How To Use CPT Code 9004F

CPT 9004F describes the presence of an aortic aneurysm with a maximum diameter of 6.0 cm or greater on a computed tomographic (CT) imaging study. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples.

1. What is CPT Code 9004F?

CPT 9004F can be used to indicate the presence of an abdominal aortic aneurysm (AAA) with a maximum diameter of 6.0 cm or greater on a CT imaging study. This code is used to document the measurement of the aneurysm and is important for diagnosing and managing the condition.

2. Official Description

The official description of CPT code 9004F is: ‘Aortic aneurysm 6.0 cm or greater maximum diameter on centerline formatted CT or minor diameter on axial formatted CT (NMA-No Measure Associated)’

3. Procedure

1. The provider performs a CT imaging study of the patient’s abdomen to assess the aorta.
2. The maximum diameter of the aortic aneurysm is measured on the centerline formatted CT or the minor diameter is measured on the axial formatted CT.
3. If the measurement is 6.0 cm or greater, the provider documents the presence of an aortic aneurysm using CPT code 9004F.

4. Qualifying circumstances

CPT 9004F is used when a patient has an abdominal aortic aneurysm with a maximum diameter of 6.0 cm or greater. The measurement is obtained from a CT imaging study, which provides a detailed image of the aorta. This code is specific to abdominal aortic aneurysms and does not apply to aneurysms in other areas of the body.

5. When to use CPT code 9004F

CPT code 9004F should be used when the provider has documented the presence of an abdominal aortic aneurysm with a maximum diameter of 6.0 cm or greater on a CT imaging study. It is important to accurately measure the diameter of the aneurysm to determine the appropriate treatment and management plan for the patient.

6. Documentation requirements

To support a claim for CPT code 9004F, the provider must document the following information:

• Presence of an abdominal aortic aneurysm
• Maximum diameter of the aneurysm measured on the CT imaging study
• Type of CT imaging study performed (centerline formatted or axial formatted)

7. Billing guidelines

When billing for CPT code 9004F, ensure that the provider has accurately measured the diameter of the abdominal aortic aneurysm on a CT imaging study. This code should be reported only for aneurysms with a maximum diameter of 6.0 cm or greater. It is important to follow the specific guidelines for reporting this code and to ensure accurate documentation to support the claim.

8. Historical information

CPT code 9004F was added to the Current Procedural Terminology system on January 1, 2014. There have been no updates to the code since its addition.

9. Examples

1. A patient undergoes a CT imaging study of the abdomen, and the provider documents the presence of an abdominal aortic aneurysm with a maximum diameter of 6.5 cm. CPT code 9004F is used to indicate the measurement of the aneurysm.
2. During a routine check-up, a patient with a history of smoking undergoes a CT imaging study, which reveals an abdominal aortic aneurysm with a maximum diameter of 7.2 cm. The provider uses CPT code 9004F to document the measurement of the aneurysm.
3. An elderly patient presents with abdominal pain, and a CT imaging study shows the presence of an abdominal aortic aneurysm with a maximum diameter of 6.8 cm. The provider reports CPT code 9004F to indicate the measurement of the aneurysm.
4. A patient with a family history of abdominal aortic aneurysms undergoes a CT imaging study, which reveals the presence of an aneurysm with a maximum diameter of 6.3 cm. The provider uses CPT code 9004F to document the measurement of the aneurysm.
5. During a routine screening, a patient is found to have an abdominal aortic aneurysm with a maximum diameter of 6.1 cm on a CT imaging study. The provider reports CPT code 9004F to indicate the measurement of the aneurysm.