Transcription
6Ancillary ServicesLaboratory . . . . . . . . . . . . . . . . . . . . . . . . . .87Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . .91Physical and Occupational Therapy . . . . . .110Acupuncture and Chiropractic Guidelines . .113Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . .114
Section 6 — Ancillary Services86www.oxfordhealth.com
Ancillary Services — Section 6LaboratoryFull Service LaboratoriesThrough Oxford’s laboratory network, we intend toprovide you access to the tests you need to treat yourpatients, to reasonably control the increasing cost ofmedical care, and to limit your patients’ unnecessaryout-of-pocket costs.Acu-Path Laboratories, Inc.Client servicesBayside Diagnostics LaboratoryClient services718-886-8500Oxford’s outpatient laboratory network is comprised of:Clinical Lab PartnersClient services860-696-8222 Full-service labs Niche labs (i.e., esoteric/specialty labs) Hospital labs (not all participating hospitalshave participating outpatient laboratories)Dianon Systems, Inc.Client servicesEnzo Clinical LabsClient servicesOutpatient LaboratoryPolicies and ProceduresEsoterix, Inc.Client services All outpatient laboratory specimens must be sent toone of the contracted laboratory as listed in thesepages and on our web site at www.oxfordhealth.comGJL Medical LabsClient services A referral is not required for lab specimens sentto participating laboratories (only a physician’sprescription or lab order form is required) When billing for laboratory services performed in theoffice, specimen handling and/or venipuncture: If you bill specimen handling and venipuncturecodes in conjunction with a lab code, for a labprocedure performed in your office, only thelab and venipuncture codes will be reimbursed(please remember that in order for the lab codeto be reimbursed, the code must be on theIn-office Laboratory Testing List) If you bill specimen handling and venipuncturecodes without a lab code, the specimen handlingand venipuncture codes will be reimbursedaccording to Oxford’s fee schedule Oxford reviews laboratory ordering informationon a periodic basis in an effort to support full use ofOxford’s contracted laboratory network; if our datashows a pattern of out-of-network utilization for yourpractice, we will contact you to share this informationand engage you to utilize the contracted network1-800-328-2666631-755-5500 or 1-800-522-50521-800-444-9111516-326-0700 or 1-800-924-1650Lab Corporation of America HoldingsClient services, home blood draws,STAT testing services:New Jersey1-800-223-0631New York1-800-745-0233Connecticut1-800-342-2475Patient service center locatornumber for Members1-888-LabCorpQuest Diagnostics, IncorporatedClient services, home blood draws,STAT testing services:New Jersey1-800-631-1390Long Island, New York1-800-877-7530All other New York t service center locatornumber for Members1-800-377-8448Quentin Medical Laboratory, Inc.Client servicesShiel Medical Laboratory, Inc.Client 2600718-714-5700 or1-800-553-0873, ext. 90087
Section 6 — Ancillary ServicesSpecialty LaboratoriesAckerman Academy ofDermatopathology*212-889-6225 or 1-800-553-6621Genzyme Genetics*Home Healthcare Laboratoryof yriad Genetics, Inc.1-800-469-7423Pathology Associates, P.C.*Client services1-800-388-3995University Pathology, P.C.*914-594-4150212-241-8014Mount Sinai Medical Center,Department of Dermatopathology212-241-6064New York University Medical Center*NYU Medical Center Laboratories212-263-7313NYU Pathology Associates212-263-5475NYU Dermatopathology Associates212-263-7250North Shore University Hospital —Long Island Jewish Medical Health System*Client Services:Nassau and Suffolk counties516-719-1000Brooklyn and Richmond counties718-226-5227Participating hospitals in theNorth Shore system include:Hospital LaboratoriesBarnert Hospital*Client servicesMount Sinai Pathology Consultants973-977-6647North Shore University Hospital ManhassetNorth Shore Hospital System Central LaboratoriesContinuum Health Partners, Inc.