tar and non cd7
TAR and Non-Benefit List: Codes 70000 – 799991
BenefitBenefit
CodeDescriptionRestrictionsCodeDescriptionRestrictions
RADIOLOGY
DIAGNOSTIC RADIOLOGY
(DIAGNOSTIC IMAGING)
Head and Neck
70336MRI of jaw joint(s)...... 1
70371Dynamic pharyngeal and speech evaluation...... 1
70540Magnetic resonance imaging, orbit, face and/or neck, without contrast2
70542Magnetic resonance imaging, orbit, face, and neck; with contrast2
70543Magnetic resonance imaging, orbit, face, and neck; with and without contrast2
70544Magnetic resonance angiography, head; without contrast 2
70545Magnetic resonance angiography, head; with contrast.2
70546Magnetic resonance angiography, head; with and without contrast2
70547Magnetic resonance angiography, neck; without contrast 2
70548Magnetic resonance angiography, neck; with contrast..2
70549Magnetic resonance angiography, neck; with and without contrast2
70551Magnetic resonance imaging, brain and brain stem, without contrast2
70552Magnetic resonance imaging, brain, with contrast.....2
70553Magnetic resonance imaging, brain (including brain stem); with and without contrast2
70557..Magnetic resonance (e.g., proton) imaging, brain (including brain stem and skull base), during open intracranial procedure (eg, to assess for residual tumor or residual vascular malformation); without contrast material. 2
70558Magnetic resonance (e.g., proton) imaging, brain (including brain stem and skull base), during open intracranial procedure (e.g., to assess for residual tumor or residual vascular malformation); with contrast material(s) 2
70559Magnetic resonance (e.g., proton) imaging, brain (including brain stem and skull base), during open intracranial procedure (e.g., to assess for residual tumor or residual vascular malformation); without contrast material(s), followed by contrast material(s) and further sequences 2
Chest
71550Magnetic resonance imaging, chest; without contrast..2
71551Magnetic resonance imaging, chest; with contrast.....2
71552Magnetic resonance imaging, chest; with and without contrast2
71555Magnetic resonance angiography, chest...... 2
Spine and Pelvis
72141Magnetic resonance imaging, spinal canal and contents, cervical; without contrast2
72142Magnetic resonance imaging, spinal canal and contents, cervical; with contrast 2
72146Magnetic resonance imaging, spinal canal and contents, thoracic; without contrast2
72147Magnetic resonance imaging, spinal canal and contents, thoracic; with contrast 2
72148Magnetic resonance imaging, spinal canal and contents, lumbar; without contrast2
72149Magnetic resonance imaging, spinal canal and contents, lumbar; with contrast 2
72156Magnetic resonance imaging, spinal canal and contents, with and without contrast; cervical2
72157Magnetic resonance imaging, spinal canal and contents, with andwithout contrast; thoracic2
72158Magnetic resonance imaging, spinal canal and contents, with and without contrast; lumbar2
72159Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s)2
72195Magnetic resonance imaging, pelvis; without contrast.2
72196Magnetic resonance imaging, pelvis; with contrast....2
72197Magnetic resonance imaging, pelvis; with and without contrast2
72198Magnetic resonance angiography, pelvis, with or without contrast2
Upper Extremities
73218Magnetic resonance imaging, upper extremity, other than joint; without contrast2
73219Magnetic resonance imaging, upper extremity, other than joint; with contrast2
73220Magnetic resonance imaging, upper extremity, other than joint; with and without contrast2
73221Magnetic resonance imaging, any joint of upper extremity; without contrast2
73222Magnetic resonance imaging, any joint of upper extremity; with contrast2
73223Magnetic resonance imaging, any joint of upper extremity; with and without contrast2
73225Magnetic resonance angiography, upper extremity...2
Benefit Restriction Descriptions:1Non-Benefit3Assistant Surgeon services not payable
2Requires TAR,
Primary Surgeon/Provider
2 – TAR and Non-Benefit List: Codes 70000 – 79999
October 2016
tar and non cd7
1
BenefitBenefit
CodeDescriptionRestrictionsCodeDescriptionRestrictions
Lower Extremities
73718Magnetic resonance imaging, lower extremity other than joint; without contrast2
73719Magnetic resonance imaging, lower extremity other than joint; with contrast2
73720Magnetic resonance imaging, lower extremity other than joint; with and without contrast2
73721Magnetic resonance imaging, any joint of lower extremity; without contrast2
73722Magnetic resonance imaging, any joint of lower extremity; with contrast2
73723Magnetic resonance imaging, any joint of lower extremity; with and without contrast2
73725Magnetic resonance angiography, lower extremity....2
Abdomen
74181Magnetic resonance imaging, abdomen; without contrast 2
74182Magnetic resonance imaging, abdomen; with contrast.2
74183Magnetic resonance imaging, abdomen; with and without contrast2
74185Magnetic resonance angiography, abdomen,with or without contrast material(s)2
Gastrointestinal Tract
74261Computed tomographic colonography, diagnostic, including image postprocessing; without contrast material1
74262Computed tomographic colonography, diagnostic, including image postprocessing; with contrast material including non-contrast images, if performed 1
