Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 00.03.02y


Attachment:A

Policy #:00.03.02y

Description:Diagnostic Radiology Procedure Codes Included in Capitation for Pennsylvania (PA) Health Maintenance Organization (HMO) Members

Title:Diagnostic Radiology Services Included in Capitation


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.


DIAGNOSTIC RADIOLOGY PROCEDURE CODES INCLUDED IN CAPITATION FOR PENNSYLVANIA (PA) HEALTH MAINTENANCE ORGANIZATION (HMO) MEMBERS

The procedure codes listed in this attachment are included in the designated radiology provider’s monthly capitation.

The Effective Date indicates the date a valid code is included in capitation.

The Delete Date indicates either the date the code becomes invalid and/or is no longer included in capitation.


Radiology Procedure Codes Included in Capitation


Code
Effective
Date
Delete
Date
0144T
01/01/06
10/31/07
0145T
01/01/06
10/31/07
0146T
01/01/06
10/31/07
0147T
01/01/06
10/31/07
0148T
01/01/06
10/31/07
0149T
01/01/06
10/31/07
0150T
01/01/06
10/31/07
0151T
01/01/06
10/31/07
0330T
07/01/13
0331T
07/01/13
0332T
07/01/13
0346T
01/01/14
01/01/19
0348T
07/01/14
0349T
07/01/14
0350T
07/01/14
0482T
0541T
01/01/19
0542T
01/01/19
70030
03/01/96
70100
12/01/93
70110
12/01/93
70120
12/01/93
70130
12/01/93
70134
12/01/93
70140
12/01/93
70150
12/01/93
70160
12/01/93
70190
12/01/93
70200
12/01/93
70210
12/01/93
70220
12/01/93
70240
12/01/93
70250
12/01/93
70260
12/01/93
70328
12/01/93
70330
12/01/93
70336
03/01/96
70360
12/01/93
70370
12/01/93
70380
12/01/93
70450
12/01/93
70460
12/01/93
70470
12/01/93
70480
12/01/93
70481
12/01/93
70482
12/01/93
70486
12/01/93
70487
12/01/93
70488
12/01/93
70490
12/01/93
70491
12/01/93
70492
12/01/93
70496
12/01/93
70498
12/01/93
70540
03/01/96
70542
12/01/93
70543
12/01/93
70544
12/01/93
70545
12/01/93
70546
12/01/93
70547
12/01/93
70548
12/01/93
70549
12/01/93
70551
03/01/96
70552
03/01/96
70553
03/01/96
71010
12/01/93
12/31/17
71015
12/01/93
12/31/17
71020
12/01/93
12/31/17
71021
12/01/93
12/31/17
71022
12/01/93
12/31/17
71023
12/01/93
12/31/17
71030
12/01/93
12/31/17
71034
12/01/93
12/31/17
71035
12/01/93
12/31/17
71045
01/01/18
71046
01/01/18
71047
01/01/18
71048
01/01/18
71100
12/01/93
71101
12/01/93
71110
12/01/93
71111
12/01/93
71120
12/01/93
71130
12/01/93
71250
12/01/93
71260
12/01/93
71270
12/01/93
71275
12/01/93
71550
03/01/96
71551
12/01/93
71552
01/01/01
71555
03/01/96
72010
12/01/93
12/31/2015
72020
12/01/93
72040
12/01/93
72050
12/01/93
72052
12/01/93
72069
12/01/93
12/31/2015
72070
12/01/93
72072
12/01/93
72074
12/01/93
72080
12/01/93
72081
01/01/2016
72082
01/01/2016
72083
01/01/2016
72084
01/01/2016
72090
12/01/93
12/31/2015
72100
12/01/93
72110
12/01/93
72114
12/01/93
72120
12/01/93
72125
12/01/93
72126
12/01/93
72127
12/01/93
72128
12/01/93
72129
12/01/93
72130
12/01/93
72131
12/01/93
72132
12/01/93
72133
12/01/93
72141
03/01/96
72142
03/01/96
72146
03/01/96
72147
03/01/96
72148
03/01/96
72149
03/01/96
72156
03/01/96
72157
03/01/96
72158
03/01/96
72159
03/01/96
72170
12/01/93
72190
12/01/93
72191
12/01/93
72192
12/01/93
72193
12/01/93
72194
12/01/93
72195
12/01/93
72196
03/01/96
72197
12/01/93
72198
03/01/96
72200
12/01/93
72202
12/01/93
72220
12/01/93
73000
12/01/93
73010
12/01/93
73020
12/01/93
73030
12/01/93
73050
12/01/93
73060
12/01/93
73070
12/01/93
73080
12/01/93
73090
12/01/93
73100
12/01/93
73110
12/01/93
73120
12/01/93
73130
12/01/93
73140
12/01/93
73200
12/01/93
73201
12/01/93
73202
12/01/93
73206
12/01/93
73218
12/01/93
73219
12/01/93
73220
03/01/96
73221
03/01/96
73222
12/01/93
73223
12/01/93
73225
03/01/96
73500
12/01/93
12/31/2015
73501
01/01/2016
73502
01/01/2016
73503
01/01/2016
73510
12/01/93
12/31/2015
73520
12/01/93
12/31/2015
73521
01/01/2016
73522
01/01/2016
73523
01/01/2016
73540
12/01/93
12/31/2015
73550
12/01/93
12/31/2015
73551
01/01/2016
73552
01/01/2016
73560
12/01/93
73562
12/01/93
73564
12/01/93
73565
12/01/93
73590
12/01/93
73600
12/01/93
73610
12/01/93
73620
12/01/93
73630
12/01/93
73650
12/01/93
73660
12/01/93
73700
12/01/93
73701
12/01/93
73702
12/01/93
73706
12/01/93
73718
12/01/93
73719
12/01/93
73720
03/01/96
73721
03/01/96
73722
12/01/93
73723
12/01/93
73725
03/01/96
74000
12/01/93
12/31/17
74010
12/01/93
12/31/17
74018
01/01/18
74019
01/01/18
74020
12/01/93
12/31/17
74021
01/01/18
74022
12/01/93
74150
12/01/93
74160
12/01/93
74170
12/01/93
74174
01/01/12
74175
12/01/93
74176
01/01/11*
74177
01/01/11*
74178
01/01/11*
74181
03/01/96
74182
12/01/93
74183
12/01/93
74185
03/01/96
74210
12/01/93
74220
12/01/93
74230
12/01/93
74240
12/01/93
74241
12/01/93
74245
12/01/93
74246
12/01/93
74247
12/01/93
74249
12/01/93
74250
12/01/93
74251
12/01/93
74260
12/01/93
74270
12/01/93
74280
12/01/93
74283
12/01/93
74290
12/01/93
74291
12/01/93
01/01/15
74400
12/01/93
74410
12/01/93
74415
12/01/93
74710
12/01/93
74775
12/01/93
75552
03/01/96
12/31/07
75553
03/01/96
12/31/07
75554
03/01/96
12/31/07
75555
03/01/96
12/31/07
75556
03/01/96
12/31/07
75557
01/01/08
75558
01/01/08
12/31/09

