Independent Diagnostic Testing Facility (IDTF) Supplies and Ancillary Procedures

Every IDTF will have a specific and unique list of HCPCS codes for which it can be paid.

The below CPT codes do not imply coverage of the procedure. All of the procedure codes are subject to Medicare rules and regulations, applicable Local Coverage Decisions (LCD's), and medical necessity. This list was compiled based on current billing patterns. Therefore, some codes have been inadvertently omitted.

If the procedure code is not included in the table below, providers will need to send in a written request explaining the procedure they are performing. If the medical directors determine it to be an appropriate diagnostic procedure that can be safely performed in an IDTF, it will be added to the provider's file.

HCPCS Code Code Description
A4642 In111 satumomab
A9500 Tc99m sestamibi
A9502 Tc99m tetrofosmin
A9503 Tc99m medronate
A9504 Tc99m apcitide
A9505 Tl201 thallium
A9507 In111 capromab
A9508 I131 iodobenguate, dx
A9509 Iodine i-123 sod iodide mil
A9510 Tc99m disofenin
A9512 Tc99m pertechnetate
A9516 Iodine i-123 sod iodide mic
A9521 Tc99m exametazime
A9524 I131 serum albumin, dx
A9526 Nitrogen n-13 ammonia
A9528 I131 iodide sol, dx
A9529 I131 iodide sol, dx
A9531 I131 max 100uci
A9532 I125 serum albumin, dx
A9536 Tc99m depreotide
A9537 Tc99m mebrofenin
A9538 Tc99m pyrophosphate
A9539 Tc99m pentetate
A9540 Tc99m maa
A9541 Tc99m sulfur colloid
A9542 In111 ibritumomab, dx
A9544 I131 tositumomab, dx
A9546 Co57/58
A9547 In111 oxyquinoline
A9548 In111 pentetate
A9550 Tc99m gluceptate
A9551 Tc99m succimer
A9552 F18 fdg
A9553 Cr51 chromate
A9555 Rb82 rubidium
A9556 Ga67 gallium
A9560 Tc99m labeled rbc
A9561 Tc99m oxidronate
A9562 Tc99m mertiatide
A9566 Tc99m fanolesomab
A9567 Technetium tc-99m aerosol
A9583 Gadofosveset trisodium inj
A9954 I125 iothalamate, dx
A9557 Tc99m bicisate
A9558 Xe133 xenon 10mci
A9559 Co57 cyano
A9569 Technetium tc-99m auto wbc
A9570 Indium in-111 auto wbc
A9571 Indium in-111 auto platelet
A9572 Indium in-111 pentetreotide
A9575 Inj gadoterate meglumi 0.1ml
A9576 Inj prohance multipack
A9577 Inj multihance
A9579 Gad-base mr contrast nos,1ml
A9580 Sodium fluoride f-18
A9581 Gadoxetate disodium inj
A9582 Iodine i-123 iobenguane
A9584 Iodine i-123 ioflupane
A9585 Gadobutrol injection
A9586 Florbetapir f18
A9587 Gallium ga-68
A9588 Fluciclovine f-18
A9597 Pet dx for tumor id, noc
A9598 Pet dx for non-tumor id, noc
J0153 Inj Adenosine
J1245 Dipyridamole (Persantin)
J1610 Injection; glucagon hydrochrloride or glucagen, per 1 mg
J2785 Regadenoson injection
J2805 Sincalide injection
Q9954 Oral mr contrast, 100 ml
Q9965 Locm 100-199mg/ml iodine, 1ml
Q9966 Locm 200-299mg/ml iodine,1ml
Q9967 Locm 300-399mg/ml iodine,1ml
Q9982 Flutemetamol f18 diagnostic
Q9983 Florbetaben f18 diagnostic
23350 Injection for shoulder x-ray
24220 Injection for elbow x-ray
25246 Injection for wrist x-ray
27093 Injection for hip x-ray
27095 Injection for hip x-ray
27096 Inject sacroiliac joint
27369 Njx contrast kne arthg/CT/MRI
27370 Injection for knee x-ray
27648 Injection for ankle x-ray
62302 Myelography lumbar injection


Last Updated Fri, 15 Mar 2019 15:05:00 +0000