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Utilization Review Matrix — CPT imaging code management (professional claims)

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Matrix governing how NIA (on behalf of Maryland Physicians Care) manages utilization review and claim adjudication for specified professional CPT-4 procedure codes (primarily imaging). It affects claims processing and prior authorization/management of those CPT codes when submitted on professional (HCFA 1500) claims.

Policy Summary

Payermarylandphysicianscarempc

PolicyUtilization Review Matrix — CPT imaging code management (professional claims)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionWhen requesting authorization, submit the applicable professional CPT codes on HCFA 1500 claims and follow the matrix's allowable billed groupings; NIA will manage authorization and determine medical necessity for listed CPTs.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~60distinct CPT/HCPCS codes referenced

~100imaging CPT/HCPCS codes referenced

yesAllowable billed groupings provided

ED/obs/inpatientExcluded settings

professionalApplies to claim type

Utilization Review & Coverage Criteria

Utilization and billing rules from matrix

The matrix lists CPT codes that NIA manages and, for many, provides allowable billed groupings; inclusion means NIA will manage requests but does not guarantee approval.

NIA manages authorization/claims requests for the CPT-4 codes listed in the matrix; inclusion indicates the code is managed by NIA but does not imply the service will be approved.

When an authorized CPT includes an 'Allowable Billed Grouping', any code in that grouping may be submitted on a claim representing the authorized procedure provided: member eligibility at time of service, appropriate rebundling rules are applied, the claim includes an appropriate diagnosis code for the CPT code, and the service is performed within the date-of-service validity period.

If a family of CPT codes is not listed in the matrix, an exact match is required between the authorized CPT code and the billed CPT code; if no exact match exists, adjudicate the charge accordingly.

Codes submitted by facilities using CMS Outpatient PPS logic (C-codes) are excluded from this matrix and are not managed by NIA.

Services rendered in an Emergency Room, Observation Room, surgery center or hospital inpatient setting are not managed by NIA.

Imaging code mapping (no explicit coverage decision in this excerpt)

The matrix pairs procedure types with CPT/HCPCS codes; explicit per-code medical necessity criteria are not provided in this excerpt — the table maps procedure groups to associated codes and allowable billed groupings.

Procedure-to-code mappings are provided by procedure group (examples include CT colonography / virtual colonoscopy, fetal MRI, MRI heart / cardiac CT / CCTA, CT angiography and follow-up/localized CT).

The rows list an 'Authorized CPT Code' and an 'Allowable Billed Grouping' for that procedure; these mappings indicate which billed codes may represent an authorized procedure (see matrix rows for full mappings).

Where present, unlisted procedure codes (e.g., 76497, 76498) and MR spectroscopy (76390) are included in groupings and mapped to procedure categories; consult the matrix for exact group membership per procedure row.

PET and related imaging coverage and billing guidance

Billing and coverage guidance for PET and PET+CT studies as summarized from the matrix notes.

NIA will determine whether a PET scan is clinically indicated (medical necessity) but will not make the determination of which specific CPT code is appropriate; the imaging facility is expected to bill accurately for what was performed.

The 78814 series (PET with CT technology for attenuation/focusing) and the non-CT PET code series are acceptable when a PET scan is clinically indicated; the matrix expands 'Allowable Billable Groupings' to reflect either series may be used depending on technology.

A PET fusion study (simultaneous PET and diagnostic CT on the same machine) is billed with both a PET CPT code and the CT code describing the body region; the CT code should be appended with modifier 59 per CPT guidance. In PET fusion cases, NIA will review medical necessity for both PET and CT and issue UM determinations on both codes.

Payment for add-on codes may depend on the appropriateness of the add-on code relative to the approved primary code; consult the matrix rows for grouping and payment guidance.

Code-level exclusions: +0698T is not a covered benefit; CPT codes +0722T and +0724T are considered Experimental/Investigational and are not covered.

CPT / HCPCS Codes Referenced

Sample authorized CPT codes and descriptions (partial list from matrix)CPTCovered

70336	MRI Temporomandibular Joint
70450	CT Head/Brain
70480	CT Orbit
70486	CT Maxillofacial/Sinus
70490	CT Soft Tissue Neck
70496	CT Angiography, Head
70498	CT Angiography, Neck
70540	MRI Orbit, Face, and/or Neck

Imaging CPT/HCPCS referencedCPT

74261	CT Colonography (diagnostic/screening variant listed)
74263	CT Colonography with contrast/additional descriptor
74185	Abdomen CT (diagnostic)
75557	Cardiac MRI (various heart studies referenced)
75572	CT Heart (electron beam/CT heart referenced)
75574	CTA coronary arteries (CCTA)
76390	MR Spectroscopy
76497	Unlisted Computed Tomography Procedure
76498	Unlisted Magnetic Resonance Procedure

