eviCore healthcare

Horizon NJ Health partners with eviCore healthcare (eviCore) to manage Advanced Imaging Services for our members through Prior Authorizations/Medical Necessity Determinations (PA/MND) with providers. eviCore helps to ensure our members receive appropriate radiology/imaging services, provides clinical consultation to our participating healthcare professionals and assists in the scheduling of radiology/imaging services. The Advanced Imaging Services included in this program are CT/CTA, MRI/MRA, PET and Nuclear Medicine studies (including Nuclear Cardiology).

As of January 1, 2020, eviCore provides Utilization Management for Horizon NJ Health and Horizon NJ TotalCare (HMO D-SNP) members. Please note, eviCore began to accept authorization requests on December 16, 2019 for dates of service beginning January 1, 2020.

Radiology
eviCore manages Advanced Imaging Services for our members through PA/MND with providers.

Cardiology
eviCore administers our Cardiology Imaging program by using evidence-based criteria. They ensure requests for advanced cardiac imaging meet quality standards recommended by organizations such as the American College of Cardiology, American Heart Association and Heart Rhythm Society. eviCore identifies the most appropriate cardiac imaging study based on the patient’s medical and prior imaging history.

Radiation Therapy
eviCore implements our Pre-service MND program to ensure that the radiation therapy services provided to our members are consistent with nationally-recognized clinical standards. The Radiation Therapy program addresses a patient’s specific disease state, stage and treatment goals and offers clinicians the necessary flexibility to render appropriate quality care in a timely manner.

Please note that eligibility and participation may vary based on line of business; therefore, all providers should check eligibility and benefits prior to performing any services related to this program.

Prior authorization will be required for the following non emergent outpatient radiology procedures:

Prior authorization applies to services that are:

  • Outpatient
  • Elective/non-emergent

Prior authorization through eviCore does not apply to services that are performed in:

  • Emergency Room
  • Inpatient facilities
  • 24-hour observation

Prior authorization is required for members enrolled in the following programs:

  • Medicaid Managed Care
  • NJ FamilyCare
  • Horizon NJ TotalCare (HMO D-SNP)
  • Managed Long Term Services & Supports (MLTSS)

For the list of eviCore CPT codes, review the CPT Code List.

Providers and/or staff can request prior authorization in one of the following ways:

Web Portal: The quickest and most efficient way to request prior authorization is by using the eviCore portal at eviCore.com, which is available 24 hours a day, seven days a week.

Call Center: eviCore’s is available from 7 a.m. to 7 p.m. Providers and/or staff can request prior authorization and make revisions to existing cases by calling 1-866-496-6200.

For Multiple Procedure Payment Reduction rules, view the Bundling Rules for Medicaid.

For more information on eviCore, refer to the frequently asked questions.

Tikka Attach

? 2020 eviCore healthcare. All Rights Reserved. This presentation contains CONFIDENTIAL and PROPRIETARY
information.

CPT Description

93461

Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural
injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free
arterial, venous grafts) with bypass graft angiography

93460

Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural
injection(s) for left ventriculography, when performed

93457

Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free
arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization

93453
Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging
supervision and interpretation, when performed

93459

Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for
left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous
grafts) with bypass graft angiography

93456
Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation; with right heart catheterization

93458

Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for
left ventriculography, when performed

93455

Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free
arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography

33249 Insertion or replacement of permanent implantable defibrillator system, with transvenous lead(s), single or dual chamber

93454
Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation;

93452
Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and
interpretation, when performed

33270

Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode,
including defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and
programming or reprogramming of sensing or therapeutic parameters, when performed

33224

Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed
pacemaker or implantable defibrillator pulse generator (including revision of pocket, removal, insertion, and/or
replacement of existing generator)

33214

Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes
removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse
generator)

33264
Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; multiple
lead system

33231 Insertion of implantable defibrillator pulse generator only; with existing multiple leads

33263
Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; dual
lead system

78803

Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes
vascular flow and blood pool imaging, when performed); tomographic (SPECT), single area (eg, head, neck, chest,
pelvis), single day imaging

