Medical Policy: 06.01.20
Original Effective Date: October 2005
Reviewed: April 2016
Revised: February 2016
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Contrast enhanced computed tomographic angiography of the coronary arteries (CCTA) is a non-invasive imaging test that requires the use of intravenously administered contrast material and high resolution, high speed computed tomography (CT) machinery to obtain detailed volumetric images of the blood vessels of the heart. It has been used as an alternative to conventional invasive coronary angiography for evaluating coronary artery disease (CAD) and coronary artery anomalies.
Studies in the peer reviewed scientific literature support the use of 64 slice system for CCTA. Studies have demonstrated that 64 slice CCTA performs with high accuracy for the diagnosis of CAD and can reduce referrals for invasive coronary angiography.
The 2010 Appropriate Use Criteria for Computed Tomographic Angiography of the Coronary Arteries (CCTA) written by the American College of Cardiology Foundation, the Society of Cardiovascular CT, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the Society for Cardiovascular Angiography and Interventions and the Society of Cardiovascular MR includes the following:
In general, the use of CCTA for diagnosis and risk assessment in patients with low or intermediate risk or pretest probability for coronary artery disease (CAD) was viewed favorably. Testing in high risk patients, routine repeat testing and general screening was viewed less favorably.
- Screening asymptomatic patients using CCTA, repeat CCTA in asymptomatic patients or patients with stable symptoms with prior test results, considered inappropriate.
- One area of expansion compared with the 2006 criteria involves symptomatic patients without known heart disease. CCTA was felt to be appropriate primary for situation involving a low or intermediate pretest probability of obstructive CAD.
- Detectection of CAD including those with prior abnormal cardiac testing using exercise and stress imaging
- Patient with abnormal myocardial perfusion scan (MPI) or stress echo suspected to be false positive who have low coronary heart disease risk
- Patient with equivocal myocardial perfusion scan (MPI) or stress echo who have low or moderate coronary heart disease risk
- Within heart failure with reduced left ventricular ejection fraction with low or intermediate pretest CAD probablity, CCTA considered appropriate.
- As part of a pre-operative evaluation for patients undergoing heart surgery for non-coronary indications, CCTA considered appropriate.
- Evaluation of coronary anomalies, CCTA considered appropriate.
This document represents the current understanding of the net clinical benefit of CCTA imaging with respect to the balance between benefit and risk to the patient as assessed under the American College of Cardiology Foundation (ACCF) appropriate use criteria methodology.
Framingham risk score: is a multivariable risk function that predicts 10 year risk of developing cardiovascular disease events (coronary heart disease, stroke, peripheral artery disease or heart failure). This risk score includes the following factors:
- Total and high density lipoprotein cholesterol
- Systolic blood pressure
- Diabetic status
- Cigarette Smoking
Framingham risk score key:
- High: greater than 90% pre-test probability
- Intermediate: between 10% and 90% pre-test probability
- Low: between 5% and 10% pre-test probability
- Very low: less than 5% pre-test probablity
SCORE (Systemic Coronary Risk Evaluation): predicts a 10 year risk on fatal cardiovascular disease. The SCORE incorporates the following:
- Systolic blood pressure
- Total Cholesterol
- Diabetic status
- High risk: >10%
- Intermediate risk: 5%-9%
- Low risk: 0% - 4%
U.S. Food and Drug Administration (FDA)
Multiple manufacturers have received FDA 510(k) clearance to market CT machines. Multislice CT technology has evolved rapidly over the past several years, beginning with 4-slice scanners that were first introduced in 1998. Since then, multi-slice scanners have been approved and available for diagnostic use, with the first 64-slice system receiving FDA approval in 2004.
Preauthorization is required.
- The use of CCTA is considered not medically necessary as a screening study for asymptomatic individuals because its effectiveness for this indication has not been established.
Computerized Tomographic Angiography Coronary Arteries (CCTA) may be considered medically necessary for the following indications:
- Evaluation of suspected cardiac chest pain when all of the following are met:
- No known history of coronary artery disease (CAD); and
- Low or intermediate pre-test probability of coronary artery disease (CAD) (using Framingham risk score calculation); and
- ECG normal/non-diagnostic for etiology of chest pain
- Evaluation of suspected coronary artery disease (CAD) including those individuals with prior abnormal cardiac testing (myocardial perfusion imaging (MPI) or stress echo)
- Individual with abnormal MPI or stress echo within the preceding 90 days suspected to be false positive on the basis of low coronary heart disease risk (using standard methods of risk assessment such as the SCORE risk calculation).
