Horizon NJ Health Claims/Utilization Review Matrix



Claim Resolution/Utilization Review Matrix


The matrix below contains all of the CPT-4 codes for which National Imaging Associates
(NIA) authorizes on behalf of Horizon NJ Health. This matrix is designed to assist in the
resolution of claims adjudication and claims questions related to those services
authorized by NIA. If a procedure is billed under any one of the given codes for that
grouping and a valid authorization number has been issued within the date of service
validity period, the charge for any of the codes should be allowed.

If a family of CPT codes is not listed in this matrix, an exact match is required between
the authorized CPT code and the billed CPT code. If the exact match does not occur,
the charge should be adjudicated accordingly.

*Please note: Services rendered in an emergency room, observation room, or hospital
inpatient setting are not managed by NIA.

Authorized
CPT Code

Description Allowable Billed Groupings

33225 Cardiac Resynchronization Therapy
(CRT)

33221, 33224, 33225, 33229,
33231, 33264

33249 Implantable Cardioverter Defibrillator
(ICD)

33230, 33240, 33249, 33262, 33263

33208 Pacemaker Insertion 33206, 33207, 33208, 33212,
33213, 33214, 33227, 33228

70336 MRI Temporomandibular Joint 70336
70450 CT Head/Brain 70450, 70460, 70470
70480 CT Orbit 70480, 70481, 70482
70486 CT Maxillofacial/Sinus 70486, 70487, 70488, 76380
70490 CT Soft Tissue Neck 70490, 70491, 70492
70496 CT Angiography, Head 70496
70498 CT Angiography, Neck 70498
70540 MRI Orbit, Face, and/or Neck 70540, 70542, 70543
70551 MRI Internal Auditory Canal 70551, 70552, 70553, 70540,

70542, 70543
70544 MRA Head 70544, 70545, 70546
70547 MRA Neck 70547, 70548, 70549
70551 MRI Brain 70551, 70552, 70553
70554 Functional MRI Brain 70554, 70555
71250 CT Chest 71250, 71260, 71270
71275 CT Angiography, Chest (non coronary) 71275
71550 MRI Chest 71550, 71551, 71552
71555 MRA Chest (excluding myocardium) 71555
72125 CT Cervical Spine 72125, 72126, 72127
72128 CT Thoracic Spine 72128, 72129, 72130
72131 CT Lumbar Spine 72131, 72132, 72133
72141 MRI Cervical Spine 72141, 72142, 72156
72146 MRI Thoracic Spine 72146, 72147, 72157




Horizon NJ Health Claims/Utilization Review Matrix


Authorized
CPT Code

Description Allowable Billed Groupings

72148 MRI Lumbar Spine 72148, 72149, 72158
72159 MRA Spinal Canal 72159
72191 CT Angiography, Pelvis 72191
72192 CT Pelvis 72192, 72193, 72194
72196 MRI Pelvis 72195, 72196, 72197
72198 MRA Pelvis 72198
73200 CT Upper Extremity 73200, 73201, 73202
73206 CT Angiography, Upper Extremity 73206
73220 MRI Upper Extremity, other than Joint 73218, 73219, 73220
73221 MRI Upper Extremity Joint 73221, 73222, 73223
73225 MRA Upper Extremity 73225
73700 CT Lower Extremity 73700, 73701, 73702
73706 CT Angiography, Lower Extremity 73706
73720 MRI Lower Extremity, other than Joint 73718, 73719, 73720, 73721,

73722, 73723
73721 MRI Lower Extremity Joint 73721, 73722, 73723, 73718,

73719, 73720
73721 MRI Hip 72195, 72196, 72197, 73721,

73722, 73723
73725 MRA Lower Extremity 73725
74150 CT Abdomen 74150, 74160, 74170
74174 CT Angiography, Abdomen and Pelvis 74174
74175 CT Angiography, Abdomen 74175
74176 CT Abdomen and Pelvis Combination 74176, 74177, 74178
74181 MRI Abdomen 74181, 74182, 74183, S8037
74185 MRA Abdomen 74185
74261 Diagnostic CT Colonoscopy (Virtual

