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This guide lists common indications for frequently ordered advanced imaging exams that often require insurance pre-authorizations. It is a reference tool and does not establish protocol standards for all clinical situations. When ordering any examination, include the pertinent history (signs and symptoms) and any speciﬁc clinical question to be addressed.

Last Updated: 5/27/2024

ADVANCED-IMAGING ORDERING GUIDE CT

This guide lists common indications for commonly ordered advanced imaging exams that often require insurance pre-authorizations. This guide is for reference only and does not imply protocol standards for all clinical situations. When ordering any examination, pertinent history (signs and symptoms) as well as any specific clinical question to be addressed should be included.

FOR PATIENT SAFETY:

Valid Order MUST Contain:

1. Patient Name

2. Patient DOB

3. Procedure

4. Diagnosis – Medical Necessity if required, please include actual symptoms in addition to ICD codes

5. Physician signature

6. List appropriate body part and contrast medium

7. Auth if required

If Allergy to Contrast:

1. Provide patient with a prescription for prednisone and Benadryl

2. Fax copy of Allergy Prep Order and Procedure Order to Central Scheduling

If AT-RISK Patient to have Contrast (60 years old or greater, Diabetes, Renal disease or Solitary Kidney, Multiple Myeloma, Liver disease, Jaundice, Hypertension, Dehydration, Anemia, Hypoalbuminemia), then Creatinine Result with GFR Needed:

1. Provide patient with a Lab Order for creatinine with GFR

2. Fax Creatinine Results with GFR and Procedure Order to Central Scheduling—Creatinine result must be within 30 days of scheduled procedure

If Hydration is Needed:

1. Fax hydration order and Procedure Order to Central Scheduling

Table Weight Limit is 675 lbs

Brain/Head

CT (W=With Contrast, WO=Without Contrast, W&WO=With and Without Contrast = Combined)

CT Brain/Head WO Contrast

• Alzheimer’s

• Dementia

• Mental Status Changes

• CVA

• Stroke

• TIA

• Confusion

• Memory Loss

• Headache (less than 7 days)

• Trauma

• Tumor/Mass

• Cancer/Metastases (METS)

• Seizure

• Vascular Lesions

• Dizziness/Vertigo

• Multiple Sclerosis (MS)

• Neurofibromatosis

• Adenoma

• Headache (more than 7 days)

• Meningioma

• Infection/Meningitis/Mastoiditis

•

BODY PART PROCEDURE

CT Internal Auditory

Canal (IAC)

CT IAC, Temporal Bones

W&WO Contrast 70482

CT Sinus /Facial Bones

Pituitary (MRI Unless Contraindicated)

CT Sinus/Facial Bones

WO Contrast

CT Sinus/Facial

Bones W/Contrast 70486

CT Brain/Head

W&WO

Special views

Skull 70470

• Cholesteatoma

• Trauma/Ear Injury

• Hearing Loss

• Tinnitus

• Vertigo

• Trigeminal Neuralgia

• Sinusitis

• Endoscopic Surgery

• Osteomata Evaluation

• Infection

• Redness/Swelling

• Tumor

• Elevated Prolactin

• Sella Lesion

2 hours Hospital, McCreary Imaging Center

BODY PART PROCEDURE

CT Soft Tissue Neck

CT Soft Tissue Neck W/Contrast

CT Soft Tissue Neck W/WO Contrast 70492

• Cancer Staging

• Infection

• Pain

• Tumor/Mass

TMJ

CT Maxofacial WO Contrast 70486

LDCT Lung Screening

CT Chest

71271

• Parotid stone (W/WO)

• Parotid infection (W/WO)

*CT Soft Tissue should not be done without unless contraindicated

• Jaw Pain

• Locking Jaw

• Trauma

• Low-Dose CT (LDCT) Cancer Screening, Initial or Annual

CT Chest W&WO Contrast 71270

CT Chest Chest WO Contrast

71250

• Appropriate for known cancer or Radiologist recommendation only

• Low-Dose CT (LDCT) Cancer Screening, 3–6month Follow-up

• F/U Nodule

• Contrast Dye Contraindication

McCreary Imaging Center

Hospital, McCreary Imaging Center

CT Chest Chest

W Contrast

71260

• Mediastinal abnormality

• Hilar abnormality

• Hemoptysis

• Abn CXR

• Lung CA/Mets

• Mass Tumor

• Abscess

• Pleural Effusion

• Chronic Effusion

• Chronic Dyspnea

CT Chest, High

Res.