33230 Insertion of implantable defibrillator pulse generator only; with existing dual leads

33229 Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; multiple lead system

33262
Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; single
lead system

MPPR Rules
2020

Multiple Procedure Payment Reduction (MPPR)

2=Standard payment adjustment rules for multiple procedures apply. If procedure is reported on the same day as another procedure
with an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100%, 50%,
50%, 50%, 50% and by report). Base the payment on the lower of (a) the actual charge, or (b) the fee schedule amount reduced by the
appropriate percentage



? 2020 eviCore healthcare. All Rights Reserved. This presentation contains CONFIDENTIAL and PROPRIETARY
information.

CPT Description

2=Standard payment adjustment rules for multiple procedures apply. If procedure is reported on the same day as another procedure
with an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100%, 50%,
50%, 50%, 50% and by report). Base the payment on the lower of (a) the actual charge, or (b) the fee schedule amount reduced by the
appropriate percentage

33240 Insertion of implantable defibrillator pulse generator only; with existing single lead

33221 Insertion of pacemaker pulse generator only; with existing multiple leads

33228 Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; dual lead system

33227 Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; single lead system

78802
Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes
vascular flow and blood pool imaging, when performed); planar, whole body, single day imaging

78306 Bone and/or joint imaging; whole body



? 2020 eviCore healthcare. All Rights Reserved. This presentation contains CONFIDENTIAL and PROPRIETARY information.

CPT Description

71552
Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast
material(s), followed by contrast material(s) and further sequences

74262
Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including non-
contrast images, if performed

75563
Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and
further sequences; with stress imaging

73220
Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s), followed by contrast
material(s) and further sequences

74261 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material

74712
Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; single or first
gestation

73223
Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s), followed by contrast material(s)
and further sequences

73723
Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s)
and further sequences

75559 Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging

75635
Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s),
including noncontrast images, if performed, and image postprocessing

71551
Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); with contrast
material(s)

70554
Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement
and/or visual stimulation, not requiring physician or psychologist administration

75561
Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and
further sequences;

74174
Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and
image postprocessing

72159 Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s)

77049
Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion
detection, characterization and pharmacokinetic analysis), when performed; bilateral

71550
Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast
material(s)

73225 Magnetic resonance angiography, upper extremity, with or without contrast material(s)

74183
Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further
sequences

72197 Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences

73219 Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; with contrast material(s)

73720
Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s), followed by contrast material(s)
and further sequences

70549 Magnetic resonance angiography, neck; without contrast material(s), followed by contrast material(s) and further sequences

70543
Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and
further sequences

77048
Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion
detection, characterization and pharmacokinetic analysis), when performed; unilateral

74185 Magnetic resonance angiography, abdomen, with or without contrast material(s)

73725 Magnetic resonance angiography, lower extremity, with or without contrast material(s)

MPPR Rules
2020

Multiple Procedure Payment Reduction (MPPR)

4=Special rules for the technical component (TC) of diagnostic imaging procedures apply if procedure is billed with another diagnostic imaging
procedure in the same family (per the diagnostic imaging family indicator, below). If procedure is reported in the same session on the same day as
another procedure with the same family indicator, rank the procedures by fee schedule amount for the TC. Pay 100% for the highest priced
procedure, and 50% for each subsequent procedure. Base the payment for subsequent procedures on the lower of (a) the actual charge, or (b) the
fee schedule amount reduced by the appropriate percentage. Subject to 50% reduction of the TC diagnostic imaging (effective for services July 1,
2010 and after). Subject to 25% reduction of the PC of diagnostic imaging (effective for services January 1, 2012 through December 31, 2016).
Subject to 5% reduction of the PC of diagnostic imaging (effective for services January 1, 2017 and after).



? 2020 eviCore healthcare. All Rights Reserved. This presentation contains CONFIDENTIAL and PROPRIETARY information.