Colonoscopy, CT Colonography)
74261, 74262

74263 Screening CT Colonoscopy (Virtual
Colonoscopy, CT Colonography)

74263

75557 MRI Heart 75557, 75559, 75561, 75563,
+75565

75571


Coronary Artery Ca Score, Heart Scan,
Ultrafast CT Heart, Electron Beam CT

75571, S8092

75572 CT Heart 75572
75573 CT Heart congenital studies, non-

coronary arteries
75573

75574 CTA coronary arteries (CCTA) 75574
75635 CT Angiography, Abdominal Arteries 75635
76380 Follow-Up, Limited or Localized CT 76380, 70486, 70487, 70488
76390 MR Spectroscopy 76390
76497 Unlisted Computed Tomography

Procedure
76497

76498 Unlisted Magnetic Resonance Procedure 76498
76536 Head and Neck Ultrasound 76536
76700 Abdomen Ultrasound 76700, 76705, 76770, 76775
76856 Pelvic Ultrasound 76856, 76857
76870 Scrotum Ultrasound 76870




Horizon NJ Health Claims/Utilization Review Matrix


Authorized
CPT Code

Description Allowable Billed Groupings

77058 MRI Breast 77058, 77059
77078 CT Bone Density Study 77078
77084 MRI Bone Marrow 77084
78205 Liver SPECT Imaging 78205, 78206
78320 Bone and/or Joint SPECT Imaging 78320
78451 Myocardial Perfusion Imaging ? Nuclear

Cardiology
78451, 78452, 78453, 78454,
78466, 78468, 78469, 78481,
78483, 78499

78459 PET Scan, Heart 78459, 78491, 78492
78472 MUGA Scan 78472, 78473, 78494, +78496
78607 Brain SPECT Imaging 78607
78608 PET Scan, Brain 78608, 78609
78647 Cerebrospinal Fluid Flow Imaging

(SPECT)
78647

78710 Kidney SPECT Imaging 78710
78813 PET Scan 78811, 78812, 78813, 78814,

78815, 78816
78816 PET Scan with concurrently acquired CT

for attenuation correction and anatomic,
localization.

78811, 78812, 78813, 78814,
78815, 78816

93307 Transthoracic Echocardiology (TTE) 93303, 93304, 93306, 93307,
93308, +93320, +93321, +93325

93312 Transesophageal Echocardiology (TEE) 93312, 93313, 93314, 93315,
93316, 93317, 93318, +93320,
+93321, +93325

93350 Stress Echocardiography 93350, 93351, +93320, +93321,
+93325, +93352

93452 Heart Catheterization 93452, 93453, 93454, 93455,
93456, 93457, 93458, 93459,
93460, 93461, +93462, +93463,
+93464, +93565, +93566, +93567,
+93568

93880 Carotid Duplex Scan (Ultrasound) 93880, 93882
93886 Transcranial Doppler (Ultrasound) 93886, 93888
93925 Lower Extremity Arterial Duplex Scan

(Ultrasound)
93925, 93926

93930 Upper Extremity Arterial Duplex Scan
(Ultrasound)

93930, 93931

93970 Extremity Venous Duplex Scan
(Ultrasound)

93970, 93971

93975 Abdominal, Pelvis, Scrotal,
Retroperitoneal Organ Duplex Scan
(Ultrasound)

93975, 93976

93978 Aorta, Inferior Vena Cava, Iliac Duplex
Scan (Ultrasound)

93978, 93979

93980 Penile Vessels Duplex Scan (Ultrasound) 93980, 93981
93990 Hemodialysis Access Duplex Scan

(Ultrasound)
93990




Horizon NJ Health Claims/Utilization Review Matrix


Authorized
CPT Code

Description Allowable Billed Groupings

0042T Cerebral Perfusion Analysis CT 0042T
0159T CAD Breast MRI for Lesion Detection 0159T
G0219 PET imaging whole body, melanoma for

non-covered indications
G0219

G0235 PET imaging, any site, not otherwise
specified

G0235

G0252 PET imaging, initial diagnosis of breast
cancer and/or surgical planning for
breast cancer

G0252

S8037 MR Cholangiopancreatography S8037, 74181, 74182, 74183
S8042 MRI low field S8042


+ codes (add on codes) do not require separate authorization and are to be used in conjunction with
approved primary code for the service rendered.







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1?Horizon
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Radiation Oncology Claim Resolution Matrix 2013
The matrix below contains all of the CPT-4 codes for which National Imaging Associates
(NIA) authorizes on behalf of Horizon NJ Health. This matrix is designed to assist in the
resolution of claims adjudication and claims questions related to those services
authorized by NIA. If a procedure is billed under any one of the given codes for that
grouping and a valid authorization number has been issued within the date of service
validity period, the charge for any of the codes should be allowed.