*Beth Israel Medical CenterLong Island Jewish Medical CenterStaten Island University HospitalPathology and Laboratory Medicine1-800-420-LABSLong Island Medical College*Pathology and Laboratory Medicine1-800-420-LABSSt. Luke’s — Roosevelt Hospital*Pathology and Laboratory Medicine1-800-420-LABSNew York Weill Center/New York Hospital Laboratories212-746-0675Greenwich Hospital Laboratory*Client services203-863-3380Columbia Presbyterian Center/Clinical Lab Services212-305-2155Griffin Hospital*Client services203-732-7280New York Presbyterian Healthcare System*New York Presbyterian Hospital:Columbia Presbyterian Pathologists1-800-653-8200212-305-4840Hackensack University Medical Center*Totalab1-877-868-2522The Brooklyn Hospital Center,Department of Pathology718-250-8000Client services201-996-4881Milford Hospital Laboratory*Client Services203-876-4256Laboratory of Dermatopathology,Department of DermatopathologyCollege of Physicians and Surgeonsof Columbia University212-305-2155Mount Sinai Medical Center*Mount Sinai Hospital of New York212-241-4675Mount Sinai Hospital of Queens212-241-4675New York Community Hospital ofBrooklyn, Department of Pathologyand Lab Medicine718-692-5372Mount Sinai Hospital Clinic212-241-4675New York Methodist Hospital —Outpatient Laboratory718-780-3645Mount Sinai Center forClinical Laboratories212-241-4675New York United HospitalMedical Center Lab914-934-3070Mount Sinai Pathology Associates212-241-398588www.oxfordhealth.com
Ancillary Services — Section 6New York Westchester SquareMedical Center Laboratory85013 Spun microhematocrit718-430-7300NYHQ/Charter Diagnostics Laboratory 718-670-2575Palisades Medical Hospital/Clinical Laboratory201-854-5054Wyckoff Heights Medical CenterLaboratories718-963-7519*Provides anatomic pathology servicesIn-office LaboratoryTesting ListThe In-office Laboratory Testing List includes codesfor laboratory procedures reimbursed to physicianswhen performed in their offices. All other laboratoryprocedures must be performed by one of theparticipating laboratories in Oxford’s network.Primary Care Physicians and Specialists*81000 Urinalysis, with microscopy*81002 Urinalysis, non-automated,without microscopy*81003 Urinalysis, automated,without microscopy81025 Urine pregnancy test, by visualcolor comparison methods82270 Blood, occult; feces screening,1-3 simultaneous determinations82273 Blood, occult; other sources, qualitative82274 Blood, occult, by fecal hemoglobindetermination by immunoassay,qualitative, feces, 1-3 simultaneousdeterminations82948 Glucose; blood, reagent strip82962 Glucose, blood sugar by glucometer83014 Helicobacter pylori, breath testanalysis; drug administration andsample collection (Note: Dianonprovides test kit free of charge —call 1-800-328-2666.)83026 Hemoglobin; by copper sulfatemethod, non-automatedwww.oxfordhealth.com85018 Blood count, hemoglobin85651 Sedimentation rate, erythrocyte;non-automated****86403 Particle agglutination, screen,each antibody86485-86586 Skin tests; various**87070 Culture, bacterial; any other sourcebut urine, blood or stool, withisolation and presumptiveidentification of isolates**87081 Culture, bacterial, screening only,for single organisms87177 Ova and parasites, direct smears,concentration and identification87210 Smear, wet mount with simplestain, for bacteria, fungi, ova,and/or parasites87220 Tissue examination for fungi(e.g., KOH slide)****87880 Infectious agent detection byimmunoassay — streptococcus group A89100 Duodenal intubation and