are evaluated. Propelling solids or liquids requires a complex set of movements including retraction of the base of the tongue, elevation of the hyolarynx, closure of the velopharyngeus, contraction of the pharynx, opening of the upper esophageal sphincter, and closure of the airway. The speech-language pathologist observes the patient to determine whether solids and liquids are being prepared, transferred, and propelled from the pharynx into the esophagus. A written report of findings is provided.

Self-care or home management training, each 15 minutes [CPT 97535]

Self-care/home managemeThe patient receives one-on-one training to improve the ability to care for himself/herself and maintain independence. This may include training in activities of daily living (ADL), such as bed mobility, transfers, dressing, grooming, eating, bathing and toileting. The patient is given instruction on compensatory measures that can be taken to overcome any physical, mental or emotional disabilities. The patient receives training in how to adapt meal preparation to his/her specific needs and how to perform activities safely. The patient may also receive instruction in the use of assistive technology devices and adaptive equipment which includes any item used to improve the functional capability of the patient in the home and with ADL. This code is reported for each 15 minutes of one-on-one self-care/home management training designed to meet the specific needs of the patient.nt training, which includes instructions in the use of any assisting equipment.

Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes [CPT 97530]

In a one-on-one physical therapy session, the provider instructs and assists the patient in therapeutic activities designed to address specific functional limitations. The therapeutic activities are specifically developed and modified for the patient. Dynamic/movement activities, also called kinetic activities, that are designed to improve functional performance such as lifting, bending, pushing, pulling, jumping and reaching are included in this service. For example, the patient may be given therapeutic activities to perform to improve the ability to sit, stand, and get out of bed after an injury without straining or risking reinjury. This code is reported for each 15 minutes of one-on-one therapeutic activity provided.

Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes [CPT 97112]

Therapeutic procedures for neuromuscular reeducation are used to develop conscious control of a single muscle or muscle group and heighten the awareness of the body's position in space, especially the position of the extremities when sitting or standing. Neuromuscular reeducation is employed during the recovery or regeneration stage following severe injury or trauma, cerebral vascular accident, or systemic neurological disease. The goal of therapy is improved range of motion (ROM), balance, coordination, posture, and spatial awareness. Techniques may include proprioceptive neuromuscular facilitation which uses diagonal contract-relax patterns of skeletal muscles to stimulate receptors in the joints that communicate body position to the brain via motor and sensory nerves. Feldenkrais is a method which observes the patient's habitual movement patterns and teaches new patterns based on efficient active or passive repetitive conditioning. Additional techniques that may be useful for neuromuscular reeducation are Bobath concept, which promotes motor learning and efficient motor control, and biomechanical ankle platform system (BAPS) boards.

Walking training to 1 or more areas, each 15 minutes [CPT 97116]

Gait training is a therapeutic procedure that observes and educates an individual in the manner of walking including the rhythm, cadence, step, stride, and speed. The objective of gait training is to strengthen muscles and joints, improve balance and posture, and develop muscle memory. As the lower extremities are retrained for repetitive motion, the body also benefits from the exercise with increased endurance, improved heart/lung function, and reduced or improved osteoporosis. Gait training is an appropriate therapeutic procedure following brain and/or spinal cord injury, stroke, fracture of the pelvis and/or lower extremity, joint injury or replacement of the knee, hip, or ankle, amputation, and for certain musculoskeletal and/or neurological diseases. A treadmill fitted with a safety harness is initially used to ensure safe walking. As the patient gains strength and balance, step training and stair climbing is added to the treatment modality.

Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring [CPT 93017]

An ECG is used to evaluate the electrical activity of the heart using treadmill, bicycle exercise, and/or pharmacologically induced stress. Small plastic patches are attached at specific locations on the chest, abdomen, arms, and/or legs. Leads (wires) from the stress ECG device are then attached to the patches. A baseline ECG is obtained. The exercise portion of the study is then initiated. Heart rate and blood pressure are monitored. Staged stress protocol is used and the patient's response to stress is monitored as the stress ECG is recorded. Unless contraindicated, exercise or pharmacological stress continues until the patient is unable to continue or until the target heart rate is achieved. Upon completion of the study, the stress ECG is reviewed and a written interpretation of findings is provided.

Measurement and graphic recording of the amount and speed of breathed air, before and following medication administration [CPT 94060]

Spirometry with bronchodilation responsiveness is a pulmonary function test that is used to help diagnose the cause of shortness of breath and to monitor existing pulmonary disease, such as chronic bronchitis, emphysema, pulmonary fibrosis, chronic obstructive pulmonary disease (COPD), and asthma. The test is first performed without administration of a bronchodilator. A spirometry device consisting of a mouthpiece and tubing connected to a machine that records and displays results is used to perform the test. The patient inhales deeply and then exhales through the mouthpiece. Inhalation and exhalation measurements are first taken with the patient breathing normally. The patient is then instructed to perform rapid, forceful inhalation and exhalation. The spirometer records the volume of air inhaled, exhaled, and the length of time each breath takes. A bronchodilator medication is administered and the test is repeated. The test results are displayed on a graph that the physician reviews and interprets in a written report.

Routine electrocardiogram (EKG) with tracing using at least 12 leads [CPT 93005]

An ECG is used to evaluate the electrical activity of the heart. The test is performed with the patient lying prone on the exam table. Small plastic patches are attached at specific locations on the chest, abdomen, arms, and/or legs. Leads (wires) from the ECG tracing device are then attached to the patches. A tracing is obtained of the electrical signals from the heart. Electrical activity begins in the sinoatrial node which generates an electrical stimulus at regular intervals, usually 60 to 100 times per minute. This stimulus travels through the conduction pathways to the sinoatrial node causing the atria to contract. The stimulus then travels along the bundle of His which divides into right and left pathways providing electrical stimulation of the ventricles causing them to contract. Each contraction of the ventricles represents one heart beat. The ECG tracing includes the following elements: P wave, QRS complex, ST segment, and T wave. The P wave, a small upward notch in the tracing, indicates electrical stimulation of the atria. This is followed by the QRS complex which indicates the ventricles are electrically stimulated to contract. The short flat ST segment follows and indicates the time between the end of the ventricular contraction and the T wave. The T wave represents the recovery period of the ventricles. The physician reviews, interprets, and provides a written report of the ECG recording taking care to note any abnormalities.