WO Contrast

CT

Abdomen (ABD)

CT Abdomen

W&WO

Contrast

71250

• Asbestosis

• Bronchiectasis

• Fibrosis

• Interstitial Lung Disease

• Pleural Plaques

• Sarcoidosis

74170 Adrenal Protocol:

• Adrenal Mass

Liver Protocol:

• Liver Mass/Lesion

• Elevated Liver Enzymes

• Hepatitis

• Cirrhosis

• Liver Hemangioma (MRI Preferred)

NPO 2 hours Hospital, McCreary Imaging Center

None Hospital, McCreary Imaging Center

NPO 2 hours Hospital, McCreary Imaging Center

CT

Abdomen (ABD)

CT Abdomen

W&WO

Contrast

CT Abdomen

W Contrast

Pancreatic Protocol:

• Pancreatic Mass

• Pancreatitis

• Pseudocyst (1st Exam Performed) NPO 2 hours Hospital, McCreary Imaging Center

Renal Mass Protocol:

• Any Renal Pathology except Kidney Stones;

Note: To include Kidneys, Ureters, & Bladder (CT Urogram),

use 74178 Abdomen/Pelvis CT Without & With Contrast NPO 2 hours Hospital, McCreary Imaging Center

74160 Follow-Up Pancreatic CT (After Initial WO&W Scan) NPO 2 hours Hospital, McCreary Imaging Center

• Upper Abdominal Pain

• Gallbladder

• Hepatitis/Cirrhosis

• Chronic Pancreatitis

• Mass

• Splenomegaly NPO 2 hours Hospital, McCreary Imaging Center

CT Pelvis

CT Pelvis (Soft Tissue)

W Contrast

CT Pelvis W/WO (Cystogram) 72194

CT Pelvis (Bony)

WO Contrast 72192

• Cancer

• Mass/Tumor

• Fibroid

• Endometriosis

• Infection

• Trauma

2 hours

McCreary Imaging Center

CT ABD & Pelvis

CT ABD & Pelvis WO Contrast 74176

• Fistula

• Tumor/Mass

• Fracture

• SI Joints

CT ABD & Pelvis W Contrast 74177

• Kidney Stones

• Trauma

• Bowel Perforation

• Abdominal Pain

• Cancer Staging

• Mass

• Appendicitis, Crohn’s/Ulcerative Colitis/Diverticulitis/Abscess/Acute Pancreatitis

McCreary Imaging Center

Hospital, McCreary Imaging Center

• Hematoma NPO 2 hours Hospital, McCreary Imaging Center

CT ABD & Pelvis

W&WO Contrast

Spine:

Herniation, Mets, Infection)

CT Cervical Spine

WO Contrast

74178

CT Cervical Spine

W Contrast

CT Cervical W/WO 72125

• CT Urogram (Kidneys, Ureters, & Bladder)

• Acute pyelonephritis

• Hematuria

• Bladder Cancer

• Recurrent UTIs

*CT Abdomen & Pelvis W/WO is not routinely needed unless indicated above or by radiologist.

• Trauma

• Pain

• Radiculopathy

• Fracture

• Post-Fusion

• Infection, Mets, Tumor/Mass, Infectious Spondylodiscitis, MRI Contraindication

Routinely Not Necessary, order should be discussed with and approved by radiologist first.