- Individual with an equivocal MPI or stress echo within the preceding 90 days who have low or intermediate coronary heart disease risk (using standard methods of risk assessment such as the SCORE risk calculation).
- Individuals with congestive heart failure/cardiomyopathy/left ventricular dysfunction
- For exclusion of coronary artery disease in patients with left ventricular ejection fraction <55% and intermediate coronary heart disease risk (using standard methods of risk assessment such as the SCORE risk calculation) in whom coronary artery disease has not been excluded as the etiology of the cardiomyopathy.
- Evaluation for non coronary artery cardiac surgery
- Individual with intermediate coronary heart disease risk (using standard methods of risk assessment such as the SCORE risk calculation) and being evaluated for non coronary artery cardiac surgery (including valvular and ascending aortic surgery) to avoid an invasive angiogram. All the necessary pre-operative information can be obtained using cardiac CT.
- Congenital coronary artery anomalies
- For evaluation of suspected congenital anomalies of the coronary arteries
Procedure Codes and Billing Guidelines:
To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS) level 2) codes, Revenue codes, and/or diagnosis codes.
- 75574 Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed)
- Leber AW, Knez A, Becker C et al. Non-invasive intravenous coronary angiography using electron beam tomography and multi-slice computed tomography. Heart. 2003; 89(6):633-9.
- Achenbach S, Ropers D, Regenfus M et al. Noninvasive coronary angiography by magnetic resonance imaging, electron-beam computed tomography, and multi-slice computed tomography. Am J Cardiol. 2001; 88(2A):70E-73E.
- Mollet NR, Cademartiri, F, Nieman K et al. Multislice spiral computed tomography coronary angiography in patients with stable angina pectoris. J Am Coll Cardiol. 2004; 43(12):2265-70.
- Maruyama T, Yoshizumi T, Tamura R et al. Comparison of visibility and diagnostic capability of noninvasive coronary angiography by eight-slice multidetector-row computed tomography versus conventional coronary angiography. Am J Cardiol. 2004; 93(5):537-42.
- Raff GL, Gallagher MJ, O'Neill WW, Goldstein JA. Diagnostic Accuracy of Noninvasive Coronary Angiography Using 64-Slice Sprial Computed Tomography. J Am Coll Cardiol. 2005; 46(3)552-7.
- Hoffman MHK, Heshui S, Schmitz BL et al. Noninvasive Coronary Angiography With Multislice Computed Tomography. JAMA. 2005; 293(20):2471-8.
- Blue Cross and Blue Shield Association. Contrast-Enhanced Cardiac Computed Tomographic Angiography for Coronary Artery Evaluation. Technology Evaluation Center. Assessment Program 2005; 20(4).
- Schoenhagen P, Stillman A, Garcia M et al. Coronary artery imaging with multidetector computed tomography: A call for an evidence-based, multidisciplinary approach. Am Heart J 2006 May; 151(5):945-8.
- Fine JJ, Hopkins CB, Ruff N et al. Comparison of Accuracy of 64-slice Cardiovascular Computed Tomography with Coronary Angiography in Patients with Suspected Coronary Artery Disease. Am J Cardiol 2006 Jan; 97(2):173-4.
- Ropers D, Rixe J, Anders K et al. Usefulness of Multidetector Row Spiral Computed Tomography With 64- × 0.6-mm Collimation and 330-ms Rotation for the Noninvasive Detection of Significant Coronary Artery Stenoses. Am J Cardiol 2006 Feb; 97(3):343-348.
- Mollet NR, Cademartiri F, van Mieghem CAG et al. High-Resolution Spiral Computed Tomography Coronary Angiography in Patients referred for Diagnostic Conventional Coronary Angiography. Circulation. 2005; 112:2318-2323.
- Leschka S, Alkadhi H, Plass A et al. Accuracy of MSCT coronary angiography with 64-slice technology: a first experience. Eur Heart J. Aug 2005; 26(15):1451-3.
- Stein PD, Beemath A Kayali F et al. Multidetector Computed Tomography for the Diagnosis of Coronary Artery Disease: A Systematic Review. Am J Med. 2006 Mar; 119(3):203-16.
- Agency for Healthcare Research and Quality. Technology Assessment Program. Non-Invasive Imaging for Coronary Artery Disease. April 28, 2006.
- Blue Cross Blue Shield Association. Technology Evaluation Center. Contrast-Enhanced Cardiac Computed Tomographic Angiography in the Diagnosis of Coronary Artery Stenosis or for Evaluation of Acute Chest Pain. TEC Assessment Program 2006 Aug; 21(5).