Imaging CPT/HCPCS codesCPT

75572	CT heart (congenital studies) with or without +0722T noted
75573	CT heart congenital studies, non-coronary arteries
75574	CTA coronary arteries (CCTA)
75635	CT angiography, abdominal arteries
76380	Follow Up, Limited or Localized CT
76390	MR Spectroscopy
76497	Unlisted Computed Tomography Procedure
76498	Unlisted Magnetic Resonance Procedure
77046	MRI breast (one or more codes 77046-77049 appear)
77078	CT bone density study

1–10 of 17

1/2

Major imaging groups appearing in matrixCPT

78451	Myocardial perfusion imaging
78459	Myocardial perfusion imaging, single study / add-on groupings
78472	Heart PET scan
78608	MUGA scan / brain PET references appear in matrix
78811	PET scan codes series (78811-78816 listed)

Add-on and special-status codesCPT

+0742T	Add-on/technology code shown among allowable billable groupings
+0698T	Not a covered benefit
+0722T	Not covered; Experimental/Investigational
+0724T	Not covered; Experimental/Investigational

Provider Responsibilities & Authorization Rules

Prior Authorization

NIA management scope and authorization applicability

NIA manages authorization and claim requests for the CPT‑4 codes listed in this matrix on behalf of its clients; inclusion of a code in the matrix does not imply the service will be approved. The matrix applies to CPT-4 codes as they would appear on a professional (HCFA 1500) claim and excludes facility outpatient PPS C‑codes and services delivered in ED, observation, surgery center or inpatient settings.

Inclusion in the matrix indicates NIA will manage requests for the code, not guarantee approval.
Matrix entries reflect professional (HCFA 1500) claims only; facility C‑codes are excluded.
Services in ED, Observation, surgery center or inpatient settings are not managed by NIA.

Prior Authorization

Imaging procedure → CPT/HCPCS group mappings

The matrix groups imaging procedures with related CPT/HCPCS codes for utilization review and authorization mapping (examples include CT colonography/virtual colonoscopy, fetal MRI, MRI heart/cardiac CT/CCTA, CT angiography of abdominal arteries, follow‑up/limited CT, MR spectroscopy, and unlisted CT/MR procedures).

CT Colonography / Virtual Colonoscopy: examples include 74261, 74263 mapped with abdomen CT codes.
MRI Heart / Cardiac CT / CCTA: includes 75557 series and 75572–75574 mappings.
Other groups: CT angiography (e.g., 75635), Follow up/limited CT (76380), MR Spectroscopy (76390), unlisted CT/MR (76497/76498).

Billing Rule

Imaging CPT/HCPCS codes referenced for review

The matrix identifies specific imaging CPT/HCPCS codes that NIA references for utilization review and claim management, including CT heart/CTA, CT angiography, follow‑up CT, MR spectroscopy, unlisted CT/MR, MRI breast, CT bone density, MRI bone marrow, PET/MUGA/brain PET series, and others.

CT heart / CTA coronary arteries: 75572, 75573, 75574
CT angiography, abdominal arteries: 75635
Follow up / limited CT: 76380; MR Spectroscopy: 76390; Unlisted CT/MR: 76497, 76498
MRI breast: 77046 series; CT bone density: 77078; MRI bone marrow: 77084
PET and related codes: 78429, 78451, 78459, 78472, 78608, 78811–78816 (series referenced)

Prior Authorization

PET medical necessity vs. CPT code selection

NIA will determine whether a PET scan is clinically indicated (medical necessity) but will not select which specific CPT code is appropriate; the imaging facility is expected to bill accurately for the procedure(s) actually performed.

NIA issues a determination on whether PET is indicated, not which CPT code to submit.
Imaging facility must bill the CPT codes that accurately describe the performed study.

Documentation Required

Review and billing instructions for PET+CT (PET fusion) studies

When a PET and a diagnostic CT are performed simultaneously (a PET fusion study), NIA will review medical necessity for both the PET and the CT and issue utilization management determinations on both codes; CPT guidance instructs that the CT code should be appended with modifier 59.

PET fusion = PET + diagnostic CT performed simultaneously; both PET and CT codes are reviewed.
Append modifier 59 to the CT code per CPT guidance to ensure proper payment.

Scope, Terms & Exclusions

Allowable billed groupings

DefinitionWhen a given procedure is authorized, any of the listed procedure codes could be submitted on a claim representing that service (subject to member eligibility, rebundling rules, appropriate diagnosis, and date-of-service validity).

