Claims submitted with the procedure codes listed in this document must be accompanied by clinical information that supports the services rendered. Some services may require medical review because of one or more of the following reasons:
- The procedure is considered new technology
- There is limited effectiveness when the procedure is used for certain medical conditions
- The procedure was performed for an indication that is not FDA-approved
- The procedure is not performed very often
- There is a potential for the procedure to be used inappropriately or for other reasons related to medical necessity
In some cases, practitioners may request that HMSA review the planned procedures prior to the services being rendered for benefit predetermination. See Benefit Information.
This document will be updated when HMSA requirements change.
I. Codes That Require Clinical Information
Claims for the following codes should be submitted with the required documentation indicated in this table.
| Code | Description | Documentation Required |
|---|---|---|
| 0067T (CPT Catgeory III code) | Computed tomographic (CT) (I.e., virtual colonoscopy; diagnostic | Clinical notes |
| 0648T | Quantitative magnetic resonance for analysis of tissue composition (eg, fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation and report, obtained without diagnostic mri examination of the same anatomy (eg, organ, gland, tissue, target structure) during the same session | Clinical notes |
| 0649T | Quantitative magnetic resonance for analysis of tissue composition (eg, fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation and report, obtained with diagnostic mri examination of the same anatomy (eg, organ, gland, tissue, target structure) (list separately in addition to code for primary procedure) | Clinical notes |
| 0689T | Quantitative ultrasound tissue characterization (non-elastographic), including interpretation and report, obtained without diagnostic ultrasound examination of the same anatomy (eg, organ, gland, tissue, target structure) | Clinical notes |
| 0690T | Quantitative ultrasound tissue characterization (non-elastographic), including interpretation and report, obtained with diagnostic ultrasound examination of the same anatomy (eg, organ, gland, tissue, target structure) (List separately in addition to code for primary procedure) | Clinical notes |
| 0694T | 3-dimensional volumetric imaging and reconstruction of breast or axillary lymph node tissue, each excised specimen, 3-dimensional automatic specimen reorientation, interpretation and report, real time intraoperative | Clinical notes |
| 0697T | Quantitative magnetic resonance for analysis of tissue composition (eg, fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation and report, obtained without diagnostic MRI examination of the same anatomy (eg, organ, gland, tissue, target structure) during the same session; multiple organs | Clinical notes |
| 0698T | Quantitative magnetic resonance for analysis of tissue composition (eg, fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation and report, obtained with diagnostic MRI examination of the same anatomy (eg, organ, gland, tissue, target structure); multiple organs (List separately in addition to code for primary procedure) | Clinical notes |
| 0721T | Quantitative computed tomography (CT) tissue characterization, including interpretation and report, obtained without concurrent CT examination of any structure contained in previously acquired diagnostic imaging | Clinical notes |
| 0722T | Quantitative computed tomography (CT) tissue characterization, including interpretation and report, obtained with concurrent CT examination of any structure contained in the concurrently acquired diagnostic imaging dataset (list separately in addition to code for primary procedure) | Clinical notes |
| 0723T | Quantitative magnetic resonance cholangiopancreatography (QMRCP) including data preparation and transmission, interpretation and report, obtained without diagnostic magnetic resonance imaging (MRI) examination of the same anatomy (eg, organ, gland, tissue, target structure) during the same session | Clinical notes |
| 0724T | Quantitative magnetic resonance cholangiopancreatography (QMRCP) including data preparation and transmission, interpretation and report, obtained with diagnostic magnetic resonance imaging (MRI) examination of the same anatomy (eg, organ, gland, tissue, target structure) (list separately in addition to code for primary procedure) | Clinical notes |
| 0815T | ULTRASOUND-BASED RADIOFREQUENCY ECHOGRAPHIC MULTI-SPECTROMETRY (REMS), BONE-DENSITY STUDY AND FRACTURE-RISK ASSESSMENT, 1 OR MORE SITES, HIPS, PELVIS, OR SPINE | Diagnostic/Imaging Report, Consult Report, History and Physical |
| 0865T | QUANTITATIVE MAGNETIC RESONANCE IMAGE (MRI) ANALYSIS OF THE BRAIN WITH COMPARISON TO PRIOR MAGNETIC RESONANCE (MR) STUDY(IES), INCLUDING LESION IDENTIFICATION, CHARACTERIZATION, AND QUANTIFICATION, WITH BRAIN VOLUME(S) QUANTIFICATION AND/OR SEVERITY SCORE | Diagnostic/Imaging Report, Consult Report, History and Physical |
