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INTEGRISDiagnostic Imaging ServicesORDER GUIDEThis Order Guide is intended for informational purposes onlyand not for diagnostic purposes.Computer Tomography Order GuideArea of ConcernHEADBody PartBrainReason for ExamTraumaHeadachesCVAStroke / BleedAlzheimer’sMemory LossConfusionShunt CheckHydrocephalusDizziness, VertigoMass / TumorInfectionMetastatic StagingMelanomaHIVOrbitFACESinusFacialComputed Tomography IV Contrast Oral Prep CPT CODENoneNone70450YesNone70470CT Head withoutInfusionCT Head with andwithout InfusionTraumaFractureForeign BodyCT Orbits withoutInfusionNoneNone70480Grave’s DiseaseMassPainCT Orbits with /without InfusionYesNone70482SinusitisMassPainCT Sinus withoutInfusionNoneNone70486Mass/AbscessCT Orbits with /without InfusionYesNone70482TraumaPainFractureCT Maxillofacialwithout InfusionNoneNone70486TumorInfectionCT Maxillofacialwith / without InfusionYesNone70488Call to confirm that there have been no changes in CPT codes or other information.integrisok.com/radiology 855-38IMAGE (855-384-6243)Diagnostic Services Ordering Guide 14797 no pictures.indd 14/15/16 2:20 PM
Area of ConcernBody PartReason for ExamHearing LossTinnitusTraumaCholesteatomaCT Temporal d MassNECKABDOMENGeneralGeneralGIComputed Tomography IV Contrast Oral Prep CPT CODENoneNone70480CT Neck withContrastYesNone70491(Very Rare)Parotid StoneParotid InfectionCT Neck with andwithout InfusionYesNone70492Abdominal painCancerMassCrohn’sUlcerative ost opColon cancerCT Abdomen andPelvis with InfusionYesYes74177ObstructionTraumaAppendicitis (rectal ifat the age of 13and younger)CT Abdomen andPelvis with InfusionYesYes74177CT Mastoids2Diagnostic Services Ordering Guide 14797 no pictures.indd 24/15/16 2:20 PM
Area of ConcernBody PartReason for ExamLiverPost isHigh Liver EnzymesJaundiceLiver MassHep CComputed Tomography IV Contrast Oral Prep CPT CODECT Abdomen Upperwith and withoutInfusionCT Abdomen Upperwith and without infusionorPainless HematuriaCT Abdomen / PelvisCancerRenal Mass (cyst vs. solid) with and without infusionHematuria with No74176Adrenal MassCT Abdomen Upperwith and withoutYesNo74170Pancreas MassIslet Cells TumorJaundiceInsulinomaPancreatitisCT Abdomen Upperwith and onCT Upper / morMassCancerCT Upper / LowerExtremitywith w KneeShoulderTib / FibAnkleKneeHipPelvis74170NoRenal StoneExtremityNon JointYesCT Abdomen / Pelviswithout infusionrenal stoneRenalStonePancreasYesHematuria71250CT Chest without3Diagnostic Services Ordering Guide 14797 no pictures.indd 34/15/16 2:20 PM
Area of ConcernBody PartCervical(neck)SPINEThoracicReason for ExamComputed Tomography IV Contrast Oral Prep CPT CODEDegenerative DiskFractureInjuryNeck PainCT Cervical Spine withoutNoNo72125Epidural Abscess*CT Cervical Spine withYesNo72126Mets*(with / without)YesNo72127Degenerative DiskFractureInjuryNeck PainCT Thoracic Spine withoutNoNo72128Epidural Abscess*CT Thoracic Spine withYesNo72129YesNo72130Mets*LumbarDegenerative DiskFractureInjuryNeck PainCT Lumbar Spine withoutNoNo72131Epidural Abscess*CT Lumbar Spine withYesNo72132Mets*(with / without)YesNo72133* Only if patient cannot have an MRICHESTGeneralChestChest PainSHOBRule Out PEPositive D DimerCT Chest r/o PEYesNone71275PneumoniaLung NoduleMassHemoptysisSarcoidosisCancerEsophageal CancerCT Chest with InfusionYesNone71260Interstitial DiseaseFibrosisBronchiectasisCT Chest withoutInfusion(high resolution)NoNo71250PneumoniaLung NoduleCT Chest withoutNoNo712504Diagnostic Services Ordering Guide 14797 no pictures.indd 44/15/16 2:20 PM