ApplicabilityApplies to CPT-4 codes managed by NIA on professional (HCFA 1500) claims; inclusion in the matrix indicates management by NIA but not guarantee of approval.

LimitationsIf a family of CPT codes is not listed, an exact match is required between authorized CPT and billed CPT; otherwise adjudicate accordingly.

Facility C-code exclusion

Scope ExclusionCodes submitted by facilities using CMS Outpatient PPS logic (C codes) are not included in this matrix.

Claim TypeMatrix is structured for professional claims (HCFA 1500) and does not incorporate facility C-codes.

Operational NoteClients should not expect facility outpatient PPS (C-code) billing to be governed by these mappings.

Setting exclusions (ED/Observation/Surgery center/Inpatient)

Setting ExclusionServices rendered in an Emergency Room, Observation Room, surgery center or hospital inpatient setting are not managed by NIA.

ImplicationRequests for services performed in these settings should be adjudicated outside NIA's managed matrix.

Provider ActionDo not submit prior authorization/management requests to NIA for services delivered in excluded settings.

CT Colonography / Virtual Colonoscopy

DescriptorCT Colonography / Virtual Colonoscopy referenced via CPTs such as 74261 and 74263 in the matrix.

Associated CodesMatrix rows reference 74263 alongside related entries (e.g., 74712) and modifiers/add-on codes in colonography groupings.

NoteScreening CT Colonoscopy (Virtual Colonoscopy) appears mapped to allowable billed groupings in matrix rows.

MRI Heart / Cardiac CT / CCTA

GroupMRI Heart / Cardiac CT / CCTA includes CPT series such as 75557 (MRI heart), 75572-75574 (CT heart/CCTA).

ExamplesMatrix lists 75557, 75571, 75572, 75573 and specifically 75574 for CTA coronary arteries (CCTA).

Related entriesSome cardiac CT entries reference add-on codes (+0722T) and device/tech modifiers in the matrix rows.

CCTA (CTA coronary arteries)

DefinitionCCTA refers to CTA coronary arteries and is represented by CPT code 75574 in the matrix.

Associated CodesCCTA appears alongside other vascular CTs such as 75635 (CT angiography, abdominal arteries) in matrix groupings.

ContextCCTA rows include follow-up and unlisted CT/MR entries as allowable billed groupings where applicable.

MR Spectroscopy (76390)

CodeMR Spectroscopy is represented by CPT 76390 in the matrix.

Grouping76390 is listed with follow-up/limited CT (76380) and unlisted CT/MR procedure codes (76497/76498) in allowable billable groupings.

NotesMatrix rows flag MR Spectroscopy as a distinct modality and include cross-references to unlisted procedure entries.

MUGA

DefinitionMUGA scan is referenced in the matrix and appears associated with heart imaging groupings (e.g., code 78472 referenced as Heart PET/MUGA group).

Associated CodesMUGA appears alongside myocardial perfusion and PET cardiac codes in allowable billed groupings (see 78429, 78451, 78459 listings).

ContextMatrix maps MUGA and other cardiac nuclear studies in the cardiac imaging section for utilization management.

PET fusion

DefinitionPET fusion (PET + diagnostic CT performed simultaneously) is distinguished from PET with CT for attenuation; when PET fusion is performed both PET and CT codes are billed and reviewed.

Billing GuidanceFor PET fusion, CPT instructs billing both PET and the diagnostic CT code with the CT appended by modifier 59; NIA will review medical necessity for both codes.

Operational NoteThe matrix expands allowable billable groupings to account for PET techniques (78814 series vs. PET fusion) and clarifies review expectations.

PET with CT / PET fusion distinction

DistinctionPET with CT for attenuation (78814 series) is acceptable when PET is clinically indicated and is not to be used to represent PET fusion studies.

Billing ExpectationWhen PET fusion (simultaneous diagnostic CT) is performed, both PET and diagnostic CT codes should be billed and the CT appended with modifier 59 per CPT guidance.

NIA RoleNIA will determine whether the PET scan itself is indicated but will not determine which specific PET CPT code is appropriate; facilities must bill accurately for what was performed.

Policy Summary

Payermarylandphysicianscarempc

PolicyUtilization Review Matrix — CPT imaging code management (professional claims)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

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Utilization Review Matrix — CPT imaging code management (professional claims)

Customize your policy alerts

Sign up for all marylandphysicianscarempc policy alerts

Know when marylandphysicianscarempc releases new policies or updates existing guidance.

