How To Use CPT Code 70491

CPT 70491 is a medical code used for computed tomography (CT) scans of the soft tissue neck with contrast material. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 70491 procedures.

1. What is CPT 70491?

CPT 70491 is a medical code used by healthcare providers to bill for computed tomography (CT) scans of the soft tissue neck with contrast material. This code is used when a provider performs a CT scan to examine the neck’s soft tissue structures and administers contrast material to enhance the images. The images obtained from the CT scan help the provider identify tumors, anatomic abnormalities, and foreign bodies in the neck’s soft tissue structures.

2. 70491 CPT code description

The official description of CPT code 70491 is: “Computed tomography, soft tissue neck; with contrast material(s)”.

3. Procedure

  1. The patient is positioned on the CT scanner table.
  2. Contrast material is injected intravenously, intraarticularly, or intrathecally, depending on the specific case and the provider’s preference.
  3. The patient remains still while the CT scanner takes cross-sectional images of the neck’s soft tissue structures.
  4. A computer processes the scans and creates images called slices, which help the provider identify any abnormalities or foreign bodies in the neck’s soft tissue structures.

4. Qualifying circumstances

Patients eligible to receive CPT code 70491 services are those who require a detailed examination of the soft tissue structures in their neck. This may include patients with suspected tumors, anatomic abnormalities, or foreign bodies in the neck’s soft tissue structures. Additionally, patients with a history of neck trauma or those experiencing unexplained neck pain or swelling may also be eligible for this procedure.

5. When to use CPT code 70491

It is appropriate to bill the 70491 CPT code when a healthcare provider performs a CT scan of the soft tissue neck with contrast material to diagnose or evaluate a patient’s condition. This code should be used when the provider administers contrast material to enhance the images and provide a more detailed examination of the neck’s soft tissue structures.

6. Documentation requirements

To support a claim for CPT 70491, healthcare providers must document the following information:

  • Medical necessity for the CT scan, including the patient’s symptoms, history, and physical examination findings.
  • Type and route of contrast material administration.
  • Details of the CT scan procedure, including the patient’s positioning and the number of images obtained.
  • Findings and interpretation of the CT scan images, including any identified abnormalities or foreign bodies.
  • Impression and recommendations for further evaluation or treatment, if applicable.

7. Billing guidelines

When billing for CPT code 70491, healthcare providers should adhere to the following guidelines:

  • For CT imaging of the soft tissues of the neck without contrast, report CPT 70490.
  • For CT imaging of the soft tissues of the neck without and with contrast, report CPT 70492.
  • Depending on the payer’s guidelines, providers who supply contrast may also separately report the contrast using a 99070 supply code or a HCPCS Level II code. Check individual payers’ policies for contrast coverage and reportable supply codes.
  • If reporting only the physician’s interpretation for the radiology service, append professional component modifier 26 to the radiology code.
  • If reporting only the technical component for the radiology service, append modifier TC to the radiology code. Note that payer policy may exempt hospitals from appending modifier TC because the hospital’s portion is inherently technical.
  • Do not append a professional or technical modifier to the radiology code when reporting a global service in which one provider renders both the professional and technical components.

8. Historical information

CPT 70491 was added to the Current Procedural Terminology system on January 1, 1990. The code descriptor was changed on January 1, 2003, from “Computerized axial tomography, soft tissue neck; with contrast material(s)” to its current description.

9. Similar codes to CPT 70491

Five similar codes to CPT 70491 and how they differentiate are:

  • CPT 70490: This code is used for CT imaging of the soft tissues of the neck without contrast material.
  • CPT 70492: This code is used for CT imaging of the soft tissues of the neck without and with contrast material.
  • CPT 70450: This code is used for CT imaging of the head without contrast material.
  • CPT 70460: This code is used for CT imaging of the head with contrast material.
  • CPT 70470: This code is used for CT imaging of the head without and with contrast material.

10. Examples

Here are 10 detailed examples of CPT code 70491 procedures:

  1. A patient with a history of neck trauma and persistent neck pain undergoes a CT scan with contrast to evaluate for soft tissue injury.
  2. A patient with a suspected neck tumor undergoes a CT scan with contrast to assess the extent of the tumor and its relationship to surrounding structures.
  3. A patient with unexplained neck swelling undergoes a CT scan with contrast to identify any underlying anatomic abnormalities or foreign bodies.
  4. A patient with a history of thyroid cancer undergoes a CT scan with contrast to evaluate for possible recurrence or metastasis in the neck’s soft tissue structures.
  5. A patient with a suspected abscess in the neck undergoes a CT scan with contrast to confirm the diagnosis and guide treatment planning.
  6. A patient with a known vascular malformation in the neck undergoes a CT scan with contrast to assess the lesion’s size and location.
  7. A patient with a history of head and neck radiation therapy undergoes a CT scan with contrast to monitor for radiation-induced changes in the neck’s soft tissue structures.
  8. A patient with a suspected salivary gland stone undergoes a CT scan with contrast to confirm the diagnosis and determine the stone’s size and location.
  9. A patient with a history of neck surgery undergoes a CT scan with contrast to evaluate for postoperative complications or changes in the neck’s soft tissue structures.
  10. A patient with a suspected cervical spine infection undergoes a CT scan with contrast to assess the extent of the infection and its impact on surrounding soft tissue structures.

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