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Medical Policy CT Angiography (CTA) Abdomen and Pelvis Combination

Table of Contents

Policy: Commercial Policy History Information Pertaining to All Policies

Authorization Information References

Coding Information Endnotes

Policy Number: 761 BCBSA Reference Number: N/A

Related Policies Medicare Advantage: High-Technology Radiology and Sleep Disorder Management Clinical

and Utilization Guidance Redirect, #923

Computed Tomographic Angiography Coronary Arteries (CCTA), #831

CT Angiography (CTA) Abdominal Aorta and Bilateral Iliofemoral Lower Extremity Run-Off, #762

CT Angiography (CTA) and MR Angiography (MRA) Abdomen, #763

CT Angiography (CTA) and MR Angiography (MRA) Lower Extremity, #764

CT Angiography (CTA) and MR Angiography (MRA) Pelvis, #765

CT Angiography (CTA) and MR Angiography (MRA) Upper Extremity, #766

CT Angiography (CTA) Chest (Non-Coronary), #767

CT/MR Angiography (CTA/MRA) Head: Cerebrovascular, #768

CT/MR Angiography (CTA/MRA) Neck, #769

Policy1

Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity

ADULTS CT Angiography (CTA) Abdomen and Pelvis Combination are considered MEDICALLY NECESSARY for the following conditions: Aneurysm of the abdominal aorta, iliac or femoral vessels

Following inconclusive ultrasound in patients with suspected aneurysm/dilation of the abdominal aorta, iliac or femoral vessels

Follow-up imaging of patients with an established aneurysm/dilation when most recent ultrasound imaging is inconclusive

Preoperative assessment or prior to percutaneous endovascular stent graft placement

Annual post-operative surveillance of stable patients who have undergone open surgical repair when most recent ultrasound imaging is inconclusive

Post-operative surveillance of stable patients who have been treated with endovascular stent graft

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Suspected complication of an aneurysm/dilation, such as aneurysmal rupture or infection—requiring urgent imaging

Prior to transcatheter aortic valve implantation/replacement (TAVI or TAVR), unless advanced imaging has been performed for this indication within the preceding 60 days

Arteriovenous malformation (AVM) or arteriovenous fistula (AVF) Note: For renal or superficial AVM, ultrasound should be considered as the first imaging modality Dissection Of the abdominal aorta and/or branch vessel Hematoma / hemorrhage Of the abdominal aorta and/or branch vessel Mesenteric ischemia

May have an acute or chronic and progressive (intestinal or abdominal angina) presentation Preoperative or pre-procedure evaluation Note: This indication is for preoperative evaluation of conditions not specifically referenced elsewhere in this policy. Prior to resection of pelvic neoplasm Pseudoaneurysm Of the abdominal aorta and/or branch vessel Stenosis or occlusion of the abdominal aorta or branch vessels Due to:

o Atherosclerosis o Thromboembolism o Other causes

Suspected leak following abdominal aortic surgery or intervention (endoleak) Traumatic vascular injury Unexplained blood loss in the abdomen Vascular anatomic delineation for other surgical and interventional procedures

Including but not limited to the following clinical scenarios: o For vascular delineation prior to operative resection of an abdominal neoplasm o For pre- and post-procedure evaluation of bypass grafts, stents and vascular anastomoses

Vascular invasion or compression by an abdominal tumor Vasculitis Venous thrombosis or occlusion Evaluation of suspected thrombosis or occlusion of major abdominal vessels, including portal and systemic venous systems

Ultrasound is required as the initial study to evaluate the following: o Hepatic or portal vein thrombosis o Renal vein thrombosis o Splenic vein thrombosis

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Note: Ultrasound is not required for suspected thrombosis of the IVC or other venous structures in the abdomen and pelvis. Visceral artery aneurysms

Diagnosis, management, and surveillance of visceral artery aneurysms including: o Renal o Celiac o Splenic o Hepatic o Superior/inferior mesenteric and their branches

PEDIATRICS CT Angiography (CTA) Abdomen and Pelvis Combination are considered MEDICALLY NECESSARY for the following conditions: Aneurysm of the abdominal and iliac arteries

Following non-diagnostic ultrasound and (any one of the following) o Annual screening in patients with connective tissue disease o Follow-up imaging of patients with an established aneurysm/dilation o Suspected complication of an aneurysm/dilation o Pre/post-operative

