Download TEE - Presence Health

TEE TESTING
REQUISITION
COMMENT
All orders - please fax to (815) 773-7419
DATE:____________________________
Interpreting MD to Initial _____________
*REQUIRED - HEIGHT:______________
PATIENT NAME:_______________________________________________
WEIGHT:_____________
DOB:_______________________
HOME PHONE:__________________________________ WORK PHONE:___________________________________
ORDERING PHYSICIAN:____________________________ CONTACT PERSON:______________________________
OFFICE PHONE:___________________ FAX NUMBER:______________________ Pt. is a diabetic: Yes No
CARDIOLOGIST TO INTERPRET TEST:
 HEARTLAND
 JMG – Bhatt
TEE – TRANSESOPHAGEAL ECHO
PS 1957 (2/02)
PLEASE CHECK DIAGNOSIS CODE: ICD-9 CODES
THAT SUPPORT MEDICAL NECESSITY:
**REQUIRED**
HCG 11- 50 years of age
Not done due to
________________________
H&P to accompany order
Septicemia (038.0-038.9)
 Neoplasm of unspecified nature (heart) (239.8)
 Mitral stenosis (394.0)
 Mitral stenosis with insufficiency (394.2)
 Other and unspecified mitral valve diseases (394.9)
 Diseases of tricuspid valve (397.0)
 Aneurysm of heart (wall) (414.10)
 Acute and subacute bacterial endocarditis (421.0)
 Mitral valve disorders (424.0)
 Aortic valve disorders (424.1)
 Pulmonary valve disorders (424.3)
 Endocarditis, valve unspecified, unspecified cause (424.90)
 Hypertrophic obstructive cardiomyopathy (425.1)
 Alcoholic cardiomyopathy (425.5)
 Secondary cardiomyopathy, unspecified (425.9)
 Atrial fibrillation (427.31)
 Atrial flutter (427.32)
 Myocarditis, unspecified (429.0)
 Cardiomegaly (429.3)
 Functional disturbances following cardiac surgery (429.4)
 Rupture of chordae tendineae (429.5)
 Rupture of papillary muscle (429.6)
 Acute, but ill-defined cerebrovascular disease (436)
 Other specified transient cerebral ischemias (TIA) (435.8)
 Atherosclerosis of aorta (440.0)
 Dissection of aorta (thoracic) (441.01)
 Dissection of aorta (thoracoabdominal) (441.03)
 Thoracic aneurysm without mention of rupture (441.2)
 Arterial embolism and thrombosis of arteries of the upper extremity (444.21)
 Arterial embolism and thrombosis of arteries of the lower extremity (444.22)
 Ventricular septal defect (745.4)
 Ostium secundum type atrial septal defect (745.5)
 Obstructive anomalies of heart, not else where classified (746.84)
**REQUIRED**
 Shock, unspecified (785.50)
Physician Signature:
 Cardiogenic shock (785.51)
 Mechanical complication of heart valve prosthesis (996.02)
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Other ___________________________________________