Area of ConcernBody PartReason for ExamAortaAneurysmPost Stent GraftingRenal Artery StenosisMesenteric IschemiaDissectionComputed Tomography IV Contrast Oral Prep CPT CODEYesNo74175CTA Abdomen orthe exam listed belowPeripheral Artery DiseaseCTA Abdomen withBilateral Runoff withand without InfusionYesNo75635AneurysmDissectionChest Pain / DyspneaTachypneaHemoptysisShortness of BreathPulmonary HypertensionPulmonary Venous MappingCTA Chest with InfusionYesNo71275Chest PainShortness of BreathCT Chest with Infusion PEYesNo71275UpperExtremityBlockageEvaluate Blood Flow(post injury*)CTA Upper Extremitywith and without InfusionYesNo73206LowerExtremityBlockageEvaluate Blood Flow(post injury*)CTA Lower Extremitywith and without InfusionYesNo73706LowerExtremitiesArteriesin theChestPulmonaryCTANGIOGRAPHY Embolism* Post injury - Fracture affecting artery, gunshot or stab wound. Loss of limb.CTA Neck withand without InfusionYesNone70498CarotidCarotid StenosisBruitTIACVAVascular TumorCTA BrainYesNone70496BrainBrain AneurysmIntracranial HemorrhageTIACVA5Diagnostic Services Ordering Guide 14797 no pictures.indd 54/15/16 2:20 PM
Nuclear Medicine Order GuideArea of ConcernReason for ExamNuclear MedicineProcedureDosePrepCPT and DoseCodesNM Bone Scan3 Phase25 mCi MDPPatient must bewell hydrated.78315 &A9503NM Bone ScanWhole Body25 mCi MDPPatient must bewell hydrated.78306 &A9503NM Bone / JointorNM Scan Limited25 mCi MDPPatient must bewell hydrated.78300Osteomyelitis vs. CellulitisReflex Sympathetic DystrophyInfectionAvascular NecrosisProsthetic LooseningHardware FailureDetection of MetastaticBone DiseaseBONEDetection of Primary Bone TumorsDiagnosis of OsteomyelitisStress and TraumaticBone FracturesChronic Bone PainPaget’s DiseaseOsteoarthritisBone scan intended to evaluatespecific areas of clinical interest.Detection of Coronary ArteryDiseaseClassification of LeftInformedConsentVentricular Myocardium asNormal, Irreversible Ischemicand Reversible IschemicEvaluation of PhysicalIndicators: MyocardialInfarction, Chest Pain,Shortness of BreathCARDIAC/HEARTFamily History of Heart DiseaseEvaluation on LaboratoryIndicators: Troponin, CreatinePhosphokinase, LactateDehydrogenase and MyoglobinNM Myocard SpectREST or STRESSREST:20mCi TC99m Nothing to eatTetrofosmin or drink 6 hoursprior to test.orNo caffeine orNicotine.STRESS:45mCi TC99m Hold cardiacTetrofosminmedicine.78452 &A9502Patient must bewell hydrated.6Diagnostic Services Ordering Guide 14797 no pictures.indd 64/15/16 2:20 PM
