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Download MRI Ordering Guide: MRA/MRV - Saint Francis Hospital and Medical
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SAINT SAFRANCIS INTFRANCIS Department of Radiology/Imaging Hospital and Medical Hospital and MCenter edical Center MRI Ordering Guide: MRA/MRV TO SCHEDULE AN APPOINTMENT: CALL (860) 714-XRAY (714-9729) or FAX REQUISITION TO (860) 714-8002 Any patient, who will be receiving contrast, with hypertension, diabetes, kidney or liver disease will need creatinine and BUN or GFR within six weeks of exam. All patients over 60 yrs who will be receiving contrast, must have a creatinine & BUN or GFR within six weeks of exam If RENAL FAILURE (Creatinine over 1.8)-ORDER EXAM WITHOUT CONTRAST-CONFIRM RENAL FAILURE WITH SCHEDULER This is for reference only. Referring provider responsible for insurance pre-authorization. Body Part MRA Abdomen Reason for Exam IV Contrast AAA (abdominal aortic aneurysm Dissection Mesenteric Ischemia Procedure to Pre-Cert CPT Code MRA Abdomen With & Without contrast 74185 Yes Renal Artery Stenosis Pre Liver Transplant Pre Kidney transplant Yes Renal Mass Order 2 Exams: MRA Abdomen With & Without contrast & MRI Abdomen With & Without contrast 74185 74183 MRV Abdomen Venous Occlusion Yes 74185 MRA Chest Venous Thrombosis Venous Anomaly Thoracic Aorta (other than the heart) MRA Abdomen With & Without Contrast Yes MRA Chest With & Without contrast 71555 MRV Chest Aneurysm Coarctation Vascular Anomalies Dissection Thoracic Outlet Syndrome Pulmonary Embolism Arterial Venous Malformation Subclavian Vessels Venous Occlusion/ Thrombosis MRA Pelvis Arterial Venous Malformation AVM (arteriovenous malformation) Or MRV Pelvis MRA Peripheral (Run-off) May Thurner Syndrome Venous Occlusion Aneurysm Pelvic Congestion Claudication Cold foot MRA Chest With & Without Contrast 71555 Yes MRA Pelvis With & Without contrast 72198 Yes Order 2 Exams: MRA Pelvis With & Without contrast 72198 MRI Pelvis With & Without contrast 72197 Yes Yes Order 3 Exams: MRA Abdomen With & Without contrast & MRA Lower Extremity With & Without contrast LEFT & MRA Lower Extremity With & Without Contrast RIGHT Pain Gangrene Ulcer MRA Extremity or MRV Arterial Occlusion/ Stenosis Extremity Aneurysm Venous Occlusion/ Thrombosis 1/2010 Yes 74185 73725 73725 MRA Extremity With & Without Contrast Upper Extremity Lower Extremity 73225 73725 Department of Radiology/Imaging SAINT FRANCIS Hospital and Medical Center MRI Ordering Guide: Brain TO SCHEDULE AN APPOINTMENT: CALL (860) 714-XRAY (714-9729) or FAX REQUISITION TO (860) 714-8002 Any patient, who will be receiving contrast, with hypertension, diabetes, kidney or liver disease will need creatinine and BUN or GFR within six weeks of exam. All patients over 60 yrs who will be receiving contrast, must have a creatinine & BUN or GFR within six weeks of exam If RENAL FAILURE (Creatinine over 1.8)-ORDER EXAM WITHOUT CONTRAST-CONFIRM RENAL FAILURE WITH SCHEDULER This is for reference only. Referring provider responsible for insurance pre-authorization. Body Part Brain Reason for Exam Alzheimer’s Mental Status Changes Confusion Dementia Memory Loss Headache Without Focal Symptoms Seizures Stroke CVA