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Physician CPT Code Desktop Reference Radiology Diagnostic Center Five Cities Medical Imaging Digital Medical Imaging 1310 Las Tablas Road, Ste 103 Templeton 921 Oak Park Blvd, Ste. 102 Pismo Beach 522 East Plaza Drive Santa Maria P: (805) 434-0829 F: (805) 434-0826 P: (805) 779-7900 F: (805) 779-7910 P: (805) 928-3673 F: (805) 928-9588 Interventional Radiology Services – P: (805) 792-0115 * F: (805) 461-5570 WHY THIS GUIDE IS IMPORTANT TO YOU AND YOUR PATIENTS This ordering guide is meant to assist you when ordering a study with Radiology Associates. The guide includes common indications as well as recommendations for the most appropriate exam. It is our goal to provide you and our mutual patients with the most appropriate and complete imaging. After the correct order is placed, exams are further tailored to each patient’s specific condition. Thus, it is very important for the radiologist to be aware of the clinical question or specific condition in question so that the appropriate imaging can be performed. It is ideal for us to receive the most recent chart notes relating to the patient’s condition or reason for their imaging study in addition to the imaging order. When ordering an examination please include pertinent history as well as signs or symptoms. Please refrain from ordering “R/O”, “Possible”, or “Suspected” exams such as “Suspected tear” or “Rule out anomaly” unless history and signs/symptoms are included as well. Feel free to specify a particular entity or condition upon which you would like comment in the report. If you have any questions or concerns, please contact us at one of the numbers listed on the cover of this book. Thank you, The Physicians at Radiology Associates _______________________________________________________________________________________ Diagnostic Services DMI Bone Density CT Scan Digital Mammography Fluoroscopy MRI – High Field MRI – High Field Open FCMI RDC QCT only QCT only DX & QCT Nuclear Medicine PET / CT Imaging Ultrasound X-Ray Interventional Radiology (IR) Services – Most procedures performed at SVH or FH. Call IR to coordinate. Abdominal Aortic Aneurysm Abscess / Fluid Drainage Angiography / Angioplasty / Stenting Arterial Disease / Plaque Excision Biliary Interventions Biopsies Dialysis Access DVT Thrombolysis Fibroid Embolization Gastrostomy Tubes Inferior Vena Cava (IVC) Filters Infertility Internal Bleeding Pelvic Congestion Syndrome Peripheral Arterial Disease Spine Interventions / Pain Management Thromobolysis TIPS (Transjugular Intrahepatic Portosystemic Shunt) Varicose Vein / Spider Vein Treatment Vascular Access Vertebroplasty CT - Head REASON FOR EXAM EXAM TO PRE-CERT Head / Brain Trauma CT Head / Brain Headaches Without Contrast CPT CODE 70450 CVA, Stroke Bleed, Hemorrhage Alzheimer’s Memory Loss, Confusion Vertigo, Dizziness Shunt Check Hydrocephalus Metastatic Staging CT Head / Brain Mass/Tumor With Contrast 70460 Infection Headache w/ associated neurologic signs Melanoma CT Head / Brain HIV Without and With Contrast 70470 Toxoplasmosis Orbits Trauma CT Orbit Fracture Without Contrast 70480 Foreign Body Graves Disease Pseudo Tumor CT Orbit Pain With Contrast 70481 Exopthalmus Abscess Facial Bones Sinuses Mass CT Orbit Retinoblastoma Without and With Contrast 70482 Trauma CT Facial Bones Fracture Without Contrast Cellulitis CT Facial Bones With Contrast 70487 Sinusitis CT Sinus Limited 76380 Osteomeatal Complex CT Sinus Complete 70486 70480 70486 Sinusitis Polyps Temporal