Hospital, McCreary Imaging Center

CT Spine: (MRI Recommended for Disc Herniation, Mets, Infection)

CT Thoracic Spine WO Contrast

CT Thoracic Spine W Contrast

CT Thoracic Spine W/WO

CT Lumbar Spine WO Contrast

72128

CT Lumbar Spine

W Contrast

72131

• Assess Boney Degenerative Changes

• Trauma

• Pain

• Radiculopathy

• Fracture

• Post-Fusion

• Infection, Mets, Tumor/Mass, Infectious Spondylodiscitis, MRI Contraindication

Routinely Not Necessary, order should be discussed with and approved by radiologist first.

• Pars Defect

• Trauma

• Pain

• Radiculopathy

• Fracture

• Post-Fusion

• Infection, Mets, Tumor/Mass, Infectious Spondylodiscitis, MRI Contraindication

None NPO 2 hours Hospital, McCreary Imaging Center

CT Lumbar Spine W/W/O

Routinely Not Necessary, order should be discussed with and approved by radiologist first.

Health Sensitive Information

None NPO 2 hours Hospital, McCreary Imaging Center

CT Extremity: All Bone CT Is Performed Without Contrast Except For Tumor Evaluation when MRI is contraindicated.

CT Upper Extremity (Shoulder, Humerus, Elbow, Radius/Ulna, Wrist, Hand)

WO Contrast

CT Upper Extremity (Shoulder, Humerus, Elbow, Radius/Ulna, Wrist, Hand)

W Contrast

73200

1. Include Specific Body Part on Order: Shoulder, Humerus, Elbow, Radius/Ulna, Wrist, Hand

2. Include Laterality on Order: Left or Right or Bilateral

3. Include Indication:

• Trauma

• Fracture

• Osteoarthritis (OA)

• Post-surgery

73201

None Hospital, McCreary Imaging Center

CT Lower Extremity (Hip, Fever, Knee, Tibia/Fibula, Ankle, Foot)

WO Contrast

73700

1. Include Specific Body Part on Order: Shoulder, Humerus, Elbow, Radius/Ulna, Wrist, Hand

2. Include Laterality on Order: Left or Right or Bilateral

3. Include Indication:

• Tumor/Mass

• Cancer or Metastasis (Mets)

• Infection

1. Include Specific Body Part on Order: Hip, Femur, Knee, Tibia/Fibula, Ankle, Foot

2. Include Laterality on Order: Left or Right or Bilateral

3. Include Indication:

• Trauma

• Fracture

• Osteoarthritis (OA)

• Post-surgery

NPO 2 hours Hospital, McCreary Imaging Center

None Hospital, McCreary Imaging Center

CT Extremity: All Bone CT Is Performed Without Contrast Except For Tumor Evaluation when MRI is contraindicated.

CT Lower Extremity (Hip, Fever, Knee, Tibia/Fibula, Ankle, Foot) W Contrast 73701

1. Include Specific Body Part on Order: Hip, Femur, Knee, Tibia/Fibula, Ankle, Foot

2. Include Laterality on Order: Left or Right or Bilateral

3. Include Indication:

• Tumor/Mass

• Cancer or Metastasis (Mets)

• Infection

NPO 2 hours Hospital, McCreary Imaging Center

CT Heart Calcium Score 75571

• Screening

Hyperlipidemia

BODY PART PROCEDURE CPT CODE INDICATION(S)

CTA Head or COW

W&WO 70496

(Any noncontrast imaging performed at the same session is included in CTA code)

CTA Neck

W&W/O (Carotid Artery) 70498

• Aneurysm

CTA Chest (PE or Aorta Study) 71275

• Arterio-Venous Malformation (AVM)

• Bruit

• CVA (Stroke)

• TIA

• Vascular Tumor

Note: If CTA of Brain and CTA of Neck are both ordered, both must be authorized.

• Dissection

• Stroke

• Carotid Stenosis

• Arterio-Venous Malformation (AVM)

• Bruit

• CVA (Stroke)

• TIA

• Vascular Tumor

Note: If CTA of Brain and CTA of Neck are both ordered, both must be authorized.