Arteriovenous malformation (AVM) or arteriovenous fistula (AVF) Note: For renal or superficial AVM, ultrasound should be considered as the first imaging modality. Dissection Of the abdominal aorta and/or branch vessel Hematoma/hemorrhage Of the abdominal aorta and/or branch vessel Mesenteric ischemia Note: May have an acute or chronic and progressive (intestinal or abdominal angina) presentation Preoperative or pre-procedure evaluation Note: For preoperative evaluation of conditions not specifically referenced elsewhere in this policy. Prior to resection of pelvic neoplasm Pseudoaneurysm Of the abdominal aorta and/or branch vessel Stenosis or occlusion of the abdominal aorta or branch vessels (any one♦ of the following)

Atherosclerosis

Thromboembolism

Other causes Traumatic vascular injury Unexplained blood loss in the abdomen Vascular anatomic delineation for other surgical and interventional procedures (any one♦ of the following)

For vascular delineation prior to operative resection of an abdominal neoplasm

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For pre- and post-procedure evaluation of bypass grafts, stents and vascular anastomoses Vascular invasion or compression by an abdominal tumor Vasculitis Venous thrombosis or occlusion Evaluation of suspected thrombosis or occlusion of major abdominal vessels, including portal and systemic venous systems

Ultrasound is recommended as the initial study to evaluate the following: o Hepatic or portal vein thrombosis o Renal vein thrombosis o Splenic vein thrombosis

♦ List may not be exclusive

Prior Authorization Information Pre-service approval is required for all inpatient services for all products. See below for situations where prior authorization may be required or may not be required. Yes indicates that prior authorization is required. No indicates that prior authorization is not required. N/A indicates that this service is primarily performed in an inpatient setting. Outpatient

Commercial Managed Care (HMO and POS) Commercial PPO and Indemnity

The requirements of BCBSMA Radiology Management Program may require a precertification/prior authorization via AIM Specialty Health. These requirements are member-specific: please verify member eligibility and requirements through Online Services by logging onto Provider Central (www.bluecrossma.com/provider). Refer to our Quick Tip https://provider.bluecrossma.com/ProviderHome/portal/home/office-resources/plans-and-products/bluecard-and-out-of-area-programs/ for an overview of pre-certification and prior authorization requirements. Ordering clinicians should request pre-certification from AIM Specialty Health at www.aimspecialtyhealth.com or call 1-866-745-1783 (when applicable).

Policy History Date Action 3/2018 Clarified coding information.

1/2018 Prior authorization information for Medicare HMO Blue and Medicare PPO Blue removed. 1/1/2018

11/2017 Clinical literature was reviewed.

10/2017 Clarified coding information.

9/2017 Medically necessary criteria revised. Effective 9/5/2017. Based on AIM Clinical Appropriateness Guidelines: Advanced Imaging Appropriate Use Criteria: Imaging of the Abdomen and Pelvis. Effective Date: September 5, 2017.

5/2017 Prior Authorization Information clarified. 5/1/2017

4/2017 Policy updated to include pediatric imaging indications. Effective 4/1/2017. Adopted AIM Clinical Appropriateness Guidelines: Advanced Imaging Appropriate Use Criteria: Pediatric Imaging. Effective Date: February 20, 2017.

11/2016 New medically necessary indications. Effective 11/1/2016. Adopted AIM Clinical Appropriateness Guidelines: Advanced Imaging Appropriate Use Criteria: Imaging of the Abdomen and Pelvis. Clarified coding information. Effective Date: October 31, 2016.

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10/2016 Coding information clarified.

7/2016 New medical policy describing medically necessary indications. Effective 7/1/2016. Adopted AIM Clinical Appropriateness Guidelines: Advanced Imaging Appropriate Use Criteria: Imaging of the Abdomen and Pelvis. Effective Date: May 4, 2015.

Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

References

Adults 1. Holmes DR Jr, Mack MJ, Kaul S, et al. 2012 ACCF/AATS/SCAI/STS expert consensus document on

transcatheter aortic valve replacement. J Am Coll Cardiol. 2012 Mar 27;59(13):1200-1254. 2. Zhang LJ, Yang GF, Qi J, Shen W. Renal artery aneurysm: diagnosis and surveillance with

multidetector-row computed tomography. Acta Radiol. 2007;48(3):274-279.

CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member. Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable. The following codes are included below for informational purposes only; this is not an all-inclusive list. The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity: CPT Codes CPT codes:

Code Description

74174 Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing

The following ICD Diagnosis Codes are considered medically necessary when submitted with the

CPT codes above if medical necessity criteria are met:

ICD-10 Diagnosis Coding ICD-10 Code ICD-10 Name

C16.0 Malignant neoplasm of cardia

C16.1 Malignant neoplasm of fundus of stomach

C16.2 Malignant neoplasm of body of stomach

C16.3 Malignant neoplasm of pyloric antrum

C16.4 Malignant neoplasm of pylorus

C16.5 Malignant neoplasm of lesser curvature of stomach, unspecified

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C16.6 Malignant neoplasm of greater curvature of stomach, unspecified

C16.8 Malignant neoplasm of overlapping sites of stomach

C16.9 Malignant neoplasm of stomach, unspecified

C17.0 Malignant neoplasm of duodenum

C17.1 Malignant neoplasm of jejunum

C17.2 Malignant neoplasm of ileum

C17.3 Meckel's diverticulum, malignant

C17.8 Malignant neoplasm of overlapping sites of small intestine

C17.9 Malignant neoplasm of small intestine, unspecified

C18.0 Malignant neoplasm of cecum

C18.1 Malignant neoplasm of appendix

C18.2 Malignant neoplasm of ascending colon

C18.3 Malignant neoplasm of hepatic flexure

C18.4 Malignant neoplasm of transverse colon

C18.5 Malignant neoplasm of splenic flexure

C18.6 Malignant neoplasm of descending colon

C18.7 Malignant neoplasm of sigmoid colon

C18.8 Malignant neoplasm of overlapping sites of colon

C18.9 Malignant neoplasm of colon, unspecified

C19 Malignant neoplasm of rectosigmoid junction

C20 Malignant neoplasm of rectum

C21.0 Malignant neoplasm of anus, unspecified

C21.1 Malignant neoplasm of anal canal

C21.2 Malignant neoplasm of cloacogenic zone

C21.8 Malignant neoplasm of overlapping sites of rectum, anus and anal canal

C22.0 Liver cell carcinoma

C22.1 Intrahepatic bile duct carcinoma

C22.2 Hepatoblastoma

C22.3 Angiosarcoma of liver

C22.4 Other sarcomas of liver

C22.7 Other specified carcinomas of liver

C22.8 Malignant neoplasm of liver, primary, unspecified as to type

C22.9 Malignant neoplasm of liver, not specified as primary or secondary

C23 Malignant neoplasm of gallbladder

C24.0 Malignant neoplasm of extrahepatic bile duct

C24.1 Malignant neoplasm of ampulla of Vater

C24.8 Malignant neoplasm of overlapping sites of biliary tract

C24.9 Malignant neoplasm of biliary tract, unspecified

C25.0 Malignant neoplasm of head of pancreas

C25.1 Malignant neoplasm of body of pancreas

C25.2 Malignant neoplasm of tail of pancreas

C25.3 Malignant neoplasm of pancreatic duct

C25.4 Malignant neoplasm of endocrine pancreas

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C25.7 Malignant neoplasm of other parts of pancreas