- Hendel RC, Patel MR, Kramer CM, et al. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR Appropriateness Criteria for Cardiac Computed Tomography and Cardiac Magnetic Resonance Imaging. J Am Coll Cardiol 2006 Oct; 48(7):1475-97.
- Jacobs JE, Boxt LM, Desjardins B et al. ACR Practice Guideline for the Performance and Interpretation of Cardiac Computed Tomography. J Am Coll Radiol 2006;48(3):677-685.
- Jones CM, Athanasiou T, Dunne N et al. Multi-detector computed tomography in coronary artery bypass graft assessment: a meta-analysis. Ann Thorac Surg. 2007 Jan;83(1):341-8.
- Hamon M, Biondi-Zoccai GG, Malagutti P et al. Diagnostic performance of multislice spiral computed tomography of coronary arteries as compared with conventional invasive coronary angiography: a meta-analysis. J Am Coll Cardiol 2006;48(9):1896-910.
- Mark DB, Berman DS, Budoff MJ et al. ACCF/ACR/AHA/NASCI/SAIP/SCAI/SCCT 2010 expert consensus document on coronary computed tomographic angiography: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. J Am Coll Cardiol 2010;55:2663-99.
- Raff GL, Chinnaiyan KM, Share DM et al. Radiation dose from cardiac computed tomography before and after implementation of radiation dose-reduction techniques. JAMA. 2009;301:2340-8.
- Kim JW, Kang EY, Yong HS et al. Incidental extracardiac findings at cardiac CT angiography: comparison of prevalence and clinical significance between precontrast low-dose whole thoracic scan and postcontrast retrospective ECG-gated cardiac scan. Int J Cardiovasc Imaging. 2009;25 Suppl 1:75-81.
- Bamberg F, Sommer WH, Hoffmann V et al. Meta-analysis and systematic review of the long-term predictive value of assessment of coronary atherosclerosis by contrast-enhanced coronary computed tomography angiography. J Am Coll Cardiol 2011;57(24):2426-36.
- Shaw LJ, Hausleiter J, Achenbach S et al. Coronary Computed Tomographic Angiography as a Gatekeeper to Invasive Diagnostic and Surgical Procedures: Results from the Multicenter CONFRIM (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter) Registry. J Am Coll Cardiol. 2012 Oct 5. pii: S0735-1097(12)04231-3. doi:10.1016/j.jacc.2012.05.062. [Epub ahead of print].
- Hausleiter J, Meyer TS, Martuscelli E et al. Image quality and radiation exposure with prospectively ECG-triggered axial scanning for coronary CT angiography: the multicenter, multivendor, randomized PROTECTION-III study. JACC Cardiovasc Imaging 2012; 5(5):484-93.
- Hoffmann U, Truong QA, Schoenfeld DA et al. Coronary CT angiography vs standard evaluation in acute chest pain. N Engl J Med 2012;367(4):299-308. doi: 10.1056/NEJMoa1201161.
- Litt HI, Gatsonis C, Snyder B et al. CT angiography for safe discharge of patients with possible acute coronary syndromes. N Engl J Med 2012;366(15):1393-1403.