Tc99m sestamibi [HCPCS A9500]

Application of cast, elbow to finger (short arm) [CPT 29075]

Procedure performed in the clinic to apply a cast from the elbow to the fingers (the short-arm)

Aspiration and/or injection of large joint or joint capsule [CPT 20610]

Arthrocentesis, aspiration, and/or injection of a joint or bursa is performed. Arthrocentesis and aspiration is performed to remove fluid from a joint or bursa in order to diagnose the cause of joint effusion and/or to reduce pain caused by the excess fluid. Injection of a joint or bursa may be performed in conjunction with the arthrocentesis procedure and is typically performed using an anti-inflammatory medication such as a steroid to reduce inflammation of the joint or bursa. The skin over the joint is cleansed. A local anesthetic is injected as needed. A needle with a syringe attached is inserted into the affected joint or bursa. Fluid is removed and sent for separately reportable laboratory analysis. This may be followed by a separate injection of medication into the joint or bursa.

Biopsy of finger or toe nail [CPT 11755]

Biopsy of voice box using an endoscope with operating microscope or telescope [CPT 31536]

Destruction of up to 14 skin growths [CPT 17110]

Diagnostic examination of nasal passages using an endoscope [CPT 31231]

Diagnostic examination of voice box using flexible endoscope [CPT 31575]

Drainage of abscess [CPT 10060]

This skin is cleansed and local anesthetic injected as needed. A straight or elliptical incision is made spanning the entire area of fluctuance. Any pockets of pus are opened using blunt dissection. The abscess is drained and then irrigated with sterile solution.

Implantation of spinal neurostimulator electrodes [CPT 63655]

Incisional biopsy of single skin lesion [CPT 11106]

Injections of lower or sacral spine facet joint using imaging guidance, single level [CPT 64493]

Injections of upper or middle spine facet joint using imaging guidance, single level [CPT 64490]

Insertion of needle into vein for collection of blood sample [CPT 36415]

An appropriate vein is selected, usually one of the larger anecubital veins such as the median cubital, basilic, or cehalic veins. A tourniquet is placed above the planned puncture site. The site is disinfected with an alcohol pad. A needle is attached to a hub and the vein is punctured. A Vacuainer tube is attached to the hub and the blood specimen is collected. The Vacutainer tube is removed. Depending on the specific blood tests required, multiple Vacutainers may be filled from the same punchture site.

Insertion of spinal neurostimulator pulse generator or receiver [CPT 63685]

Partial removal of collar bone at shoulder using an endoscope [CPT 29824]

Release and/or relocation of median nerve of hand [CPT 64721]

Release of shoulder biceps tendon using an endoscope [CPT 29828]

Removal of 2 to 4 thickened skin growths [CPT 11056]

Removal of deep bone implant [CPT 20680]

Removal of foreign body from ear canal [CPT 69200]

Removal of gallbladder with X-ray study of bile ducts using endoscope [CPT 47563]

Removal of impact ear wax, one ear [CPT 69210]

Procedure performed in the clinic to remove impacted ear wax (cerumen)

Removal of nasal air passage, under the lining tissue [CPT 30140]

Removal of tissue from 1 to 5 finger or toe nails [CPT 11720]

Removal of tissue from 6 or more finger or toe nails [CPT 11721]

Repair of wound (2.5 centimeters or less) of the scalp, neck, underarms, trunk, arms and/or legs [CPT 12001]

Simple repair of superficial wounds of the scalp, neck, axillae, external genitalia, trunk, and/or extremities is performed. The wound is cleansed and a local anesthetic is administered. The wound is inspected and determined to be superficial involving only the epidermis, dermis, or subcutaneous tissue without involvement of deeper tissues and without heavy contamination. A simple, one-layer closure using sutures, staples, or tissue adhesive is performed. Alternatively, chemical cautery or electrocautery may be used to treat the wound without closure.

Transfusion of blood or blood products [CPT 36430]

Blood and blood components include whole blood, platelets, packed red blood cells, and plasma products. Transfusions are performed to replace blood that is lost or depleted due to an injury, surgery, sickle cell disease, or treatment for a malignant neoplasm. Red blood cells are given to increase the number of blood cells that transport oxygen and nutrients throughout the body, platelets to control bleeding and improve blood clotting, and plasma to replace total blood volume and provide blood factors that improve blood clotting. The skin is prepped over the planned transfusion site and an intravenous line inserted. Any medication ordered by the physician is administered prior to the transfusion. The blood and/or blood components are administered. The patient is monitored during the transfusion for any signs of adverse reaction.

Als 1 [HCPCS A0426]

Als1-emergency [HCPCS A0427]

Bls [HCPCS A0428]

Ground mileage [HCPCS A0425]

CT scan of abdomen and pelvis [CPT 74176]

Computerized tomography, also referred to as a CT scan, uses special x-ray equipment and computer technology to produce multiple cross-sectional images of the abdomen and pelvis. The patient is positioned on the CT examination table. An initial pass is made through the CT scanner to determine the starting position of the scans. The CT scan is then performed. As the table moves slowly through the scanner, numerous x-ray beams and electronic x-ray detectors rotate around the abdomen and pelvis. The amount of radiation being absorbed is measured. As the beams and detectors rotate around the body, the table is moved through the scanner. A computer program processes the data which is then displayed on the monitor as two-dimensional cross-sectional images of the abdomen or pelvis. The physician reviews the data and images as they are obtained and may request additional sections to provide more detail on areas of interest.