Area of ConcernReason for ExamCARDIAC/HEARTThe Treadmill or exerciseprotocol is designed toadequately stress a patientto reach 85%-100% of theirtarget heart rate maximum. Forthe treadmill stress we followthe Bruce protocol. Every3 minutes the treadmill willadvance stages until the targetis met or the patient tires.Nuclear MedicineProcedureNM Stress TreadmillDosePrepCPT and DoseCodesNoneNPO andChest Hairmust beremoved priorto test.9301730mCi TC99mLabeled RBCsNone78472 &A9560Ventricular regional wall motionQuantitative ventricular ejectionMonitor cardio toxicityDifferentiate pulmonary andcardiac dyspneaCARDIACMEDSNM Resting NuclearVentriculogramaka NM Gated NVG RestLexiscan is a pharmacologicalstress agent indicated forradionuclide myocardial perfusionimaging on patients who areunable to undergo adequateexercise stress on a treadmill.Lexiscan is administered undercardiologist supervision.Lexiscan0.4MG / 5MLNO CaffeineJ2785Dobutamine stress is for patientswho cannot complete anexercise protocol due to physicalhandicaps, deconditioning,or the effects of antianginaldrugs. Dobutamine is infusedto simulate exercise andis administered under thesupervision of a cardiologist.Dobutamine250MGNO BetaBlockersJ1250Diagnosis of acute or chroniccholecystitisNO Pain MedsFor 24 hoursEvaluation of extra hepaticbiliaryGASTROINTESTINALEvaluation of the post surgicalbiliaryDetection of bile leaksDiagnosis of biliary atresia andother congenital anomalies ofthe biliary tractNM Hepatobiliary Imagew/ (HIDA or DEIDA)5mCi TC99mMebrofeninSincalideNPO 8 hoursprior to test78227Cannot BePregnant7Diagnostic Services Ordering Guide 14797 no pictures.indd 74/15/16 2:20 PM
Area of ConcernReason for ExamNuclear MedicineProcedureDosePrepCPT and DoseCodesNM Liver / Spleen6mCi TC99mSulfur ColloidNo bariumstudies for24 hours78215 &A9541NM Hemangioma30mCi TC99mLabeled RBCsNo bariumstudies for24 hours78216 &A9560NPO No GastricMotility Meds78264 &A9541 orA9548Assessment of chronicliver diseaseAssessment of liver or spleen sizeDetection of focal liver / spleenDetection of accessoryspleen tissueEvaluation of trauma to liveror spleenDiagnosis of focal nodularhyperplasiaDiagnosis of hepatichemangiomasEvaluation of the rate of gastricemptying50uCi IN111DTPA in WaterNM Gastric Emptying1mCi TC99mSulfur Colloidin Beef StewPatientshould nothave had anyradiographicbarium studiesin the last 2-3days.GASTROINTESTINALDetection and localizationof a Meckel’s Detection andlocalization of other pathologicstructures containing gastricmucosa.20mCi TC99mNM Meckel’s DiverticulumPertechnetateSome juvenilepatients mayrequire mildsedation for theprocedure.78290 &A9512Patient shouldwear a hospitalgown forimaging; metalcan create anartifactLocalization of gastrointestinalbleeding sites.30mCi TC99m78278Localization of nongastrointestinal bleeding sites. Evaluation of renal perfusionand function Evaluation of renal traumaNM GI BleedNoneLabeled RBCsA9560 Diagnosis of renovascularhypertension8Diagnostic Services Ordering Guide 14797 no pictures.indd 84/15/16 2:20 PM
Area of ConcernReason for ExamNuclear MedicineProcedureDoseNM Renal Flowand Function6mCi TC99mDTPANM Renal Scan withPharm Single10mCi TC99mDTPA or MAG3NMLymphoscintigraphy1mCi TC99mFiltered SulfurColloidPrepCPT and DoseCodesWell Hydrated78707NO Lasix MedsA9539Detection and evaluation of renalcollecting system obstructionEvaluation of renal transplantsHistory of renal stonesGENITOURINARYEvaluation of renal traumaDiagnosis of renovascularhypertensionDetection and evaluation of