CPT Description

4=Special rules for the technical component (TC) of diagnostic imaging procedures apply if procedure is billed with another diagnostic imaging
procedure in the same family (per the diagnostic imaging family indicator, below). If procedure is reported in the same session on the same day as
another procedure with the same family indicator, rank the procedures by fee schedule amount for the TC. Pay 100% for the highest priced
procedure, and 50% for each subsequent procedure. Base the payment for subsequent procedures on the lower of (a) the actual charge, or (b) the
fee schedule amount reduced by the appropriate percentage. Subject to 50% reduction of the TC diagnostic imaging (effective for services July 1,
2010 and after). Subject to 25% reduction of the PC of diagnostic imaging (effective for services January 1, 2012 through December 31, 2016).
Subject to 5% reduction of the PC of diagnostic imaging (effective for services January 1, 2017 and after).

72198 Magnetic resonance angiography, pelvis, with or without contrast material(s)

71555 Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s)

70546 Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequences

72157
Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and
further sequences; thoracic

72156
Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and
further sequences; cervical

74178
Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s)
and further sections in one or both body regions

72158
Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and
further sequences; lumbar

73722 Magnetic resonance (eg, proton) imaging, any joint of lower extremity; with contrast material(s)

73222 Magnetic resonance (eg, proton) imaging, any joint of upper extremity; with contrast material(s)

70553
Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and
further sequences

75574

Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D
image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of
venous structures, if performed)

73706
Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if performed, and image
postprocessing

73218 Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s)

74182 Magnetic resonance (eg, proton) imaging, abdomen; with contrast material(s)

75573

Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital
heart disease (including 3D image postprocessing, assessment of LV cardiac function, RV structure and function and evaluation of
venous structures, if performed)

73206
Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast images, if performed, and image
postprocessing

74177 Computed tomography, abdomen and pelvis; with contrast material(s)

76978 Ultrasound, targeted dynamic microbubble sonographic contrast characterization (non-cardiac); initial lesion

74175
Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image
postprocessing

72191
Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image
postprocessing

75557 Cardiac magnetic resonance imaging for morphology and function without contrast material;

72142 Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; with contrast material(s)

72147 Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; with contrast material(s)

72149 Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s)

72196 Magnetic resonance (eg, proton) imaging, pelvis; with contrast material(s)

70542 Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; with contrast material(s)

70552 Magnetic resonance (eg, proton) imaging, brain (including brain stem); with contrast material(s)

70336 Magnetic resonance (eg, proton) imaging, temporomandibular joint(s)

73719 Magnetic resonance (eg, proton) imaging, lower extremity other than joint; with contrast material(s)

71275
Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and
image postprocessing

70496
Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image
postprocessing



? 2020 eviCore healthcare. All Rights Reserved. This presentation contains CONFIDENTIAL and PROPRIETARY information.

CPT Description

4=Special rules for the technical component (TC) of diagnostic imaging procedures apply if procedure is billed with another diagnostic imaging
procedure in the same family (per the diagnostic imaging family indicator, below). If procedure is reported in the same session on the same day as
another procedure with the same family indicator, rank the procedures by fee schedule amount for the TC. Pay 100% for the highest priced
procedure, and 50% for each subsequent procedure. Base the payment for subsequent procedures on the lower of (a) the actual charge, or (b) the
fee schedule amount reduced by the appropriate percentage. Subject to 50% reduction of the TC diagnostic imaging (effective for services July 1,
2010 and after). Subject to 25% reduction of the PC of diagnostic imaging (effective for services January 1, 2012 through December 31, 2016).
Subject to 5% reduction of the PC of diagnostic imaging (effective for services January 1, 2017 and after).