CT scan of abdomen and pelvis before and after contrast [CPT 74178]

Computerized tomography, also referred to as a CT scan, uses special x-ray equipment and computer technology to produce multiple cross-sectional images of the abdomen and pelvis. The patient is positioned on the CT examination table. An initial pass is made through the CT scanner to determine the starting position of the scans. The CT scan is then performed. As the table moves slowly through the scanner, numerous x-ray beams and electronic x-ray detectors rotate around the abdomen and pelvis. The amount of radiation being absorbed is measured. As the beams and detectors rotate around the body, the table is moved through the scanner. A computer program processes the data which is then displayed on the monitor as two-dimensional cross-sectional images of the abdomen or pelvis. The physician reviews the data and images as they are obtained and may request additional sections to provide more detail on areas of interest.

CT scan of blood vessels in chest with contrast [CPT 71275]

A computed tomographic angiography (CTA) of the noncoronary vessels of the chest is performed with contrast material including image postprocessing. Noncontrast images may also be obtained and are included when performed. CTA provides images of the blood vessels using a combination of computed tomography (CT) and angiography with contrast material. When angiography is performed using CT, multiple images are obtained and processed on a computer to create detailed, two-dimensional, cross-sectional views of the blood vessels. These images are then displayed on a computer monitor. The patient is positioned on the CT table. An intravenous line is inserted into a blood vessel, usually in the arm or hand. Non-contrast images may be obtained. A small dose of contrast is injected and test images are obtained to verify correct positioning. The CTA is then performed. Contrast is injected at a controlled rate and the CT table moves through the CT machine as the scanning is performed. After completion of the CTA, the radiologist reviews and interprets the CTA images of the noncoronary vessels of the chest.

CT scan of face [CPT 70486]

Computerized tomography, also referred to as a CT scan, uses special x-ray equipment and computer technology to produce multiple cross-sectional images of the region being studied. In this study, CT scan of the maxillofacial area is obtained. The maxillofacial area includes the forehead (frontal bone), sinuses, nose and nasal bones, jaw (maxilla and mandible). The only facial region not included in this study is the orbit. The patient is positioned on the CT examination table. An initial pass is made through the CT scanner to determine the starting position of the scans, after which the CT scan is performed. As the table moves slowly through the scanner, numerous x-ray beams and electronic x-ray detectors rotate around the body region being examined. The amount of radiation being absorbed is measured. As the beams and detectors rotate around the body, the table is moved through the scanner. A computer program processes the data and renders the data in two-dimensional cross-sectional images of the body region being examined. This data is displayed on a monitor. The physician reviews the data as it is being obtained and may request additional sections to provide more detail of areas of interest.

CT scan of lower spine with contrast [CPT 72132]

Diagnostic computed tomography (CT) is done on the lumbar spine. CT uses multiple, narrow x-ray beams aimed around a single rotational axis, taking a series of 2D images of the target structure from multiple angles. Contrast material is used to enhance the images. Computer software processes the data and produces several images of thin, cross-sectional 2D slices of the targeted organ or area. Three-dimensional models of the spine can be created by stacking multiple, individual 2D slices together. The patient is placed inside the CT scanner on the table and images are obtained of the lumbar spine. The physician reviews the images to look for suspected problems with the spine such as bone disease, and evaluate for fractures or other injuries as well as birth defects of the spine in children.

CT scan of neck with contrast [CPT 70491]

Computerized tomography, also referred to as a CT scan, uses special x-ray equipment and computer technology to produce multiple cross-sectional images of the region being studied. In a CT scan of the soft tissues of the neck, the patient is positioned on the CT examination table. An initial pass is made through the CT scanner to determine the starting position of the scans, after which the CT scan is performed. As the table moves slowly through the scanner, numerous x-ray beams and electronic x-ray detectors rotate around the body region being examined. The amount of radiation being absorbed is measured. As the beams and detectors rotate around the body, the table is moved through the scanner. A computer program processes the data and renders the data in two-dimensional cross-sectional images of the body region being examined. This data is displayed on a monitor. The physician reviews the data as it is being obtained and may request additional sections to provide more detail of areas of interest.

CT scan of upper spine [CPT 72125]

Diagnostic computed tomography (CT) is done on the cervical spine. CT uses multiple, narrow x-ray beams aimed around a single rotational axis, taking a series of 2D images of the target structure from multiple angles. Contrast material is used to enhance the images. Computer software processes the data and produces several images of thin, cross-sectional 2D slices of the targeted organ or area. Three-dimensional models of the spine can be created by stacking multiple, individual 2D slices together. The patient is placed inside the CT scanner on the table and images are obtained of the cervical spine.

Complete X-ray study of abdomen with single X-ray of chest [CPT 74022]

A radiologic examination of the abdomen images the internal organs, soft tissue (muscle, fat), and supporting skeleton. X-ray imaging uses indirect ionizing radiation to take pictures of non-uniform material, such as human tissue, because of its different density and composition, which allows some of the x-rays to be absorbed and some to pass through and be captured. This produces a 2D image of the structures. The radiographs may be taken to look for size, shape, and position of organs, pattern of air (bowel gas), obstruction, foreign objects, and calcification in the gallbladder, urinary tract, and aorta. A radiologic examination of the abdomen may be ordered to diagnose abdominal distention and pain, vomiting, diarrhea or constipation, and traumatic injury; it may also be obtained as a screening exam or scout film prior to other imagining procedures.

Diagnostic CT scan of chest [CPT 71250]

Diagnostic computed tomography (CT) is done on the thorax. CT uses multiple, narrow x-ray beams aimed around a single rotational axis, taking a series of 2D images of the target structure from multiple angles. Contrast material is used to enhance the images. Computer software processes the data and reconstructs a 3D image. Thin, cross-sectional 2D and 3D slices are then produced of the targeted organ or area. The patient is placed inside the CT scanner on the table and images are obtained of the thorax to look for problems or disease in the lungs, heart, esophagus, soft tissue, or major blood vessels of the chest, such as the aorta. The physician reviews the images to look for suspected disease such as infection, lung cancer, pulmonary embolism, aneurysms, and metastatic cancer to the chest from other areas.