renalcollecting system obstructionusing LasixBreast CancerLYMPHATICMelanomaWell HydratedNO LasixNPO78708 & A9539or J194078195A9541Pulmonary Embolism (PE)Chest PainShortness of BreathDyspneaNM Lung Scan ParticulateCOPD6mCi TC99mChest X-rayMAAwithin 12 hours78580 &A9540Low Oxygen LevelsPrior or Present DVTPULMONARYCOPDEvaluation of S.O.B.Regional VentilationPre-surgical or pre-transplantevaluation of lung functionalityComparative (right vs. left)lung functionalityNM Pulmonary /Ventilation ImagingNM LungQuantification45mCi TC99mDTPA AerosolChest X-ray6mCi TC99m within 12 hoursMAA6mCi TC99mMAANone78579785979Diagnostic Services Ordering Guide 14797 no pictures.indd 94/15/16 2:20 PM
Area of ConcernReason for ExamNuclear MedicineProcedureDosePrepCPT and DoseCodesNM ParathyroidScan25mCi TC99mSestamibiNone78070 &A9500HypercalcemiaElevated parathyroidhormone (PTH) levelsHyperparathyroidismParathyroid adenomasNPO 4 hourspriorEvaluation of clinical hyper- orhypothyroidismCannot bepregnant orbreast feedingDiagnosis of Grave’s diseaseEvaluation of subacute andchronic thyroiditisTHYROIDEvaluation of patients who hadirradiation of the head and neckin childhoodStop thyroidhormones4 weeks priorNM Thyroid Uptakeand Scan200uCi I-123CapsuleEvaluation for ectopic thyroidtissueStop thyroidmeds 1 weekprior78006 &A9516No recent X-ray /CT procedurescontaining IodineEvaluation of palpable nodules,goiters thyroiditis, substernalmasses, and clinical hyper - orhypothyroidism (in conjunctionwith uptake study)Stopmultivitamins,kelp, fish oilBoost and Ensure1 week priorOff thyroidhormonesEvaluation for functioning thyroidcancer, either recurrent in thethyroid bed or metastasesNM WholebodyIodine Scan2-4mCiI-131CapsuleNO Iodinatedcontrast78018A9517NPO 4 hoursprior to exam10Diagnostic Services Ordering Guide 14797 no pictures.indd 104/15/16 2:20 PM
Reason for ExamNuclear MedicineProcedureDosePrepCPT and DoseCodesDiagnosis of Brain DeathNM Brain Completew/ Flow25 mCiDTPANone78606 &A9539NM Cisternogram500uCiIN-111 DTPAInformedconsent signedfor LPArea of ConcernBRAINNormal Pressure HydrocephalusCFS LeaksGrave’s DiseaseNM Hyperthyroid TherapyHyperthyroidismOral NM Thyroid AblationThyroid CancerCA OralLocalization of abscesses andinfectionNM In-111 WBC ScanTHERAPYEvaluation of inflammationTUMOR/ABSCESSOR A FEVEROFUNKNOWNORIGINDetection and Localizationof Neuroendocrine Tumors:Carcinoid, Insulinomas,Paragangliomas, gonomas, MedullaryThyroid Carcinomas, PituitaryTumors, Small Cell LungCancersDetection and Localization ofNon-neuroendocrine Tumors:Non-Hodgkin’s Lymphoma,Hodgkin’s and Non Small CellLung CancersNM Octreoscan Spect10-30mCiI-131 Capsule30-200mCiI-131 Capsule50uCi In-111WBC OxyqNoneWrittenDirective78630 tionsand aLaxative 24hours prior tostudy7880311Diagnostic Services Ordering Guide 14797 no pictures.indd 114/15/16 2:20 PM