aspirationsingle specimen plus appropriate test89105 Duodenal intubation and aspiration;collection of multiple fractionalspecimens with pancreatic orgallbladder stimulation, singleor double lumen tube89130-89141 Gastric intubation and aspiration;various89350 Sputum, obtaining specimen,aerosol-induced technique99195 Phlebotomy, therapeutic(separate procedure)For STAT Purposes Only, claim must be marked STAT***85025 Hemogram and platelet count,automated and automated completedifferential WBC count (CBC)*, **, ***, **** Reimbursement is limited to one procedure (within the relatedfamily of codes) per visit.89
Section 6 — Ancillary ServicesPediatricians Only82247 Bilirubin, TotalPulmonologist Only82803 Gases, blood, any combination of pH,pCO2, pO2, CO2, HCO3 (includingcalculated O2 saturation)Obstetricians, Gynecologists, ReproductiveEndocrinologists, and Infertility Specialists Only82670 Estradiol83001 Gonadotropin; follicle stimulatinghormone (FSH)83002 Gonadotropin; luteinizinghormone (LH)89320 Semen analysis; complete (volume,count, motility, and differential)89321 Semen analysis; presence and/ormotility of sperm 89325 Sperm antibodies 89329 Sperm evaluation; hamsterpenetration test 89330 Sperm evaluation; cervical mucuspenetration test, with or withoutspinnbarkeit test Member must have the infertility benefitReproductive Endocrinologists and InfertilitySpecialists Only89268 Insemination of oocytes84144 Progesterone84702 Gonadotropin, chorionic (hCG);quantitative 89250 Culture and fertilization of oocyte(s) 89251 Culture and fertilization of oocyte(s)with co-culture of embryos 89253 Assisted embryo hatching,microtechniques (any method) 89254 Oocyte identification fromfollicular fluid 89255 Preparation of embryo for transfer(any method) 89257 Sperm identification from aspiration(other than seminal fluid) 89260 Sperm isolation; simple prep (e.g.,sperm wash, swim-up) for inseminationor diagnosis w/semen analysis 89261 Sperm isolation; complex prep (e.g.,Percoll gradient, albumin gradient)for insemination or diagnosis withsemen analysis 89300 Semen analysis; presence and/ormotility of sperm including Huhnertest (post coital)89272 Extended culture ofoocyte(s)/embryo(s), 4-7 days89280 Assisted oocyte fertilization,microtechnique; less than orequal to 10 oocytes89281 Assisted oocyte fertilization,microtechnique; greater than10 oocytes89290 Biopsy, oocyte polar body or embryoblastomere, microtechnique (forpre-implantation genetic diagnosis);less than or equal to 5 embryos89291 Biopsy, oocyte polar body or embryoblastomere, microtechnique (forpre-implantation genetic diagnosis);greater than 5 embryos89352 Thawing of cryopreserved; embryo(s)Rheumatologists Only89060 Crystal identification by lightmicroscopy with or without polarizinglens analysis, and body fluid(except urine)89310 Semen analysis; motility and count90www.oxfordhealth.com
Ancillary Services — Section 6Hematologists and Oncologists Only85007 BL Smear w/diff WBC count***85025 Hemogram and platelet count,automated and automated completedifferential WBC count (CBC)85027 Complete WBC, automated85097 Bone marrow; smear interpretationonly, with or without differentialcell count86077 Blood bank physician services;difficult cross-match and/orevaluation of irregular antibody(s),interpretation and written report86078 Blood bank physician services;investigation of transfusionreaction, including suspicionof transmissible disease,interpretation and written report86079 Blood bank physician services;authorization for deviation fromstandard blood-banking procedures,with written reportRadiology86927-86999 Transfusion medicine*** Reimbursement is limited to one procedure per visit.Urologists Only89300 Semen analysis; presence and/ormotility of sperm