TIA Trauma Cranial Nerve Lesions Dizziness Vertigo HIV IAC/Hearing Loss Infection Multiple Sclerosis Neurofibromatosis Pituitary Lesion Elevated Prolactin Adenoma Tumor/Mass/Cancer/Mets Vascular lesions Vision Changes Alzheimer’s H Brain Spectroscopy MRA Brain 1/2010 IV Contrast o s p i t a l a n d M e d i c a l C e n t e Procedure to Pre-Cert CPT Code Yes MRI Brain With & Without Contrast 70553 MRI Spectroscopy With and/or Without Contrast 76390 Yes No MRA Brain Without Contrast 70551 r Dementia Tumor/Mass/Cancer/Mets Infection Seizures Encephalopathy Ischemia Hypoxia Multiple Sclerosis Brain Injury Stroke CVA TIA Aneurysm Arterial Venous Malformation (AVM) SAINT FRANCIS Department of Radiology/Imaging Hospital and Medical Center MRI Ordering Guide: Brain/Neck/Spine TO SCHEDULE AN APPOINTMENT: CALL (860) 714-XRAY (714-9729) or FAX REQUISITION TO (860) 714-8002 This is for reference only. Referring provider responsible for insurance pre-authorization. Any patient, who will be receiving contrast, with hypertension, diabetes, kidney or liver disease will need creatinine and BUN or GFR If RENAL FAILURE (Creatinine over 1.8)-ORDER EXAM WITHOUT CONTRAST-CONFIRM RENAL FAILURE WITH SCHEDULER This is for reference only. Referring provider responsible for insurance pre-authorization. Body Part Reason for Exam MRA Neck Stroke CVA TIA Subclavian Steal Arterial Venous Malformation (AVM) Aneurysm MRI Neck Infection IV Contrast Procedure to Pre-Cert Yes MRA Neck With & Without Contrast Yes MRI Orbits/Face/Neck With & Without Contrast CPT Code 70543 Pain Tumor/Mass/Cancer/Mets Vocal Cord Paralysis MRA Arch & Great Vessels MRV Brain Orbits Spine: Cervical Stroke MRA Neck With & Without Contrast 70547 70544 70543 Yes MRV Without Contrast MRI Orbits/Face/Neck With & Without Contrast No MRI Cervical Spine Without Contrast 72141 MRI Cervical Spine With & Without Contrast 72156 Yes MRI Cervical Spine With & Without Contrast 72156 Yes Yes CVA TIA Subclavian Steal Arterial Venous Malformation (AVM) Aneurysm Venous Thrombosis Grave’s Disease Demyelination/Multiple Sclerosis Diplopia Dysthyroid Eye Disease Trauma Exopthalmos, Proptosis Pseudotumor Tumor/Mass/Cancer/Mets Vascular Lesions Arm/Shoulder Pain and/or Weakness Degenerative Disease Neck Pain Disc Herniation Radiculopathy Post-op (any hx cervical surgery) No Syrinx Discitis Osteomyelitis Multiple Sclerosis Myelopathy Abscess/ Infection Tumor/Mass/Cancer/Mets Vascular Lesions/AVM 1/2010 SAINT FRANCIS Department of Radiology/Imaging Hospital and Medical Center MRI Ordering Guide: Spine TO SCHEDULE AN APPOINTMENT: CALL (860) 714-XRAY (714-9729) or FAX REQUISITION TO (860) 714-8002 Any patient, who will be receiving contrast, with hypertension, diabetes, kidney or liver disease will need creatinine and BUN or GFR within six weeks of exam. All patients over 60 yrs who will be receiving contrast, must have a creatinine & BUN or GFR within six weeks of exam. If RENAL FAILURE (Creatinine over 1.8)-ORDER EXAM WITHOUT CONTRAST-CONFIRM RENAL FAILURE WITH SCHEDULER This is for reference only. Referring provider responsible for insurance pre-authorization. Body Part Spine: Thoracic Spine: Lumbar 1/2010 Reason for Exam Back Pain Compression Fracture (no hx