X417

PDF page 377 / D19

DIAGNOSTIC RADIOLOGY
 COMPUTED TOMOGRAPHY (CT)
                                                                              H         P
     Cardio-thoracic
       Cardio-thoracic CT is an imaging service of the cardio-thoracic structures including cardiac
       gating and 3D imaging post-processing, cardiac structure and morphology and computed
       tomographic angiography of coronary arteries (including native and anomalous coronary
       arteries, coronary bypass grafts) and requires imaging with contrast material(s) and which may
       be preceded by imaging without contrast material(s).
   X235 Cardio-thoracic ...................................................................... - 147.50
       Payment rules:
       1.X235 includes performance or supervision of the following activities when clinicallyindicated:
                i.  Administration of chronotropic medications (intravenous (IV) or oral beta blockers,
                     calcium channel blockers, ivabradine, etc.)
              ii. Venipuncture, IV insertion, and medication injection
         2.X235 is only eligible for payment when the service is performed using a minimum of a
           64-slice CT scanner.
         3.X235 is only eligible for payment when one or more of the following indications or clinical
           presentations are present:
              i. arterial and venous aneurysms;
              ii. traumatic injuries of arteries and veins;
              iii. arterial dissection and intramural hematoma;
              iv. arterial thromboembolism;
              v. vascular congenital anomalies and variants;
              vi. percutaneous and surgical, vascular interventions;
              vii. vascular infection, vasculitis, and collagen vascular disease;
              viii. sequelae of ischemic coronary disease (i.e. myocardial scarring, ventricular
                    aneurysms, thrombi);
              ix. cardiac tumours and thrombi;
              x. pericardial diseases;
              xi. cardiac function evaluation, especially when Magnetic Resonance Imaging (MRI) or
                    echocardiography are unsuitable
              xii. a clinically stable symptomatic patient with low to intermediate probability of
                    obstructive coronary disease;
              xiii. a clinically stable symptomatic patient who has planned surgery for valvular or
                    structural heart disease;
              xiv. a patient has low to intermediate probability of stent stenosis where the stent has a
                    diameter > 3mm; or
              xv. a patient with suspected congenital coronary artery anomalies that are clinically
                    relevant.
         4.X417, X406, X407, and X125 are not eligible for payment with X235.
         5.X235 includes all elements required to perform the study, including additional CT acquisition
           sequencing and/or post-processing, two or three dimensional reconstruction(s), and
           administration of contrast.
         6.X235 is not eligible for payment solely for coronary artery calcium scoring.

PDF page 379 / D21

DIAGNOSTIC RADIOLOGY
 COMPUTED TOMOGRAPHY (CT)
                                                                                                H    P
         [Commentary:
         1.For services where the heart vasculature and structures are not being visualized for the
           indications above, CT thorax (X406, X407 and/or X125) may be payable instead of X235.
         2.The maintenance of radiation dose should be consistent with the As Low As Responsibly
           Achievable principle and current standards under the direction of the radiologist Radiation
           Protection Officer.
         3.Ontario Clinical Guidance on Patient Selection and Prioritization for Coronary Computed
           Tomography Angiography can be found at https://www.corhealthontario.ca/Provincial-
           Clinical-Guidance-on-CCTA_Final.pdf] ]
     Abdomen
   X409 - without IV contrast..............................................................     -    86.60
   X410 - with IV contrast...................................................................   -    97.50
   X126 - with and without IV contrast ...............................................          -   108.30
     Pelvis
   X231 - without IV contrast..............................................................     -    86.60
   X232 - with IV contrast...................................................................   -    97.50
   X233 - with and without IV contrast ...............................................          -   108.30
   X234 CT colonography .................................................................... - 235.30
       Note:
       1.X234 includes all elements required to perform the study, including additional CT acquisition
         sequencing and/or post processing, two or three dimensional reconstruction(s),
         administration of contrast, and faecal tagging, if rendered.
         2.X417, X409, X410, X126, X231, X232, X233 are not eligible for payment with X234.
         Payment rules:
         1.CT colonography is an insured service only in the following circumstances:
            a.individuals who are at moderate risk for colorectal cancer based on family history and the
              patient refuses colonoscopy or where the patient has been advised of the relative risks
              and benefits of CT colonography and colonoscopy and the patient refuses colonoscopy;
            b.for surveillance examination in patients with a history of previous colonic neoplasm,
              where clinically appropriate;
            c.for diagnostic examination in symptomatic patients;
         [Commentary:
         Examples of relevant symptomatology include unexplained abdominal pain, diarrhea,
         constipation, gastrointestinal bleeding, anemia, intestinal obstruction, or weight loss.]
             d.when rendered for a patient for whom colonoscopy is technically infeasible, has been
                difficult in the past, or contraindicated;
             e.for patients who are at increased risk for complications during endoscopy such as,
                advanced age, sedation or anti-coagulation therapy, prior incomplete or difficult
                colonoscopy;
             f. when double contrast barium enema services are unavailable or regarded as inadequate
                for clinical or diagnostic reasons.