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Utilization Review & Coverage Criteria

Utilization and billing rules from matrix

The matrix lists CPT codes that NIA manages and, for many, provides allowable billed groupings; inclusion means NIA will manage requests but does not guarantee approval.

NIA manages authorization/claims requests for the CPT-4 codes listed in the matrix; inclusion indicates the code is managed by NIA but does not imply the service will be approved.

If a family of CPT codes is not listed in the matrix, an exact match is required between the authorized CPT code and the billed CPT code; if no exact match exists, adjudicate the charge accordingly.

Codes submitted by facilities using CMS Outpatient PPS logic (C-codes) are excluded from this matrix and are not managed by NIA.

Services rendered in an Emergency Room, Observation Room, surgery center or hospital inpatient setting are not managed by NIA.

Imaging code mapping (no explicit coverage decision in this excerpt)

PET and related imaging coverage and billing guidance

Billing and coverage guidance for PET and PET+CT studies as summarized from the matrix notes.

Payment for add-on codes may depend on the appropriateness of the add-on code relative to the approved primary code; consult the matrix rows for grouping and payment guidance.

Code-level exclusions: +0698T is not a covered benefit; CPT codes +0722T and +0724T are considered Experimental/Investigational and are not covered.

CPT / HCPCS Codes Referenced

Sample authorized CPT codes and descriptions (partial list from matrix)CPTCovered

70336	MRI Temporomandibular Joint
70450	CT Head/Brain
70480	CT Orbit
70486	CT Maxillofacial/Sinus
70490	CT Soft Tissue Neck
70496	CT Angiography, Head
70498	CT Angiography, Neck
70540	MRI Orbit, Face, and/or Neck

Imaging CPT/HCPCS referencedCPT

74261	CT Colonography (diagnostic/screening variant listed)
74263	CT Colonography with contrast/additional descriptor
74185	Abdomen CT (diagnostic)
75557	Cardiac MRI (various heart studies referenced)
75572	CT Heart (electron beam/CT heart referenced)
75574	CTA coronary arteries (CCTA)
76390	MR Spectroscopy
76497	Unlisted Computed Tomography Procedure
76498	Unlisted Magnetic Resonance Procedure

Imaging CPT/HCPCS codesCPT

75572	CT heart (congenital studies) with or without +0722T noted
75573	CT heart congenital studies, non-coronary arteries
75574	CTA coronary arteries (CCTA)
75635	CT angiography, abdominal arteries
76380	Follow Up, Limited or Localized CT
76390	MR Spectroscopy
76497	Unlisted Computed Tomography Procedure
76498	Unlisted Magnetic Resonance Procedure
77046	MRI breast (one or more codes 77046-77049 appear)
77078	CT bone density study

1–10 of 17

1/2

Major imaging groups appearing in matrixCPT

78451	Myocardial perfusion imaging
78459	Myocardial perfusion imaging, single study / add-on groupings
78472	Heart PET scan
78608	MUGA scan / brain PET references appear in matrix
78811	PET scan codes series (78811-78816 listed)

Add-on and special-status codesCPT

+0742T	Add-on/technology code shown among allowable billable groupings
+0698T	Not a covered benefit
+0722T	Not covered; Experimental/Investigational
+0724T	Not covered; Experimental/Investigational

Provider Responsibilities & Authorization Rules

Prior Authorization

NIA management scope and authorization applicability

Inclusion in the matrix indicates NIA will manage requests for the code, not guarantee approval.
Matrix entries reflect professional (HCFA 1500) claims only; facility C‑codes are excluded.
Services in ED, Observation, surgery center or inpatient settings are not managed by NIA.

Prior Authorization

Imaging procedure → CPT/HCPCS group mappings

CT Colonography / Virtual Colonoscopy: examples include 74261, 74263 mapped with abdomen CT codes.
MRI Heart / Cardiac CT / CCTA: includes 75557 series and 75572–75574 mappings.
Other groups: CT angiography (e.g., 75635), Follow up/limited CT (76380), MR Spectroscopy (76390), unlisted CT/MR (76497/76498).

Billing Rule

Imaging CPT/HCPCS codes referenced for review

CT heart / CTA coronary arteries: 75572, 75573, 75574
CT angiography, abdominal arteries: 75635
Follow up / limited CT: 76380; MR Spectroscopy: 76390; Unlisted CT/MR: 76497, 76498
MRI breast: 77046 series; CT bone density: 77078; MRI bone marrow: 77084
PET and related codes: 78429, 78451, 78459, 78472, 78608, 78811–78816 (series referenced)

Prior Authorization

PET medical necessity vs. CPT code selection

NIA issues a determination on whether PET is indicated, not which CPT code to submit.
Imaging facility must bill the CPT codes that accurately describe the performed study.