C25.8 Malignant neoplasm of overlapping sites of pancreas

C25.9 Malignant neoplasm of pancreas, unspecified

C41.4 Malignant neoplasm of pelvic bones, sacrum and coccyx

C65.1 Malignant neoplasm of right renal pelvis

C65.2 Malignant neoplasm of left renal pelvis

C65.9 Malignant neoplasm of unspecified renal pelvis

C76.2 Malignant neoplasm of abdomen

C76.3 Malignant neoplasm of pelvis

C76.8 Malignant neoplasm of other specified ill-defined sites

C79.00 Secondary malignant neoplasm of unspecified kidney and renal pelvis

C79.01 Secondary malignant neoplasm of right kidney and renal pelvis

C79.02 Secondary malignant neoplasm of left kidney and renal pelvis

C79.51 Secondary malignant neoplasm of bone

C79.89 Secondary malignant neoplasm of other specified sites

D09.8 Carcinoma in situ of other specified sites

I70.0 Atherosclerosis of aorta

I70.1 Atherosclerosis of renal artery

I71.00 Dissection of unspecified site of aorta

I71.02 Dissection of abdominal aorta

I71.03 Dissection of thoracoabdominal aorta

I71.1 Thoracic aortic aneurysm, ruptured

I71.2 Thoracic aortic aneurysm, without rupture

I71.3 Abdominal aortic aneurysm, ruptured

I71.4 Abdominal aortic aneurysm, without rupture

I71.5 Thoracoabdominal aortic aneurysm, ruptured

I71.6 Thoracoabdominal aortic aneurysm, without rupture

I71.8 Aortic aneurysm of unspecified site, ruptured

I71.9 Aortic aneurysm of unspecified site, without rupture

I72.2 Aneurysm of renal artery

I72.3 Aneurysm of iliac artery

I72.4 Aneurysm of artery of lower extremity

I72.8 Aneurysm of other specified arteries

I72.9 Aneurysm of unspecified site

I74.01 Saddle Embolus Of Abdominal Aorta

I74.09 Other Arterial Embolism And Thrombosis Of Abdominal Aorta

I74.5 Embolism and thrombosis of iliac artery

I77.0 Arteriovenous fistula, acquired

I77.1 Stricture of artery

I77.2 Rupture of artery

I77.3 Arterial fibromuscular dysplasia

I77.4 Celiac artery compression syndrome

I77.5 Necrosis of artery

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I77.6 Arteritis, unspecified

I77.70 Dissection of unspecified artery

I77.72 Dissection of iliac artery

I77.73 Dissection of renal artery

I77.74 Dissection of vertebral artery

I77.79 Dissection of other specified artery

I77.811 Abdominal aortic ectasia

I77.812 Thoracoabdominal aortic ectasia

I77.819 Aortic ectasia, unspecified site

I77.89 Other specified disorders of arteries and arterioles

I77.9 Disorder of arteries and arterioles, unspecified

I79.0 Aneurysm of aorta in diseases classified elsewhere

I81 Portal vein thrombosis

I82.0 Budd-Chiari syndrome

I82.220 Acute embolism and thrombosis of inferior vena cava

I82.221 Chronic embolism and thrombosis of inferior vena cava

I82.290 Acute Embolism And Thrombosis Of Other Thoracic Veins

I82.3 Embolism and thrombosis of renal vein

I82.609 Acute Embolism And Thrombosis Of Unspecified Veins Of Unspecified Upper Extremity

I82.619 Acute Embolism And Thrombosis Of Superficial Veins Of Unspecified Upper Extremity

I82.629 Acute Embolism And Thrombosis Of Deep Veins Of Unspecified Upper Extremity

I82.890 Acute Embolism And Thrombosis Of Other Specified Veins

I82.A19 Acute Embolism And Thrombosis Of Unspecified Axillary Vein

I82.C19 Acute Embolism And Thrombosis Of Unspecified Internal Jugular Vein

I86.2 Pelvic varices

I86.3 Vulval varices

I87.1 Compression of vein

K55.011 Focal (segmental) acute (reversible) ischemia of small intestine

K55.012 Diffuse acute (reversible) ischemia of small intestine

K55.019 Acute (reversible) ischemia of small intestine, extent unspecified

K55.021 Focal (segmental) acute infarction of small intestine

K55.022 Diffuse acute infarction of small intestine

K55.029 Acute infarction of small intestine, extent unspecified

K55.031 Focal (segmental) acute (reversible) ischemia of large intestine

K55.032 Diffuse acute (reversible) ischemia of large intestine

K55.039 Acute (reversible) ischemia of large intestine, extent unspecified

K55.041 Focal (segmental) acute infarction of large intestine

K55.042 Diffuse acute infarction of large intestine

K55.049 Acute infarction of large intestine, extent unspecified

K55.051 Focal (segmental) acute (reversible) ischemia of intestine, part unspecified

K55.052 Diffuse acute (reversible) ischemia of intestine, part unspecified

K55.059 Acute (reversible) ischemia of intestine, part and extent unspecified

K55.061 Focal (segmental) acute infarction of intestine, part unspecified

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K55.062 Diffuse acute infarction of intestine, part unspecified

K55.069 Acute infarction of intestine, part and extent unspecified

K55.1 Chronic vascular disorders of intestine

K55.30 Necrotizing enterocolitis, unspecified

K55.31 Stage 1 necrotizing enterocolitis

K55.32 Stage 2 necrotizing enterocolitis

K55.33 Stage 3 necrotizing enterocolitis

K76.89 Other specified diseases of liver

K92.2 Gastrointestinal hemorrhage, unspecified

M31.4 Aortic arch syndrome [Takayasu]

M54.9 Dorsalgia, unspecified

N28.89 Other specified disorders of kidney and ureter

N48.89 Other specified disorders of penis

N50.1 Vascular disorders of male genital organs

N83.6 Hematosalpinx

N83.8 Other noninflammatory disorders of ovary, fallopian tube and broad ligament