- Journal of the American College of Cardiology: Prognostic Value of CT Angiography for Major Adverse Cardiac Events in Patients with Acute Chest Pain from the Emergency Department: 2 Year Outcomes of the ROMICAT Trial. Img. 2011; 4:481-491, doi: 10.1016/j.jcmg.2010.12.008
- Journal of the American College of Cardiology: Prognostic Value of Cardiac Computed Tomography Angiography: A Systemic Review and Meta-Analysis: 2011;57;1237-1247, doi:10.1016/j.jacc.2010.10.011
- Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Coronary Computed Tomographic Angiography in the Evaluation of Patients with Acute Chest Pain. TEC Assessments 2011; Volume 26, Tab 9
- Jonathan Leipsic, M.D., Suhny Abbara, M.D., et. al. SCCT Guidelines for the Interpretation and Reporting of Coronary CT Angiography: A Report of the Society of Cardiovascular Computed Tomography Guidelines Committee, July 2014. Also available at http:dx.doi.org/10.1016/j.jcct.2014.07.003
- Mastouri R, Sawada SG, Mahenthiran J. Current noninvasive imaging techniques for detection of coronary artery disease. Expert Rev Cardiovasc Ther. Jan 2010;8(1):77-91. PMID 20030023
- Chow BJ, Small G, Yam Y, et al. The incremental prognostic value of cardiac CT in CAD using CONFIRM (COroNary computed tomography angiography evaluation For clinical outcomes: an InteRnational Multicenter registry). Circulation. Cardiovascular imaging. Jul 5 2011. PMID 21730027
- Hausleiter J, Meyer T, Hermann F, et al. Estimated radiation dose associated with cardiac CT angiography. JAMA : the journal of the American Medical Association. Feb 4 2009;301(5):500-507. PMID 19190314
- Goldstein JA, Gallagher MJ, O'Neill WW, et al. A randomized controlled trial of multi-slice coronary computed tomography for evaluation of acute chest pain. J Am Coll Cardiol. Feb 27 2007;49(8):863-871. PMID 17320744
- Goldstein JA, Chinnaiyan KM, Abidov A, et al. The CT-STAT (Coronary Computed Tomographic Angiography for Systematic Triage of Acute Chest Pain Patients to Treatment) trial. J Am Coll Cardiol. Sep 27 2011;58(14):1414-1422. PMID 21939822
- Litt HI, Gatsonis C, Snyder B, et al. CT angiography for safe discharge of patients with possible acute coronary syndromes. N Engl J Med. Apr 12 2012;366(15):1393-1403. PMID 22449295
- Hollander JE, Chang AM, Shofer FS, et al. One-year outcomes following coronary computerized tomographic angiography for evaluation of emergency department patients with potential acute coronary syndrome. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. Aug 2009;16(8):693-698. PMID 19594460
- Schlett CL, Banerji D, Siegel E, et al. Prognostic value of CT angiography for major adverse cardiac events in patients with acute chest pain from the emergency department 2-year outcomes of the ROMICAT trial. JACC Cardiovasc Imaging. May 2011;4(5):481-491. PMID 21565735
- Nasis A, Meredith IT, Sud PS, et al. Long-term outcome after CT angiography in patients with possible acute coronary syndrome. Radiology. Sep 2014;272(3):674-682. PMID 24738614
- Hoffmann U, Truong QA, Schoenfeld DA, et al. Coronary CT angiography versus standard evaluation in acute chest pain. N Engl J Med. Jul 26 2012;367(4):299-308. PMID 22830462
- Hamilton-Craig C, Fifoot A, Hansen M, et al. Diagnostic performance and cost of CT angiography versus stress ECG--a randomized prospective study of suspected acute coronary syndrome chest pain in the emergency department (CT-COMPARE). Int J Cardiol. Dec 20 2014;177(3):867-873. PMID 25466568
- Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. Dec 18 2012;60(24):e44-e164. PMID 23182125
- Nielsen LH, Ortner N, Norgaard BL, et al. The diagnostic accuracy and outcomes after coronary computed tomography angiography vs. conventional functional testing in patients with stable angina pectoris: a systematic review and meta-analysis. Eur Heart J Cardiovasc Imaging. Sep 2014;15(9):961-971. PMID 24618659
- Ollendorf DA, Kuba M, Pearson SD. The diagnostic performance of multi-slice coronary computed tomographic angiography: a systematic review. Journal of general internal medicine. Mar 2011;26(3):307-316. PMID 21063800
- Douglas PS, Hoffmann U, Patel MR, et al. Outcomes of anatomical versus functional testing for coronary artery disease. N Engl J Med. Apr 2 2015;372(14):1291-1300. PMID 25773919
- investigators S-H. CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): an open-label, parallel-group, multicentre trial. Lancet. Jun 13 2015;385(9985):2383-2391. PMID 25788230
- Min JK, Koduru S, Dunning AM, et al. Coronary CT angiography versus myocardial perfusion imaging for nearterm quality of life, cost and radiation exposure: a prospective multicenter randomized pilot trial. J Cardiovasc Comput Tomogr. Jul-Aug 2012;6(4):274-283. PMID 22732201
