How To Use CPT Code 70481

CPT 70481 describes the use of computed tomography (CT) to examine various structures in the head and neck, including the orbit, sella or posterior fossa, and the outer, middle, or inner ear. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 70481?

CPT 70481 is a code used to describe a diagnostic radiology procedure known as computed tomography (CT). This procedure is used to examine specific areas in the head and neck, such as the orbit (eye socket), sella or posterior fossa (base of the skull), and the outer, middle, or inner ear. During the CT scan, contrast material(s) may be administered to improve the visibility of internal structures or organs.

2. Official Description

The official description of CPT code 70481 is: ‘Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material(s).’ This code specifically refers to the use of CT imaging with the administration of contrast material(s) to examine the specified areas in the head and neck.

3. Procedure

1. The procedure begins with the provider administering contrast material to the patient.
2. The patient is then positioned on a table that slides into the CT scanner.
3. While the patient remains still, the provider uses the CT scanner to take X-ray images of the targeted anatomy, such as the orbit, sella, posterior fossa, or ear structures.
4. The CT scanner creates computer-generated cross-sectional images called slices, which help the provider identify any tumors, anatomical abnormalities, or foreign bodies.

4. Qualifying circumstances

CPT 70481 is used when a CT scan is performed on the orbit, sella, posterior fossa, or outer, middle, or inner ear, and contrast material(s) are administered. This procedure is typically performed to diagnose, manage, and treat diseases or conditions affecting these specific areas in the head and neck.

5. When to use CPT code 70481

CPT code 70481 should be used when a CT scan is performed on the specified areas in the head and neck, and contrast material(s) are administered. It is important to ensure that the documentation supports the use of contrast material(s) during the procedure to accurately report this code.

6. Documentation requirements

To support a claim for CPT 70481, the provider must document the following information:

• Specific areas in the head and neck examined (orbit, sella, posterior fossa, or outer, middle, or inner ear)
• Administration of contrast material(s)
• Date and time of the procedure
• Any specific findings or abnormalities observed during the CT scan
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 70481, it is important to ensure that the documentation supports the use of contrast material(s) during the CT scan. Additionally, providers may need to separately report the administration of contrast material(s) using appropriate supply codes or HCPCS Level II codes, depending on payer policies. Modifier 26 should be appended to the radiology code if only the physician’s interpretation is being reported, while modifier TC should be appended if only the technical component is being reported. However, payer policies may exempt hospitals from appending modifier TC.

8. Historical information

CPT 70481 was added to the Current Procedural Terminology system on January 1, 1990. The code underwent a change on January 1, 2003, with the addition of the term ‘computerized axial tomography’ to the code description.

9. Examples

1. A patient undergoes a CT scan of the orbit with contrast material to evaluate a suspected tumor.
2. A CT scan of the sella is performed on a patient with hormonal imbalances, using contrast material to assess the pituitary gland.
3. A CT scan of the posterior fossa is conducted on a patient with movement disorders, with contrast material to identify any abnormalities in the brainstem and cerebellum.
4. A CT scan of the outer ear is performed on a patient with recurrent infections, using contrast material to assess the presence of any foreign bodies.
5. A CT scan of the middle ear is conducted on a patient with hearing loss, with contrast material to evaluate the structures within the ear.