Summary & Overview
CPT 9004F: Aortic Aneurysm ≥6.0 cm on CT
CPT code 9004F denotes provider documentation of an aortic aneurysm with a maximum diameter of 6.0 cm or greater identified on CT imaging. This measure codifies a clinically significant aneurysm size that typically informs surveillance, referral, or intervention pathways and is relevant for quality reporting and risk stratification. Nationally, standardized capture of large aortic aneurysms supports population health monitoring, surgical planning, and value-based contracting metrics tied to vascular care.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the code’s clinical meaning, typical service settings, and the reporting context. The publication also summarizes benchmark usage patterns, common billing considerations where available, and implications for coding workflows and documentation standards.
The report focuses on clinical context and documentation capture rather than treatment recommendations. It highlights what organizations need to track when this finding is present on CT imaging, how the code is used in administrative and quality measurement contexts, and where documentation supports downstream care coordination and surgical referral decisions.
Billing Code Overview
CPT code 9004F documents an aortic aneurysm with a maximum diameter of 6.0 cm or greater measured on a computed tomographic (CT) imaging study. The code captures the provider’s documentation that the largest artery in the body contains a weakened, bulging segment meeting or exceeding the specified diameter threshold.
Service type: Imaging-based vascular assessment and clinical documentation
Typical site of service: Hospital outpatient radiology departments, imaging centers, or inpatient/ED settings where CT imaging of the chest/abdomen is performed
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A 72-year-old male with a long-standing history of hypertension and a 40-pack-year smoking history is referred to vascular surgery after an incidental finding on chest CT. The computed tomographic (CT) imaging study documents an infrarenal aortic aneurysm with a maximum transverse diameter of 6.0 cm. The patient presents for preoperative evaluation and surgical planning. The clinical workflow includes review of imaging by the interpreting radiologist, documentation of aneurysm size in the vascular surgery note, correlation with prior imaging to assess growth rate, risk stratification, and scheduling for intervention (open repair or endovascular aneurysm repair) or urgent inpatient admission if symptomatic or rapidly expanding. Relevant clinical documentation includes the CT report specifying the maximum diameter, the vascular surgeon’s history and physical documenting the aneurysm and planned management, informed consent, and perioperative anesthesia and procedural notes when repair is performed.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
26 | Professional component | Use when only the physician's interpretation/report of the imaging study is billed separate from the technical component. |
TC | Technical component |