including Huhnertest (post coital)89310 Semen analysis; motility and count89320 Semen analysis; complete (volume,count, motility and differential)89321 Semen analysis; presence and/ormotility of spermwww.oxfordhealth.comCareCore National Management Services, LLC, aphysician-owned radiology network comprised ofleading board certified radiologists, is Oxford’snetwork manager for all outpatient commercialand Oxford Medicare Advantage imaging services.Please be aware that inpatient, ambulatory surgery,emergency room radiology services, radiation therapy,radionuclide therapy, ophthalmic ultrasound, andany delegated physician arrangement are notincluded in this arrangement. Oxford has eliminatedthe need to submit referrals for outpatient radiologyprocedures performed by participating radiologistsor radiology facilities.91
Section 6 — Ancillary ServicesPrivileging by SpecialtyOxford’s privileging program is designed to improve the quality of imaging services by limiting coverage to servicesprovided in the most appropriate setting. Below is a list of imaging CPT codes for services that physicians, otherthan radiologists, can perform in their office.Please note: The privileging program applies to office and outpatient (non-ambulatory surgery) procedures.Privileging List* These following procedures require precertification; call 1-877-PRE-AUTH.*** Any studies beyond three (3) require precertification; call 1-877-PRE-AUTH.Physician TypeCPT CodesDescriptionPrimary Care Physicians:Internal Med., Family Practice71010-7103076075, 76076, 0028TChest imagingDEXA studies, bone densitometryGeneral Surgeons:AIUM-accredited76942Ultrasonic guidance for needle biopsyCardiologists71010-71030Chest imaging78464*, 78465*, 78469*Tomographic SPECT studies78472*, 78473*, 78494*Cardiac blood pool imaging78478*Wall motion study78480Ejection fraction studyCardiologists — Pediatric only76825, 76826, 76827, 76828Echocardiography, fetalChiropractors72010, 72040, 72069, 72070,72080, 72100Spine imagingEndocrinologists76075, 76076DEXA studies, bone densitometry76942, 0028TUltrasonic guidance for needle biopsy76536 (AACE AccreditedEndocrinologists only)Thyroid ultrasoundGastroenterologists76975*Endoscopic ultrasoundGeneral Surgeons, VascularSurgeons, Cardiovascular Surgeons75940Percutaneous placement ofIVC filter, radiological supervisionand interpretation75952Endovascular repair of infrarenalabdominal aortic aneurysm75953Placement of proximal or distalextensionprosthesis for endovascular repairHand Surgeons76000, 73000-73140FluoroscopyMaternal Fetal Medicine76083Digitization of radiographic images92www.oxfordhealth.com
Ancillary Services — Section 6Privileging List (continued)Physician TypeCPT 2Screening mammography76801***, 76802***,Ultrasounds — pelvis76805***, 76810***,Ultrasounds — pelvis76811***, 76812***,Ultrasounds — pelvis76818***, 76819***,Ultrasounds — pelvis76820***, 76821***,Ultrasounds — pelvis76825***, 76826***,Ultrasounds — pelvis76827***, 76828***,Ultrasounds — pelvis76830 - 76857Ultrasounds — pelvis76930, 76945, 76946, 76941Ultrasonic guidance76942Ultrasound — pelvis, non-obstetrical76948Ultrasonic guidance for aspiration of ova76075, 76076DEXA studies, bone densitometry76083Digitization of radiographic images76092Screening mammography76815***, 76816***,Ultrasounds — pelvis76817***Ultrasounds — pelvis76830, 76831, 76856, 76857,Ultrasonic guidance76930, 76941, 76945, 76946Ultrasonic guidance76075, 76076DEXA studies, bone densitometry76801***, 76802***,Ultrasounds — pelvis76805***, 76810***,Ultrasounds — pelvis76811***, 76812***,Ultrasounds — pelvis76818***, 76819***,Ultrasounds — pelvis76820***, 76821***Doppler velocimetry76825***, 76826***,Ultrasounds — pelvis76827***, 76828***Ultrasounds — pelvis70100, 70110, 70140, 70150Mandible and facial bone imaging70300, 70310, 70320Teeth imaging70328, 70330TMJ imaging70350Cephalogram, orthodontic70355OrthopantogramOB/GYNSOB/GYNS (AIUM/ACR Accredited)Oral Surgeonswww.oxfordhealth.com93
