CurrentQualChoicePolicy N/A

Utilization Review Matrix — Imaging Procedure Billing Groupings

This document lists CPT and HCPCS imaging procedure codes with descriptions and allowable billed groupings for QualChoice Commercial PPO and POS plans; it governs billing and utilization review for providers submitting imaging claims.

Policy Summary

PayerQualChoice

PolicyUtilization Review Matrix — Imaging Procedure Billing Groupings

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionUse the matrix to apply allowable billed groupings when submitting imaging claims for QualChoice Commercial PPO and POS.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~140procedure lines listed

multiplemodalities included

groupingsgrouping guidance present

PPO/POSplan applicability

Coverage and Medical Necessity

Coverage stance

No explicit coverage criteria or medical necessity conditions are included in the provided matrix excerpts.

Document provides a utilization review matrix mapping CPT/HCPCS imaging procedure codes to 'Allowable Billed Groupings' for QualChoice Commercial PPO and POS but does not state clinical medical necessity criteria or coverage conditions within the supplied excerpts.

CPT / HCPCS Procedure Codes and Allowable Groupings

Sample head/neck imaging codesCPT

70336	MRI Temporomandibular Joint
70450	CT Head/Brain
70471	CT Angiography, Head and Neck
70551	MRI Brain (with or without Internal Auditory Canal views)

Sample chest imaging codesCPT

71250	CT Chest
71271	Low Dose CT for Lung Cancer Screening
71550	MRI Chest

Sample extremity imaging codesCPT

73720	MRI Lower Extremity
73221	MRI Upper Extremity Joint

inv-05: allowable billed grouping presence

Policy Summary

PayerQualChoice

PolicyUtilization Review Matrix — Imaging Procedure Billing Groupings

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionUse the matrix to apply allowable billed groupings when submitting imaging claims for QualChoice Commercial PPO and POS.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Presence on each entryEach CPT/HCPCS procedure line in the matrix includes one or more 'Allowable Billed Groupings' values to indicate related billable codes (e.g., 70450 Allowable Billed Groupings = 70450, 70460, 70470, +0722T, +70472)

PurposeIndicates which additional or alternative CPT/HCPCS codes are considered grouped or allowable with the listed procedure for billing and utilization review

ScopeApplies across listed imaging procedures in the matrix (CT, MRI, MRA, PET, Nuclear Cardiology, Echocardiography)

Format used in matrixSingle-line listing after each code entry showing one or more codes and occasionally add-on codes prefixed with '+' (e.g., 93307 Allowable Billed Groupings = 93303, 93304, 93306, 93307, 93308, +93320, +93321, +93325, +93356)

Example entries70336 Allowable Billed Groupings = 70336; 70496 Allowable Billed Groupings = 70496, +70472; 78459 Allowable Billed Groupings = 78459, 78491, 78492, +78434

Billing Guidance and Utilization Review Instructions

Billing Rule

Imaging Code Grouping Guidance

When submitting imaging claims, bill only the CPT/HCPCS code(s) that reflect the actual service(s) performed. Some imaging CPTs are grouped for allowable billed combinations; billing codes outside the allowed groupings may be subject to utilization review adjustment or claim denial. Review the allowable billed groupings below and ensure documentation supports each billed code.

70336 — Allowable Billed Groupings: 70336
70450 — Allowable Billed Groupings: 70450, 70460, 70470, +0722T, +70472
70471 — Allowable Billed Groupings: 70471, +70472
70473 — Allowable Billed Groupings: 70473
70480 — Allowable Billed Groupings: 70480, 70481, 70482, +0722T
70486 — Allowable Billed Groupings: 70486, 70487, 70488, +0722T
70490 — Allowable Billed Groupings: 70490, 70491, 70492, +0722T
70496 — Allowable Billed Groupings: 70496, +70472
70498 — Allowable Billed Groupings: 70498
70540 — Allowable Billed Groupings: 70540, 70542, 70543, +0698T
70544 — Allowable Billed Groupings: 70544, 70545, 70546
70547 — Allowable Billed Groupings: 70547, 70548, 70549
70551 — Allowable Billed Groupings: 70551

Terminology and Modality Definitions

inv-07: Allowable Billed Groupings — definition of grouped/allowable CPT/HCPCS billing relationships

Definition'Allowable Billed Groupings' are the related CPT/HCPCS codes listed with a procedure that are considered grouped or allowable with that procedure for billing purposes (e.g., 70540 Allowable Billed Groupings = 70540, 70542, 70543, +0698T)

Includes add-on codesGroupings may include standalone and add-on codes; add-on codes are shown with a '+' prefix in the matrix (e.g., +0722T, +93320)

Function in utilization reviewUsed to inform billing adjudication and utilization review by specifying which codes may be billed together or are considered equivalent/related

Displayed per procedureEach procedure line in the matrix shows its Allowable Billed Groupings immediately after the description (e.g., 78608 Allowable Billed Groupings = 78608, 78609)

inv-08: Modality — modality descriptions included

Modalities listedMatrix entries include modality designations such as MRI, CT, MRA, PET, Nuclear Cardiology, and Echocardiography (examples: MRI Temporomandibular Joint 70336; CT Head/Brain 70450; MRA Head 70544; Heart PET Scan 78459; Transthoracic Echocardiography 93307)

How shownModality is conveyed via the CPT/HCPCS procedure description that accompanies each code in the matrix (e.g., 'MRI Brain', 'CT Pelvis', 'PET Scan, Brain')

Coverage of imaging typesMultiple imaging types are included across entries to guide billing and utilization review for diverse diagnostic modalities

Notation examplesDescriptions inline with codes indicate modality and anatomic region (e.g., 70480 Description = CT Orbit; 78608 Description = PET Scan, Brain; 93312 Description = Transesophageal Echocardiography)