1
ACRIN 6651/Economic Forms CPT Code Listing
EX Form
1.
Pelvic Exam – (unsure of how to capture, only pelvic exam with anesthesia available).
2.
Intravenous Pyelogram
74400- Urography (pyelography), intravenous, with or without KUB, with or without tomography
74405- Urography (pyelography), intravenous, with or without KUB, with or without tomography; with
special hypersensitive contrast concentration and/or clearance studies.
3.
Barium Enema Exam
74270- Radiologic examination, colon; barium enema, with or without KUB
74280- Radiologic examination, colon; air contrast with specific high density barium, with or
without glucagon
4.
Cystoscopy
52000- Cystourethroscopy (separate procedure)
52005- Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or
ureteropyelography, exclusive of radiologic service
52007- Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or
ureteropyelography, exclusive of radiologic service; with brush biopsy of ureter and/or renal
pelvis
5.
Proctoscopy
45300- Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushing or
washing (separate procedure)
45303- Proctosigmoidoscopy, rigid; with dilation, any method
45305- Proctosigmoidoscopy, rigid; with biopsy, single or multiple
6.
Lymphangiogram
75805- Lymphangiography, pelvic/abdominal, unilateral, radiological supervision and interpretation
75807- Lymphangiography, pelvic/abdominal, bilateral, radiological supervision and interpretation
7.
Pelvic Exam With Anesthesia
57410- Pelvic exam with anesthesia
8.
Colposcopy
57452- Colposcopy (vaginoscopy); (separate procedure)
57454- Colposcopy (vaginoscopy); with biopsy(s) of the cervix and/or endocervical curettage
57460- Colposcopy (vaginoscopy); with loop electrode excision procedure of the cervix
9.
Chest Imaging
71020- Radiologic examination, chest, two views, frontal and lateral;
71030- Radiologic examination, chest, complete, minimum of four views;
71250- Computerized axial tomography, thorax; without contrast material
71260- Computerized axial tomography, thorax; with contrast material
2
EX Form (con’t)
10. Pelvic CT
72192- Computerized axial tomography, thorax; without contrast material
72193- Computerized axial tomography, thorax; with contrast material
72194- Computerized axial tomography, thorax; without contrast material, followed by contrast
material(s)and further sections
11. Pelvic MRI
72196- Magnetic resonance (eg, proton) imaging, pelvis
12. 13, 14: Other, specify
15. CT – see number 10
16. MRI – see number 11
17. PAP
88150- Cytopathology, smears, cervical or vaginal, up to three smears; screening by technician under
physician supervision
88151- Cytopathology, smears, cervical or vaginal, up to three smears; requiring interpretation by
physician
88155- Cytopathology, smears, cervical or vaginal, up to three smears; with definitive hormonal evaluation
(eg, maturation index, karyopyknotic index, estrogenic index)
Consultations: 17, 18, 19, 20, 21
99241- Office consultation for a new or established patient, which requires these three key components:
a) problem focused history; b) a problem focused examination; c) straightforward medical
decision making
99242- Office consultation for a new or established patient, which requires these three key components:
a) an expanded problem focused history; b) an expanded problem focused examination;
c) straightforward medical decision making
99243- Office consultation for a new or established patient, which requires these three key components:
a) detailed history; b) a detailed examination; c) medical decision making of low complexity
99244- Office consultation for a new or established patient, which requires these three key components:
a) a comprehensive history; b) a comprehensive examination; c) medical decision making of
moderate complexity
99245- Office consultation for a new or established patient, which requires these three key components:
a) a comprehensive history; b) a comprehensive examination; c) medical decision making of high
complexity
Follow Up: 17, 18, 19, 20 ,21
99211- Office or other outpatient visit for the evaluation and management of an established
patient, that may not require the presence of a physician. Usually, the presenting problem(s) are
minimal. Typically, 5 minutes are spent performing or supervising these services.
99212- Office or other outpatient visit for the evaluation and management of an established patient, which
requires at least two of these three key components: a) a problem focused history; b) a problem
focused examination; c) straightforward medical decision making.
99213- Office or other outpatient visit for the evaluation and management of an established patient, which
requires at least two of these three key components: a) an expanded problem focused history; b) an
expanded problem focused examination; c) medical decision making of low complexity.
3
99214- Office or other outpatient visit for the evaluation and management of an established patient, which
requires at least two of these three key components: a) a detailed history; b) a detailed
examination; c) medical decision making of moderate complexity.
99215- Office or other outpatient visit for the evaluation and management of an established patient, which
requires at least two of these three key components: a) a comprehensive history; b) a
comprehensive examination; c) medical decision making of high complexity.
EX Form (con’t)
22.