70498
Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image
postprocessing

74170 Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections

73202 Computed tomography, upper extremity; without contrast material, followed by contrast material(s) and further sections

70548 Magnetic resonance angiography, neck; with contrast material(s)

72194 Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sections

72195 Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s)

70540 Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s)

73718 Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s)

70545 Magnetic resonance angiography, head; with contrast material(s)

77047 Magnetic resonance imaging, breast, without contrast material; bilateral

75572
Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image
postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed)

70482
Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material, followed by contrast
material(s) and further sections

74160 Computed tomography, abdomen; with contrast material(s)

70547 Magnetic resonance angiography, neck; without contrast material(s)

70544 Magnetic resonance angiography, head; without contrast material(s)

77046 Magnetic resonance imaging, breast, without contrast material; unilateral

70492 Computed tomography, soft tissue neck; without contrast material followed by contrast material(s) and further sections

72193 Computed tomography, pelvis; with contrast material(s)

G0297 Low dose ct scan (ldct) for lung cancer screening

73702 Computed tomography, lower extremity; without contrast material, followed by contrast material(s) and further sections

76391 Magnetic resonance (eg, vibration) elastography

71270 Computed tomography, thorax; without contrast material, followed by contrast material(s) and further sections

72130 Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections

72127 Computed tomography, cervical spine; without contrast material, followed by contrast material(s) and further sections

73221 Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s)

72133 Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections

73721 Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material

74181 Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s)

70481 Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material(s)

70551 Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material

73201 Computed tomography, upper extremity; with contrast material(s)

72148 Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material

72141 Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material

72146 Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material

70488 Computed tomography, maxillofacial area; without contrast material, followed by contrast material(s) and further sections

70491 Computed tomography, soft tissue neck; with contrast material(s)

70480 Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material

74176 Computed tomography, abdomen and pelvis; without contrast material



? 2020 eviCore healthcare. All Rights Reserved. This presentation contains CONFIDENTIAL and PROPRIETARY information.

CPT Description

4=Special rules for the technical component (TC) of diagnostic imaging procedures apply if procedure is billed with another diagnostic imaging
procedure in the same family (per the diagnostic imaging family indicator, below). If procedure is reported in the same session on the same day as
another procedure with the same family indicator, rank the procedures by fee schedule amount for the TC. Pay 100% for the highest priced
procedure, and 50% for each subsequent procedure. Base the payment for subsequent procedures on the lower of (a) the actual charge, or (b) the
fee schedule amount reduced by the appropriate percentage. Subject to 50% reduction of the TC diagnostic imaging (effective for services July 1,
2010 and after). Subject to 25% reduction of the PC of diagnostic imaging (effective for services January 1, 2012 through December 31, 2016).
Subject to 5% reduction of the PC of diagnostic imaging (effective for services January 1, 2017 and after).

72129 Computed tomography, thoracic spine; with contrast material

71260 Computed tomography, thorax; with contrast material(s)

72132 Computed tomography, lumbar spine; with contrast material

72126 Computed tomography, cervical spine; with contrast material

73701 Computed tomography, lower extremity; with contrast material(s)

70470 Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections

73200 Computed tomography, upper extremity; without contrast material

70487 Computed tomography, maxillofacial area; with contrast material(s)

70490 Computed tomography, soft tissue neck; without contrast material

70460 Computed tomography, head or brain; with contrast material(s)

71250 Computed tomography, thorax; without contrast material

76776 Ultrasound, transplanted kidney, real time and duplex Doppler with image documentation

72125 Computed tomography, cervical spine; without contrast material

72128 Computed tomography, thoracic spine; without contrast material

72131 Computed tomography, lumbar spine; without contrast material

73700 Computed tomography, lower extremity; without contrast material

74150 Computed tomography, abdomen; without contrast material

72192 Computed tomography, pelvis; without contrast material

70486 Computed tomography, maxillofacial area; without contrast material

76700 Ultrasound, abdominal, real time with image documentation; complete

76831 Saline infusion sonohysterography (SIS), including color flow Doppler, when performed

70450 Computed tomography, head or brain; without contrast material

76770 Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete

76856 Ultrasound, pelvic (nonobstetric), real time with image documentation; complete

76981 Ultrasound, elastography; parenchyma (eg, organ)

76870 Ultrasound, scrotum and contents

75571 Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium

76982 Ultrasound, elastography; first target lesion

76705 Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up)