Section 6 — Ancillary ServicesPrivileging List (continued)Physician TypeCPT CodesDescriptionOrthopedists71100-71111Radiologic examination, ribs71120-71130Radiologic examination, sternum72010-72120, 72170, 72190,Spine and pelvis imaging72200-72220Spine and pelvis imaging73000-73140, 73500-73660Imaging — upper and lower extremities76000, 76003, 76005Fluoroscopies76006Radiologic examination, any joint76040Bone length studies76066Joint surveyPain Management Specialists:Physiatrists, Anesthesiologists,Neurologists, and Neurosurgeons76000, 76005FluoroscopyPediatricians71010-71030Chest imaging76075, 76076, 0028TDEXA studies, bone densitometryPodiatrists73620, 73630, 73650, 73660Lower extremity imagingPulmonologists71010-71030Chest imagingRadiation Oncologists76950Ultrasonic guidance for placementof radiation therapy fields76965Ultrasonic guidance for interstitialradioelement application76370Computerized tomography guidance76873Determinate of prostate volumefor brachytherapy76083Digitization of radiographic images76092Screening mammography76801-76857Ultrasounds — pelvis76820, 76821Doppler velocimetry76930, 76941, 76945, 76946Ultrasonic guidance76948Ultrasonic guidance for aspiration of ova,imaging supervision and interpretation76075, 76076DEXA studies, bone densitometryReproductive Endocrinologists94www.oxfordhealth.com
Ancillary Services — Section 6Privileging List (continued)Physician TypeCPT CodesDescriptionRheumatologists72010-72120, 72170, 72190,Spine and pelvis imaging72200-72220Spine and pelvis imaging73000-73140, 73500-73660Imaging — upper and lower extremities76000, 76003Fluoroscopies76040, 76066Bone length studies, joint survey76075, 76076, 0028TDEXA studies, bone densitometryG0188Full length radiography of lower extremity76870, 76872, 76873Ultrasounds — echography,genitalia, bladder76942Ultrasonic guidance for needle biopsyUrologistsImaging RequiringPrecertificationIt is the responsibility of the referring physician,who has access to the patient’s complete medicalhistory, to contact CareCore National, LLC to requestprecertification and to provide sufficient history todemonstrate the appropriateness of the requested.Radiology Precertification Policyfor Urgent CasesIt is the imaging facility’s responsibility to confirmthat an authorization number has been issued prior toproviding a service. In the case of urgent examinations,in which there is no time to obtain an authorizationnumber and in cases in which, in the opinion of theattending physician, a change is required from theprecertified examination, the services may beperformed, and you may request a new or modifiedauthorization number. Please make your requests withintwo (2) business days of the date of service through theImaging Care Management Department in the usualmanner by calling or faxing your request. Clinicaljustification for the request will be reviewed using thesame criteria as a routine request.www.oxfordhealth.comRadiology Precertification OnlineCareCore now provides a secure web-based processto initiate clinical certification for diagnostic imagingrequests. Log onto www.carecorenational.com andthe automated system will guide you through a seriesof computer screen prompts to collect routinedemographic data. Each web-initiated request isevaluated promptly by CareCore clinical review staff.A short return call to you from CareCore completesthe certification process. This eliminates the needfor a call to CareCore’s intake staff and allows youto enter multiple clinical certification requests atyour convenience.95