Pelvic Lymph Node Sampling
38500- Biopsy or excision of lymph nodes(s); superficial (separate procedure)
38505- Biopsy or excision of lymph node(s); by needle, superficial (eg, cervical, inguinal, axillary)
38562- Limited lymphadenectomy for staging (separate procedure); pelvic and para-aortic
38564- Limited lymphadenectomy for staging (separate procedure); retroperitoneal (aortic and/or splenic)
23.
Other, specify
4
WX Form
1.
Hysterectomy
58210- Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic
lymph node sampling (biopsy), with or without removal of tube(s), with or without removal of
ovary(s)
58240- Pelvic exenteration for gynecologic malignancy, with total abdominal hysterectomy or
cervicectomy, with or without removal of tube(s), with or without removal of ovary(s), with
removal of bladder and ureteral transplantations, and/or abdominoperineal resection of rectum and
colon and colostomy, or any combination thereof
2.
Pelvic Lymphadenectomy
38770- Pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes (separate
procedure)
38562- Limited lymphadenectomy for staging (separate procedure); pelvic and para-aortic
38564- Limited lymphadenectomy for staging (separate procedure); retroperitoneal (aortic and/or splenic)
3.
Hospital stay – (I am not sure if these codes are needed, but the following are CPT codes for hospital stay)
Initial Hospital Care/New or Established Patient
99221- Initial hospital care, per day, for the evaluation and management of a patient which requires these
three key components: a) a detailed or comprehensive history; b) detailed or comprehensive
examination; c) medical decision making that is straightforward or of low complexity
99222- Initial hospital care, per day, for the evaluation and management of a patient which requires these
three key components: a) a comprehensive history; b) a comprehensive examination; c) medical
decision making of moderate complexity
99223- Initial hospital care, per day, for the evaluation and management of a patient which requires these
three key components: a) a comprehensive history; b) a comprehensive examination; c) medical
decision making of high complexity
Subsequent Hospital Care
99231- Subsequent hospital care, per day, for the evaluation and management of a patient, which requires
at least two of these three key components: a) a problem focused interval history; b) a problem
focused examination; c) medical decision making that is straightforward or of low complexity
99232- Subsequent hospital care, per day, for the evaluation and management of a patient, which requires
at least two of these three key components: a) an expanded problem focused interval history; b) an
expanded problem focused examination; c) medical decision making of moderate complexity
99233- Subsequent hospital care, per day, for the evaluation and management of a patient, which requires
at least two of these three key components: a) a detailed interval history; b) a detailed
examination; c) medical decision making of high complexity
Hospital Discharge Services
99238- Hospital discharge day management; 30 minutes or less
99239- Hospital discharge day management; more than 30 minutes
5
WX Form (con’t)
4.
Radiation Therapy
77261- Therapeutic radiology treatment planning; simple
77262- Therapeutic radiology treatment planning; intermediate
77263- Therapeutic radiology treatment planning; complex
77280- Therapeutic radiology simulation-aided field setting; simple
77285- Therapeutic radiology simulation-aided field setting; intermediate
77290- Therapeutic radiology simulation-aided field setting; complex
77295- Therapeutic radiology simulation-aided field setting; by three-dimensional reconstruction of tumor
volume in preparation for treatment with non-coplanar therapy beams
77300- Basic radiation dosimetry calculation, central axis depth dose, TDF, NSD, gap calculation, off axis
factor, tissue inhomogeneity factors, as required during course of treatment, only when prescribed
by the treating physician
77305- Teletherapy, isodose plan (whether hand or computer calculated); simple (one or two parallel
opposed unmodified ports directed to a single area of interest
77310- Teletherapy, isodose plan (whether hand or computer calculated); intermediate (three or more
treatment ports directed to a single area of interest)
77315- Teletherapy, isodose plan (whether hand or computer calculated); complex (mantle or inverted Y,
tangential ports, the use of wedges, compensators, complex blocking, rotational beam, or special
beam considerations)
77326- Brachytherapy isodose calculation; simple (calculation made from single plane, one to four
sources/ribbon application, remote afterloading brachytherapy, 1 to 8 sources)
77327- Brachytherapy isodose calculation; intermediate (multiplane dosage calculations, application
involving five to ten sources/ribbons, remote afterloading brachytherapy, 9-12 sources)
77328- Brachytherapy isodose calculation; complex (multiplane isodose plan, volume implant calculations,
over ten sources/ribbons used, special spatial reconstruction, remote afterloading brachytherapy,
over 12 sources)
77331- Special Dosimetry (eg, TLD, microdosimetry) (specify), only when prescribed by the treating MD
77332- Treatment devices, design and construction; simple (simple block, simple bolus)
77333- Treatment devices, design and construction; intermediate (multiple blocks, stents, bite blocks,
special bolus)
77334- Treatment devices, design and construction; complex (irregular blocks, special shields,
compensators, wedges, molds or casts)
77336- Continuing medical radiation physics consultation in support of therapeutic radiologist including
continuing quality assurance reported per week of therapy.