PDF page 381 / D23

DIAGNOSTIC RADIOLOGY
 COMPUTED TOMOGRAPHY (CT)
                                                                                                H    P
     Extremities (one or more)
   X412 - without IV contrast..............................................................     -    43.25
   X413 - with IV contrast...................................................................   -    64.95
   X127 - with and without IV contrast ...............................................          -    75.85
     Spine(s)
   X415 - without IV contrast..............................................................     -    86.60
   X416 - with IV contrast...................................................................   -    97.50
   X128 - with and without IV contrast ...............................................          -   108.30
   X168 CT guidance of biopsy ............................................................      -    42.50
   X417 Three dimensional CT acquisition sequencing, including post-
          processing (minimum of 60 slices; maximum 1 scan per
          patient per day) ..................................................................   -    32.70

PDF page 382 / D24

DIAGNOSTIC RADIOLOGY
MISCELLANEOUS EXAMINATIONS
                                                                                                       H             P
X151 Cordotomy, percutaneous.......................................................                   48.40         34.85
X163 Dacrocystogram......................................................................             29.60         11.60
  Discogram(s)
X164   - one or more levels ...........................................................               28.95         25.10
X167 Fistula or sinus........................................................................         21.50         17.55
X169 Laminogram, planigram, tomogram........................................                          39.90         12.40
X170 Laryngogram...........................................................................           28.95         23.00
X171 Lymphangiogram ....................................................................              49.00         25.15
X192 Mammary ductography ...........................................................                  25.05         11.60
  Mammogram
    No signs or symptoms
X172 - unilateral.............................................................................        28.05         21.15
X178 - bilateral...............................................................................       37.15         33.85
    Signs or symptoms
X184 - unilateral.............................................................................        28.05         21.15
X185 - bilateral...............................................................................       37.15         33.85
E448    - with 3D tomosynthesis, to X172C, X178C, X184C, or
          X185C ................................................................ add 50%
      [Commentary:
      “Signs or symptoms” pertains to individuals with identified signs or symptoms or follow-up of
      established disease.
      “No Signs or Symptoms” refers to individuals where the sole reason for the request for a
      mammogram is for an identified risk factor in accordance with clinical practice guidelines]
      Payment rules:
      X169 and X417 are not eligible for payment with X172, X178, X184, or X185.
      Claims submission instructions:
      Where a patient requires an additional mammogram on the same day using a different
      mammogram modality, consistent with practice guidelines, submit claims for payment for the
      additional mammogram using the manual review indicator.

Master, record 6727. Record Layout PDF, page 1.

X41720250401999999990000000000000000000000000000000000000032700000000327000

Auxiliary master fields are preserved as raw scaled values. The linked layout calls them zero-filled, but this edition contains non-zero values. They are not presented as final dollar fees or PDF units.