• Pulmonary Embolism

• Shortness of breath (SOB)

• Vascular Evaluation

• Chest Pain

• CardioMerge

• Thoracic aorta

• Aneurysm

• Coarctation

CTA ABD 74175

McCreary Imaging Center

• Aortic Dissection 2 hours Hospital, McCreary Imaging Center

• Pre-kidney transplant

• Renal Artery Stenosis (RAS)

CTA

Abdominal

Aorta & Run Off 75635

CTA ABD & Pelvis 74174

• Claudication

• Peripheral Artery Disease (PAD)

• Peripheral Vascular Disease (PVD) 2

CTA Upper Extremity 73206

• AAA

• Crossing Vessels

• Mesenteric Vessel Evaluation

• Renal Artery Stenosis (RAS)

• Stent Obstruction/Leak/Malfunction

• Ischemic Bowel 2

• Vascular disease

• Ischemia

Hospital, McCreary Imaging Center

• Upper arterial emboli 2 hours Hospital, McCreary Imaging Center

(Any noncontrast imaging performed at the same session is included in CTA code) McCreary Imaging Center

CTA Lower Extremity 73706

CTA Heart 75574

• Peripheral Artery Disease

• Peripheral Vascular Disease

• Ischemia

• Stenosis Evaluation 2 hours Hospital, McCreary Imaging Center

• Coronary Artery Disease (CAD)

• Bypass graft evaluation

• Abnormal Echocardiogram

• Chest Pain

*Patients must be able to put both arms over head, have a regular heart rhythm (AFIB is a contraindication), BMI

4 hours solid food

No caffeine or smoking 24 hours prior

Must follow Medication Prep according to Protocol Heart Rate below 70 Hospital Only

CTA/CTE CT

Enterography

below 50, Normal Renal function, be able to hold their breath and follow instructions.

• Crohns

• GI bleed

• Blood in Stool

• Inflammatory Bowel Disease

• Gastroinstestinal Tumors

8 hours Hospital, McCreary Imaging Center

Myelography – Performed and Interpreted by Same Provider

Myelogram

With CT to Follow

Cervical

Spine 72240 (Precert 72240 & 72126) If MRI Contraindicated and/or as suggested by MRI NPO after midnight

Thoracic

Spine 72255 (Precert 72255 & 72129)

Lumbar

Spine 72265 (Precert 72265 & 72132)

2 or more Regions of the Spine 72270– Myelogram and CPT Code for Desired CT Spine Area W Contrast

after midnight

ADVANCED-IMAGING ORDERING GUIDE FLUOROSCOPY

FOR PATIENT SAFETY:

Valid Order MUST Contain:

1. Patient Name

2. Patient DOB

3. Procedure

4. Diagnosis – Medical Necessity if required, please include actual symptoms in addition to ICD codes

5. Physician signature

6. List appropriate body part and contrast medium

7. Auth if required

If Allergy to Contrast:

1. Provide patient with a prescription for prednisone and Benadryl

2. Fax copy of Allergy Prep Order and Procedure Order to Central Scheduling

1. Provide patient with a Lab Order for creatinine with GFR

2. Fax Creatinine Results with GFR and Procedure Order to Central Scheduling—Creatinine result must be within 30 days of scheduled procedure

If Hydration is Needed:

1. Fax hydration order and Procedure Order to Central Scheduling

Table Weight Limit is 300 lbs

Fluoroscopy – Performed and Interpreted by Same Provider

Upper GI (UGI)

Esophagram/ Barium Swallow

Modified Barium Swallow (MBS)

• Vomiting/Nausea/Coughing after eating

• Heartburn

• Reflux

• Hernia

• Epigastric Pain

• Abdominal Pain

• N/V/D

• Heartburn

• Dysphagia (Mid-Low Esophagus)

• GERD

• Hiatal Hernia

• Epigastric Pain

• Aspiration

• Dysphagia

• Coughing/Choking During Eating

after midnight Yes

• Ulcerative Colitits

• IBS

• Incomplete Colonoscopy

• Change in Bowel Habits

• Abdominal Pain

• Rectal Bleeding

Suspected Crohns • Abdominal Pain • Change in Bowel Habits

Eval for unilateral diaphragm paralysis

Arthrogram – Performed and Interpreted by Same Provider BODY

Arthrogram With MRI to Follow (unless contraindicated)