74263Computed tomographic colonography, screening, including image postprocessing1
Gynecological and Obstetrical
74712Magnetic resonance imaging, fetal; single or first gestation2
74713Magnetic resonance imaging, fetal; each additional gestation2
74742Transcervical catheterization fallopian tube, radiological supervision and interpretation1
Heart
75557Cardiac magnetic resonance imaging for morphology and function without contrast material1
75559Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging1
75561Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; 2
75563Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging 1
Heart (continued)
75564Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with flow/velocity quantification and stress 1
75565Cardiac magnetic resonance imaging for velocity flow mapping2
75571Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium2
75572Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology2
75573Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease 2
75574Computed tomographic angiography, heart, coronary arteries and bypass grafts, with contrast material, including 3D image post processing 2
Other Procedures
763763D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image post-processing on an independent workstation 1
763773D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image post-processing on an independentworkstation 1
76390Magnetic resonance spectroscopy...... 1
76496Unlisted fluoroscopic procedure...... 2
76497Unlisted computed tomography procedure...... 2
76498Unlisted magnetic resonance procedure...... 2
76499Unlisted diagnostic radiographic procedure...... 2
DIAGNOSTIC ULTRASOUND
Pelvis
76818Fetal biophysical profile; with non-stress testing...... 1
76819Fetal biophysical profile; without non-stress testing....1
Ultrasonic Guidance Procedures
76936Ultrasound guided compression repair of arterial pseudo-aneurysm or arteriovenous fistulae (includes diagnostic ultrasound evaluation, compression of lesion and imaging) 1
76945Ultrasonic guidance for chorionic villus sampling...... 1
76948Ultrasonic guidance foraspiration of ova...... 1
Other Procedures
76977Ultrasound bone density measurement and interpretation, peripheral site(s), any method1
Benefit Restriction Descriptions:1Non-Benefit3Assistant Surgeon services not payable
2Requires TAR,
Primary Surgeon/Provider
2 – TAR and Non-Benefit List: Codes 70000 – 79999
July 2017
tar and non cd7
1
BenefitBenefit
CodeDescriptionRestrictionsCodeDescriptionRestrictions
BREAST MAMMOGRAPHY
77058Magnetic resonance imaging, breast, without and/or with contrast material(s); unilateral2
77059Magnetic resonance imaging, breast, without and/or with contrast material(s); bilateral2
BONE/JOINT STUDIES
77078Computed tomography, bone mineral density study; axial skeleton1
77084Magnetic resonance imaging, bone marrow blood supply 1
RADIATION ONCOLOGY
Hyperthermia
77600Hyperthermia; superficial...... 2
77605Hyperthermia; deep...... 1
77610Hyperthermia generated by interstitial probe; five or fewer applicators2
77615Hyperthermia generated by interstitial probe; more than five applicators2
77620Hyperthermia generated by intracavitary probe...... 1
DIAGNOSTICNUCLEAR MEDICINE
Gastrointestinal System
78267Urea breath test, C-14; acquisition for analysis...... 1
78268Urea breath test, C-14; analysis...... 1
Musculoskeletal System
78350Bone density study, one or more sites; single photon absorptiometry1
78351Bone density study; dual photon absorptiometry, one or more sites1
Cardiovascular System
78459Myocardial imaging, positron emission tomography (PET), metabolic evaluation2
78469Myocardial imaging, infarct avid, planar; tomographic SPECT with or without quantification1
78491Myocardial imaging, positron emission tomography (PET), perfusion; single study at rest or stress1
78492Myocardial imaging, positron emission tomography (PET), perfusion; multiple studies at rest and/or stress1
Nervous System
78607Brain imaging; tomographic (SPECT)...... 1
78608Brain imaging, positron emission tomography (PET); metabolic evaluation2
78609Brain imaging, PET; perfusion evaluation...... 2
78647Cerebrospinal fluid flow, imaging; tomographic (SPECT)1
Genitourinary System
78710Kidney imaging, tomographic (SPECT)...... 1
Other Procedures
78803Radiopharmaceutical localization of tumor; tomographic (SPECT)1
78807Radiopharmaceutical localization of abscess; tomographic (SPECT)1
78810Tumor imaging, positron emission tomography (PET), metabolic evaluation2
78811Tumor imaging, positron emission tomography (PET); limited area (eg, chest, head/neck)2
78812Tumor imaging, positron emission tomography (PET); skull base to mid-thigh2
78813Tumor imaging, positron emission tomography (PET); whole body2
78814Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; limited area
(eg, chest, head/neck)...... 2
78815Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; skull base to mid-thigh 2
78816Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; whole body 2
78890Generation automated data, not to exceed
30 minutes...... 1
78891Generation automated data, exceeding 30 minutes
Benefit Restriction Descriptions:1Non-Benefit3Assistant Surgeon services not payable
2Requires TAR,
Primary Surgeon/Provider
2 – TAR and Non-Benefit List: Codes 70000 – 79999
September 2015