Documentation Required

Review and billing instructions for PET+CT (PET fusion) studies

PET fusion = PET + diagnostic CT performed simultaneously; both PET and CT codes are reviewed.
Append modifier 59 to the CT code per CPT guidance to ensure proper payment.

Scope, Terms & Exclusions

Allowable billed groupings

ApplicabilityApplies to CPT-4 codes managed by NIA on professional (HCFA 1500) claims; inclusion in the matrix indicates management by NIA but not guarantee of approval.

LimitationsIf a family of CPT codes is not listed, an exact match is required between authorized CPT and billed CPT; otherwise adjudicate accordingly.

Facility C-code exclusion

Scope ExclusionCodes submitted by facilities using CMS Outpatient PPS logic (C codes) are not included in this matrix.

Claim TypeMatrix is structured for professional claims (HCFA 1500) and does not incorporate facility C-codes.

Operational NoteClients should not expect facility outpatient PPS (C-code) billing to be governed by these mappings.

Setting exclusions (ED/Observation/Surgery center/Inpatient)

Setting ExclusionServices rendered in an Emergency Room, Observation Room, surgery center or hospital inpatient setting are not managed by NIA.

ImplicationRequests for services performed in these settings should be adjudicated outside NIA's managed matrix.

Provider ActionDo not submit prior authorization/management requests to NIA for services delivered in excluded settings.

CT Colonography / Virtual Colonoscopy

DescriptorCT Colonography / Virtual Colonoscopy referenced via CPTs such as 74261 and 74263 in the matrix.

Associated CodesMatrix rows reference 74263 alongside related entries (e.g., 74712) and modifiers/add-on codes in colonography groupings.

NoteScreening CT Colonoscopy (Virtual Colonoscopy) appears mapped to allowable billed groupings in matrix rows.

MRI Heart / Cardiac CT / CCTA

GroupMRI Heart / Cardiac CT / CCTA includes CPT series such as 75557 (MRI heart), 75572-75574 (CT heart/CCTA).

ExamplesMatrix lists 75557, 75571, 75572, 75573 and specifically 75574 for CTA coronary arteries (CCTA).

Related entriesSome cardiac CT entries reference add-on codes (+0722T) and device/tech modifiers in the matrix rows.

CCTA (CTA coronary arteries)

DefinitionCCTA refers to CTA coronary arteries and is represented by CPT code 75574 in the matrix.

Associated CodesCCTA appears alongside other vascular CTs such as 75635 (CT angiography, abdominal arteries) in matrix groupings.

ContextCCTA rows include follow-up and unlisted CT/MR entries as allowable billed groupings where applicable.

MR Spectroscopy (76390)

CodeMR Spectroscopy is represented by CPT 76390 in the matrix.

Grouping76390 is listed with follow-up/limited CT (76380) and unlisted CT/MR procedure codes (76497/76498) in allowable billable groupings.

NotesMatrix rows flag MR Spectroscopy as a distinct modality and include cross-references to unlisted procedure entries.

MUGA

DefinitionMUGA scan is referenced in the matrix and appears associated with heart imaging groupings (e.g., code 78472 referenced as Heart PET/MUGA group).

Associated CodesMUGA appears alongside myocardial perfusion and PET cardiac codes in allowable billed groupings (see 78429, 78451, 78459 listings).

ContextMatrix maps MUGA and other cardiac nuclear studies in the cardiac imaging section for utilization management.

PET fusion

DefinitionPET fusion (PET + diagnostic CT performed simultaneously) is distinguished from PET with CT for attenuation; when PET fusion is performed both PET and CT codes are billed and reviewed.

Billing GuidanceFor PET fusion, CPT instructs billing both PET and the diagnostic CT code with the CT appended by modifier 59; NIA will review medical necessity for both codes.

Operational NoteThe matrix expands allowable billable groupings to account for PET techniques (78814 series vs. PET fusion) and clarifies review expectations.

PET with CT / PET fusion distinction

DistinctionPET with CT for attenuation (78814 series) is acceptable when PET is clinically indicated and is not to be used to represent PET fusion studies.

Billing ExpectationWhen PET fusion (simultaneous diagnostic CT) is performed, both PET and diagnostic CT codes should be billed and the CT appended with modifier 59 per CPT guidance.

NIA RoleNIA will determine whether the PET scan itself is indicated but will not determine which specific PET CPT code is appropriate; facilities must bill accurately for what was performed.