Shoulder 73040 (Precert 73040 & 73222 )

Hip 73525 (Precert 73525 & 73722)

Rotator cuff tear

Limited ROM

Pain

Knee 73580 (Precert 73580 & 73722)

Limited ROM

Labral Tear

Pain

Wrist 73115 (Precert 73115 & 73222)

Pain • Limited ROM • Meniscus Tear • Pain • Limited Rom

after midnight Blood thinners

No contrast Allergy

after midnight Blood thinners withheld No contrast Allergy

ADVANCED-IMAGING ORDERING GUIDE MRI

FOR PATIENT SAFETY:

Valid Order MUST Contain:

1. Patient Name

2. Patient DOB

3. Procedure

4. Diagnosis – Medical Necessity if required, please include actual symptoms in addition to ICD codes

5. Physician signature

6. List appropriate body part and contrast medium

7. Auth if required

If Allergy to Contrast:

1. Provide patient with a prescription for prednisone and Benadryl

2. Fax copy of Allergy Prep Order and Procedure Order to Central Scheduling

1. Provide patient with a Lab Order for creatinine with GFR

2. Fax Creatinine Results with GFR and Procedure Order to Central Scheduling—Creatinine result must be within 30 days of scheduled procedure

If Hydration is Needed:

1. Fax hydration order and Procedure Order to Central Scheduling

If Pacemaker, defibrillator, bladder stimulator, spinal stimulator, brain stimulator of any other implanted device:

1. Fax Make, Model and Type (or a copy of patient’s device card) with Procedure Order to Central Scheduling

Table Weight Limit 550 lbs at Hospital Table Weight Limit of Open at Imaging Center is 650 lbs

MRI (W=With Contrast, WO=Without Contrast, W&WO = With and Without Contrast = Combined)

BODY PART

MRI Brain/Head W/O Contrast

Includes:

Whole brain

Brain stem

70551

• Alzheimer’s,

• Mental Status Changes

• Confusion

• Memory Loss

• Dementia

• Headaches

• Stroke

• CVA

• TIA

BRAIN

MRI Brain/Head W&W/O Contrast

Includes: Whole Brain

Brain stem 70553

• Tumor/Mass

• Cancer or Metastases

• Seizures

• Trauma

• Dizziness/Vertigo

• Infection

• Multiple Sclerosis (MS)

• Neurofibromatosis

• Adenoma

• Vascular Lesions

• Chiari

• All Other Reasons Except for W/O Indications Above

PREP/PREREQUISITE

• Metal removal

• MRI screening clearance

• Metal removal

• MRI screening clearance

• Hydrate 24-48 hrs prior

• IF Diabetic/Kidney Failure: Creatine and BUN done at most 6 weeks (about 1 and a half months) prior (Kidney function)

Yes

All magnets: Hospital, IMC Closed, IMC Open

Yes

All magnets: Hospital, IMC Closed, IMC Open

BODY PART PROCEDURE

MRI Orbits

W&W/O Contrast

BRAIN

Includes: Eyeball, Optic muscles

Optic nerve 70543

• Graves’ disease

• Exophthalmos/Proptosis

• Diplopia/Double-vision

• Visual field Defect

• Optic Neuritis

• Optic Nerve Lesion/Tumor/Infection

Note: Add CPT Code 70553 for Brain W&WO if whole brain assessment is also required (This WILL BE a separate exam if a brain is wanted AS WELL)

• Metal Removal

• MRI screening clearance

• Hydrate 24-48 hrs prior

• IF

Diabetic/Kidney

Failure: Creatine and BUN done at most 6 weeks (about 1 and a half months) prior (Kidney function)

BRAIN

MRI Face/Paranasal Sinuses

W&W/O Contrast

All Facial Bones, All Sinuses 70543

Includes:

• Sinusitis

• Sinonasal Cancer

• Lesion in Oropharynx/Nasopharynx/Tongue/Floor of Mouth

• Lesion/bone mets to Mandible/Maxilla/ Zygoma

Note: Add CPT Code 70553 for Brain W&WO if whole brain assessment is also required (This WILL BE a separate exam if a brain is wanted AS WELL)