Ultrasound Order GuideUltrasound ExamPrepCPT CodeUS Abdomen CompleteNPO 8 hours76700US GB, Liver, PancreasNPO 6-8 hours76705US Abdomen LimitedNPO 6-8 hours76705US SpleenNPO 6-8 hours76705US AppendixNPO 6-8 hours76705US Doppler AbdominalNPO 12 hours93975US KidneysNo prep76775Pre and Post void bladder volume imagingUS Post Void BladderDrink 15-30oz ofwater 30 minutesprior to ultrasound51798Proximal, Middle, and Distal Abdominal AortaBilateral KidneysProximal, Middle, and Distal Abdominal AortaUS AortaNPO 12 hours76775US RetroperitonealCompleteNPO 12 hours76770PylorusUS PylorusNPO 4 hours76705Common Femoral VeinProximal Greater SaphenousProfundaSuperficial FemoralPoplitealPosterior TibialPeronealUS Leg Venous DopplerNone93970-Bilat93971-RT or LTInternal Jugular ial and Ulnar when indicated.US Arm Venous DopplerNone93970-Bilat93971-RT or LTArea of ConcernABDOMINALAnatomy ImagedLiverGallbladderPancreasCBDSpleenLimited KidneysProximal AortaLiverGallbladderPancreasCBDAbdominal QuadrantsSingle Abdominal OrganFollow up on previous abdomen examSpleenAppendixRight Lower Quadrant AbdomenDoppler / Duplex of any of the following:Renal Arteries or VeinsLiver Vasculature (Portal V, Hepatic V,Hepatic A, Splenic V)Mesenteric (SMA, IMA, Celiac A)Bilateral KidneysBladderVENOUSPERIPHERAL**(commonly used for renal Doppler study)12Diagnostic Services Ordering Guide 14797 no pictures.indd 124/15/16 2:20 PM
Anatomy ImagedUltrasound ExamPrepCPT CodeSubclavianAxillaryBrachialRadiusUlnaUS Arm Arterial DopplerNone93930-Bilat93931-RT or LTCommon FemoralProfundaSuperficial FemoralPoplitealPosterior TibiaPeronealAnterior TibiaDorsalis PedisUS Leg Arterial DopplerNone93925-Bilat93926-RT or LTUS PS Single LevelLower ExtremityRT, LT, BilatNone92922US Physio Bilat 3 Levels or MultilevRT or Multilev LTNone92923US PelvicDrink 32 oz ofwater 30 minutesprior to appt. time76856Limited assessment of Uterus, Ovaries,Bladder or ProstateUS Pelvic LimitedDrink 32 oz ofwater 30 minutesprior to appt. time.***No Prep forProstate US76857To view female reproductive organsUS TransvaginalNone76830Area of ConcernARTERIALPERIPHERALVASCULARAnkle Brachial Index**Done in conjunction with all arterialleg DopplersMulti-level segmental pressures of the legsPulse Volume RecordingsDoppler of thigh, popliteal, and ankle arteriesAnkle Brachial IndexesToe Brachial IndexesToe PhotoplethysmographyCFA and CFB assessed for the presence ofan aneurysmCompression of Pseudoaneurysm NeckFor complete evaluation of male or femaleanatomy to include Uterus, Ovaries,Bladder or ProstatePELVIC13Diagnostic Services Ordering Guide 14797 no pictures.indd 134/15/16 2:20 PM
Ultrasound ExamPrepCPT CodeUS Biophysical ProfileNone76819US OB Comp 14 WeeksDrink 30oz waterprior to exam76805UterusOvariesGestational SacCrown Rump LengthYolk SacUS OB Comp 14 WeeksDrink 30oz water30 minutes priorto exam76801Early 1st trimester imaging or cervical lengthson 2nd and 3rd trimestersUS OB TransvaginalNone76830If patient has had a previous 2nd or 3rdTrimester Complete exam then a follow upcan be ordered to assess any of the following:GrowthAnatomy not seen well in previous studyHeart RatePlacentaAFIUS OB Repeat Follow UpNone76816AFIHeart RatePlacenta LocationFetal PositionUS OB LimitedNone76815Doppler of the Umbilical Artery at the fetusinsertion, and mid umbilical cord.US Fetal DopplerUmbilical ArteryNone76820Procedure to sample AFIUS AmniocentesisNone76946Area of ConcernAnatomy Imaged30 sec fetal breathing3 or more gross body movements1 episode of motion of a limb from flexion toextension with rapid return.1 cm pocket of fluid in any quadrantAFI, Placenta, Fetal Position4ch Heart, Diaphragm, Stomach,Kidneys, Cord Insertion, Bladder,Umbilical Arteries, 3VC, Limbs,Lateral Ventricles, Posterior FossaCervical Length if requestedOBSTETRICS14Diagnostic Services Ordering Guide 14797 no pictures.indd 144/15/16 2:20 PM
