16.2.4 Computed Tomography (CT) Scan

CT imaging may be reimbursed by the CSHCN Services Program using the following procedure codes:

Procedure Codes
70450	70460	70470	70480	70481	70482
70486	70487	70488	70490	70491	70492
70496	70498	71250	71260	71270	71275
72125	72126	72127	72128	72129	72130
72131	72132	72133	72191	72192	72193
72194	73200	73201	73202	73206	73700
73701	73702	73706	74150	74160	74170
74174	74175	74176	74177	74178	75571
75572	75573	75574	75635	76376	76377
76380	77011

Prior authorization is not required for up to four CT imaging procedures per year.

Prior authorization will be considered for any additional CT procedures with documentation of a severe or life-threatening medical condition that requires close monitoring with CT imaging to determine appropriate treatment, and that without such monitoring and treatment, the condition could progress to severe disability or death.

Prior authorization requests for CT scans that exceed four per client, per rolling year must be submitted on the “CSHCN Services Program Authorization and Prior Authorization Request” form and must include documentation of medical necessity for the procedure.

Medical necessity for CT scans includes, but is not limited to, clients with any of the following:

•	Ventriculoperitoneal shunt

•	Routine postoperative follow-up of ventriculoperitoneal shunt

•	Congenital anomaly or deformity

•	Suspected fracture when plain film is inconclusive

•	Hydrocephalus

•

Epilepsy

•	Other neurological symptoms

•	Craniofacial malformation

•	Primary or metastatic cancer

•	Known or suspected primary tumor (malignant or nonmalignant)

•	Tumor staging

•	Progressively severe symptoms despite conservative management

Note: The American College of Radiology Practice Guidelines for CT scans may be used as a reference for specific indications.

Documentation of medical necessity, including the specific rationale for the requested procedure, must be maintained in the client’s medical record.

CT scan procedure codes are subject to National Correct Coding Initiative (NCCI) relationships with the following exceptions.

The procedure codes in Column A of the following table will be denied if they are billed with the procedure codes in Column B:

Column A (Denied)	Column B
70450	70460
70450, 70460	70470
70480	70481
70480, 70481	70482
70486	70487
70486, 70487	70488
70490	70491
70490, 70491	70492
76376, 76377	70496, 70498, 71275, 72191, 73206, 73706, 74175
71250, 76380	71260
71250, 71260	71270
72125	72126
72125, 72126	72127
72128	72129
72128, 72129	72130
72131	72132
72131, 72132	72133
72192	72193
72192, 72193	72194
73200	73201
73200, 73201	73202
73700	73701
73700, 73701	73702
76380	74150
74150, 76380	74160
74150, 74160, 76380	74170
76376	76377
76380	77011
70480, 70481, 70482	70450, 70460, 70470