How To Use CPT Code 70488

CPT 70488 describes the use of computed tomography (CT) to examine the maxillofacial area, specifically the upper jaw and face structures. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 70488?

CPT 70488 can be used to describe the use of CT imaging to examine the maxillofacial area, which includes the upper jaw and face structures. This code is used when the provider takes images without administering contrast and then administers contrast before taking the remaining images.

2. Official Description

The official description of CPT code 70488 is: ‘Computed tomography, maxillofacial area; without contrast material, followed by contrast material(s) and further sections.’ This code does not include 3D rendering, which should be reported separately using codes 76376 and 76377.

3. Procedure

1. The provider positions the patient on the CT scanner table.
2. The provider takes X-ray images of the upper jaw and face structures, such as sinuses, without administering contrast.
3. The provider then administers contrast material.
4. Additional images are taken to capture the remaining sections of the maxillofacial area.
5. A computer generates cross-sectional images called slices, which help the provider identify tumors, anatomical abnormalities, and foreign bodies.

4. Qualifying circumstances

CPT 70488 is used when the provider needs to examine the maxillofacial area using CT imaging. This may be necessary to diagnose, manage, or treat diseases affecting the upper jaw and face structures. The use of contrast material is required for this code, and it can be administered intravascularly, intraarticularly, or intrathecally.

5. When to use CPT code 70488

CPT code 70488 should be used when a provider performs CT imaging of the maxillofacial area without contrast material, followed by the administration of contrast material and further sections. This code should not be used for similar studies without contrast (CPT 70486) or with contrast (CPT 70487).

6. Documentation requirements

To support a claim for CPT 70488, the provider must document the following information:

• Reason for the CT imaging of the maxillofacial area
• Details of the contrast material administered
• Date and time of the procedure
• Specific sections imaged
• Findings and any abnormalities identified
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 70488, ensure that the procedure involves CT imaging of the maxillofacial area without contrast material, followed by the administration of contrast material and further sections. It is important to note that if the provider administers oral or rectal contrast, the service should still be reported as without contrast. Additionally, depending on payer guidelines, the contrast material may be separately reportable using a supply code or a HCPCS Level II code.

8. Historical information

CPT 70488 was added to the Current Procedural Terminology system on January 1, 1990. The code was later changed on January 1, 2003, to its current description.

9. Examples

1. A patient undergoes CT imaging of the maxillofacial area without contrast material, followed by the administration of contrast material and further sections to evaluate a suspected tumor in the upper jaw.
2. A provider performs CT imaging of the maxillofacial area without contrast material, followed by the administration of contrast material and further sections to assess the extent of facial fractures in a trauma patient.
3. CT imaging of the maxillofacial area without contrast material is performed on a patient with chronic sinusitis, followed by the administration of contrast material and further sections to identify any anatomical abnormalities.
4. A provider uses CT imaging of the maxillofacial area without contrast material, followed by the administration of contrast material and further sections to evaluate the presence of foreign bodies in the upper jaw and face structures.
5. CT imaging of the maxillofacial area without contrast material is performed on a patient with suspected dental pathology, followed by the administration of contrast material and further sections to aid in diagnosis and treatment planning.