Diagnostic CT scan of chest with contrast [CPT 71260]

Diagnostic computed tomography (CT) is done on the thorax. CT uses multiple, narrow x-ray beams aimed around a single rotational axis, taking a series of 2D images of the target structure from multiple angles. Contrast material is used to enhance the images. Computer software processes the data and reconstructs a 3D image. Thin, cross-sectional 2D and 3D slices are then produced of the targeted organ or area. The patient is placed inside the CT scanner on the table and images are obtained of the thorax to look for problems or disease in the lungs, heart, esophagus, soft tissue, or major blood vessels of the chest, such as the aorta. The physician reviews the images to look for suspected disease such as infection, lung cancer, pulmonary embolism, aneurysms, and metastatic cancer to the chest from other areas.

MRI scan of arm joint [CPT 73221]

Magnetic resonance imaging is done on a joint of the upper or lower arm. Magnetic resonance is a noninvasive, non-radiating imaging technique that uses the magnetic properties of hydrogen atoms in the body. The patient is placed on a motorized table within a large MRI tunnel scanner that contains the magnet. The powerful magnetic field forces the hydrogen atoms to line up. Radiowaves are then transmitted within the strong magnetic field. Protons in the nuclei of different types of tissues emit a specific radiofrequency signal that bounces back to the computer, which processes the signals and converts the data into tomographic, 3D images with very high resolution. The patient is placed on a motorized table within a large MRI tunnel scanner that contains the magnet. Small coils that help transmit and receive the radiowaves may be placed around the joint. MRI scans on joints of the upper extremity are often done for injury, trauma, unexplained pain, redness, or swelling, and freezing of a joint with loss of motion. MRI scans provide clear images of areas that may be difficult to see on CT.

MRI scan of middle spinal canal [CPT 72146]

Magnetic resonance imaging (MRI) is done on the thoracic spinal canal and contents. MRI is a noninvasive, non-radiating imaging technique that uses the magnetic properties of nuclei within hydrogen atoms of the body. The powerful magnetic field forces the hydrogen atoms to line up. Radiowaves are then transmitted within the strong magnetic field. Protons in the nuclei of different types of tissues emit a specific radiofrequency signal that bounces back to the computer, which records the images. The computer processes the signals and converts the data into tomographic, 3D, sectional images in slices with very high resolution. The patient is placed on a motorized table within a large MRI tunnel scanner that contains the magnet. MRI scans of the spine are often done when conservative treatment of back/neck pain is unsuccessful and more aggressive treatments are considered or following surgery.

MRI scan of upper spinal canal [CPT 72141]

Magnetic resonance imaging (MRI) is done on the cervical spinal canal and contents. MRI is a noninvasive, non-radiating imaging technique that uses the magnetic properties of nuclei within hydrogen atoms of the body. The powerful magnetic field forces the hydrogen atoms to line up. Radiowaves are then transmitted within the strong magnetic field. Protons in the nuclei of different types of tissues emit a specific radiofrequency signal that bounces back to the computer, which records the images. The computer processes the signals and converts the data into tomographic, 3D, sectional images in slices with very high resolution. The patient is placed on a motorized table within a large MRI tunnel scanner that contains the magnet. MRI scans of the spine are often done when conservative treatment of back/neck pain is unsuccessful and more aggressive treatments are considered or following surgery.

Nuclear medicine study of vessels of heart using drugs or exercise multiple studies [CPT 78452]

Myocardial perfusion imaging is a nuclear medicine procedure used to evaluate the heart muscle and blood flow to the heart. An intravenous line is inserted into a vein in the hand or arm. ECG leads are placed and a blood pressure cuff is placed on the arm. The patient lies flat on a table in the procedure room for myocardial perfusion imaging performed at rest. For a stress study, the patient is either on a treadmill or bike or an injection of a pharmacologic agent is administered to stress the heart. A radionuclide, also called a tracer, is injected into the intravenous line and allowed to circulate. The radionuclide localizes in healthy heart tissue. Ischemic heart tissue does not absorb the radionuclide. Images of the heart and great vessels are obtained using single photon emission computed tomography (SPECT). When SPECT images are obtained, the scanner rotates around the body to obtain images in multiple planes. The physician evaluates heart wall motion to determine how effective the heart muscle is in pumping blood through the heart and to the peripheral vascular system. Ejection fraction, which is the percentage of blood pumped out of the heart to the peripheral vascular system, is measured using either a first pass or gated technique. In a first pass technique, images are obtained as the blood circulates through the heart during the first pass of the radionuclide. In a gated technique, a series of images are obtained between heart beats. Using electrical signals from the heart, the camera captures a series of images as the heart rests, creating very sharp, high resolution images. Additional images are obtained as needed. The physician reviews the images, calculates the ejection fraction and quantifies other parameters of heart function based on the distribution of the radionuclide. The physician then provides a written report of findings.

Ultrasound behind abdominal cavity [CPT 76770]

A real time retroperitoneal ultrasound is performed with image documentation. The patient is placed supine. Acoustic coupling gel is applied to the skin of the abdomen. The transducer is pressed firmly against the skin and swept back and forth over the abdomen and images obtained of the retroperitoneal area. The ultrasonic wave pulses directed at the retroperitoneum are imaged by recording the ultrasound echoes. Any abnormalities are evaluated to identify characteristics that might provide a definitive diagnosis. The physician reviews the ultrasound images of the retroperitoneum and provides a written interpretation.

Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function [CPT 93306]

The physician performs complete transthoracic real-time echocardiography with image documentation (2-D) including M-mode recording, if performed, with spectral Doppler and color flow Doppler echocardiography. Cardiac structure and dynamics are evaluated using a series of real-time tomographic images with multiple views recorded digitally or on videotape. Time-motion (M-mode) recordings are made as needed to allow dimensional measurement. Blood flow and velocity patterns within the heart, across valves and within the great vessels are evaluated by color flow Doppler. Normal blood flow patterns through these regions have a characteristic pattern defined by direction, velocity, duration, and timing throughout the cardiac cycle. Spectral Doppler by pulsed or continuous wave technique is used to evaluate antegrade flow through inflow and outflow tracts and cardiac valves. Multiple transducer positions or orientations may be required. The physician reviews the echocardiography images and orders additional images as needed to allow evaluation of any abnormalities. Digital or videotaped images are then reviewed by the physician. Abnormalities of cardiac structure or dynamics are noted. The extent of the abnormalities is evaluated and quantified. Any previous cardiac studies are compared to the current study and any quantitative or qualitative changes are identified. The physician provides an interpretation of the echocardiography with a written report of findings.

Ultrasound of head and neck [CPT 76536]

An ultrasound examination of soft tissues of the head and neck is performed with image documentation. The thyroid, parathyroid, or parotid glands and surrounding soft tissue may be examined. Ultrasound visualizes the body internally using sound waves far above human perception bounce off interior anatomical structures. As the sound waves pass through different densities of tissue, they are reflected back to the receiving unit at varying speeds and converted into pictures displayed on screen. A linear scanner or mechanical sector scanner is used to evaluate the shape, size, border, internal architecture, distal enhancement, color flow, and echogenicity of the soft tissue structures of the head and neck as well as any lesions or masses. The echogenicity is compared to that of the surrounding muscle tissue. The physician reviews the images and provides a written interpretation.

Ultrasound of one breast, complete [CPT 76641]

A real time ultrasound of the right or left breast is performed with image documentation, including the axillary area, when performed. Breast ultrasound is used to help diagnose breast abnormalities detected during a physical exam or on mammography. Ultrasound imaging can identify masses as solid or fluid-filled and can show additional structural features of the abnormal area and surrounding tissues. The patient is placed supine with the arm raised above the head on the side being examined. Acoustic coupling gel is applied to the breast and the transducer is pressed firmly against the skin of the breast. The transducer is then swept back and forth over the area of the abnormality and images are obtained. The ultrasonic wave pulses directed at the breast are imaged by recording the ultrasound echoes. Any abnormalities are evaluated to identify characteristics that might provide a definitive diagnosis. The physician reviews the ultrasound images of the breast and provides a written interpretation.

Ultrasound of scrotum [CPT 76870]

An ultrasound examination of the scrotum and its contents is a non-invasive procedure that uses a transducer probe placed firmly against the skin to deliver high frequency sound waves and create a gray scale and/or color (Doppler) image of the internal anatomy. Ultrasound may be used to detect scrotal masses/tumors and undescended testicle(s), as well as to evaluate testicular torsion, scrotal injury or trauma, hydrocele(s), varicocele(s), and male infertility. Ultrasonic conduction gel is applied to the scrotum and the transducer probe is held against the skin and swept over the area. The images produced are captured on a screen and viewed in real-time and/or saved for later analysis.

Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers [CPT 93970]

A vascular ultrasound study is performed to evaluate veins in the extremities. A duplex scan uses both B-mode and Doppler studies. A clear gel is placed on the skin of the extremity over the region to be studied. A B-mode transducer is placed on the skin and real-time images of the veins are obtained. A Doppler probe within the B-mode transducer provides information on the pattern and direction of blood flow in the veins. The B-mode transducer produces ultrasonic sound waves that move through the skin and bounce off the veins when the probe is moved over the region being studied. The Doppler probe produces sound waves that bounce off blood cells moving within the veins. The reflected sound waves are sent to an amplifier that makes the sound waves audible. The pitch of the sound waves changes if there is reduced blood flow, or ceases altogether if a vessel is completely obstructed. A computer converts the sound waves to images that are overlaid with colors to produce video images showing the speed and direction of blood flow as well as any obstruction. Spectral Doppler analysis is performed to provide information on anatomy and hemodynamic function. The duplex scan may include a baseline evaluation followed by additional scans obtained with compression or using other maneuvers that alter blood flow. The physician reviews the duplex scan and provides a written interpretation of findings.

Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers [CPT 93971]

A vascular ultrasound study is performed to evaluate veins in the extremities. A duplex scan uses both B-mode and Doppler studies. A clear gel is placed on the skin of the extremity over the region to be studied. A B-mode transducer is placed on the skin and real-time images of the veins are obtained. A Doppler probe within the B-mode transducer provides information on the pattern and direction of blood flow in the veins. The B-mode transducer produces ultrasonic sound waves that move through the skin and bounce off the veins when the probe is moved over the region being studied. The Doppler probe produces sound waves that bounce off blood cells moving within the veins. The reflected sound waves are sent to an amplifier that makes the sound waves audible. The pitch of the sound waves changes if there is reduced blood flow, or ceases altogether if a vessel is completely obstructed. A computer converts the sound waves to images that are overlaid with colors to produce video images showing the speed and direction of blood flow as well as any obstruction. Spectral Doppler analysis is performed to provide information on anatomy and hemodynamic function. The duplex scan may include a baseline evaluation followed by additional scans obtained with compression or using other maneuvers that alter blood flow. The physician reviews the duplex scan and provides a written interpretation of findings.

Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck [CPT 93880]

A vascular ultrasound study is performed to evaluate the extracranial arteries which include the common carotid and external carotid arteries. A duplex scan uses both B-mode and Doppler studies. A clear gel is placed on the skin over the arteries to be studied. A B-mode transducer is placed on the skin and real-time images of the artery are obtained. A Doppler probe within the B-mode transducer provides information on pattern and direction of blood flow in the artery. The B-mode transducer produces ultrasonic sound waves that move through the skin and bounce off the arteries when the probe is placed over the arteries at various locations and angles. The Doppler probe produces sound waves that bounce off blood cells moving within the artery. The reflected sound waves are sent to an amplifier that makes the sound waves audible. The pitch of the sound waves changes if there is reduced blood flow, or ceases altogether if a vessel is completely obstructed. A computer converts the sound waves to images that are overlaid with colors to produce video images showing the speed and direction of blood flow as well as any obstruction. Spectral Doppler analysis is performed to provide information on anatomy and hemodynamic function, including information on the presence of narrowing and plaque formation within the arteries. The physician reviews the duplex scan and provides a written interpretation of findings.

X-ray of abdomen, 1 view [CPT 74018]

A radiologic examination of the abdomen images the internal organs, soft tissue (muscle, fat), and supporting skeleton. X-ray imaging uses indirect ionizing radiation to take pictures of non-uniform material, such as human tissue, because of its different density and composition, which allows some of the x-rays to be absorbed and some to pass through and be captured. This produces a 2D image of the structures. The radiographs may be taken to look for size, shape, and position of organs, pattern of air (bowel gas), obstruction, foreign objects, and calcification in the gallbladder, urinary tract, and aorta. A radiologic examination of the abdomen may be ordered to diagnose abdominal distention and pain, vomiting, diarrhea or constipation, and traumatic injury; it may also be obtained as a screening exam or scout film prior to other imagining procedures. Common views of the abdomen include front to back anteroposterior (AP) with the patient lying supine or standing erect, back to front posteroanterior (PA) with the patient lying prone, lateral with the patient lying on the side, lateral decubitus anteroposterior (side lying, front to back view), lateral dorsal decubitus (lying supine, side view), oblique (anterior or posterior rotation), and coned (small collimated) views which may be used to localize and differentiate lesions, calcifications, or herniations.

X-ray of chest, 1 view [CPT 71045]

A radiologic examination of the chest is performed. Chest radiographs (X-rays) provide images of the heart, lungs, bronchi, major blood vessels (aorta, vena cava, pulmonary vessels), and bones, (sternum, ribs, clavicle, scapula, spine). The most common views are frontal (also referred to as anteroposterior or AP), posteroanterior (PA), and lateral. To obtain a frontal view, the patient is positioned facing the x-ray machine. A PA view is obtained with the patient's back toward the x-ray machine. For a lateral view, the patient is positioned with side of the chest toward the machine. Other views that may be obtained include apical lordotic, oblique, and lateral decubitus. An apical lordotic image provides better visualization of the apical (top) regions of the lungs. The patient is positioned with the back arched so that the tops of the lungs can be x-rayed. Oblique views may be obtained to evaluate a pulmonary or mediastinal mass or opacity or to provide additional images of the heart and great vessels. There are four positions used for oblique views including right and left anterior oblique, and right and left posterior oblique. Anterior oblique views are obtained with the patient standing and the chest rotated 45 degrees. The arm closest to the x-ray cassette is flexed with the hand resting on the hip. The opposite arm is raised as high as possible. The part of the chest farthest away from the x-ray cassette is the area being studied. Posterior oblique views are typically obtained only when the patient is too ill to stand or lay prone for anterior oblique views. A lateral decubitus view is obtained with the patient lying on the side; the patient's head rests on one arm, and the other arm is raised over the head with the elbow bent. Images are recorded on hard copy film or stored electronically as digital images. The physician reviews the images, notes any abnormalities, and provides a written interpretation of the findings.

X-ray of chest, 2 views [CPT 71046]

A radiologic examination of the chest is performed. Chest radiographs (X-rays) provide images of the heart, lungs, bronchi, major blood vessels (aorta, vena cava, pulmonary vessels), and bones, (sternum, ribs, clavicle, scapula, spine). The most common views are frontal (also referred to as anteroposterior or AP), posteroanterior (PA), and lateral. To obtain a frontal view, the patient is positioned facing the x-ray machine. A PA view is obtained with the patient's back toward the x-ray machine. For a lateral view, the patient is positioned with side of the chest toward the machine. Other views that may be obtained include apical lordotic, oblique, and lateral decubitus. An apical lordotic image provides better visualization of the apical (top) regions of the lungs. The patient is positioned with the back arched so that the tops of the lungs can be x-rayed. Oblique views may be obtained to evaluate a pulmonary or mediastinal mass or opacity or to provide additional images of the heart and great vessels. There are four positions used for oblique views including right and left anterior oblique, and right and left posterior oblique. Anterior oblique views are obtained with the patient standing and the chest rotated 45 degrees. The arm closest to the x-ray cassette is flexed with the hand resting on the hip. The opposite arm is raised as high as possible. The part of the chest farthest away from the x-ray cassette is the area being studied. Posterior oblique views are typically obtained only when the patient is too ill to stand or lay prone for anterior oblique views. A lateral decubitus view is obtained with the patient lying on the side; the patient's head rests on one arm, and the other arm is raised over the head with the elbow bent. Images are recorded on hard copy film or stored electronically as digital images. The physician reviews the images, notes any abnormalities, and provides a written interpretation of the findings.

X-ray of elbow, minimum of 3 views [CPT 73080]

A radiologic examination of the elbow is done. X-ray imaging uses indirect ionizing radiation to take pictures inside the body. X-rays work on non-uniform material, such as human tissue, because of the different density and composition of the object, which allows some of the x-rays to be absorbed and some to pass through and be captured behind the object on a detector. This produces a 2D image of the structures. X-rays of the elbow are usually considered necessary to assess for fractures or dislocations when the normal range of motion for extension, flexion, supination, and pronation cannot be carried out. Most acute disruptions of the elbow joint can be diagnosed by conventional x-ray examination, with the minimum number of views including the front to back anteroposterior projection with the elbow in as full extension as possible, and the side, or lateral image taken in flexion. A complete series of images also includes an oblique view of the radial head-capitellar image to help diagnose suspected subtle fractures involving the radial head or in cases of acute pain and trauma. The patient needs to be able to hold the elbow in full extension for the front view and in 90 degree flexion for the oblique and lateral views as much as possible.