• Metal Removal

• MRI screening clearance

• Hydrate 24-48 hrs prior

• IF Diabetic/KIdney

Failure: Creatine and BUN done at most 6 weeks (about 1 and a half months) prior (Kidney function)

Yes

All magnets: Hospital, IMC Closed, IMC Open

Yes

All magnets: Hospital, IMC Closed, IMC Open

BODY PART PROCEDURE

MRI Soft Tissue Neck

W&W/O Contrast

NECK

**Not to evaluate Cervical Spine, only soft tissue/organs of the neck** 70543

INDICATION(S)

• Vocal Cord Paralysis

• Infection

• Pain

• Tumor/Mass

• Cancer or Metastases (Mets)

BRAIN

MRI Pituitary or IAC (Ear) W&W/O Contrast Includes: Pituitary gland & its stalk

All bones of the ear & nerves

70553

Pituitary:

• Elevated Prolactin

• Sella Lesion

• Prolactinoma

• Abnormal Testosterone levels

• Galactorrhea

Note: Add CPT Code 70553 for Brain W&WO if whole brain assessment is also required (This WILL BE a separate exam if a brain is wanted AS WELL)

• Metal Removal

• MRI screening clearance

• Hydrate 24-48 hrs prior

• IF Diabetic/Kidney

Failure: Creatine and BUN done at most 6 weeks

(about 1 and a half months) prior (Kidney function)

• Metal Removal

• MRI screening clearance

• Hydrate 24-48 hrs prior

• IF Diabetic/Kidney

Failure: Creatine and BUN done at most 6 weeks (about 1 and a half months) prior (Kidney function)

Yes

All magnets: Hospital, IMC Closed, IMC Open

Yes

All magnets: Hospital, IMC Closed, IMC Open

BODY PART PROCEDURE CPT

INDICATION(S)

IAC/Ear:

• Hearing Loss (SNHL)

• Tinnitus

• Vertigo

• Acoustic Neuroma

• Trauma

• Dizziness

Note: Add CPT Code 70553 for Brain W&WO if whole brain assessment is also required (This WILL BE a separate exam if a brain is wanted AS WELL)

• Metal Removal

• MRI screening clearance

• Hydrate 24-48 hrs prior

• IF Diabetic/Kidney Failure: Creatine and BUN done at most 6 weeks (about 1 and a half months) prior (Kidney function) Yes

BRAIN MRI TMJ

W/O Contrast Includes: TMJ joints 70336

• Jaw Pain

• Locking Jaw

• Jaw Popping/Clicking

• Difficulty Opening Jaw

• Metal Removal

All magnets: Hospital, IMC Closed, IMC Open

• MRI screening clearance Yes All magnets: Hospital, IMC Closed, IMC Open

BODY PART PROCEDURE

MRI

Chest/Mediastinum

W&W/O Contrast **or**

W/O Contrast

INDICATION(S)

• Brachial Plexus Injury (Please Specify)

• Nerve Avulsion

• Tumor/Mass

• Cancer or Metastases (Mets)

• Avascular Necrosis

• Trauma

CHEST

Includes: Brachial Plexus, Sternum, Clavicle, Scapula, Pectoral Muscle, Chest Wall, Ribs (Disclose on order area/anatomy of interest. MRI does NOT do whole chests only parts)

71552

ABDOMEN

MRI ABD

W/O Contrast

Includes: Pancreas, Spleen, Appendix (If pregnant)

General View of organs

74181

• Clavicular Tuberculosis

• Multiple Myeloma

• Ligament tear

• Stress Fractures (Clavicle, Scapula, Sternum)

• Osteomyelitis (Clavicle, Rib, Sternum< Scapula)

• Dislocation (Clavicle)