| 0866T | 0866T QUANTITATIVE MAGNETIC RESONANCE IMAGE (MRI) ANALYSIS OF THE BRAIN WITH COMPARISON TO PRIOR MAGNETIC RESONANCE (MR) STUDY(IES), INCLUDING LESION DETECTION, CHARACTERIZATION, AND QUANTIFICATION, WITH BRAIN VOLUME(S) QUANTIFICATION AND/OR SEVERITY SCORE, WHEN PERFORMED, DATA PREPARATION AND TRANSMISSION, INTERPRETATION AND REPORT, OBTAINED WITH DIGNOSTIC MRI EXAMINATION OF THE BRAIN | Diagnostic/Imaging Report, Consult Report, History and Physical |
| 76391 | Magnetic Resonance (Eg, Vibration) Elastography | Clinical notes |
| 76392 | Ultrasound, Elastography; First Target Lesion | Clinical notes |
| 76393 | List Separately In Addition To Code For Primary Procedure) | Clinical notes |
| 76979 | Ultrasound, targeted dynamic microbubble sonographic contrast characterization (non-cardiac); each additional lesion with separate injection (list separately in addition to code for primary procedure) | Clinical notes |
| 76984 | ULTRASOUND, INTRAOPERATIVE THORACIC AORTA (EG, EPIAORTIC), DIAGNOSTIC | Diagnostic/Imaging Report, Consult Report, History and Physical |
| 76987 | INTRAOPERATIVE EPICARDIAL CARDIAC ULTRASOUND (IE, ECHOCARDIOGRAPHY) FOR CONGENITAL HEART DISEASE, DIAGNOSTIC; INCLUDING PLACEMENT AND MANIPULATION OF TRANSDUCER, IMAGE ACQUISITION, INTERPRETATION AND REPORT | Diagnostic/Imaging Report, Consult Report, History and Physical |
| 76988 | INTRAOPERATIVE EPICARDIAL CARDIAC ULTRASOUND (IE, ECHOCARDIOGRAPHY) FOR CONGENITAL HEART DISEASE, DIAGNOSTIC; PLACEMENT, MANIPULATION OF TRANSDUCER, AND IMAGE ACQUISITION ONLY | Diagnostic/Imaging Report, Consult Report, History and Physical |
| 76989 | INTRAOPERATIVE EPICARDIAL CARDIAC ULTRASOUND (IE, ECHOCARDIOGRAPHY) FOR CONGENITAL HEART DISEASE, DIAGNOSTIC; INTERPRETATION AND REPORT ONLY | Diagnostic/Imaging Report, Consult Report, History and Physical |
| 78429 | Myocardial imaging, positron emission tomography (pet), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), single study; with concurrently acquired computed tomography transmission scan | Clinical notes |
| 78266 | Gastric emptying imaging study (eg, solid, liquid, or both); with small bowel and colon transit, multiple days | Clinical notes |
| 78430 | Myocardial imaging, positron emission tomography (pet), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at rest or stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan | Clinical notes |
| 78431 | Myocardial imaging, positron emission tomography (pet), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at rest and stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan | Clinical notes |
| 78432 | Myocardial imaging, positron emission tomography (pet), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability); | Clinical notes |
| 78433 | Myocardial imaging, positron emission tomography (pet), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability); with concurrently acquired computed tomography transmission scan | Clinical notes |
| 78832 | Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (spect) with concurrently acquired computed tomography (ct) transmission scan for anatomical review, localization and determination/detection of pathology, minimum 2 areas (eg, pelvis and knees, abdomen and pelvis), single day imaging, or single area imaging over 2 or more days | Clinical notes |
| 78835 | Radiopharmaceutical quantification measurement(s) single area (list separately in addition to code for primary procedure) | Clinical notes |
| 93985 | Duplex scan of arterial inflow and venous outflow for preoperative vessel assessment prior to creation of hemodialysis access; complete bilateral study | Clinical notes |
| A9515 | Choline C-11, diagnostic, per study dose up to 20 millicuries | Diagnostic/Imaging report |
| A9588 | Fluciclovine F-18, diagnostic, 1 millicurie | Diagnostic/Imaging report |
| A9590 | Iodine i-131, iobenguane, 1 millicurie | Clinical notes |
| A9598 | Positron emission tomography radiopharmaceutical, diagnostic, for non-tumor identification, not otherwise classified | Diagnostic/Imaging report |
| A9615 | Injection, pegulicianine, 1 mg | Operative Report, Clinical Notes and Pathology Report |
| G0562 | Therapeutic radiology simulation-aided field setting; complex, including acquisition of pet and CT imaging data required for radiopharmaceutical-directed radiation therapy treatment planning (i.e., modeling), | Diagnostic/Imaging Report and Clinical Notes |
| S8035 | Magnetic source imaging | Clinical notes |
| S8092 | Electron beam computed tomography (also known as Ultrafast CT, Cine CT) |
Does not need payment determination criteria for ICD-9: 414.00 or 414.01 and ICD-10: I25.10, I25.110, I25.111, I25.118 or I25.119 Subject to medical review when performed for other diagnoses - additional information may be requested in certain circumstances |
In addition, HMSA may require submission of clinical records before or after payment of claims for the purpose of investigating potential fraudulent, abusive or other inappropriate billing practices, but only as long as there is a reasonable basis for believing such investigation is warranted.
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 |
|