How To Use CPT Code 70482

CPT 70482 describes the use of computed tomography (CT) to examine various structures in the head and neck region. 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 70482?

CPT 70482 is a code used to describe a specific diagnostic radiology procedure known as computed tomography (CT). This procedure is used to examine the orbit, sella, posterior fossa, or outer, middle, or inner ear. It involves taking images of these structures using X-ray technology and a computer to create cross-sectional images called slices. CPT 70482 specifically refers to CT scans performed without the use of contrast material, followed by contrast material(s) and further sections.

2. Official Description

The official description of CPT code 70482 is: ‘Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material, followed by contrast material(s) and further sections.’ This code does not include 3D rendering, which is reported separately using codes 76376 and 76377.

3. Procedure

1. The patient is positioned on a table that slides into the CT scanner.
2. The CT scanner rotates an X-ray tube and X-ray detectors around the patient, producing tomograms (cross-sectional images) of the target anatomy.
3. Initial images are taken without the administration of contrast material.
4. The provider then administers contrast material, either intravenously or through other routes, depending on the specific requirements of the examination.
5. Additional images are taken after the administration of contrast material.
6. A computer processes the images to create slices, which help the provider identify tumors, anatomical abnormalities, and foreign bodies.

4. Qualifying circumstances

CPT 70482 is used when a CT scan is performed on the orbit, sella, posterior fossa, or outer, middle, or inner ear. The use of contrast material is an important qualifying circumstance for this code. The contrast material can be administered intravenously, intraarticularly, or intrathecally. It is important to note that the use of oral or rectal contrast does not qualify for reporting CPT 70482, as the radiology service already includes these contrast materials.

5. When to use CPT code 70482

CPT code 70482 should be used when a provider performs a CT scan on the specified structures without the use of contrast material, followed by the administration of contrast material and further sections. It is important to ensure that the specific anatomical areas mentioned in the code description are included in the examination. If the CT scan does not meet these criteria, a different code should be used to accurately report the service.

6. Documentation requirements

To support a claim for CPT 70482, the provider must document the following information:

• The specific structures examined (orbit, sella, posterior fossa, or outer, middle, or inner ear)
• Whether contrast material was administered and the route of administration
• Date and time of the CT scan
• Any relevant findings or abnormalities identified
• Signature of the provider performing the service

7. Billing guidelines

When billing for CPT 70482, it is important to ensure that the CT scan was performed without contrast material, followed by the administration of contrast material and further sections. If the contrast material is administered orally or rectally, it should not be separately reported. However, if the contrast material is administered intravenously, intraarticularly, or intrathecally, it may be separately reportable using appropriate codes. It is also important to follow payer policies regarding the reporting of contrast material and any applicable supply codes.

8. Historical information

CPT 70482 was added to the Current Procedural Terminology system on January 1, 1990. There have been historical changes to the code, including a code change on January 1, 2003, which modified the description to its current form.

9. Examples

1. A patient undergoes a CT scan of the orbit without contrast material, followed by the administration of contrast material and further sections to evaluate a suspected orbital tumor.
2. A provider performs a CT scan of the sella without contrast material, followed by the administration of contrast material and further sections to assess a patient with suspected pituitary gland abnormalities.
3. A CT scan of the posterior fossa is performed without contrast material, followed by the administration of contrast material and further sections to evaluate a patient with symptoms of cerebellar dysfunction.
4. A provider performs a CT scan of the outer ear without contrast material, followed by the administration of contrast material and further sections to assess a patient with suspected external auditory canal abnormalities.
5. A CT scan of the middle ear is performed without contrast material, followed by the administration of contrast material and further sections to evaluate a patient with chronic otitis media.
6. A provider performs a CT scan of the inner ear without contrast material, followed by the administration of contrast material and further sections to assess a patient with suspected vestibular schwannoma.
7. A CT scan of the orbit, sella, and posterior fossa is performed without contrast material, followed by the administration of contrast material and further sections to evaluate a patient with multiple cranial nerve palsies.