- Muhlestein JB, Lappe DL, Lima JA, et al. Effect of screening for coronary artery disease using CT angiography on mortality and cardiac events in high-risk patients with diabetes: the FACTOR-64 randomized clinical trial. JAMA. Dec 3 2014;312(21):2234-2243. PMID 25402757
- McKavanagh P, Lusk L, Ball PA, et al. A comparison of cardiac computerized tomography and exercise stress electrocardiogram test for the investigation of stable chest pain: the clinical results of the CAPP randomized prospective trial. Eur Heart J Cardiovasc Imaging. Apr 2015;16(4):441-448. PMID 25473041
- Douglas PS, Pontone G, Hlatky MA, et al. Clinical outcomes of fractional flow reserve by computed tomographic angiography-guided diagnostic strategies vs. usual care in patients with suspected coronary artery disease: the prospective longitudinal trial of FFRct: outcome and resource impacts study. Eur Heart J. Sep 1 2015. PMID 26330417
- Nielsen LH, Olsen J, Markenvard J, et al. Effects on costs of frontline diagnostic evaluation in patients suspected of angina: coronary computed tomography angiography vs. conventional ischaemia testing. Eur Heart J Cardiovasc Imaging. May 2013;14(5):449-455. PMID 22922828
- Shreibati JB, Baker LC, Hlatky MA. Association of coronary CT angiography or stress testing with subsequent utilization and spending among Medicare beneficiaries. JAMA. Nov 16 2011;306(19):2128-2136. PMID 22089720
- Min JK, Kang N, Shaw LJ, et al. Costs and clinical outcomes after coronary multidetector CT angiography in patients without known coronary artery disease: comparison to myocardial perfusion SPECT. Radiology. Oct 2008;249(1):62-70. PMID 18796668
- Yamauchi T, Tamaki N, Kasanuki H, et al. Optimal initial diagnostic strategies for the evaluation of stable angina patients: a multicenter, prospective study on myocardial perfusion imaging, computed tomographic angiography, and coronary angiography. Circ J. 2012;76(12):2832-2839. PMID 22975716
- Aglan I, Jodocy D, Hiehs S, et al. Clinical relevance and scope of accidental extracoronary findings in coronary computed tomography angiography: a cardiac versus thoracic FOV study. Eur J Radiol. Apr 2010;74(1):166-174. PMID 19268514
- Husmann L, Tatsugami F, Aepli U, et al. Prevalence of noncardiac findings on low dose 64-slice computed tomography used for attenuation correction in myocardial perfusion imaging with SPECT. Int J Cardiovasc Imaging. Dec 2009;25(8):859-865. PMID 19662511
- Lehman SJ, Abbara S, Cury RC, et al. Significance of cardiac computed tomography incidental findings in acute chest pain. Am J Med. Jun 2009;122(6):543-549. PMID 19486717
- Machaalany J, Yam Y, Ruddy TD, et al. Potential clinical and economic consequences of noncardiac incidental findings on cardiac computed tomography. J Am Coll Cardiol. Oct 13 2009;54(16):1533-1541. PMID 19815125
- Hausleiter J, Meyer TS, Martuscelli E, et al. Image quality and radiation exposure with prospectively ECGtriggered axial scanning for coronary CT angiography: the multicenter, multivendor, randomized PROTECTIONIII study. JACC. Cardiovascular imaging. May 2012;5(5):484-493. PMID 22595156
- McEvoy JW, Blaha MJ, Nasir K, et al. Impact of coronary computed tomographic angiography results on patient and physician behavior in a low-risk population. Arch Intern Med. Jul 25 2011;171(14):1260-1268. PMID 21606093
- Taylor AJ, Cerqueira M, Hodgson JM, et al. CCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 Appropriate Use Criteria for Cardiac Computed Tomography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. J Cardiovasc Comput Tomogr. Nov-Dec 2010;4(6):407 e401-433. PMID 21232696
- Taylor AJ, Cerqueira M, Hodgson JM, et al. ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. J Am Coll Cardiol. Nov 23 2010;56(22):1864-1894. PMID 21087721
- Mark DB, Berman DS, Budoff MJ, et al. ACCF/ACR/AHA/NASCI/SAIP/SCAI/SCCT 2010 expert consensus document on coronary computed tomographic angiography: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions. Aug 1 2010;76(2):E1-42. PMID 20687247
- Wolk MJ, Bailey SR, Doherty JU, et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol. Feb 4 2014;63(4):380-406. PMID 24355759
- NICE. NICE clinical guideline CG95 Chest pain of recent onset: assessment and diagnosis. Published March 2010.
- April 2016 - Annual Reviewed, Policy Renewed
- February 2016 - Interim Reviewed, Policy Revised
- December 2015 - Interim Reviewed, Policy Renewed
- May 2015 - Annual Reviewed, Policy Renewed
- June 2014 - Annual Reviewed, Policy Renewed
- August 2013 - Annual Reviewed, Policy Revised
- January 2013 - Interim Reviewed, Policy Revised
- November 2012 - Annual Reviewed, Policy Renewed
- September 2011 - Annual Reviewed, Policy Renewed
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*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.