Section 6 — Ancillary ServicesRadiology Utilization Review ProcessMedical Identifiers:The utilization review process involves matching thepatient clinical history and diagnostic informationwith the approved criteria for each imaging procedurerequested. Utilization review decisions are made byqualified health professionals including board certifiedradiologists. Data collection for clinical certificationof imaging services may be assigned to non-medicalpersonnel working under the direction of qualifiedhealth professionals. You will receive notification ofreview determinations for non-urgent care by telephonewithin two (2) working days of receiving all the necessaryinformation. Notification for a determination involvingan urgent request is given within three (3) hours. Ordering doctor’s name and addressFor non-urgent care requests for Oxford MedicareAdvantage Members, a determination must be issuedwithin 14 calendar days of the request for service.For commercial Members, requests for retrospectiveclinical certification review of medically urgent care areaccepted up to two (2) business days after the care hasbeen given. Retrospective review decisions are madewithin 30 business days of receiving all of the necessaryinformation. If your request is not authorized, thereview determination will be sent in writing to theMember and the requesting physician within five (5)business days of the decision.Below is a list of imaging CPT codes that requireauthorization for commercial and Oxford MedicareAdvantage Members.Please note: Oxford will inform you of any new proceduresor other changes to this list on the Oxford web page andin our quarterly Program and Policy Update.To precertify a procedure, you can call CareCoreNational at 1-877-PRE-AUTH (1-877-773-2884), fax to845-298-1490 or log onto www.carecorenational.com.When you call or fax a request to the RadiologyPrecertification unit, please provide thefollowing information: Facility to which the patient is being referredand its address Contact person at your officeClinical Information: Examination(s) being requested, with CPT codesif available Presumptive diagnosis or “rule out,” with ICD-9 codesif available Patient’s signs and symptoms, listed in some detail,with severity and duration Any treatments that have been tried, including dosageand duration for drugs and dates for other therapies Any other information that you believe will help inevaluating the request, including prior diagnostic tests,consultation reports, etc.All authorization reference numbers are issued at thetime of approval. CareCore National uses the referenceCPT code as the last five (5) digits of the authorizationnumber. Please provide the authorization referencenumber to the imaging provider when schedulingthe procedure.Oxford requires the submission of clinical officenotes for specific procedures. Clinical notes includethe patient’s medical record and/or letters receivedfrom specialists that indicate: Patient symptoms, with duration and severity Patient medical history Previous imaging studies and findings Prior treatment and/or therapy, including surgery,with history Drug dosage prescribed and durationPatient Identifiers: Oxford ID number and health plan Name Date of birth Address96Please note: Radiopharmaceuticals in excess of 50.00 willbe reimbursed. Submission of an invoice detailing the costand name of the administered material is still required.If you choose to fax your authorization request,please include all of the information mentionedabove, including the request form, to CareCoreNational at 845-298-1490.www.oxfordhealth.com
