Code Head, Brain, and Neck CT Scans With This Detailed Guide – Part 1
Explore the many reasons why head, brain, and neck CT scans are performed. Computed tomography scans, or CT scans, are a versatile imaging technique that uses X-rays to create 2D cross-sectional images of tissues. These “sections” or “slices” are thin image layers taken at different depths through the body, allowing physicians to see internal structures in detail. Physicians use CT scans to evaluate a wide range of conditions, from locating blood clots to monitoring cancer progression. Unlike traditional X-rays, CT visualizes soft tissues and blood vessels in addition to bone. This two-part series will explore the head, neck, and brain CT series of CPT® codes, covering clinical indications and coding guidance to help you select the correct code. Start at The Top With Head or Brain Imaging The first group of codes covers CT imaging of the head or brain: Notice that these codes differ by contrast usage: 70450 for noncontrast studies, 70460 for contrast-enhanced studies, and 70470 for studies performed both without and with contrast. What Is Contrast Material and How Do You Know It Was Used? Contrast materials are dyes (usually iodine-based) that enhance visualization of specific structures on CT images. Contrast can be injected intravenously (IV) or intra-arterially to visualize vessels. Documentation may reference “IV contrast,” “radiocontrast,” or “contrast medium.” Studies with and without contrast may use the terms “pre- and post-contrast” or “w/ and w/o contrast.” Reporting contrast: Facilities typically report the contrast material supply using HCPCS Level II codes. If a physician’s office owns the equipment, they will report the contrast. Coding tip: Per CPT® radiology guidelines, contrast administered orally and rectally alone does not qualify as “with contrast.” Clinical indications: When a patient comes to the emergency department with head trauma, a suspected stroke, or a sudden severe headache, providers need to see if there’s bleeding in the brain. CT of the head or brain can help locate intracerebral and subdural hematomas (SDH), and subarachnoid hemorrhages (SAH). Other indications include cerebral vascular accident (stroke), transient ischemic attack (TIA), seizures, vertigo (dizziness), whiplash injuries, traumatic brain injury (TBI), and follow-up for cancer metastasis. Coding tip: Contrast CT is often performed following noncontrast CT, particularly if bleeding is found. Using code 70470 would be appropriate in this scenario. Supporting ICD-10-CM examples: Diagnosis codes that support medical necessity when reporting 70450-70470 include G44.53 (Primary thunderclap headache), I63.442 (Cerebral infarction due to embolism of left cerebellar artery), S02.101A (Fracture of base of skull, right side, initial encounter for closed fracture), S06.0X0A (Concussion without loss of consciousness, initial encounter), and C71.1 (Malignant neoplasm of frontal lobe). Use CTA to Examine the Head and Neck Blood Vessels Code 70471 (Computed tomographic angiography (CTA), head and neck, with contrast material(s), including noncontrast images, when performed, and image postprocessing) is new for 2026 and describes CT angiography (CTA) of the head and neck. CTA uses contrast to visualize the vascular system and generates detailed cross-sectional images of blood vessels. Clinical indications: While noncontrast CT helps locate bleeding, CTA provides detailed vascular imaging so physicians can identify the extent and nature of vascular injuries. In ischemic stroke, CTA can help physicians pinpoint the thrombus location and map surrounding vascular anatomy to guide treatment planning. CTA is also used to evaluate vascular abnormalities, vessel injuries, aneurysms (enlarged vessels), atherosclerosis (narrowed vessels from plaque buildup), and tumors. Coding tip: Do not report 70471 with 70450 when performed during the same session. See 70496 (Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing) for CTA of just the head (not head and neck). Supporting ICD-10-CM examples: Diagnosis codes that support medical necessity include I63.12 (Cerebral infarction due to embolism of basilar artery), I65.21 (Occlusion and stenosis of right carotid artery), Q28.2 (Arteriovenous malformation of cerebral vessels), and I72.0 (Aneurysm of carotid artery). Assign +70472-70473 for Cerebral Perfusion Analysis Two new codes for 2026 describe cerebral perfusion analysis: Code +70472 is an add-on code reported with 70450, 70460, 70470, 70471, or 70496 when perfusion analysis is performed concurrently with CT or CTA of the same anatomy. Assign 70473 when the provider performed perfusion analysis without concurrent CT or CTA of the same anatomy. Clinical indications: Cerebral perfusion analysis evaluates blood flow to brain tissue. The more active an area of the brain is, the more blood flow it needs to supply oxygen. Following head trauma or stroke, this study assesses whether cerebral blood flow has been affected. Perfusion imaging also evaluates brain tumors, determining vascularity and identifying tumors that recruit nearby vessels for growth. Coding tip: The “+” symbol attached to +70472 indicates this is an add-on code and cannot be reported alone. Refer to your CPT® manual for the complete list of codes that +70472 and 70473 can and cannot be coded with. Supporting ICD-10-CM examples: G45.9 (Transient cerebral ischemic attack, unspecified), I60.4 (Nontraumatic subarachnoid hemorrhage from basilar artery), I67.7 (Cerebral arteritis, not elsewhere classified), and F01.A11 (Vascular dementia, mild, with agitation). Next month, Revenue Cycle Insider will examine codes for CT scans of the face, skull cavities, ears, and neck tissues. Angela Halasey, BS, CPC, CCS, Contributing Writer