If a family of CPT codes is not listed in this matrix, an exact match is required between
the authorized CPT code and the billed CPT code. If the exact match does not occur,
the charge should be adjudicated accordingly.

*Please note: Services rendered in hospital inpatient setting are not managed by NIA.


CPT Codes
Requiring

Authorization

Description Allowable Billed
Groupings

19296 Brachytherapy Applicator Insertion (Breast
Surgeon)

19296, 19297,19298i

19297 Brachytherapy Applicator Insertion (Breast
Surgeon)

19296, 19297,19298

19298 Brachytherapy Applicator Insertion (Breast
Surgeon)

19296, 19297,19298

76950 Ultrasonic Guidance - IGRT 76950, 77014, 77421
77014 CT Guidance - Planning or IGRT 76950, 77014, 77421
77280 Simulation - Set Up Simple or Verification 77280
77285 Simulation - Set Up Complex/ Interm. 77285, 77290
77290 Simulation - Set Up Complex/ Interm. 77285, 77290
77295 3D Simulation Plan 77295
77300 Dosimetry - Calculation 77300
77301 IMRT Isodose Plan 77301
77305 Teletherapy Isodose Plan 77305, 77310,

77315,77321
77310 Teletherapy Isodose Plan 77305, 77310,

77315,77321
77315 Teletherapy Isodose Plan 77305, 77310,

77315,77321
77321 Teletherapy Isodose Plan 77305, 77310,

77315,77321
77326 Brachytherapy Isodose Plan 77326, 77327, 77328
77327 Brachytherapy Isodose Plan 77326, 77327, 77328
77328 Brachytherapy Isodose Plan 77326, 77327, 77328
77331 Dosimetry - Special 77331



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CPT Codes
Requiring

Authorization

Description Allowable Billed
Groupings

77332 Treatment Devices 77332, 77333, 77334
77333 Treatment Devices 77332, 77333, 77334
77334 Treatment Devices 77332, 77333, 77334
77336 Weekly Physics Consultation 77336
77338 Treatment Devices - IMRT (MLC) 77338
77370 Special Physics Consultation 77370
77371 Treatment Deliveries - Gamma Knife 77371
77372 Treatment Deliveries - SRS 77372, G0173
77373 Treatment Deliveries - SBRT - Non-Robotic 77373, G0251,
77399 Dosimetry -Unlisted 77399
77401 Treatment Deliveries - EBRT 77401, 77402, 77403,

77404, 77406, 77407,
77408, 77409,
77411,77412, 77413,
77414, 77416

77402 Treatment Deliveries - EBRT 77401, 77402, 77403,
77404, 77406, 77407,
77408, 77409,
77411,77412, 77413,
77414, 77416

77403 Treatment Deliveries - EBRT 77401, 77402, 77403,
77404, 77406, 77407,
77408, 77409,
77411,77412, 77413,
77414, 77416

77404 Treatment Deliveries - EBRT 77401, 77402, 77403,
77404, 77406, 77407,
77408, 77409,
77411,77412, 77413,
77414, 77416

77406 Treatment Deliveries - EBRT 77401, 77402, 77403,
77404, 77406, 77407,
77408, 77409,
77411,77412, 77413,
77414, 77416

77407 Treatment Deliveries - EBRT 77401, 77402, 77403,
77404, 77406, 77407,
77408, 77409,
77411,77412, 77413,
77414, 77416



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CPT Codes
Requiring

Authorization

Description Allowable Billed
Groupings

77408 Treatment Deliveries - EBRT 77401, 77402, 77403,
77404, 77406, 77407,
77408, 77409,
77411,77412, 77413,
77414, 77416

77409 Treatment Deliveries - EBRT 77401, 77402, 77403,
77404, 77406, 77407,
77408, 77409,
77411,77412, 77413,
77414, 77416

77411 Treatment Deliveries - EBRT 77401, 77402, 77403,
77404, 77406, 77407,
77408, 77409,
77411,77412, 77413,
77414, 77416

77412 Treatment Deliveries - EBRT 77401, 77402, 77403,
77404, 77406, 77407,
77408, 77409,
77411,77412, 77413,
77414, 77416

77413 Treatment Deliveries - EBRT 77401, 77402, 77403,
77404, 77406, 77407,
77408, 77409,
77411,77412, 77413,
77414, 77416