Hearing Loss, Conductive* CT Inner Ears, Temporal Bones Bone Cholesteotoma Without Contrst Trauma *Sensory neuro hearing loss, order MRI with and without contrast. CT - Computed Tomography BODY PART CT - Head (Continued) REASON FOR EXAM EXAM TO PRE-CERT Neck Mass CT Neck Infection With Contrast Cancer Workups *If elevated creatinine order Parotid Mass without contrast Hoarseness CT Neck Vocal Chord Paralysis Without Contrast CPT CODE 70491 70490 Voice Changes Submandibular Stone CT Soft Tissue Neck Infection of Submandibular Gland Without and With Contrast 70492 Infection of Parotid Gland Parotid Stone CT- Spine BODY PART REASON FOR EXAM EXAM TO PRE-CERT Cervical Spine Trauma, Fracture, Fusion CT Cervical Spine Assess Bone Degenerative Changes Without Contrast CPT CODE 72125 *MRI recommended for disc herniation, mets, infection Thoracic Spine Trauma, Fracture, Fusion CT Thoracic Spine Assess Bony Degenerative Changes Without Contrast 72128 *MRI recommended for disc herniation, mets, infection Lumbar Spine Trauma, Fracture, Fusion CT Lumbar Spine Assess Bony Degenerative Changes Without Contrast 72131 *MRI recommended for disc herniation, mets, infection Chest F/U nodules CT Chest Renal Failure Patients Without Contrast Cough CT Chest Pneumonia With Contrast Lung CA Esophageal CA Lymphoma Lung Nodule Mass Tracheal Stenosis Chest Wall Mass 71250 71260 CT - Computed Tomography BODY PART CT- Chest REASON FOR EXAM EXAM TO PRE-CERT Chest, High Resolution Interstitial Disease CT Chest Fibrosis Without Contrast CPT CODE 71250 COPD Hemoptysis Bronchiectasis Sarcoidosis Pleural Plaques Asbestosis CT- Abdomen & Pelvis CPT CODE BODY PART REASON FOR EXAM EXAM TO PRE-CERT Abdomen F/U for pts with renal cell carcinoma in renal failure (recommend MRI) CT Abdomen Without Contrast 74150 Abdominal Pain (generalized) CT Abdomen 74160 Mass With Contrast RUQ Pain LUQ Pain Epigastric Pain Pseudocyst Pancreatitis Abdomen & Hematuria with Pain CT Abdomen and Pelvis Pelvis Stone (Stone Study) Without Contrast Abdominal Pain CT Abdomen and Pelvis Crohns/Ulcerative Colitis/IBD With Contrast 74176 74177 Diverticulitis Abscess Mass Hernia (i.e., umbilical, inguinal) Kidney Cyst vs. Mass CT Abdomen Without and Cancer Staging With Contrast 74178 CT Pelvis With Contrast Abdomen Adrenal Mass - No Oral Prep CT Abdomen (Renal/ Adrenal) Abnormal Ultrasound Without and With Contrast Renal Mass - No Oral Prep Liver Hemangioma - No Oral Prep (recommend MRI) Hepatitis, Cirrhosis - No Oral Prep 74170 CT - Computed Tomography BODY PART CT- Abdomen & Pelvis (Continued) REASON FOR EXAM EXAM TO PRE-CERT Pelvis Fracture CT Pelvis Non-Union Without Contrast 72192 Prostate Treatment Planning Arthritis CT Pelvis Cancer Staging With Contrast 72193 Mass Cysts Pain Infection Abscess CT Urogram (Kidneys/ Bladder) Bone Infection CT Pelvis (recommend MRI) Without and With Contrast Transitional Cell Carcinoma of CT Abdomen and Pelvis Kidney and/or Bladder With and Without Contrast 72194 74178 Defects/Bladder Leakage CT Enteropgraphy Crohns Disease/ CT Abdomen and Pelvis Inflammatory Bowel Disease With Contrast 74177 Suspected Partial SBO (Small Bowel Obstruction) Small Bowel Masses Celiac Disease CT Cystogram Virtual Colonoscopy Leakage CT Abdomen and Pelvis Colovesical Fistula With and Without Contrast Colon Survey CT Abdomen and Pelvis Failed Colonoscopy Without Contrast 74176 DIAGNOSTIC 74261 SCREENING 74263 CT- Extremities BODY PART REASON FOR EXAM EXAM TO PRE-CERT Upper Extremities Fracture CT Upper Extremity Fusion Without Contrast Finger