N85.7 Hematometra

N94.89 Other specified conditions associated with female genital organs and menstrual cycle

Q26.5 Anomalous portal venous connection

Q26.6 Portal vein-hepatic artery fistula

Q27.33 Arteriovenous malformation of digestive system vessel

Q27.34 Arteriovenous malformation of renal vessel

R03.1 Nonspecific low blood-pressure reading

R06.02 Shortness of breath

R06.03 Acute respiratory distress

R06.89 Other abnormalities of breathing

R06.9 Unspecified abnormalities of breathing

R07.89 Other chest pain

R07.9 Chest pain, unspecified

R10.10 Upper abdominal pain, unspecified

R10.11 Right upper quadrant pain

R10.12 Left upper quadrant pain

R10.13 Epigastric pain

R10.30 Lower abdominal pain, unspecified

R10.31 Right lower quadrant pain

R10.32 Left lower quadrant pain

R10.33 Periumbilical pain

R10.84 Generalized abdominal pain

R10.9 Unspecified abdominal pain

R47.9 Unspecified speech disturbances

R49.0 Dysphonia

R53.1 Weakness

R55 Syncope and collapse

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R58 Hemorrhage, not elsewhere classified

S31.609A Unspecified open wound of abdominal wall, unspecified quadrant with penetration into peritoneal cavity, initial encounter

S31.609D Unspecified open wound of abdominal wall, unspecified quadrant with penetration into peritoneal cavity, subsequent encounter

S31.609S Unspecified open wound of abdominal wall, unspecified quadrant with penetration into peritoneal cavity, sequela

S35.00XA Unspecified injury of abdominal aorta, initial encounter

S35.00XD Unspecified injury of abdominal aorta, subsequent encounter

S35.00XS Unspecified injury of abdominal aorta, sequela

S35.01XA Minor laceration of abdominal aorta, initial encounter

S35.01XD Minor laceration of abdominal aorta, subsequent encounter

S35.01XS Minor laceration of abdominal aorta, sequela

S35.02XA Major laceration of abdominal aorta, initial encounter

S35.02XD Major laceration of abdominal aorta, subsequent encounter

S35.02XS Major laceration of abdominal aorta, sequela

S35.09XA Other injury of abdominal aorta, initial encounter

S35.09XD Other injury of abdominal aorta, subsequent encounter

S35.09XS Other injury of abdominal aorta, sequela

S35.311A Laceration of portal vein, initial encounter

S35.311D Laceration of portal vein, subsequent encounter

S35.311S Laceration of portal vein, sequela

S35.318A Other specified injury of portal vein, initial encounter

S35.318D Other specified injury of portal vein, subsequent encounter

S35.318S Other specified injury of portal vein, sequela

S35.319A Unspecified injury of portal vein, initial encounter

S35.319D Unspecified injury of portal vein, subsequent encounter

S35.319S Unspecified injury of portal vein, sequela

S35.321A Laceration of splenic vein, initial encounter

S35.321D Laceration of splenic vein, subsequent encounter

S35.321S Laceration of splenic vein, sequela

S35.328A Other specified injury of splenic vein, initial encounter

S35.328D Other specified injury of splenic vein, subsequent encounter

S35.328S Other specified injury of splenic vein, sequela

S35.329A Unspecified injury of splenic vein, initial encounter

S35.329D Unspecified injury of splenic vein, subsequent encounter

S35.329S Unspecified injury of splenic vein, sequela

S35.331A Laceration of superior mesenteric vein, initial encounter

S35.331D Laceration of superior mesenteric vein, subsequent encounter

S35.331S Laceration of superior mesenteric vein, sequela

S35.338A Other specified injury of superior mesenteric vein, initial encounter

S35.338D Other specified injury of superior mesenteric vein, subsequent encounter

S35.338S Other specified injury of superior mesenteric vein, sequela

S35.339A Unspecified injury of superior mesenteric vein, initial encounter

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S35.339D Unspecified injury of superior mesenteric vein, subsequent encounter

S35.339S Unspecified injury of superior mesenteric vein, sequela

S35.341A Laceration of inferior mesenteric vein, initial encounter

S35.341D Laceration of inferior mesenteric vein, subsequent encounter

S35.341S Laceration of inferior mesenteric vein, sequela

S35.348A Other specified injury of inferior mesenteric vein, initial encounter

S35.348D Other specified injury of inferior mesenteric vein, subsequent encounter