Ancillary Services — Section 6CT ScansAll CT units must be ACR accredited.** Study requires the submission of clinical notes to CareCore National.Please note: The information below is not to supersede any exceptions set forth by Oxford Health Plans.CPT CodeClinical Notes RequiredDescription70450CT Head/Brain w/o Contrast70460CT Head/Brain w/Contrast70470CT Head/Brain w/o and w/Contrast70480CT Orbit w/o Contrast70481CT Orbit w/Contrast70482CT Orbit w/o and w/Contrast70486CT Maxllfcl w/o Contrast70487CT Maxllfcl w/Contrast70488CT Maxllfcl w/o and w/Contrast70490CT Soft Tissue w/o Contrast70491CT Soft Tissue w/Contrast70492CT Soft Tissue w/o and w/Contrast70496CT Angiography, Head70498CT Angiography, Neck71250CT Thorax w/o Contrast71260CT Thorax w/Contrast71270CT Thorax w/o and w/Contrast71275CT Angiography Chest72125CT C Spine w/o Contrast72126CT C Spine w/Contrast72127CT C Spine w/o and w/Contrast72128CT T Spine w/o Contrast72129CT T Spine w/Contrast72130CT T Spine w/o and w/Contrast**72131YesCT L Spine w/o Contrast**72132YesCT L Spine w/Contrast**72133YesCT L Spine w/o and w/Contrast72191www.oxfordhealth.comCT Angiography Pelvis97
Section 6 — Ancillary ServicesCT Scans (continued)CPT CodeClinical Notes RequiredDescription72192CT Pelvis w/o Contrast72193CT Pelvis w/Contrast72194CT Pelvis w/o and w/Contrast73200CT Upper Extremity w/o Contrast73201CT Upper Extremity w/Contrast73202CT Upper Extremity w/o and w/Contrast73206CT Angiography Upper Extremity73700CT Lower Extremity w/o Contrast73701CT Lower Extremity w/Contrast73702CT Lower Extremity w/o and w/Contrast73706CT Angiography Lower Extremity74150CT Abdomen w/o Contrast74160CT Abdomen w/Contrast74170CT Abdomen w/o and w/Contrast74175CT Angiography Abdomen75635CT Angiography Abdominal Aorta76013X-ray Supervision and Interpretation, PercutaneousVertebralplasty Per Vertebral Body under CT Guidance76362CT Guidance for and Monitoring of Tissue Ablation76380CT Limited or Localized Follow-up StudyMRI ProceduresAll MRI units must be ACR accredited.Please note: The information below is not to supersede any exceptions set forth by Oxford Health Plans.CPT Code98Clinical Notes RequiredDescription70336MRI TMJ70540MRI Face, Orbit, Neck w/o Contrast70542MRI Face, Orbit, Neck with Contrast70543MRI Face, Orbit, Neck w/and w/o Contrast70551MRI Head w/o Contrastwww.oxfordhealth.com
Ancillary Services — Section 6MRI Procedures (continued)CPT CodeClinical Notes RequiredDescription**70552YesMRI Head w/Contrast**70553YesMRI Head w/and w/o Contrast71550MRI Chest w/o Contrast71551MRI Chest w/Contrast71552MRI Chest w/and w/o Contrast**72141YesMRI Cervical Spine w/o Contrast**72142YesMRI Cervical Spine w/Contrast**72146YesMRI Thoracic Spine w/o Contrast**72147YesMRI Thoracic Spine w/Contrast**72148YesMRI Lumbar Spine w/o Contrast**72149YesMRI Lumbar Spine w/Contrast**72156YesMRI C Spine w/and w/o Contrast**72157YesMRI T Spine w/and w/o Contrast**72158YesMRI L Spine w/and w/o Contrast72195MRI Pelvis w/o Contrast72196MRI Pelvis w/Contrast72197MRI Pelvis w/and w/o Contrast**73218YesMRI Upper Extremity other than Joint w/o Contrast**73219YesMRI Upper Extremity other than Joint w/Contrast**73220YesMRI Upper Extremity other than Joint w/and w/o Contrast**73221YesMRI Upper Extremity Joint w/o Contrast**73222YesMRI Upper Extremity Joint w/Contrast**73223YesMRI Upper Extremity Joint w/ and w/o Contrast**73718YesMRI Lower Extremity other than Joint w/o Contrast**73719YesMRI Lower Extremity other than Joint w/Contrast**73720YesMRI Lower Extremity other than Joint w/and w/o Contrast**73721YesMRI Lower Extremity Joint w/o Contrast**73722YesMRI Lower Extremity Joint w/Contrast**73723YesMRI Lower Extremity Joint w/and w/o Contrastwww.oxfordhealth.com99
