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2025 CPT code 70481

Computed tomography (CT) scan of the orbit, sella, posterior fossa, or inner/middle/outer ear with contrast material.

Follow all CPT coding guidelines, particularly those related to imaging studies and contrast administration.Adhere to payer-specific coding guidelines for the most accurate billing.

Modifiers 26 (professional component only) and TC (technical component only) may be appended, depending on the payer's policy and whether the physician is billing for professional interpretation and/or technical aspects of the study separately. Modifiers 59, 76, 77, etc. may apply for additional procedures.

Medical necessity is established when the ordering physician documents a clear clinical indication for the CT scan with contrast. This could include suspected pathology (e.g., tumor, infection, trauma), evaluation of symptoms (e.g., hearing loss, vision changes, headache), or pre-operative planning.The specific medical necessity guidelines will depend on payer and potentially specific local guidelines.

The radiologist is responsible for administering the contrast material, positioning the patient, operating the CT scanner, acquiring the images, and interpreting the results to generate a diagnostic report.

IMPORTANT:70480 (without contrast), 70482 (with and without contrast).Note that oral or rectal contrast is considered "without contrast" for coding purposes.Separate codes may apply for contrast material supply (e.g., HCPCS codes or 99070).

In simple words: A CT scan of the eye socket, the base of the skull, or the inner, middle, or outer ear is performed using a special dye to get clearer images. This helps doctors find tumors or other problems.

This CPT code encompasses a computed tomography (CT) examination of the orbit, sella turcica, posterior fossa, or the inner, middle, and outer ear structures.The procedure involves the intravenous administration of contrast material to enhance visualization of the target anatomy.The radiologist utilizes a CT scanner to acquire cross-sectional images, which are then processed by a computer to generate detailed anatomical slices. This imaging aids in the detection and characterization of tumors, anatomical abnormalities, and foreign bodies within the specified regions.

Example 1: A patient presents with suspected orbital tumor.A CT scan with contrast is ordered to assess the extent of the tumor and its relationship to surrounding structures., A patient experiences sudden hearing loss. A CT scan with contrast of the inner and middle ear is performed to rule out any structural abnormalities or masses affecting the hearing mechanism., A patient sustains a blow to the head and presents with symptoms suggestive of a basilar skull fracture. A CT scan with contrast of the posterior fossa and sella turcica is used to assess the extent of the injury and look for potential intracranial bleeding or damage.

* Physician order specifying the need for CT scan with contrast.* Patient history and clinical indication for the study.* Radiologist's report detailing findings, including image interpretation and any identified abnormalities.* Documentation of contrast type and amount administered.* Any relevant allergy information.

** Always refer to the most up-to-date CPT codebook and payer guidelines for accurate coding and billing.This information is for guidance only and does not constitute medical advice.Be sure to code accurately to avoid denials and other billing issues.

  • Revenue Code: I2A (Example - check payer specific revenue codes)
  • RVU: Refer to CMS's current Relative Value Units (RVUs) and conversion factors for the most accurate reimbursement information.This will vary based on location (geographic practice cost indices) and other factors.
  • Payment Status: Active
  • Modifier TC rule: Modifier TC applies only when billing for the technical component separately from the professional component.Hospital policies often dictate this, while independent radiology practices may apply the modifier differently.
  • Fee Schedule: Historical fee schedules are not consistently available publicly.They vary significantly by payer, location, and time period.For historical fee schedule data, consult historical fee-schedule databases specific to your payer and the relevant time frame.
  • Specialties:Radiology, Neurosurgery, Ophthalmology, Otolaryngology
  • Place of Service:Office, Hospital (Inpatient and Outpatient), Ambulatory Surgery Center, Imaging Center
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