Area of ConcernSMALL PARTSANDSOFT TISSUEUltrasound ExamAnatomy ImagedPrepCPT CodeUS ThyroidThyroid and adjacent neck soft tissue76536US TesticlesScrotum, Testicles and Groin76870US Neck Soft TissueUS Soft Tissue Abdomen / ChestUS Extremity Limited Non Vasc RTArea of interest scanned with long andtransverse imagingNoneUS Extremity Limited Non Vasc LTUS HeadUS Carotid76536767057688276882Neonatal Head76506 93880Common CarotidBulbICAECAUS Echo 2Dw/ Color Flow and Doppler Atria – size and presence of mass Ventricles – size, wall motion,presence of mass Valves – excursion, regurgitation,presence of mass Pericardium Color Flow and Doppler Included93306US Echo 2Dw/o Color Flow and Doppler Atria – size and presence of mass Ventricles – size, wall motion,presence of mass Valves – excursion, regurgitation,presence of mass Pericardium No Color Flow or Doppler93307CARDIOVASCULAR/CEREBROVASCULARNoneUS Echo 2D w/ Color Flow andDoppler with Infusion Atria – size and presence of mass Ventricles – size, wall motion,presence of mass Valves – excursion, regurgitation,presence of mass Pericardium Color Flow and Doppler Included Definity Contrast Included93306US Echo 2D w/o Color Flow andDoppler with Infusion Atria – size and presence of mass Ventricles – size, wall motion,presence of mass Valves – excursion, regurgitation,presence of mass Pericardium No Color Flow and Doppler Definity Contrast Included93306 &C892315Diagnostic Services Ordering Guide 14797 no pictures.indd 154/15/16 2:20 PM
Area of ConcernCARDIOVASCULARSPECIALPROCEDURESUltrasound ExamPrepCPT CodeValves – regurgitation, stenosis, massAtriaVentricular SeptumVentricle FunctionPresence of massUS EchocardiogramTransesophagealNPO 24 hours priorto procedure93312Usually accompanied by a TransesophagealEchoUS CardioversionAnatomy Imaged Ultrasound guidance for removal of fluid frompericardial sacHEMODIALYSIS /FISTULA EXAMSAP measurements are taken of the Cephalic V Basilic V Median Cubital V Radial AEvaluation of the fistula and correspondingvessels.***Flow Volume Rate can be assessed uponrequestContact Radiologyto ScheduleUS PericardiocentesisUS Vein MappingBilateralUS Vein MappingUnilateralUS HemodialysisAccess92960NoneShould be doneon a day whenpatient has nothad dialysisNone7693093970 G036593971 G036593990US Abd Paracentesisw/ Image49083US Aspiration76942Aspiration of fluidUS Perc Drainagewith Placement75989Aspiration of fluid with the placement of adrainUS Biopsy NeedleAbdomen76942Removal of ascites from abdomen throughtemporary tube placementUS Biopsy Needle LiverUS Biopsy NeedleLymph NodeINTERVENTIONALPROCEDURESNeedle biopsy of selected organ or massRemoval of fluid from around lungContact Radiologyto Schedule7694276942US Biopsy Needle Neck76942US Biopsy Needle Muscle76942US Biopsy Needle Thyroid76942US Guided ThoracentesisContact RadiologyLTor PulmonologistUS Guided Thoracentesisto ScheduleRT769427694216Diagnostic Services Ordering Guide 14797 no pictures.indd 164/15/16 2:20 PM