Section 6 — Ancillary ServicesMRI Procedures (continued)CPT CodeClinical Notes RequiredDescription74181MRI Abdomen w/o Contrast74182MRI Abdomen w/Contrast74183MRI Abdomen w/and w/o Contrast75552Cardiac MRI for Morphology w/o Contrast (Gated Heart)75553Cardiac MRI Morphology w/Contrast75554Cardiac MRI Complete w/or w/o Morphology75555Cardiac MRI Limited75556Cardiac MRI Velocity Flow**76093YesMRI Breast w/and/or w/o Contrast**76094YesMRI Breast Bilateral76390MRI Spectroscopy76393MRI Guidance for Placement Radiological Supervisionand Interpretation76394MRI Guidance for and Monitoring of Tissue Ablation76400MRI Bone Marrow Blood Supply76499Unlisted ProcedureMRA ProceduresCPT Code100Description70544MRA Head w/o Contrast70545MRA Head w/Contrast70546MRA Head w/and w/o Contrast70547MRA Neck w/o Contrast70548MRA Neck w/Contrast70549MRA Neck w/and w/o Contrast71555MRA Chest (Exc. Myocardium) w/or w/o Contrast72159MRA Spinal Canal w/or w/o Contrast72198MRA Pelvis w/or w/o Contrast73225MRA Upper Extremity w/or w/o Contrast73725MRA Lower Extremity w/or w/o Contrast74185MRA Abdomen w/or w/o Contrastwww.oxfordhealth.com
Ancillary Services — Section 6PET ScansAll PET units must be ACR accredited.** Study requires the submission of clinical notes to CareCore National.Please note: Clinical notes are required for all PET scans.CPT CodeClinical Notes RequiredDescription**78459YesMyocardial Imaging, Positron Emission Tomography (PET)Metabolic Evaluation**78491YesMyocardial Imaging, Positron Emission Tomography (PET),Perfusion; Single Study at Rest or Stress**78492YesMyocardial Imaging, Positron Emission Tomography (PET),Perfusion; Multiple Studies at Rest or Stress**78608YesBrain Imaging, Positron Emission Tomography (PET)Metabolic Evaluation**78609YesBrain Imaging, Positron Emission Tomography (PET)Metabolic Evaluation, Perfusion Evaluation**78811YesTumor Imaging, Positron Emission Tomography (PET);Limited Area (e.g., Chest, Head/Neck)**78812YesTumor Imaging, Positron Emission Tomography (PET);Skull Base to Mid-thigh**78813YesTumor Imaging, Positron Emission Tomography (PET);Whole Body**78814YesTumor Imaging, Positron Emission Tomography (PET)with Concurrently Acquired Computer Tomography (CT)for Attenuation Correction and Anatomical Localization;Limited Area (e.g., Chest, Head/Neck)**78815YesTumor Imaging, Positron Emission Tomography (PET)with Concurrently Acquired Computer Tomography (CT)for Attenuation Correction and Anatomical Localization;Skull Base to Mid-thigh**78816YesTumor Imaging, Positron Emission Tomography (PET)with Concurrently Acquired Computer Tomography (CT)for Attenuation Correction and Anatomical Localization;Whole Body**G0030YesPET Myocardial Perfusion Imaging; (Following PreviousPET, G0030-G0047); Single Study, Rest or Stress**G0031YesPET Myocardial Perfusion Imaging; (Following PreviousPET, G0030-G0047); Multiple Studies, Rest or Stress**G0032YesPET Myocardial Perfusion Imaging, (Following Rest/SPECT, 78464); Single Study, Rest or Stresswww.oxfordhealth.com101
Section 6 — Ancillary ServicesPET Scans (continued)CPT Code102Clinical Notes RequiredDescription**G0033YesPET Myocardial Perfusion Imaging, (Following Rest SPECT,78464); Multiple Studies, Rest or Stress**G0034YesPET Myocardial Perfusion Imaging, (Following SPECT,78465); Single Study, Rest or Stress**G0035YesPET Myocardial Perfusion Imaging, (Following SPECT,78465); Multiple Studies, Rest or Stress**G0036YesPET Myocardial Perfusion Imaging, (Following CoronaryAngiography, 93510-93529); Single Study, Rest or Stress**G0037YesPET Myocardial Perfusion Imaging, (Follo
When billing for laboratory services performed in the office, specimen handling and/or venipuncture: . Hackensack University Medical Center* Totalab 1-877-868-2522 Client services 201-996-4881 Milford Hospital Laboratory* . Medical Center Lab 914-934-3070. www.oxfordhealth.com 89 Ancillary Services— Section 6