Hand Wrist Forearm Elbow Humerus Shoulder Clavicle Scapula CPT CODE 73200 Non-Union/Malunion Infection CT Upper Extremity Tumor/Mass/Cancer/Mets With Contrast (recommend MRI) 73201 CT - Computed Tomography BODY PART CPT CODE CT- Extremities Continued REASON FOR EXAM EXAM TO PRE-CERT Sternoclavicular Joint Lower Extremities Foot Ankle Calf (Tibia/ Fibula) Knee Thigh (Femur) Fracture CT Chest Non Union/Malunion Without Contrast Fracture CT Lower Extremity Fusion Without Contrast 71250 73700 Non-Union/Malunion Arthritis Patello Femoral Malalignment Anteversion/Malrotation (Bilateral) Infection CT Lower Extremity Tumor/Mass/Cancer/Mets With Contrast 73701 (recommend MRI) Leg Lengths FAI Protocol Abnormality Leg Length CT Limited 76380 Malrotation XR Bone Length 77073 Femoral Anteversion for CT Hip Without Contrast AND 72192 FAI Cam Lesion CT Knee Without Contrast 73700 CPT CODE CT- Arthrography BODY PART REASON FOR EXAM EXAM TO PRE-CERT CT Arthrogram Cartilage Abnormality Requires 3 codes: Hip Knee Ankle Shoulder Elbow Wrist Meniscus Abnormality 1 - Choose upper or lower ext: CTA Brain/ Head Labrum Abnormality Lower Extremity With Contrast Loose Bodies 73701 OR Upper Extremity With Contrast 2 - Fluoro Guided Arthrogram 73201 77002 3 - Choose body part: TIA, CVA Vascular Malformation Aneurysm AVM (Arterio/ Venous Malformation) CTA Brain Hip 27093 Knee 27370 Ankle 27648 Shoulder 23350 Elbow 24220 Wrist 25246 70496 CT - Computed Tomography BODY PART CPT CODE CT- Angiograpghy (CTA) REASON FOR EXAM EXAM TO PRE-CERT CTA Carotid/ Neck Carotid Stenosis CTA Carotid 70498 CTA Chest 71275 CTA Chest 71275 Thoracic and Abdominal CTA Chest 71275 Aortic Dissection CTA Abdomen 72191 Calcium Score 75571 Aneurysm (AAA) CTA Abdomen and 74175 Stent Obstruction/Leak/Malfunction CTA Pelvis 72191 CTA Upper Extremity 73206 CT Lower Extremity 73706 Peripheral Artery Disease (PAD) CTA Abdomen, Pelvis, Bilateral 75635 Ischemia to Lower Extremity Lower Extremities Bruit TIA, CVA Carotid Dissection CTA Chest Thoracic Aortic Dissection Thoracic Aortic Aneurysm Coarctation Aortic Root Dilation CTA Chest PE Study Chest Pain / Dyspnea Tachypnea Shortness of Breath Pulmonary Hypertension (PA HTN) CTA Chest and CTA Abdomen * Dissection going past renals Calcium Scoring Calcium Scoring of Coronary Arteries Fanily History of CAD Aorta, Renal, Stent Crossing Vessels Anatomic Marking for Partial/ Complete Nephrectomy Renal Artery Stenosis CTA Upper Extremities CTA Upper Extremities Trauma Arterial Stenosis Peripheral Artery Disease Ischemia to Lower Extremity Arterial Stenosis CTA Run-Off Arterial Stenosis CT - Computed Tomography CPT CODE BODY PART MRI- Head & Neck REASON FOR EXAM Brain Alzheimer’s, Dementia, Memory Loss MRI Brain Mental Status Changes, Confusion PROCEDURE TO PRE-CERT CPT CODE 70551 Without Contrast Headache Without Focal Symptoms Seizures (children) Stroke, CVA, TIA Trauma Cranial Nerve Lesions MRI Brain Dizziness, Vertigo Without and With Contrast 70553 Headache With Focal Symptoms HIV IAC/Hearing Loss Infection Multiple Sclerosis Neurofibromatosis Pituitary Lesion, Elevated Prolactin Seizures (adult new onset) Tumor / Mass / Cancer / Mets Vascular Lesions Vision Changes Trigeminal Neuralgia Order 2 exams: MRI Brain Without and With Contrast 70553 MRI Orbits / Face / Neck 70543 Without and With Contrast Orbits Grave’s Disease MRI Orbits / Face / Neck Trauma Without Contrast Exopthalmos, Proptosis MRI Orbits / Face / Neck Pseudotumor Without and With Contrast 70540 70543 Tumor / Mass / Cancer / Mets Vascular