X-ray of esophagus with single contrast [CPT 74220]

Oral contrast material is swallowed and the passage of the contrast is observed fluoroscopically as it passes through the pharynx and/or esophagus. Once the lumen of the pharynx and/or esophagus is completely coated with contrast material, still radiographic images are obtained. The physician reviews the images, notes any abnormalities, and provides a written interpretation of the findings.

X-ray of fingers, minimum of 2 views [CPT 73140]

A radiologic examination of the finger(s) is done with at least 2 different projections taken. X-ray imaging uses indirect ionizing radiation to take pictures inside the body. X-rays work on non-uniform material, such as human tissue, because of the different density and composition of the object, which allows some of the x-rays to be absorbed and some to pass through and be captured behind the object on a detector. This produces a 2D image of the structures. The radiographs may be taken to look for conditions such as fractures, interphalangeal (IP) joint dislocations, deformities, degenerative bone conditions, osteomyelitis, arthritis, foreign body, or tumors. The posteroanterior projection is taken with the palm down flat, fingers extended, and slightly apart to show the metacarpals, phalanges, and IP joints of the target finger(s). Anteroposterior views are taken with the back of the hand placed on the film and the x-ray beam going from palmar to dorsal direction. Lateral views are taken with the ulnar side of the hand on the film cassette and the fingers spread apart to avoid overlap, sometimes supported from underneath. Oblique views can be obtained with the hand placed palm down and the radial side rotated 45 degrees up away from the surface, with the fingers extended and spread apart.

X-ray of foot, minimum of 3 views [CPT 73630]

A radiologic examination of the foot images the bones of the distal lower extremity and may include the tibia, fibula, talus, calcaneus, cuboid, navicular, cuneiform, metatarsals, and phalanges. X-ray imaging uses indirect ionizing radiation to take pictures inside the body. X-rays work on non-uniform material, such as human tissue, because of the different density and composition of the object, which allows some of the x-rays to be absorbed and some to pass through and be captured behind the object on a detector. This produces a 2D image of the structures. The radiographs may be taken to look for the cause of pain, limping, or swelling, or conditions such as fractures, dislocations, deformities, degenerative disease, osteomyelitis, arthritis, foreign body, and cysts or tumors. Foot x-rays may also be used to determine whether there is satisfactory alignment of foot bones following fracture treatment. Standard views of the foot include top to bottom dorsal planter (DP), lateral (side), oblique (semi-prone position with body and leg partially rotated), and stress study with traction placed on the joint manually.

X-ray of hand, minimum of 3 views [CPT 73130]

A radiologic examination of the hand is done. X-ray imaging uses indirect ionizing radiation to take pictures inside the body. X-rays work on non-uniform material, such as human tissue, because of the different density and composition of the object, which allows some of the x-rays to be absorbed and some to pass through and be captured behind the object on a detector. This produces a 2D image of the structures. The radiographs may be taken to look for conditions such as fractures, dislocations, deformities, degenerative bone conditions, osteomyelitis, arthritis, foreign body, or tumors. Hand x-rays are also used to help determine the 'bone age' of children and assess whether any nutritional or metabolic disorders may be interfering with proper development. The posteroanterior projection is taken with the palm down flat and may show not only the metacarpals, phalanges, and interphalangeal joints, but the carpal bones, radius, and ulna as well. Lateral views may be taken with the hand placed upright, resting upon the ulnar side of the palm and little finger with the thumb on top, ideally with the fingers supported by a sponge and splayed to avoid overlap. Oblique views can be obtained with the hand placed palm down and rolled slightly to the outside with the fingertips still touching the film surface. The beam is angled perpendicular to the cassette for oblique projections and aimed at the middle finger metacarpophalangeal joint.

X-ray of hip with pelvis, 2-3 views [CPT 73502]

A radiologic examination of the hip is done on either the left or the right side, which may also include the pelvis. X-ray imaging uses indirect ionizing radiation to take pictures inside the body. X-rays work on non-uniform material, such as human tissue, because of the different density and composition of the object, which allows some of the x-rays to be absorbed and some to pass through and be captured behind the object on a detector. This produces a 2D image of the structures. The radiographs may be taken to look for conditions such as fractures, dislocations, deformities, degenerative bone conditions, osteomyelitis, arthritis, foreign body, infection, or tumor. Hip standard views that are taken most frequently include the front to back anteroposterior view taken with the patient lying supine and the legs straight, rotated slightly inward; the lateral ‘frog-leg’ view, taken with the hips flexed and abducted and the knees flexed with the soles of the feet placed together; a cross table view with the unaffected hip and knee flexed at a 90 degree angle out of the way and the beam aimed perpendicular to the long axis of the femur on the affected side. Another type of lateral view is taken with the hip flexed 45 degrees and abducted 45 degrees and the beam aimed perpendicular to the table.

X-ray of knee, 1 or 2 views [CPT 73560]

A radiologic examination of the knee images the femur, tibia, fibula, patella, and soft tissue. X-ray imaging uses indirect ionizing radiation to take pictures inside the body. X-rays work on non-uniform material, such as human tissue, because of the different density and composition of the object, which allows some of the x-rays to be absorbed and some to pass through and be captured behind the object on a detector. This produces a 2D image of the structures. The radiographs may be taken to look for the cause of pain, limping, or swelling, or conditions such as fractures, dislocations, deformities, degenerative disease, osteomyelitis, arthritis, foreign body, and cysts or tumors. Knee x-rays may also be used to determine whether there is satisfactory alignment of lower extremity bones following fracture treatment. Standard views of the knee include front to back anteroposterior (AP), lateral (side), and back to front posteroanterior (PA) with variations in the flexion of the joint, and weight bearing and non-weight bearing postures.