• Gorham’s Disease of Scapula

• Ewing’s Sarcoma

Note: Scapula MRI studies are to be authorized for 71552

• Abdominal Pain

• Pancreatic Cyst

• Abdomen Fistula

• Abdomen Hernia

• Abdomen Lipoma

• Kidney Cysts

• Metal Removal

• MRI screening clearance

• Hydrate 24-48 hrs prior

• IF Diabetic/Kidney Failure: Creatine and BUN done at most 6 weeks (about 1 and a half months) prior (Kidney function) (IF contrasted) Yes

• Metal Removal

All magnets: Hospital, IMC Closed, IMC Open

• MRI screening clearance Yes All magnets: Hospital, IMC Closed, IMC Open LifePoint Health Sensitive Information

BODY PART PROCEDURE

MRCP W/O

Includes: Biliary Duct/Veins, Gallbladder, Pancreas 74181

ABDOMEN

MRI ABD

W&W/O Contrast

Includes: Kidneys, Adrenals, Spleen, Ureters

• Stones

• Jaundice

• Pancreatic Mass

• Biliary Obstruction

• Pancreatitis

• Metal Removal

• MRI screening clearance Yes All magnets: Hospital, IMC Closed, IMC Open

• Tumor/Mass/Cancer

• Abdominal Pain

• Abscess

• Ascites

• Renal lesions

• Pyelonephritis

• Hematuria

74183

• Metal Removal

• MRI screening clearance

• Hydrate 24-48 hrs prior

• IF Diabetic/Kidney Failure: Creatine and BUN done at most 6 weeks (about 1 and a half months) prior (Kidney function) Yes

All magnets: Hospital, IMC Closed (Except Adrenals), IMC Open

BODY PART PROCEDURE CPT

MRI Liver

W&W/O Contrast

ABDOMEN

Includes: Liver (3phase), Arteries, Veins 74183

• Liver Mass

• Tumor

• Cyst

• Lesion

• Hepatomegaly

• Cirrhosis

• Metal Removal

• MRI screening clearance

• Hydrate 24-48 hrs prior

• IF Diabetic/Kidney Failure: Creatine and BUN done at most 6 weeks (about 1 and a half months) prior (Kidney function)

SPINE

MRI C-Spine

W/O Contrast

Includes:

Vertebral body, Spinal cord, Disc space 72141

• Pain or Weakness in Neck/Arm/Shoulder

• Degenerative Disc Disease

• Disc Herniation

• Stenosis

• Post-Op Evaluation

• Radiculopathy

• Trauma

• Fracture

• Metal Removal

Yes

Hospital, IMC Open

Can NOT be done on IMC Closed

• MRI screening clearance Yes All magnets: Hospital, IMC Closed, IMC Open

BODY PART PROCEDURE CPT

MRI C-Spine

W&W/O Contrast

SPINE

Includes:

Vertebral body, Spinal cord, Disc space 72156

INDICATION(S)

• Syrinx

• Infection/Discitis

• Cancer or Metastases

• Compression Fracture with History of Cancer

• Tumor/Mass

• Myelopathy

• Multiple Sclerosis (MS)

SPINE

MRI T-Spine

W/O Contrast Includes:

Vertebral body, Spinal cord, Disc space 72146

• Pain

• Degenerative Disc Disease

• Disc Herniation

• Stenosis

• Post-Op Evaluation

• Radiculopathy

• Trauma

• Fracture

• Vertebroplasty Planning

• Metal Removal

• MRI screening clearance

• Hydrate 24-48 hrs prior

• IF Diabetic/Kidney Failure: Creatine and BUN done at most 6 weeks (about 1 and a half months) prior (Kidney function) Yes

• Metal Removal

• MRI screening clearance Yes

All magnets: Hospital, IMC Closed, IMC Open

BODY PART PROCEDURE CPT

MRI T-Spine

W&W/O Contrast

SPINE

Includes:

Vertebral body,

Spinal cord, Disc space 72157

INDICATION(S)

• Syrinx

• Infection/Discitis

• Cancer or Metastases

• Compression Fracture with History of Cancer

• Tumor/Mass

• Abscess

• Myelopathy

• Multiple Sclerosis (MS)