Lesions Optic Neuritis Neck Infection MRI Orbits/Face/Neck Pain Without and With Contrast 70543 Tumor / Mass / Cancer / Mets Vocal Cord Paralysis Parotid Gland MRI Orbits/Face/Neck Without and With Contrast 70543 MRI - Magnetic Resonance Imaging BODY PART MRI- Spine REASON FOR EXAM PROCEDURE TO PRE-CERT Cervical Arm / Shoulder Pain or Weakness MRI Cervical Spine Degenerative Disease Without Contrast CPT CODE 72141 Neck Pain Disc Herniation Cervical Fusion Radiculopathy Discitis MRI Cervical Spine Osteomylitis Without and With Contrast 72156 Multiple Sclerosis Myelopathy Syrinx Tumor / Mass / Cancer / Mets Vascular Lesions, AVM Thoracic Back Pain MRI Thoracic Spine Compression Fx (no hx cancer) Without Contrast 72146 Degenerative Disease Disc Herniation Radiculopathy Trauma Compression Fx (with hx cancer) MRI Thoracic Spine Discitis Without and With Contrast 72157 Osteomylitis Multiple Sclerosis Myelopathy Syrinx Tumor / Mass / Cancer / Mets Vascular Lesions AVM Lumbar Back Pain MRI Lumbar Spine 72148 Compression Fx (no hx malig / mets) Without Contrast Degenerative Disease Disc Herniation Radiculopathy Sciatica Spondylolithesis Stenosis Trauma Compression Fx (no hx malig / mets) MRI Lumbar Spine Discitis Osteomylitis Tumor / Mass / Cancer / Mets Without and With Contrast 72158 MRI - Magnetic Resonance Imaging BODY PART MRI- Chest / Abdomen / Pelvis REASON FOR EXAM PROCEDURE TO PRE-CERT Brachial Plexus Brachial Plexus Injury MRI Chest Without and With Contrast 71552 Nerve Avulsion MRI Neck Without and With Contrast 70543 Tumor / Mass / Cancer / Mets (Please authorize BOTH codes.) Tumor / Mass / Cancer / Mets MRI Chest / Mediastinum ChestMediastinum Breast 71552 Without and With Contrast Implant Rupture MRI Bilateral Breast Without Contrast 77059 Abnormal Mammogram MRI Bilateral Breast 77059 Abnormal Ultrasound Without and With Contrast Dense Breast/High Risk Mass / Lesion / Cancer Palpable Mass Abdomen MRCP (Biliary / Pancreatic Ducts) MRI Abdomen Without Contrast 74181 Adrenal Adenoma MRI Abdomen 74183 Adrenal Mass (not adenoma) Without and With Contrast Hemangioma Liver, Kidney, or Pancreas Mass Tumor / Mass / Cancer / Mets Pelvis Adenomyosis MRI Pelvis Without Contrast 72195 MRI Pelvis Without and With Contrast 72197 Fracture Muscle / Tendon Tear Urethral Diverticulum Sports Hernia Fibroids Osteomylitis Septic Arthritis Tumor / Mass / Cancer / Mets Abcess Ulcer MRI- Enterography Abdomen & Pelvis BODY PART REASON FOR EXAM PROCEDURE TO PRE-CERT Abdomen Pelvis Crohns Disease/Inflammatory Order 2 Exams: Bowel Disease MRI Abdomen GI Bleed Without and With Contrast Suspected Partial SBO (Small Bowel Obstruction) MRI Pelvis Without and With Contrast Small Bowel Masses Celiac Disease CPT CODE 74183 72197 MRI - Magnetic Resonance Imaging CPT CODE BODY PART MRI- Extremities REASON FOR EXAM PROCEDURE TO PRE-CERT Non-Joint: Arm Hand Finger Leg Foot Toe Fracture MRI — Non Joint Without Contrast Stress Fracture Muscle / Tendon Tear Abcess Ulcer CPT CODE Lower Extremity 73718 Upper Extremity 73218 MRI — Non Joint Without and With I.V. Contrast Bone Tumor / Mass / Cancer / Mets Lower Extremity 73720 Cellulitis Upper Extremity 73220 Fasciitis Myositis Morton‘s Neuroma Osteomylitis Soft Tissue Tumor / Mass / Cancer Joint: Shoulder Elbow Wrist Hip Knee Ankle Arthritis MRI — Joint Without Contrast Avascular Necrosis (AVN) Lower Extremity 73721 Fracture Upper Extremity 73221 Stress Fracture Internal Derangement Joint Pain (specify joint) Labral Tear Meniscal Tear Muscle Tear Tendon Tear Ligament Tear