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Official Description

Computed tomography, soft tissue neck; with contrast material(s)

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

Computed tomography (CT), commonly referred to 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 areas within the body. In the context of CPT® Code 70491, the focus is on the soft tissues of the neck. During this procedure, the patient is carefully positioned on a specialized CT examination table. The process begins with an initial scan to establish the starting position for the imaging. Following this, the CT scan is conducted as the table gradually moves through the scanner. This movement allows multiple X-ray beams and electronic detectors to rotate around the neck region, capturing various angles and measuring the amount of radiation absorbed by the tissues. The data collected is then processed by a computer program, which generates two-dimensional images that represent the soft tissues of the neck. These images are displayed on a monitor for the physician's review. The physician may analyze the images in real-time and can request additional scans if further detail is needed for specific areas of interest. It is important to note that CPT® Code 70491 specifically applies when intravenous contrast material is administered prior to the CT scan, enhancing the visibility of structures within the neck. For cases where no contrast is used, CPT® Code 70490 is applicable, and for situations where a non-contrast scan is followed by a contrast-enhanced scan, CPT® Code 70492 should be utilized. The physician is responsible for interpreting the findings from the CT scan, documenting any abnormalities, and providing a comprehensive written report of the results.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The indications for performing a computed tomography (CT) scan of the soft tissues of the neck with contrast material (CPT® Code 70491) include the following:

  • Evaluation of Neck Masses This procedure is indicated for assessing the presence, size, and characteristics of masses or lesions in the neck region, which may be benign or malignant.
  • Assessment of Inflammatory Conditions CT scans are useful in diagnosing and evaluating inflammatory conditions such as abscesses, cellulitis, or other infections affecting the soft tissues of the neck.
  • Investigation of Trauma In cases of neck trauma, a CT scan can help identify soft tissue injuries, vascular damage, or other complications resulting from the injury.
  • Preoperative Planning This imaging study may be performed to provide detailed anatomical information that assists surgeons in planning for procedures involving the neck.
  • Follow-Up of Known Conditions Patients with previously diagnosed conditions, such as tumors or infections, may require follow-up imaging to monitor changes or responses to treatment.

2. Procedure

The procedure for conducting a CT scan of the soft tissues of the neck with contrast material involves several key steps:

  • Patient Preparation The patient is positioned comfortably on the CT examination table, and any necessary pre-procedure instructions, such as fasting or hydration, are provided. The healthcare team ensures that the patient is informed about the procedure and any potential risks associated with the use of contrast material.
  • Initial Scanning An initial pass through the CT scanner is performed to determine the optimal starting position for the imaging. This step is crucial for ensuring that the area of interest is adequately captured in the subsequent scans.
  • Administration of Contrast Material Intravenous contrast material is administered to enhance the visibility of the soft tissues during the scan. The contrast agent helps to delineate structures and highlight any abnormalities that may be present.
  • CT Scanning As the table moves slowly through the scanner, multiple X-ray beams and electronic detectors rotate around the neck region. The system measures the radiation absorption by the tissues, capturing detailed images from various angles.
  • Image Processing The data collected during the scanning process is processed by a computer program, which generates two-dimensional cross-sectional images of the soft tissues of the neck. These images are displayed on a monitor for immediate review.
  • Physician Review The physician reviews the images in real-time, assessing for any abnormalities or areas of concern. If necessary, the physician may request additional sections to obtain more detailed views of specific areas.

3. Post-Procedure

After the CT scan is completed, the patient may be monitored briefly to ensure there are no immediate adverse reactions to the contrast material. The physician will interpret the findings from the CT images, noting any abnormalities or significant observations. A comprehensive written report will be generated, summarizing the results of the scan and any recommendations for further evaluation or treatment if necessary. Patients are typically advised to drink plenty of fluids post-procedure to help flush the contrast material from their system. Any specific post-procedure instructions or follow-up appointments will be communicated to the patient based on the findings of the scan.

Short Descr CT SOFT TISSUE NECK W/DYE
Medium Descr CT SOFT TISSUE NECK W/CONTRAST MATERIAL
Long Descr Computed tomography, soft tissue neck; with contrast material(s)
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 180 - Other CT scan

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
GC This service has been performed in part by a resident under the direction of a teaching physician
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
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
ME The order for this service adheres to appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study
QQ Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing 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.
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
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
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.
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
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
GA Waiver of liability statement issued as required by payer policy, individual case
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
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
CR Catastrophe/disaster related
GZ Item or service expected to be denied as not reasonable and necessary
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
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
PD Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days
XP Separate practitioner, a service that is distinct because it was performed by a different practitioner
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
22 Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service.
52 Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
53 Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
76 Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
ET Emergency services
FY X-ray taken using computed radiography technology/cassette-based imaging
GQ Via asynchronous telecommunications system
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
KX Requirements specified in the medical policy have been met
LT Left side (used to identify procedures performed on the left side of the body)
MB Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of insufficient internet access
MD Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of extreme and uncontrollable circumstances
Q0 Investigational clinical service provided in a clinical research study that is in an approved clinical research study
Q3 Live kidney donor surgery and related services
QJ Services/items provided to a prisoner or patient in state or local custody, however the state or local government, as applicable, meets the requirements in 42 cfr 411.4 (b)
RT Right side (used to identify procedures performed on the right side of the body)
U6 Medicaid level of care 6, as defined by each state
UD Medicaid level of care 13, as defined by each state
XE Separate encounter, a service that is distinct because it occurred during a separate encounter
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2003-01-01 Changed Code description changed.
Pre-1990 Added Code added.
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