77414 Treatment Deliveries - EBRT 77401, 77402, 77403,
77404, 77406, 77407,
77408, 77409,
77411,77412, 77413,
77414, 77416

77416 Treatment Deliveries - EBRT 77401, 77402, 77403,
77404, 77406, 77407,
77408, 77409,
77411,77412, 77413,
77414, 77416

77417 Port Films 77417
77418 Treatment Deliveries - IMRT (MLC) 77418
77421 Stereoscopic Guidance IGRT 76950, 77014, 77421
77422 Treatment Deliveries - Neutron Beam 77422, 77423
77423 Treatment Deliveries - Neutron Beam 77422, 77423
77424 Treatment Deliveries ?IORT, Xray or

Electron, Single Treatment Session
77424,77425

77425 Treatment Deliveries ?IORT, Xray or 77424,77425



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?Radiation
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?Claims
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CPT Codes
Requiring

Authorization

Description Allowable Billed
Groupings

Electron, Single Treatment Session
77427 Treatment Management - 5 Treatments 77427
77431 Treatment Management (1-2 tx) 77431
77432 Treatment Management - SRS 77432
77435 Treatment Management - SBRT 77435
77469 Treatment Management -IORT 77469
77470 Special Treatment Management 77470
77499 Radiation Therapy Management -Unlisted 77499
77520 Treatment Deliveries - Proton Beam 77520, 77522, 77523,

77525
77522 Treatment Deliveries - Proton Beam 77520, 77522, 77523,

77525
77523 Treatment Deliveries - Proton Beam 77520, 77522, 77523,

77525
77525 Treatment Deliveries - Proton Beam 77520, 77522, 77523,

77525
77600 Treatment Deliveries - Hyperthermia 77600, 77605, 77610,

77615, 77620
77605 Treatment Deliveries - Hyperthermia 77600, 77605, 77610,

77615, 77620
77610 Treatment Deliveries - Hyperthermia 77600, 77605, 77610,

77615, 77620
77615 Treatment Deliveries - Hyperthermia 77600, 77605, 77610,

77615, 77620
77620 Treatment Deliveries - Hyperthermia 77600, 77605, 77610,

77615, 77620
77761 Treatment Deliveries - Brachytherapy, LDR 77761, 77762, 77763,

77776, 77777, 77778,
77789

77762 Treatment Deliveries - Brachytherapy, LDR 77761, 77762, 77763,
77776, 77777, 77778,
77789

77763 Treatment Deliveries - Brachytherapy, LDR 77761, 77762, 77763,
77776, 77777, 77778,
77789

77776 Treatment Deliveries - Brachytherapy, LDR 77761, 77762, 77763,
77776, 77777, 77778,
77789

77777 Treatment Deliveries - Brachytherapy, LDR 77761, 77762, 77763,
77776, 77777, 77778,
77789

77778 Treatment Deliveries - Brachytherapy, LDR 77761, 77762, 77763,
77776, 77777, 77778,



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CPT Codes
Requiring

Authorization

Description Allowable Billed
Groupings

77789

77785 Treatment Deliveries - Brachytherapy, HDR 77785, 77786, 77787
77786 Treatment Deliveries - Brachytherapy, HDR 77785, 77786, 77787
77787 Treatment Deliveries - Brachytherapy, HDR 77785, 77786, 77787
77789 Treatment Deliveries - Brachytherapy, LDR 77761, 77762, 77763,

77776, 77777, 77778,
77789

77790 Supervision Loading Handling Source 77790
77799 Brachytherapy - Unspecified 77799
0073T Treatment Deliveries - IMRT - Compensator

Based
0073T

0182T Treatment Deliveries - Brachytherapy, HDR
Electronic

0182T

0197T Intra -Fraction Tracking 0197T
G0173 Treatment Deliveries - SRS 77372, G0173
G0251 Treatment Deliveries - SBRT - Non-Robotic 77373, G0251
G0339 Treatment Deliveries - SBRT - Robotic G0339, G0340
G0340 Treatment Deliveries - SBRT - Robotic G0339, G0340


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The radiation oncologist is required to obtain a medical necessity review for
Accelerated Partial Breast Irradiation (APBI). The breast surgeon will receive
approval for the insertion of the catheters if APBI is approved as medically necessary.
The surgeon can request a review for approval at www.RadMD.com or call NIA?s call
center at 1-800-642-7299.