Cartilage Tear Osteochondritis Dessicans (OCD) Abcess Ulcer MRI — Joint Without and With I.V. Contrast Cellulitis Lower Extremity 73723 Fasciitis Upper Extremity 73223 Myositis Inflammatory Arthritis (pannus eval) Osteomylitis Septic Arthritis Tumor / Mass / Cancer / Mets MRI - Magnetic Resonance Imaging BODY PART MRI- Arthrography Joints REASON FOR EXAM PROCEDURE TO PRE-CERT Shoulder Elbow Wrist Hip Knee Ankle Labral Tear MRI Joint With Intra-articular Contrast CPT CODE Loose Bodies OCD Stability Requires 3 codes: Post-op Meniscus Evaluation 1 — Lower Extremity With Contrast OR 73722 Upper Extremity With Contrast 73222 2 — Fluoro Guided Arthrogram 77002 3 — Choose one code for body part: Shoulder 23350 Elbow 24220 Wrist 25246 Hip 27093 Knee 27370 Ankle 27648 MRA / MRV- MR Angiography / MR Venography CPT CODE BODY PART REASON FOR EXAM PROCEDURE TO PRE-CERT Head (MRA) Stroke, CVA, TIA MRA Head Without Contrast 70544 Venous Thrombosis MRV Head Without Contrast 70544 Stroke, CVA, TIA MRA Neck Without Contrast 70547 Dissection MRA Neck Without and With Contrast 70549 Thoracic Aorta MRA Chest Without and With Contrast 71555 Aneurysm Head (MRV) Neck Chest (other than dissection) Vascular Anomalies Subclavian Vessels Aortic Dissection Order 2 Exams: MRA Chest Without and With Contrast 71555 MRA Abdomen 74185 Without and With Contrast Arch & Great Vessels Abdomen (MRA) Stroke, CVA, TIA MRA Neck Without and With Contrast 70549 AAA (abdominal aortic aneurysm) MRA Abdomen 74185 Abdominal Aortic Dissection Without and With Contrast Mesenteric Ischemia Pre Kidney Transplant Renal Mass Order 2 Exams: Uncontrolled Blood Pressure MRA Abdomen 74185 Without and With Contrast MRI Abdomen Without and With Contrast 74183 MRI - Magnetic Resonance Imaging BODY PART MRA / MRV- MR Angiography / MR Venography REASON FOR EXAM PROCEDURE TO PRE-CERT Abdomen (MRV) Pelvis Venous Thrombosis MRV Abdomen Venous Pathology Without and With Contrast AVM (arteriovenous malformation) MRA Pelvis CPT CODE 74185 72198 Without and With Contrast Pelvic Congestion Order 2 Exams: MRA Pelvis 72198 Without and With Contrast MRI Pelvis 72197 Without and With Contrast Peripheral Run-Off Claudication Requires 3 codes: Cold Foot MRA Abdomen Pain Without and With Contrast 74185 MRA Lower Extremity 73725 Without and With Contrast (Left) MRA Lower Extremity Without and With Contrast (Right) 73725 MRI - Magnetic Resonance Imaging BODY PART Nuclear Medicine- Bone Scan CPT CODES Total body 78306 Pain of suspected musculoskeletal etiology Multi-area 78305 Paget’s disease Stress or occult fractures Trauma 3-phase 78315 Bone SPECT 78320 Limited Area 78300 Osteomyelitis or musculoskeletal inflammation Bone viability–grafts or avascular necrosis (AVN) Metabolic bone disease Arthritities Prosthetic joint evaluation for loosening or infection Evaluation of abnormal findings by other imaging modalities Evaluation of abnormal lab findings, especially elevated alkaline phosphatase Reflex sympathetic dystrophy (RSD) Suspected Charcot’s joint Nuclear Medicine- Biliary Scan COMMON INDICATIONS Right upper quadrant or abdominal pain Gallstones on CT or ultrasound CPT CODES Biliary 78223 Biliary with CCK 78223 Evaluation of gallbladder ejection fraction i.e., CCK Biliary Assessment of liver transplant function Evaluation of biliary atresia in pediatric patients Evaluation of bile leak Evaluation of common bile duct obstruction Evaluation of choledochal cyst Nuclear Medicine- Gallium Scan COMMON INDICATIONS Evaluation of fevers of unknown origin Disk space