cancer/mets) Degenerative Disease Disc Herniation Radiculopathy Trauma Vertebroplasty Planning (no hx of cancer/mets) Compression Fracture (with hx of cancer/mets) Discitis Abscess/ Infection Osteomyelitis Post-op (any hx thoracic surgery) Multiple Sclerosis Myelopathy Syrinx Tumor/Mass/Cancer/Mets Vascualr Lesions AVM Vertebroplasty Planning (with hx of cancer/mets) Back Pain Compression Fracture (no hx cancer/mets) Degenerative Disease Disc Herniation Radiculopathy Sciatica Spondylolithesis Stenosis Trauma Vertebroplasty Planning (no hx of cancer/mets) Compression Fracture (with hx of cancer/mets) Discitis Osteomyelitis Abscess/ Infection Post-op (any hx lumbar surgery) Tumor/Mass/Cancer/Mets Vertebroplasty Planning (with hx of cancer/mets) IV Contrast Procedure to Pre-Cert CPT Code No MRI Thoracic Without Contrast 72146 Yes MRI Thoracic With & Without Contrast 72157 No MRI Lumbar Without Contrast 72148 Yes MRI Lumbar With & Without Contrast 72158 SAINT FRANCIS Department of Radiology/Imaging Hospital and Medical Center MRI Ordering Guide: Body TO SCHEDULE AN APPOINTMENT: CALL (860) 714-XRAY (714-9729) or FAX REQUISITION TO (860) 714-8002 This is for reference only. Referring provider responsible for insurance pre-authorization. Any patient, who will be receiving contrast, with hypertension, diabetes, kidney or liver disease will need creatinine and BUN or GFR within six weeks of exam. All patients over 60 yrs who will be receiving contrast, must have a creatinine & BUN or GFR within six weeks of exam If RENAL FAILURE (Creatinine over 1.8)-ORDER EXAM WITHOUT CONTRAST-CONFIRM RENAL FAILURE WITH SCHEDULER Body Part Abdomen Reason for Exam Abnormal Enzymes Fetal MRI MRCP (Biliary/Pancreatic Ducts, Stones, Jaundice) Adrenal Mass o s p i t a l a n d M e d i c a l C e n t e MRI Abdomen Without Contrast 74181 74183 Yes MRI Abdomen With & Without Contrast MRI Chest/Mediastinum With & Without Contrast 71552 Yes No Abnormal Mammogram Yes Abnormal Ultrasound Dense Breast/High Risk Mass/Lesion/Cancer Palpable Mass Tumor/Mass/Cancer/Mets Chest Yes Mediastinum 1/2010 CPT Code r Nerve Avulsion Tumor/Mass/Cancer/Mets Implant Rupture Breast Procedure to Pre-Cert No Liver Tumor/Mass/Cancer/Mets Abdominal Pain Abscess/Ascites Pancreatic Mass/Lesion Renal Lesion Brachial Plexus Injury H Brachial Plexus IV Contrast MRI Breast Without Contrast Bilateral Unilateral (specify breast) MRI Breast Bilateral With & Without Contrast MRI Breast Unilateral With & Without Contrast (Specify Side) MRI Chest/Mediastinum With & Without Contrast 76094 76093 76094 76093 71552 SAINT FRANCIS Department of Radiology/Imaging Hospital and Medical Center MRI Ordering Guide: Body (cont'd) TO SCHEDULE AN APPOINTMENT: CALL (860) 714-XRAY (714-9729) or FAX REQUISITION TO (860) 714-8002 Any patient, who will be receiving contrast, with hypertension, diabetes, kidney or liver disease will need creatinine and BUN or GFR within six weeks of exam. All patients over 60 yrs who will be receiving contrast, must have a creatinine & BUN or GFR within six weeks of exam If RENAL FAILURE (Creatinine over 1.8)-ORDER EXAM WITHOUT CONTRAST-CONFIRM RENAL FAILURE WITH SCHEDULER This is for reference only. Referring provider responsible for insurance