PET Order GuidePerformed at the INTEGRIS Cancer InstituteArea of ConcernReason for ExamDetermine benignfrom malignant tumorsin suspicious areas,survey the whole bodyfor cancer that mayhave spread, monitorsuccess of therapy,detect recurrenttumors, assess tumoraggressiveness, andevaluate for bonemetastasis for prostatecancer patients.Procedure to OrderDosePrepMaximum15 mCiFluorodeox (FDG)PET Eye to Thigh andPET Whole Body: Eata low carbohydrate diet24 hours before thetest, do not eat or drinkanything except waterfor six hours before thetest, refrain from takingdiabetic medications theday of the test. You canbring these with you andtake them once the testis complete. Diabeticmedications include,but are not limited to,Metformin, Glucophage,Avandament, Metaglipand Insulin. Medications, otherthan diabeticmedications, may betaken the day of thetest with water.PET Eye to Thigh –for most all cancersPET Whole Body –for patients withsuspected melanoma,known melanoma, orbone metastasisTUMOR,CANCER,PROGRESSIONOF DISEASE,POSTTREATMENTMONITORING,BONEMETASTASISPET Bone Scan –for those patientssuspected of bonemetastasis from cancer,generally prostatecancer.Alzheimer’s disease,other frontotemporaldementia,senile dementia,uncomplicatedepilepsy, otherconvulsions, andmemory loss.PET Metabolic BrainMaximum15 mCiSodiumFluoride(F-18)FDGPET Bone Scan:No prep for this examEat a low carbohydratediet 24 hours before thetest, do not eat or drinkanything except waterfor six hours before thetest, refrain from takingdiabetic medications theday of the test. You canbring these with you andtake them once the testis complete. Diabeticmedications include,but are not limited to,Metformin, Glucophage,Avandament, Metaglipand Insulin. Medications, otherthan diabeticmedications, may betaken the day of thetest with water.Exam and DoseCPT CodesCPT for scan78815CPT for FDGA9552CPT for scan78816CPT for FDGA9552CPT for scan78816CPT for F-18A958078606 for scan,A9552 for FDG17Diagnostic Services Ordering Guide 14797 no pictures.indd 174/15/16 2:20 PM
MRI Order GuideBody PartBRAINEYESNECKReason for ExamProcedure to OrderIV ContrastCPT CodeAlzheimer’s, mental changesConfusion, DementiaMemory Loss, Stroke, CVAHeadache without FocalSymptomsTIA, Trauma, HemorrhageAneurysmMRIBRAIN WITHOUTINFUSIONNo70551Cranial Nerve Lesions (SpecialProtocol)Dizziness, VertigoIAC / Hearing Loss (SpecialProtocol)Headache with Focal SymptomsInfection, AVMSeizuresMultiple SclerosisNeurofibromatosisPituitary LesionTumor / Mass / Cancer / MetsMRIBRAIN WITH AND WITHOUTINFUSIONYes70553Stroke, CVA, TIA, AneurysmMRA HEAD WITHOUT CONTRASTNo70544Grave’s DiseaseExophthalamusProptosisPseudotumorVascular LesionsMRIORBITS WITH AND WITHOUTINFUSIONYes70543InfectionPainVocal Cord ParalysisMRINECK WITH AND WITHOUTINFUSIONYes70543MRA NECK WITH INFUSIONYes70548Carotid Stenosis, occlusion,bruit TIA, CVAVertebral artery dissectionor occlusion18Diagnostic Services Ordering Guide 14797 no pictures.indd 184/15/16 2:20 PM