77370- Special medical radiation physics consultation
77402- Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple
blocks or no blocks; up to 5 MeV
77403- Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple
blocks or no blocks; 6-10 MeV
77404- Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple
blocks or no blocks; 11-19 MeV
77406- Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple
blocks or no blocks; 20 MeV or greater
77407- Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment
area, use of multiple blocks; up to 5 MeV
77408- Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment
area, use of multiple blocks; 6-10 MeV
77409- Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment
area, use of multiple blocks; 11-19 MeV
77411- Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment
area, use of multiple blocks; 20 MeV or greater
6
WX Form (con’t)
77412- Radiation treatment delivery, three or more separate treatment areas, three or more ports on a single
custom blocking, tangential ports, wedges, rotational beam, compensators, special particle beam
(eg, electron or neutrons); up to 5 MeV
77413- Radiation treatment delivery, three or more separate treatment areas, three or more ports on a single
custom blocking, tangential ports, wedges, rotational beam, compensators, special particle beam
(eg, electron or neutrons); 6-10 MeV
77414- Radiation treatment delivery, three or more separate treatment areas, three or more ports on a single
custom blocking, tangential ports, wedges, rotational beam, compensators, special particle beam
(eg, electron or neutrons); 11-19 MeV
77416- Radiation treatment delivery, three or more separate treatment areas, three or more ports on a single
custom blocking, tangential ports, wedges, rotational beam, compensators, special particle beam
(eg, electron or neutrons); 20 MeV or greater
77417- Therapeutic radiology port film(s)
77419- Weekly radiation therapy management; conformal
77420- Weekly radiation therapy management; simple
77425- Weekly radiation therapy management; intermediate
77430- Weekly radiation therapy management; complex
77761- Intracavitary radioelement application; simple
77762- Intracavitary radioelement application; intermediate
77763- Intracavitary radioelement application; complex
77781- Remote afterloading high intensity brachytherapy; 1-4 source positions or catheters
77782- Remote afterloading high intensity brachytherapy; 5-8 source positions or catheters
77783- Remote afterloading high intensity brachytherapy; 9-12 source positions or catheters
77784- Remote afterloading high intensity brachytherapy; over 12 source positions or catheters
77790- Supervision, handling, loading of radioelement
5.
Medications – (Are we collecting all medication in hospital, ? chemotherapy)
6.
Other, specify
7
RX Form
1.
Cystoscopy – see EX #4
2.
Proctoscopy – see EX #5
3.
Pelvic Exam with Anesthesia – see EX #7
4.
Intravenous Urograph
74420- Urography, retrograde, with or without KUB
5.
Barium Enema Examination – see EX #3
6.
Chest Imaging – see EX #9
7.
Bone Scan
78306- Bone and/or joint imaging; whole body
78399- Unlisted musculoskeletal procedure, diagnostic nuclear medicine
78305- Bone and/or joint imaging; multiple areas
78300- Bone and/or joint imaging; limited areas
8.
MRI – see EX #11
9.
CT – see EX #10
10. PAP
88150- Cytopathology, smears, cervical or vaginal, up to three smears; screening by technician under
physician supervision
88151- Cytopathology, smears, cervical or vaginal, up to three smears; requiring interpretation by
physician
88155- Cytopathology, smears, cervical or vaginal, up to three smears; with definitive hormonal evaluation
(eg, maturation index, karyopyknotic index, estrogenic index)
11. Other, specify
12. Other, specify
Consultations: 13, 14, 15, 16, and 17 – see EX #17-21
Follow Up: 13,14,15,16,17 – see EX #17-21
8
DX Form
1.
Hysterectomy – see WX # 1
2.
Pelvic Lymphadenectomy – see WX # 2
3.
Hospital Stay – see WX # 3
4.
Radiation Therapy – see WX # 4
5.
Medication – see WX # 5
6.
Other, specify
9
FX Form
1.
Pelvic Exam – see EX # 1
2.
Intravenous Pyelogram – see EX # 2
3.
Barium Enema Examination – see EX # 3
4.
Cystoscopy – see EX # 4
5.
Proctoscopy – see EX # 5
6.
Chest Imaging – see EX # 9
7.
Bone Scan – see RX # 7
8.
Pelvic MRI Scan – see EX # 11
9.
Pelvic CT Scan – see EX # 10
10. Other, specify
11. Other, specify
Consultations: 12, 13, 14, 15, 16, and 17 – see EX #17-21
Follow Up: 12, 13,14,15,16,17 – see EX #17-21