or joint space infection Evaluation of infection in immuno-compromised individuals Osteomylitis (Bone Gallium) Infection of prosthetic joints Detection of inflammatory disease such as sarcoid and tuberculosis. Evaluation of vascular graft infection Abscess localization Evaluation of pulmonary inflammation due to drug/environmental reaction, e.g., Amiodarone toxicity Polynephritis Post-operative surgical incision site infection Evaluation of inflammatory bowel disease Evaluation of diabetic ulcers CPT CODES Total body 78806 Limited area 78805 SPECT 78803 Nuclear Medicine COMMON INDICATIONS Primary or metastatic tumors – initial evaluation or follow-up of therapy Nuclear Medicine- Gastric Emptying Scan CPT CODES 78264 Gastro-esophageal reflux Vomiting Gastroparesis/Diabetics Weight loss Feeling of fullness Nuclear Medicine- Indium & Ceretec WBC Scan COMMON INDICATIONS Evaluation of fevers of unknown origin CPT CODES 78805 for both Disk space or joint space infection Evaluation of infection in immunocompromised individuals Osteomylitis Infection of prosthetic joints Evaluation of vascular graft infection Abscess localization Post-operative surgical incision site infection Evaluation of inflammatory bowel disease Evaluation of diabetic ulcers Note: Indium is a better choice for ortho patients with hardware. Nuclear Medicine- Lung (VQ) Scan COMMON INDICATIONS The assessment of the probability of acute or chronic pulmonary thromboembolic disease CPT CODES VQ scan 78585 VQ QUANT 78596 The establishment of the presence of chronic, unresolved pulmonary emboli The quantification of differential pulmonary function The evaluation of lung transplants The evaluation of the effects of congenital heart/lung disease The confirmation of the presence of bronchopleural fistulae The evaluation of effects of chronic pulmonary parenchymal disorders such as cystic fibrosis Nuclear Medicine- Parathyroid Scan COMMON INDICATIONS Parathyroid adenoma Increased PTH levels Hypercalcemia CPT CODES 78070 Nuclear Medicine COMMON INDICATIONS Abdominal pain Nuclear Medicine- Renal Scan CPT CODES DTPA or MAG3 78707 Evaluate renal function Captopril renal 78709 Renal vascular disease Renal with Lasix 78708 Polycystic kidney disease DMSA renal 78700 Post transplant evaluation Pyelonephritis Parenchymal scarring Nuclear Medicine- Thyroid Scan and Uptake COMMON INDICATIONS CPT CODES Assessment of size and location of thyroid tissue Thyroid scan only Evaluation of thyroid masses Abnormal thyroid lab results (Hyperthyroidism / Hypothyroidism) 78013 Thyroid uptake and scan Differentiation of hyperthyroidism/thyroiditis Abnormal weight gain or weight loss 78014 I123 Thyroid uptake and scan Cardiac arrythmia 78014 Nuclear Medicine- I-131 Whole Body Scan COMMON INDICATIONS Evaluation and treatment of thyroid carcinoma Hyperthyroidism CPT CODES 78018 Nuclear Medicine COMMON INDICATIONS Urinary tract obstruction Ultrasound- Neck REASON FOR EXAM PREP Soft Tissues Neck (Thyroid), Head / Face Mass None 76536 None 93880 Abnormalities detected on other imaging (CT / MRI / PET / NM) Enlarged thyroid gland Multinodular goiter (MNG) Abnormal lab tests (elevated calcium levels / abnormal thyroid level) Parathyroid adenomas Hyperthyroidism / Hypothyroidism Carotid Artery Weakness Headache Syncope Hemiplegia Difference in arm blood pressure Aphasia Ataxia Reversible ischemic neurological deficit (RIND) Bruit Vertigo / dizziness (non medicare) Memory loss (non medicare) Dementia (non medicare) Transient ischemic attack (TIA) Confusion Stroke