S35.348S Other specified injury of inferior mesenteric vein, sequela

S35.349A Unspecified injury of inferior mesenteric vein, initial encounter

S35.349D Unspecified injury of inferior mesenteric vein, subsequent encounter

S35.349S Unspecified injury of inferior mesenteric vein, sequela

S35.511A Injury of right iliac artery, initial encounter

S35.511D Injury of right iliac artery, subsequent encounter

S35.511S Injury of right iliac artery, sequela

S35.512A Injury of left iliac artery, initial encounter

S35.512D Injury of left iliac artery, subsequent encounter

S35.512S Injury of left iliac artery, sequela

S35.513A Injury of unspecified iliac artery, initial encounter

S35.513D Injury of unspecified iliac artery, subsequent encounter

S35.513S Injury of unspecified iliac artery, sequela

S35.8x9A Unspecified injury of other blood vessels at abdomen, lower back and pelvis level, initial encounter

S35.8x9D Unspecified injury of other blood vessels at abdomen, lower back and pelvis level, subsequent encounter

S35.8x9S Unspecified injury of other blood vessels at abdomen, lower back and pelvis level, sequela

S36.112A Contusion of liver, initial encounter

S36.112D Contusion of liver, subsequent encounter

S36.112S Contusion of liver, sequela

S36.113A Laceration of liver, unspecified degree, initial encounter

S36.113D Laceration of liver, unspecified degree, subsequent encounter

S36.113S Laceration of liver, unspecified degree, sequela

S36.114A Minor laceration of liver, initial encounter

S36.114D Minor laceration of liver, subsequent encounter

S36.114S Minor laceration of liver, sequela

S36.115A Moderate laceration of liver, initial encounter

S36.115D Moderate laceration of liver, subsequent encounter

S36.115S Moderate laceration of liver, sequela

S36.116A Major laceration of liver, initial encounter

S36.116D Major laceration of liver, subsequent encounter

S36.116S Major laceration of liver, sequela

S36.118A Other injury of liver, initial encounter

S36.118D Other injury of liver, subsequent encounter

S36.118S Other injury of liver, sequela

S36.119A Unspecified injury of liver, initial encounter

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S36.119D Unspecified injury of liver, subsequent encounter

S36.119S Unspecified injury of liver, sequela

T82.330A Leakage of aortic (bifurcation) graft (replacement), initial encounter

T85.810D Embolism due to nervous system prosthetic devices, implants and grafts, subsequent encounter

T85.810S Embolism due to nervous system prosthetic devices, implants and grafts, sequela

T85.818A Embolism due to other internal prosthetic devices, implants and grafts, initial encounter

T85.818D Embolism due to other internal prosthetic devices, implants and grafts, subsequent encounter

T85.818S Embolism due to other internal prosthetic devices, implants and grafts, sequela

T85.830A Hemorrhage due to nervous system prosthetic devices, implants and grafts, initial encounter

T85.830D Hemorrhage due to nervous system prosthetic devices, implants and grafts, subsequent encounter

T85.830S Hemorrhage due to nervous system prosthetic devices, implants and grafts, sequela

T85.838A Hemorrhage due to other internal prosthetic devices, implants and grafts, initial encounter

T85.838D Hemorrhage due to other internal prosthetic devices, implants and grafts, subsequent encounter

T85.838S Hemorrhage due to other internal prosthetic devices, implants and grafts, sequela

T85.840A Pain due to nervous system prosthetic devices, implants and grafts, initial encounter

T85.840D Pain due to nervous system prosthetic devices, implants and grafts, subsequent encounter

T85.840S Pain due to nervous system prosthetic devices, implants and grafts, sequela

T85.848A Pain due to other internal prosthetic devices, implants and grafts, initial encounter

T85.848D Pain due to other internal prosthetic devices, implants and grafts, subsequent encounter

T85.848S Pain due to other internal prosthetic devices, implants and grafts, sequela

Z01.818 Encounter for other preprocedural examination

Z82.49 Family history of ischemic heart disease and other diseases of the circulatory system

Endnotes 1 Based on AIM Specialty Health Clinical Appropriateness Guidelines: Advanced Imaging Appropriate Use Criteria: Imaging of the Abdomen and Pelvis. Based on AIM Clinical Appropriateness Guidelines: Advanced Imaging Appropriate Use Criteria: Pediatric Imaging.