Code
Effective
Date
Delete
Date
75559
01/01/08
75560
01/01/08
12/31/09
75561
01/01/08
75562
01/01/08
12/31/09
75563
01/01/08
75564
01/01/08
12/31/09
75565
01/01/10
75635
03/01/09
76006
12/01/93
12/31/06
76010
12/01/93
76020
12/01/93
12/31/06
76040
12/01/93
12/31/06
76061
12/01/93
12/31/06
76062
12/01/93
12/31/06
76066
12/01/93
12/31/06
76070
03/01/96
12/31/06
76071
12/01/93
12/31/06
76075
10/01/96
12/31/06
76076
01/01/98
12/31/06
76078
01/01/98
12/31/06
76093
03/01/96
12/31/06
76094
03/01/96
12/31/06
76100
12/01/93
76101
12/01/93
76102
12/01/93
76120
12/01/93
76125
12/01/93
76140
12/01/93
76150
12/01/93
01/11/11
76350
12/01/93
01/11/11
76370
12/01/93
12/31/04
76375
01/01/98
12/31/05
76376
01/01/06
76377
01/01/06
76380
12/01/93
76390
01/01/98
76400
03/01/96
12/31/06
76496
12/01/93
76497
12/01/93
76498
12/01/93
76499
12/01/93
76506
12/01/93
76536
12/01/93
76604
12/01/93
76645
12/01/93
11/30/2007
76700
12/01/93
76705
12/01/93
76706
01/01/17
76770
12/01/93
76775
12/01/93
76776
01/01/07
76778
12/01/93
12/31/06
76800
12/01/93
76801
12/01/93
76802
12/01/93
76805
12/01/93
76810
12/01/93
76811
12/01/93
76812
12/01/93
76815
01/01/98
76816
12/01/93
76817
12/01/93
76818
12/01/93
76819
01/01/98
76820
01/01/05
76821
01/01/05
76830
12/01/93
76856
12/01/93
76857
12/01/93
76870
12/01/93
76872
12/01/93
76880
12/01/93
01/01/11
76881
01/01/11
76882
01/01/11
76970
12/01/93
76977
12/01/93
76978
01/01/19
76979
01/01/19
76981
01/01/19
76982
01/01/19
76983
01/01/19
76999
12/01/93
77046
01/01/19
77047
01/01/19
77048
01/01/19
77049
01/01/19
77058
01/01/07
01/01/19
77059
01/01/07
01/01/19
77071
01/01/07
77072
01/01/07
77073
01/01/07
77074
01/01/07
77075
01/01/07
77077
01/01/07
77078
01/01/07
77079
01/01/07
12/31/11
77080
01/01/07
77081
01/01/07
77083
01/01/07
12/31/11
77084
01/01/07
77085
01/01/15
77086
01/01/15
77293
01/01/14
78000
12/01/93
12/31/12
78001
12/01/93
12/31/12
78003
12/01/93
12/31/12
78006
12/01/93
12/31/12
78007
12/01/93
12/31/12
78010
12/01/93
12/31/12
78011
12/01/93
12/31/12
78012
01/01/13
78013
01/01/13
78014
01/01/13
78015
12/01/93
78016
12/01/93
78018
12/01/93
78020
12/01/93
78070
12/01/93
78071
01/01/13
78072
01/01/13
78075
12/01/93
78099
12/01/93
78102
12/01/93
78103
12/01/93
78104
12/01/93
78110
12/01/93
78111
12/01/93
78120
12/01/93
78121
12/01/93
78122
12/01/93
78130
12/01/93
78135
12/01/93
78140
12/01/93
78160
12/01/93
12/31/05
78162
12/01/93
12/31/05
78170
12/01/93
12/31/05
78172
12/01/93
12/31/05
78185
12/01/93
78190
12/01/93
12/31/17
78191
12/01/93
78195
12/01/93
78199
12/01/93
78201
12/01/93
78202
12/01/93
78205
12/01/93
78206
12/01/93
78215
12/01/93
78216
12/01/93
78220
12/01/93
12/31/11
78223
12/01/93
12/31/11
78226
01/01/12
78227
01/01/12
78230
12/01/93
78231
12/01/93
78232
12/01/93
78258
12/01/93
78261
12/01/93
78262
12/01/93
78264
12/01/93
78265
01/01/2016
78266
01/01/2016
78270
12/01/93
01/01/19
78271
12/01/93
01/01/19
78272
12/01/93
01/01/19
78282
12/01/93
78290
12/01/93
78291
12/01/93
78299
12/01/93
78300
12/01/93
78305
12/01/93
78306
12/01/93
78315
12/01/93
78320
12/01/93
78350
10/01/00
78351
10/01/96
78399
12/01/93
78445
12/01/93
78455
12/01/93
12/31/05
78456
12/01/93
78457
12/01/93
78458
12/01/93
78579
01/01/12
78580
12/01/93
78582
01/01/12
78584
12/01/93
12/31/11
78585
12/01/93
12/31/11
78586
12/01/93
12/31/11
78587
12/01/93
12/31/11
78588
12/01/93
12/31/11
78591
12/01/93
12/31/11
78593
12/01/93
12/31/11
78594
12/01/93
12/31/11
78596
12/01/93
12/31/11
78597
01/01/12
78598
01/01/12
78599
12/01/93
78600
12/01/93
78601
12/01/93
78605
12/01/93
78606
12/01/93
78607
01/01/08
78610
12/01/93
78615
12/01/93
12/31/07
78647
12/01/93
78660
12/01/93
78699
12/01/93
78700
12/01/93
78701
12/01/93
78704
12/01/93
12/31/06
78707
01/01/98
78708
01/01/98
78709
01/01/98
78710
01/01/98
78715
12/01/93
12/31/06
78725
12/01/93
78730
12/01/93
78740
12/01/93
78760
12/01/93
12/31/06
78761
12/01/93
78799
12/01/93
78800
12/01/93
78801
12/01/93
78802
12/01/93
78803
12/01/93
78804
01/01/04
78805
12/01/93
78806
12/01/93
78807
12/01/93
78890
12/01/93
12/31/08
78891
12/01/93
12/31/08
78990
12/01/93
12/31/04
78999
12/01/93
91200
03/01/2016
93875
10/01/96
12/31/11
93880
10/01/96
93882
10/01/96
93886
10/01/96
93888
10/01/96
93890
01/01/05
93892
01/01/05
93893
01/01/05
93895
01/01/15
93922
12/01/93
93923
12/01/93
93924
12/01/93
93925
12/01/93
93926
12/01/93
93930
12/01/93
93931
12/01/93
93965
12/01/93
12/31/16
93970
02/01/95
93971
02/01/95