pre-authorization. Body Part Reason for Exam IV Contrast Anomalous Coronary Artery Cardiac If looking for Valve Insufficiency/ Regurgitation, ASD/VSD and the patient is unable to receive a contrast agent. ARVD Procedure to Pre-Cert CPT Code Morphology & Function Without Contrast Morphology & Function Without Contrast; With Flow/Velocity Quantification 75557 Morphology & Function Without and With Contrast and Further Sequences 75561 75562 Yes Morphology & Function Without and With Contrast; With Flow/Velocity Quantification MRI Orbits/Face/Neck With & Without Contrast 70543 Yes No MRI Pelvis Without Contrast 72195 MRI Pelvis With & Without Contrast 72197 No Yes 75558 Yes Sarcoidosis Pericardial Disease Mass Viability Myocardial Infarction Valve Insufficiency/ Regurgitation Atrial/Ventricular Septal Defect Infection Neck Pain Tumor/Mass/Cancer/Mets Vocal Cord Paralysis Fracture Muscle/Tendon Tear Urethral Diverticulum MRI Defecogram Fibroid Adenomyosis Endometrioma Osteomyelitis Septic Arthritis Pre/Post Fibroid Embolization Tumor/Mass/Cancer/Mets Abscess Ulcer Prostate Cancer Plexopathy Pelvis 1/2010 Yes SAINT FRANCIS Hospital and Medical Center Department of Radiology/Imaging MRI Ordering Guide: Extremities and Athrograms TO SCHEDULE AN APPOINTMENT: CALL (860) 714-XRAY (714-9729) or FAX REQUISITION TO (860) 714-8002 Any patient, who will be receiving contrast, with hypertension, diabetes, kidney or liver disease will need creatinine and BUN or GFR If RENAL FAILURE (Creatinine over 1.8)-ORDER EXAM WITHOUT CONTRAST-CONFIRM RENAL FAILURE WITH SCHEDULER This is for reference only. Referring provider responsible for insurance pre-authorization. Body Part Extremity, Non-Joint Arm Hand Finger Lower Leg Femur Foot Toe Extremity, Joint Shoulder Elbow Wrist Hip Knee Ankle Extremity, Joint Shoulder Elbow Wrist Hip Knee Ankle MR Arthrography Reason for Exam Fracture Stress Fracture Muscle/Tendon tear Abscess Ulcer Bone Tumor/Mass/Cancer/Mets Cellulitis Fasciitis Myositis Morton’s neuroma Osteomyelitis Soft Tissue Tumor/Mass/Cancer/Mets Arthritis AVN (Avascular Necrosis) Fracture Stress Fracture Internal Derangement Joint Pain (specify joint) Labral Tear Meniscus Tear Muscle Tear Tendon Tear Ligament Tear Cartilage Tear Osteochondritis Dessicans (OCD) Abscess Ulcer Cellulitis Fasciitis Myositis Inflamatory Arthritis Osteomyelitis Septic Arthritis Tumor/Mass/Cancer/Mets Post-op Knee Labral Tear IV Contrast None MRI Non-Joint Without Contrast Lower-Extremity Upper Extremity 73718 73218 Lower-Extremity Upper Extremity 73720 73220 MRI Joint Without Contrast Lower Extremity Upper Extremity 73721 73221 MRI Joint With & Without Contrast Lower Extremity Upper Extremity 73723 73223 Yes None Yes MRI Joint With Contrast- Order With 3 Codes: 1. Lower Extremity With Contrast OR Upper Extremity With Contrast 2. Fluoroscopy Guided Arthrogram Choose one body part (CPTs listed below are for Fluoroscopic guidance and arthrogram procedure): Shoulder Elbow Wrist Hip Knee Ankle 1/2010 CPT Code MRI Non-Joint With & Without Contrast Yes Loose Bodies OCD Stability Post-op Meniscus Evaluation Procedure to Pre-Cert 73722 73222 73040 and 23350 73085 and 24220 73115 and 25246 73525 and 27093 73580 and 27370 73615 and 27648
