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Official Description

Computed tomography, maxillofacial area; without contrast material, followed by contrast material(s) and further sections

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

Computed tomography (CT), commonly known as a CT scan, is a diagnostic imaging procedure that utilizes advanced X-ray technology and computer processing to create detailed cross-sectional images of specific body areas. In the case of CPT® Code 70488, the focus is on the maxillofacial area, which encompasses critical structures such as the forehead, sinuses, nose, nasal bones, and the upper and lower jaws (maxilla and mandible). Notably, the orbit, which houses the eye, is excluded from this examination. The procedure begins with the patient being positioned on a CT examination table, where an initial scan is conducted to establish the starting point for subsequent imaging. During the CT scan, the table moves slowly through the scanner while multiple X-ray beams and electronic detectors rotate around the targeted area. This rotation allows for the measurement of radiation absorption, which is crucial for generating accurate images. The data collected is processed by a computer, resulting in 2D cross-sectional images that are displayed on a monitor for the physician's review. The physician can assess these images in real-time and may request additional sections to enhance the detail of specific areas of interest. This procedure is particularly useful for diagnosing various conditions affecting the maxillofacial region. It is important to note that CPT® Code 70488 specifically refers to a CT scan performed initially without intravenous contrast material, followed by the administration of contrast material for further imaging, allowing for a more comprehensive evaluation of the area in question.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure described by CPT® Code 70488 is indicated for various clinical scenarios involving the maxillofacial area. The following conditions may warrant the use of this imaging technique:

  • Facial Trauma Assessment of injuries to the facial bones and soft tissues following trauma.
  • Sinus Disease Evaluation of chronic sinusitis or other sinus-related conditions that may affect the maxillofacial region.
  • Neoplasms Detection and characterization of tumors or lesions within the maxillofacial area.
  • Infections Identification of abscesses or other infectious processes affecting the facial structures.
  • Congenital Anomalies Assessment of congenital malformations in the maxillofacial region.

2. Procedure

The procedure for CPT® Code 70488 involves several key steps to ensure accurate imaging of the maxillofacial area. The following outlines the procedural steps:

  • Initial Positioning The patient is positioned on the CT examination table, ensuring comfort and stability for the duration of the scan.
  • Initial Scan An initial pass through the CT scanner is performed to determine the starting position for the imaging process. This step is crucial for establishing the correct alignment of the scans.
  • CT Scanning As the table moves slowly through the scanner, multiple X-ray beams are emitted, and electronic detectors rotate around the maxillofacial area. This rotation captures detailed information about the structures being examined.
  • Data Processing The absorbed radiation data is processed by a computer, which generates 2D cross-sectional images of the maxillofacial region. These images are displayed on a monitor for immediate review.
  • Administration of Contrast Material Following the initial imaging without contrast, intravenous contrast material is administered to enhance the visibility of certain structures. This step allows for a more detailed examination of areas of interest.
  • Additional Imaging After the contrast material is administered, further sections of the maxillofacial area are acquired to provide comprehensive imaging data.
  • Physician Review The physician reviews the CT images in real-time, noting any abnormalities and determining if additional sections are necessary for a thorough evaluation.

3. Post-Procedure

After the completion of the CT scan as described in CPT® Code 70488, the patient may be monitored briefly to ensure there are no immediate adverse reactions to the contrast material, if used. The physician will provide a written interpretation of the findings, which will include any identified abnormalities or areas of concern. Patients are typically advised to resume normal activities unless otherwise directed. Follow-up appointments may be scheduled to discuss the results and any further diagnostic or therapeutic steps that may be necessary based on the findings of the CT scan.

Short Descr CT MAXILLOFACIAL W/O & W/DYE
Medium Descr CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL
Long Descr Computed tomography, maxillofacial area; without contrast material, followed by contrast material(s) and further sections
Status Code Active Code
Global Days XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC) 1 - Diagnostic Tests for Radiology Services
Multiple Procedures (51) 4 - Special payment adjustment rules on the technical component (TC) of multiple diagnostic imaging procedures apply...
Bilateral Surgery (50) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 0 - Payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 88 -
APC Status Indicator Codes That May Be Paid Through a Composite APC
ASC Payment Indicator Radiology service paid separately when provided integral to a surgical procedure on ASC list; payment based on OPPS relative payment weight.
Type of Service (TOS) 4 - Diagnostic Radiology
Berenson-Eggers TOS (BETOS) I2A - Advanced imaging - CAT/CT/CTA: brain/head/neck
MUE 1
CCS Clinical Classification 177 - Computerized axial tomography (CT) scan head

This is a primary code that can be used with these additional add-on codes.

0722T Add On Code MPFS Status: Carrier Priced APC S Quantitative computed tomography (CT) tissue characterization, including interpretation and report, obtained with concurrent CT examination of any structure contained in the concurrently acquired diagnostic imaging dataset (List separately in addition to code for primary procedure)
26 Professional component: certain procedures are a combination of a physician or other qualified health care professional component and a technical component. when the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number.
X5 Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician
51 Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
MG The order for this service does not have applicable appropriate use criteria in the qualified clinical decision support mechanism consulted by the ordering professional
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
77 Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
CR Catastrophe/disaster related
CT Computed tomography services furnished using equipment that does not meet each of the attributes of the national electrical manufacturers association (nema) xr-29-2013 standard
GA Waiver of liability statement issued as required by payer policy, individual case
GC This service has been performed in part by a resident under the direction of a teaching physician
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
GW Service not related to the hospice patient's terminal condition
GZ Item or service expected to be denied as not reasonable and necessary
LT Left side (used to identify procedures performed on the left side of the body)
MA Ordering professional is not required to consult a clinical decision support mechanism due to service being rendered to a patient with a suspected or confirmed emergency medical condition
MC Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of electronic health record or clinical decision support mechanism vendor issues
ME The order for this service adheres to appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional
MF The order for this service does not adhere to the appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional
MH Unknown if ordering professional consulted a clinical decision support mechanism for this service, related information was not provided to the furnishing professional or provider
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
QQ Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional
TC Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier tc; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles
U6 Medicaid level of care 6, as defined by each state
X4 Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
Date
Action
Notes
2013-01-01 Changed Medium Descriptor changed.
2003-01-01 Changed Code description changed.
Pre-1990 Added Code added.
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