Code
Effective
Date
Delete
Date
A9508
01/01/01
11/30/03
A9510
01/01/01
11/30/03
C8900
01/01/02
C8901
01/01/02
C8902
01/01/02
C8903
01/01/02
C8904
01/01/02
01/01/19
C8905
01/01/02
C8906
01/01/02
C8907
01/01/02
01/01/19
C8908
01/01/02
C8909
01/01/02
C8910
01/01/02
C8911
01/01/02
C8912
01/01/02
C8913
01/01/02
C8914
01/01/02
C8918
07/01/03
C8919
07/01/03
C8920
07/01/03
C8931
06/03/10
C8932
06/03/10
C8933
06/03/10
C8934
06/03/10
C8935
06/03/10
C8936
06/03/10
C9744
10/01/16
01/01/19
G0130
10/01/00
G0131
10/01/00
12/31/02
G0132
10/01/00
12/31/02
G0196
01/01/01
12/31/02
G0273
01/01/03
12/31/03
G0297
01/01/16
G0389
01/01/07
S8004
01/01/03
03/31/05
S8032
10/01/14
09/30/16
S8042
01/01/03
S8080
01/01/01
S8093
10/01/04
03/31/06

*On 3/12/2012 the effective date was revised from 07/01/11 to 01/01/11.




Version Effective Date: 01/01/2019
Version Issued Date: 01/14/2019
Version Reissued Date: N/A

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