76604 Ultrasound, chest (includes mediastinum), real time with image documentation

76775 Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; limited

76857 Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (eg, for follicles)



CPT Description

78428 Cardiac shunt detection

78466 Myocardial imaging, infarct avid, planar; qualitative or quantitative

78468 Myocardial imaging, infarct avid, planar; with ejection fraction by first pass technique

78469 Myocardial imaging, infarct avid, planar; tomographic SPECT with or without quantification

78472

Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress (exercise and/or
pharmacologic), wall motion study plus ejection fraction, with or without additional quantitative
processing

78473
Cardiac blood pool imaging, gated equilibrium; multiple studies, wall motion study plus ejection
fraction, at rest and stress (exercise and/or pharmacologic), with or without additional quantification

78481

Cardiac blood pool imaging (planar), first pass technique; single study, at rest or with stress
(exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without
quantification

78483

Cardiac blood pool imaging (planar), first pass technique; multiple studies, at rest and with stress
(exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without
quantification

78494
Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection
fraction, with or without quantitative processing

MPPR Rules
2020

Multiple Procedure Payment Reduction (MPPR)

6=Subject to 25% reduction of the second highest and subsequent procedures to the TC of diagnostic
cardiovascular services, effective for services January 1, 2013, and thereafter.



Applicable payment adjustment rule for multiple procedures:

0=No payment adjustment rules for multiple procedures apply. If procedure is reported on the same day as another procedure, base the
payment on the lower of (a) the actual charge, or (b) the fee schedule amount for the procedure.

1=Standard payment adjustment rules in effect before January 1, 1995 for multiple procedures apply. In the 1995 file, this indicator only
applies to codes with a status code of "D". If procedure is reported on the same day as another procedure that has an indicator of 1, 2, or 3,
rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100%, 50%, 25%, 25%, 25%, and by report).
Base the payment on the lower of (a) the actual charge, or (b) the fee schedule amount reduced by the appropriate percentage.

2=Standard payment adjustment rules for multiple procedures apply. If procedure is reported on the same day as another procedure with an
indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100%, 50%, 50%, 50%,
50% and by report). Base the payment on the lower of (a) the actual charge, or (b) the fee schedule amount reduced by the appropriate

3=Special rules for multiple endoscopic procedures apply if procedure is billed with another endoscopy in the same family (i.e., another
endoscopy that has the same base procedure). The base procedure for each code with this indicator is identified in the Endobase field of this
file. Apply the multiple endoscopy rules to a family before ranking the family with the other procedures performed on the same day (for
example, if multiple endoscopies in the same family are reported on the same day as endoscopies in another family or on the same day as a
non-endoscopic procedure). If an endoscopic procedure is reported with only its base procedure, do not pay separately for the base procedure.

4=Special rules for the technical component (TC) of diagnostic imaging procedures apply if procedure is billed with another diagnostic imaging
procedure in the same family (per the diagnostic imaging family indicator, below). If procedure is reported in the same session on the same
day as another procedure with the same family indicator, rank the procedures by fee schedule amount for the TC. Pay 100% for the highest
priced procedure, and 50% for each subsequent procedure. Base the payment for subsequent procedures on the lower of (a) the actual
charge, or (b) the fee schedule amount reduced by the appropriate percentage. Subject to 50% reduction of the TC diagnostic imaging
(effective for services July 1, 2010 and after). Subject to 25% reduction of the PC of diagnostic imaging (effective for services January 1, 2012
through December 31, 2016). Subject to 5% reduction of the PC of diagnostic imaging (effective for services January 1, 2018 and after).

6=Subject to 25% reduction of the second highest and subsequent procedures to the TC of diagnostic cardiovascular services, effective for
services January 1, 2013, and thereafter.

9=Concept does not apply.


MPPR KEY
CRID MPPR
RadCardUltra MPPR
Cardiovascular MPPR