X-ray of lower and sacral spine, 2 or 3 views [CPT 72100]

A radiologic exam is done of the lumbosacral spine. Frontal, posteroanterior, and lateral views are the most common projections taken. X-ray uses indirect ionizing radiation to take pictures inside the body. X-rays work on non-uniform material, such as human tissue, because of the different density and composition of the object, which allows some of the x-rays to be absorbed and some to pass through and be captured behind the object on a detector. This produces a 2D image of the structures.

X-ray of middle spine, 2 views [CPT 72070]

A radiologic exam is done of the thoracic spine. X-ray uses indirect ionizing radiation to take pictures inside the body. X-rays work on non-uniform material, such as human tissue, because of the different density and composition of the object, which allows some of the x-rays to be absorbed and some to pass through and be captured behind the object on a detector. This produces a 2D image of the structures. X-rays are taken of the thoracic spine to evaluate for back pain or suspected disease or injury. Films are taken from differing views that commonly include anteroposterior, lateral, posteroanterior, and a swimmer's view for the upper thoracic spine in which the patient reaches up with one arm and down with the other as if taking a swimming stroke.

X-ray of ribs on one side of body including the chest, minimum of 3 views [CPT 71101]

Rib radiographs (x-rays) are typically obtained following trauma to the rib cage to determine if fractures or other internal injuries are present. The most common views of the ribs are anteroposterior (AP) (frontal) and oblique. There are four positions used for oblique views: right anterior oblique, left anterior oblique, right posterior oblique, and left posterior oblique. Anterior oblique views are obtained with the patient standing and the chest rotated 45 degrees. The arm closest to the x-ray cassette is flexed with the hand resting on the hip. The opposite arm is raised as high as possible. The part of the chest farthest away from the x-ray cassette is the area that is being studied. Posterior oblique views are typically obtained only when the patient is too ill to stand or lay prone for anterior oblique views.

X-ray of shoulder, minimum of 2 views [CPT 73030]

A radiologic examination of the shoulder is done. The shoulder is the junction of the humeral head and the glenoid of the scapula. Standard views include the anteroposterior (AP) view and the lateral 'Y' view, named because of the Y shape formed by the scapula when looking at it from the side. An axial view can also be obtained for further assessment when the patient is able to hold the arm in abduction. X-ray imaging uses indirect ionizing radiation to take pictures inside the body. X-rays work on non-uniform material, such as human tissue, because of the different density and composition of the object, which allows some of the x-rays to be absorbed and some to pass through and be captured behind the object on a detector. This produces a 2D image of the structures.

X-ray of spine of neck, 2 or 3 views [CPT 72040]

A radiologic exam is done of the cervical spine. Anteroposterior and lateral views are the most common projections taken. X-ray uses indirect ionizing radiation to take pictures inside the body. X-rays work on non-uniform material, such as human tissue, because of the different density and composition of the object, which allows some of the x-rays to be absorbed and some to pass through and be captured behind the object on a detector. This produces a 2D image of the structures.

X-ray of upper spine, 4 or 5 views [CPT 72050]

A radiologic exam is done of the cervical spine. Anteroposterior and lateral views are the most common projections taken. X-ray uses indirect ionizing radiation to take pictures inside the body. X-rays work on non-uniform material, such as human tissue, because of the different density and composition of the object, which allows some of the x-rays to be absorbed and some to pass through and be captured behind the object on a detector. This produces a 2D image of the structures.

X-ray of wrist, 2 views [CPT 73100]

A radiologic examination of the wrist is done. X-ray imaging uses indirect ionizing radiation to take pictures inside the body. X-rays work on non-uniform material, such as human tissue, because of the different density and composition of the object, which allows some of the x-rays to be absorbed and some to pass through and be captured behind the object on a detector. This produces a 2D image of the structures. The radiographs may be taken to look for conditions such as fractures, dislocations, deformities, arthritis, foreign body, infection, or tumor. Wrist standard views include the front to back anteroposterior (AP) or back to front posteroanterior (PA) projection; the lateral view with the elbow flexed and the hand and wrist placed thumb up; and oblique views. Oblique views are obtained with the hand and wrist either supinated or pronated with the hand slightly flexed so the carpal target area lies flat, and then rotating the wrist 45 degrees externally or internally. A more specialized image may be obtained for assessing carpal tunnel. For the carpal tunnel view, the forearm is pronated with the palm down, and the wrist is hyperextended as far as possible by grasping the fingers with the opposite hand and gently hyperextending the joint until the metacarpals and fingers are in a near vertical position.

X-ray of wrist, minimum of 3 views [CPT 73110]

A radiologic examination of the wrist is done. X-ray imaging uses indirect ionizing radiation to take pictures inside the body. X-rays work on non-uniform material, such as human tissue, because of the different density and composition of the object, which allows some of the x-rays to be absorbed and some to pass through and be captured behind the object on a detector. This produces a 2D image of the structures. The radiographs may be taken to look for conditions such as fractures, dislocations, deformities, arthritis, foreign body, infection, or tumor. Wrist standard views include the front to back anteroposterior (AP) or back to front posteroanterior (PA) projection; the lateral view with the elbow flexed and the hand and wrist placed thumb up; and oblique views. Oblique views are obtained with the hand and wrist either supinated or pronated with the hand slightly flexed so the carpal target area lies flat, and then rotating the wrist 45 degrees externally or internally. A more specialized image may be obtained for assessing carpal tunnel. For the carpal tunnel view, the forearm is pronated with the palm down, and the wrist is hyperextended as far as possible by grasping the fingers with the opposite hand and gently hyperextending the joint until the metacarpals and fingers are in a near vertical position.

Total Shoulder Replacement

Respiratory infections and inflammations with major complications