Download Ordering Guide for MRI

SpecialInstructions
Safety concerning NSF and gadolinium-based contrast agents (GBCA)
FDA and ACR guidelines are as follows:
Prior to administering MRI contrast (GBCA), any patient who answers “yes” to any of the following questions will undergo
laboratory testing in order to measure renal function (eGFR). Optim Imaging can provided the lab testing in the office.
Ø Age > 60
Ø Renal Disease (including solitary kidney, renal transplant, renal tumor)
Ø History of Hypertension (high blood pressure)
Ø History of Diabetes
Ø History of severe hepatic disease, liver transplant, or pending liver transplant
Ø Compromising blood diseases
If laboratory test for renal function (eGFR--estimated Glomerular Filtration Rate) is abnormal measuring >
30ml/min/1.73m², then MRI contrast (GBCA) injection will not be given.
The following items may be hazardous or require special attention before having an MRI exam. After certain surgeries, if you
received a card with the manufacture and model number of the stent, insulin pump , heart valve or other implant; please make a copy
and fax with MRI order to check for compatibility. If a card is not available, operative notes that show model number(s) may be
required.
Cardiac pacemaker (even if it has been removed)
Brain aneurysm clip(s)
Implanted insulin pump (COPY CARD)
Implanted drug pump (COPY CARD)
Neurostimulator (even if it has been removed)
Ear implants (cochlear, stapes, incus) MUST HAVE CARD ****Cochlear implants cannot have MRI****
Heart Valve (COPY CARD)
Heart Valve (COPY CARD)
Penile implant (MUST HAVE CARD)
Lumbar Surgery
Metal in eyes if YES, for safety need x-rays. ( Can be done at Optim Imagimg).
MRIOrderingGuide
ToScheduleanappointmentcall:OptimImaging(Savannah)office912-644-5313orOptimMedicalCenter/Tattnall(Reidsville)912-557-1204
Musculoskeletal/BoneandJoints
CPTCode
73221
73222
23350(injection)
24220(injection)
25246(injection)
73223
73218
73220
CPTCode
73721
73722
27093(injection)
27370(injection)
27648(injection)
73723
73718
73720
ExamtoOrder
UpperExtremityJointwithoutcontrast
Shoulder
Elbow
Wrist
UpperExtremityJointwithcontrast(Arthrography)
Shoulder
Elbow
Wrist
UpperExtremityJointwithandwithoutcontrast
Shoulder
Elbow
Wrist
UpperExtremityNon-Jointwithoutcontrast
Humerus
Forearm
Hand
Fingers
UpperExtremityNon-Jointwithandwithoutcontrast
Humerus
Forearm
Hand
Fingers
ExamtoOrder
LowerExtremityJointwithoutcontrast
Hip
Knee
Ankle
LowerExtremityJointwithcontrast(Arthrography)
Hip
Knee
Ankle
LowerExtremityJointwithandwithoutcontrast
Hip
Knee
Ankle
LowerExtremityNon-Jointwithoutcontrast
Femur
Tibia/Fibula
Foot
Toe
LowerExtremityNon-Jointwithandwithoutcontrast
Femur
Tibia/Fibula
Foot
Toe
Symptoms/Concerns
Arthritis
AvascularNecrosis(AVN)
Fracture/StressFracture
Pain
InternalDerangement
MuscleTear
LabralTear(mayneedMRArthrogram)
Tendon,LigamentorCartilageTear
Tendinitis
Impingement
Epicondylitis
Lipoma
LabralTear
LooseBodies
Painafterdislocation
Ligmentoustear-wrist
Rotatorcufftear-PostSurgery
TFCCinjury
Abcess
Ulcer
Cellulitis
Osteomyelitis
BoneTumor/Mass
SoftTissueTumor/Mass
Infection
Rheumatoid/InflammationArthritis
SepticArthritis
Lipoma
Tendon,LigamentorCartilageTear
Bursitis
Tendinitis
MuscleTear
Abcess
Ulcer
Cellulitis
Osteomyelitis
BoneTumor/Mass
SoftTissueTumor/Mass
Infection
Symptoms/Concerns
Arthritis
AvascularNecrosis(AVN)
Fracture/StressFracture
Pain
InternalDerangement
Lipoma
Tarsaltunnelsyndrome
LabralTear(mayneedMRArthrogram)
Tendon,LigamentorCartilageTear
MeniscalTear
OsteochondritisDessicans(OCD)
MuscleTear
PlantarFasciitis
LabralTear
LooseBodies
Painafterdislocation
LabralTear-Postsurgery
Meniscus-Postsurgery
UnstableOsteochondral
Abcess
Ulcer
Cellulitis
Osteomyelitis
SepticArthritis
BoneTumor/Mass
SoftTissueTumor/Mass
Infection
Fracture/StressFracture
Tendon,LigamentorCartilageTear
Bursitis
Tendinitis
MuscleTear
Lipoma
Abcess
Ulcer
Cellulitis
Osteomyelitis
BoneTumor/Mass