Body PartReason for ExamProcedure to OrderIV ContrastCPT CodeMRICHEST WITH AND WITHOUTINFUSIONYes71552Thoracic Aneurysm,Thoracic outlet syndromeMRA CHEST WITH / WITHOUTYes71555Post Liver ancreatitisPseudocystMRI ABDOMENWITH AND WITHOUTINFUSIONYes74183Biliary ObstructionGallbladder stonesJaundiceAbnormal Liver EnzymesAdrenal MassMRI ABDOMENWITHOUT INFUSION(MRCP)No74181AAA, vascular aneurysm,dissection, thoracic outletsyndromeMRA ABDOMEN WITH / WITHOUTMRA PELVIS WITH / WITHOUTYes7418572198Fibroid, Osteomylitis, penile,scrotal, bladder mass, Pre-PostFibroid EmbolizationMets, tumor, mass, Ovarian MassCancer, Abscess, EndometriomaMRI PELVIS WITHOUT ANDWITH INFUSIONYes72197Fracture, appy for pregnantwoman, Muscle / tendon tearUrethral DiverticulumMRI PELVIS WITHOUTINFUSIONNo72195UTERINE OR OVARIANPATHOLOGYMRI PELVIS WITH AND WITHOUT INFUSION(FEMALE)Yes72197Muscle / tendon tearPainMRI WITHOUT CONTRAST OF EXTREMITYNoUpper-73218Lower-73718Abscess, Cellulitis, FasciitisOsteomyelitisSoft tissue TumorMRI WITH AND WITHOUT CONTRASTOF EXTREMITYYesUpper-73220Lower-73720AVN, Internal Derangement, Labral,Meniscal, Ligament and Cartilage TearsMRI WITHOUT CONTRAST OF JOINTNoUpper-73221Lower-73721Abscess, Cellulitis, Fasciitis, OsteomyelitisMRI WITH AND WITHOUT CONTRASTOF JOINTYesUpper-73223Lower-73723Neural TumorCHESTABDOMENAND PELVISPELVISEXTREMITYUPPER / LOWERNON-JOINTSBrachial Plexus Pathology(Special Protocol)Mass, Cancer, MetsFracture, arthritis, stress fx, joint painEXTREMITYUPPER / LOWERJOINTSUlcer, Septic arthritis Myositis, Tumor, Mass19Diagnostic Services Ordering Guide 14797 no pictures.indd 194/15/16 2:20 PM
Body PartCERVICALTHORACICANDLUMBARSPINEReason for ExamProcedure to OrderIV ContrastCPT CodeSyrinx, Radiculopathy, Disc Herniation,Degenerative DiseaseMRI WITHOUT CONTRASTOF REGION OF SPINENocspine-72141Tspine-72146Lspine-72148POST OP FUSION, MS, TUMOR, CANCERMETS, OSTEOMYELITIS, MYELOPATHYDISCITIS, COMPRESSION FX W/ HXSpondylolisthesis, Sciatica, AVM,OF MALIGNANCY, EPIDURAL ABSCESSMRI WITH AND WITHOUT CONTRASTOF REGION OF MRI WITH CONTRAST OF REGION T OF SERVICE FINANCIAL OBLIGATION POLICYThe new policy is a three prong approach, which includes the change in scheduling time to allow financial clearance andpatient discussions for elective procedures. All non-urgent procedures and diagnostic testing will now require a minimum of three (3) business days advancescheduling prior to the date of service. Policy is intended to reduce financial losses to INTEGRIS Health by allowing adequate time to complete the financialclearance process and collect patient liability. The three (3) day scheduling policy is not applicable to services deemed as urgent/emergent by the ordering provider(procedures being scheduled will be considered elective unless the referring physician advises it is an urgent /emergentprocedure).(Nov. 2013)Call to confirm that there have been no changes in CPT codes or other information.integrisok.com/radiology 855-38IMAGE (855-384-6243)Diagnostic Services Ordering Guide 14797 no pictures.indd 204/15/16 2:20 PM
Diagnostic Imaging Services . NECK 70480 70491 70492 Diagnostic Services Ordering Guide 14797 no pictures.indd 2 4/15/16 2:20 PM. . irradiation of the head and neck in childhood Evaluation for ectopic thyroid tissue Evalua