Visual disturbance Cerebrovascular accident (CVA) Amaurosis fugax Ultrasound- Chest CPT CODE BODY PART REASON FOR EXAM PREP Chest Diaphragm paralysis None 76604 Aortic aneurysm (follow up to AAA) NPO 6 hours prior 76775 Pulsatile aorta to exam Pleural effusion Superficial mass Aorta (Limited Retroperitoneal) Bruit Family history AAA (non medicare) Ultrasound CPT CODE BODY PART Ultrasound- Abdomen REASON FOR EXAM PREP Abdomen Complete Cirrhosis or hepatic disease (Hepatitis / Portal Hypertension) NPO 6 hours prior 76700 to exam Abdominal distention (fluid collection) ascites Pain (Abdominal / Epigastric / Periumbilical) Nausea / Vomiting Gallstones Obstructive symptoms of the biliary system (Jaundice) Abnormal diagnostic tests (CT / MR) Gastroesophageal reflux (GERD) Splenomegaly Abnormal liver functions (Elevated LFT‘s / Fatty liver) Hepatomegaly Abdomen Limited Abdomen Doppler (Vascular) * all of the above NPO 6 hours prior 76705 to exam Cirrhosis or hepatic disease (hepatitis/ NPO 6 hours prior 93975 portal hypertension) to exam 93976 Ascites Varices Portal vein thrombosis Budd-Chiari Syndrome Intrahepatic Portosystemic Venous Shunts — TIPS Hepatomegaly Splenomegaly Ultrasound- Pelvis BODY PART REASON FOR EXAM Pelvis Pain (pelvic or adnexal tenderness) Ovarian cyst Uterine fibroids Enlarged uterus or ovary (mass) Adnexal abnormalities CPT CODE PREP Pelvis Complete 76856 Transvaginal 76830 *Please note: An Us Pelvis Complete is a Transabdominal exam. If a Transvaginal Us is needed it must be specifically indicated. Dysfunctional uterine bleeding Post menopausal bleeding Fill bladder with 32 oz Precocious puberty of water 1/2 hour prior Polycystic ovary Disease (PCOD) to exam. Do not void. Ovarian follicle monitoring Pelvic Doppler Ovarian torsion/Pelvic pain Fill bladder with 32 oz 93975 Follow up fibroid embolization of water 1 hour prior 93976 Ovarian vein embolization to exam. Evaluation of pelvic congestion syndrome (PCS) Do not void. Transvaginal Only: No prep Ultrasound CPT CODE BODY PART Ultrasound- Pelvis REASON FOR EXAM Scrotum Pain PREP CPT CODE 76870 Trauma Torsion Mass Varicocele Epididymitis Hydrocele (swelling) Undescended testes Ultrasound- Retroperitoneal BODY PART REASON FOR EXAM PREP Kidney (renal) and Bladder Pain (CVA tenderness/flank pain) Only for bladder: Obstruction (hydronephrosis) Fill bladder with 32 oz Hypertension of water 1/2 hour prior Follow up to other diagnostic imaging test to exam. (CT or MRI) Do not void. CPT CODE 76770 Abnormal lab values (BUN or Creatinine) Stones (renal) Chronic renal medical disease (renal function/ renal failure) Polycystic kidney disease (PCKD) Urinary tract infection/cystitis/pyelonephritis Renal cancer Trauma Hematuria (microscopic or gross) Neurogenic bladder Urinary retention - Evaluate post void residual (PVR) Bladder diverticula Renal Transplant Post renal transplant None 76776 Renal artery stenosis NPO 6 hours prior 93975 Renal artery aneurysm to exam 93976 Urinoma Lymphocele Pain Elevated lab values (creatinine) Poor renal function Renal Doppler Renal vein thrombosis Hypertension Abnormal laboratory values (elevated creatinine/BUN) Ultrasound BODY PART Ultrasound- Extremities/ Musculoskeletal REASON FOR EXAM PREP CPT CODE Upper or Lower Extremity (non Doppler) Pain None 76881 – Musculoskeletal Fluid collection (Bakers Cyst) – Limited Complete Mass – Limited Biceps tendon/rotator cuff exams (MSK radiologist 76882 – needs to perform - Book w/JRIS) – Complete Limited Biceps tendon scan with injection Bakers cyst aspiration