SoftTissueTumor/Mass
Infection
Morton'sNeuroma
ThesearegeneralguidelinestoassistinorderinganMRIexam.Forfurtherassistscall:OptimImaging912644-5313orOptimMedicalCenter/Tattnall912-557-1204
MRIOrderingGuide
ToScheduleanappointmentcall:OptimImaging(Savannah)office912-644-5313orOptimMedicalCenter/Tattnall(Reidsvillle)912-557-1204
Brain-Neuro
CPTCode
70551
ExamtoOrder
Symptoms/Concerns
BrainwithoutContrast
70553
BrainwithandwithoutContrast
70553
BrainwithandwithoutContrastforIAC
70553
BrainwithandwithoutContrastforPituitary
70544
BrainMRAwithoutContrast
70543
OrbitswithandwithoutContrast
70543
SoftTissueNeckwithandwithoutContrast
70548
MRANeckwithContrast
TIA
MemoryLoss
Confusion
ShuntCheck
KnownorSuspectedTumor
MultipleSclerosis
Dizziness
Vertigo
Seizures
Hearingloss
AcousticNeuroma
Dizziness
Vertigo
Meniere'sDisease
PituitaryLesion
ElevatedProlactinLevels
KnownorSuspectedAneurysm
Stroke
TIA
AVM
Infection
Neoplasm
VisualDisturbance
Inflammation/Swelling
NeckMass
Adenopathy
Infection
Salivaryglandmass
CarotidStenosis
Bruit
TIA
Infection
MetastaticDisease
AVM
Headache
Bell'sPalsy
CircleofWillis-Intracranialcirculation
GravesDisease
Proptosis
LossofVision
OpticNeuritis
VocalCordParalysis
KnownorSuspectedlesionThyroid,Parathyroid
Pain
VascularTumor
CerebralVascularAccident
ThesearegeneralguidelinestoassistinorderinganMRIexam.Forfurtherassistscall:OptimImaging912644-5313orOptimMedicalCenter/Tattnall912-557-1204
MRIOrderingGuide
ToScheduleanappointmentcall:OptimImaging(Savannah)office912-644-5313orOptimMedicalCenter/Tattnall(Reidsvillle)912-557-1204
Chest-Abdomen-Pelvis
CPTCode
71552
ExamtoOrder
BrachialPlexuswithoutContrast
71552
BrachialPlexuswithandwithoutContrast
71552
ChestWallwithandwithoutContrast
74181
AbdomenwithoutContrast(MRCP)
74183
AbdomenwithandwithoutContrast
74183
72179
AbdomenwithandwithoutContrast
PelviswithandwithoutContrast
72195
PelviswithoutContrast
72197
PelviswithandwithoutContrast
Symptoms/Concerns
Evaluateforentrapment
BrachialPlexuxpathology
Infection
Neoplasm
PectoralisInjury
SternoclavicularJointDisease
BiliaryObstruction
GallbladderStones
Jaundice
AbdominalPain
Complaintsrelatedtoliver,spleen,
pancreasandkidneys
Crohn'sdisease
Inflammatoryboweldisease
Ischemicboweldisease
CoccyxFracture
PelvicFracture
PubicArthralgia
SacralFracture
Sacroiliitis
SportsHernia
StressFracture
MuscleTendonTear
Suspectedpelvicmass
Endometriosis
Scrotal/Testicular/PenileCancer
Fibroids
Hernia
UterineMass
Bladder/RectalCancer
OvarianDisease
ThesearegeneralguidelinestoassistinorderinganMRIexam.Forfurtherassistscall:OptimImaging912644-5313orOptimMedicalCenter/Tattnall912-557-1204
MRIOrderingGuide
ToScheduleanappointmentcall:OptimImaging(Savannah)office912-644-5313orOptimMedicalCenter/Tattnall(Reidsvillle)912-557-1204
Spines
CPTCode
72141
72156
72156
72157
72148
72158
ExamtoOrder
Cervicalwithoutcontrast
DegenerativeDisease
Pain
DiscHerniation(HNP)
ChiariMalformation
Fracture
Symptoms/Concerns
Postop
Radiculopathy
Syrinx(known)
Stenosis
Lordosis/Scoliosis
Cervicalwithandwithoutcontrast
Discitis
Osteomyelitis
MultipleSclerosis(MS)
Myelopathy
Abscess/Infection
Syrinx(suspected)
Tumor/Mass
DegenerativeDisease
Pain
DiscHerniation(HNP)
Fracture
Schmorl'sNodes
Radiculopathy
Syrinx(known)
CompressionFracture(non-pathologic)
Stenosis
Post-opgreaterthan6months
Discitis
Osteomyelitis
MultipleSclerosis(MS)
Myelopathy
DegenerativeDisease
Pain
DiscHerniation(HNP)
Abscess/Infection
Syrinx(suspected)
Tumor/Mass
Post-oplessthan6months
CompressionFracture(pathologic)
Post-opgreaterthan2years
Radiculopathy
Syrinx(known)
Stenosis
Discitis
Osteomyelitis
MultipleSclerosis(MS)
Myelopathy
Abscess/Infection
Syrinx(suspected)
Tumor/Mass
Post-oplessthan2years
Thoracicwithoutcontrast
Thoracicwithandwithoutcontrast
Lumbarwithoutcontrast
Lumbarwithandwithoutcontrast
ThesearegeneralguidelinestoassistinorderinganMRIexam.Forfurtherassistscall:OptimImaging912644-5313orOptimMedicalCenter/Tattnall912-557-1204