with injection Joints/shoulder/elbow/ankle/knee ultrasound Upper or Lower Extremity Venous Doppler Edema/swelling None 93965 Calf pain (non medicare) 93970 Post surgical (non medicare) 93971 Redness Follow up DVT Positive Homan sign (shooting pain with foot dorsiflexion) History long plane/car trip Upper or Lower Extremity Arterial Doppler (PVR) Duplex Claudication/pain with walking None Decreased or absent pulses 93923 Arthrosclerosis Bruit 93922 93924 None 93925 High risk family history (non medicare) 93926 Numbness (non medicare) 93930 S/P graft or stenting 93931 Ulcer on foot or toe (non medicare) Discoloration of feet or legs (non medicare) Thoracic outlet syndrome Decrease arm pressure Cold fingers or toes (poor circulation) Venous Reflux Edema/swelling None 93965 None 76999 Leg ulcer (non medicare) Pain (non medicare) Venous insufficiency Varicose veins Burning or tingling (non medicare) Phlebitis/Thrombophlebitis Arterial Screening Carotid Aorta ABI (ankle brachial indices) Ultrasound BODY PART Flouroscopy PREP SPECIAL INSTRUCTIONS IR Lumbar Epidural (Includes FL Guidance 77003) CPT CODE 62311 Myelogram (Includes Intrathecal Injection 62284) - Thoracic None Schedule in morning first and CT to follow Needs Recovery Time, Needs Driver 72255 Myelogram (Includes Intrathecal Injection 62284) - Lumbar None Schedule in morning first and CT to follow Needs Recovery Time, Needs Driver 72265 Esophogram - Contrast XR w/ Barium NPO 8 hrs prior to exam Schedule in morning 74220 Swallowing Function - Contrast XR w/ Barium NPO 4 hrs prior to exam 74230 UGI (Upper Gastrointestinal) NPO 8 hrs prior to exam 74240 UGI with KUB 74241 UGI with SBFT 74245 UGI with Air 74246 UGI with Air and KUB 74247 UGI with Air and SBFT 74249 SBFT (Small Bowel Follow Thru) NPO after midnight Schedule at 8:30 (may take 4 hrs) Hypotonic Duodenography 74250 74260 BE (Barium Enema) with or without KUB Pick up BE Prep kit 2 days prior 74270 BE with Air Pick up BE Prep kit 2 days prior 74280 IVP No food 2 hrs prior to exam. Patient can drink. 74400 Cystourethrogram - Retrograde Cystourethrogram - Voiding (VCUG) Hysterosalpinogram (HSG) (Includes cpt 58340) 74450 None Patient needs to arrive pre-cathed Must be done between the 7th 10th day following the start of the patient's menstrual cycle. No sexual contact once period Schedule 7th- 10th day following first day of has started until after menstrual cycle procedure. 74455 74740 Venogram - Extremity Unilateral (Includes Injection 36005) 75820 Venogram - Extremity Bilateral (Includes Injection 36005) 75822 Arthrogram None Schedule MRI or CT to follow FL Guided Lumbar Puncture Hydrate well day before exam Schedule morning exam before 10 am Patient needs a driver FL Guided Needle Placement None FL Guided Picc Placement None FL Guided Port Study None SNIFF Test Tunneled ports need to come pre-accessed Flouroscopy EXAM X rays Chest 1 View PREP SPECIAL INSTRUCTIONS CPT CODE schedule s/p Thoracentesis Chest 2 View 71020 Lumbar Spine 2-3 Views 72100 Lumbar Spine includes bending views; only 2 or 3 views 72120 Lumbar Spine Complete includes bending views; minimum of 6 views 72114 Abdomen (KUB) 1 View 74000 Thoracic 3 View 72072 Cervical 2-3 Views 72040 Sinus less than 3 Views 70210 Pelvis 1-2 Views 72170 Shoulder minimum 3 Views 73030 Elbow minimum 3 Views 73080 Forearm 2 Views 73090 Wrist 2 Views 73100 Hand 2 Views 73120 Fingers minimum 3 Views 73140 Hip minimum 2 Views 73510 Ankle 2 View 73600 Foot 2 View 73620 Toes minimum 2 Views 73660 Small Intestines 74250 X-Rays EXAM