SPINE

MRI L-Spine

W/O Contrast

Includes:

Vertebral body,

Spinal cord, Disc space 72148

• Pain

• Degenerative Disc Disease

• Disc Herniation

• Stenosis

• Post-Op Evaluation

• Radiculopathy

• Trauma

• Fracture

• Vertebroplasty Planning

Note: If both Lumbar and Complete Sacrum are ordered, both must be preauthorized (CPT Codes 72148 & 72195)

• Metal Removal

• MRI screening clearance

• Hydrate 24-48 hrs prior

• IF Diabetic/Kidney Failure: Creatine and BUN done at most 6 weeks (about 1 and a half months) prior (Kidney function) Yes

• Metal Removal

All magnets: Hospital, IMC Closed, IMC Open

• MRI screening clearance Yes All magnets: Hospital, IMC Closed, IMC Open

BODY PART PROCEDURE CPT

MRI L-Spine

W&W/O Contrast

Includes:

SPINE

Vertebral body, Spinal cord, Disc space 72158

INDICATION(S)

• Syrinx

• Infection/Discitis

• Cancer or Metastases

• Compression Fracture with History of Cancer

• Tumor/Mass

• Abscess

• Myelopathy

• Multiple Sclerosis (MS)

• Metal Removal

• MRI screening clearance

• Hydrate 24-48 hrs prior

• IF Diabetic/Kidney Failure: Creatine and BUN done at most 6 weeks (about 1 and a half months) prior (Kidney function) Yes

PELVIS

MRI Bony Pelvis W/O Contrast

Includes: Pelvis, Hips, Sacrum, SI Joints 72195

• Muscle/tendon Tear/AVN

• Hip Pain

• Fracture

• Pubalgia/sports hernia

• Bone Infarct

• Metal Removal

• MRI screening clearance Yes

All magnets: Hospital, IMC Closed, IMC Open

BODY PART PROCEDURE

MRI Pelvis

Soft Tissue – Female

W&W/O Contrast

PELVIS

Includes: Uterus, Ovaries, Cervix 72197

• Fibroid

• Endometriosis

• Tumor/Mass

• Cancer or Metastases (Mets)

• Infection

• Abscess

• Congenital Abnormalities

PELVIS

MRI Pelvis

Soft Tissue – Male

W&W/O Contrast

Includes: Prostate, Seminal Vesicles, Testes, Urethra

72197

• Enlarged Prostate

• Tumor/Mass

• Cancer or Metastases (Mets)

• Abscess

• Infection

• Congenital Abnormalities

• Metal Removal

• MRI screening clearance

• Hydrate 24-48 hrs prior

• IF Diabetic/Kidney Failure: Creatine and BUN done at most 6 weeks (about 1 and a half months) prior (Kidney function)

• Metal Removal

• MRI screening clearance

• Hydrate 24-48 hrs prior

• IF Diabetic/Kidney Failure: Creatine and BUN done at most 6 weeks (about 1 and a half months) prior (Kidney function)

Yes

All magnets: Hospital, IMC Closed, IMC Open

Yes Hospital Magnet

BODY PART PROCEDURE

MRI Pelvis

Osteo/Mass

PELVIS

W&W/O Contrast

Includes: Whole Plevis, *Rectum

*Not true dedicated Rectal Protocol

72197

INDICATION(S)

• Cancer/Metastases (Mets)

• Wounds

• Osteomylitis

• Lesions

• Lipomas

• Abscess

• Metal Removal

• MRI screening clearance

• Hydrate 24-48 hrs prior

• IF Diabetic/Kidney Failure: Creatine and BUN done at most 6 weeks (about 1 and a half months) prior (Kidney function)

Yes

LifePoint Health Sensitive Information

All magnets: Hospital, IMC Closed, IMC Open

BODY PART PROCEDURE CPT

MRI Bilateral Breast

W&W/O Contrast

(always bilateral, our facility does not do singular breast images)

Includes:

BREAST

Breast tissue, Nipple, axillary lymph nodes 77049

INDICATION(S)

• Abnormal mammogram/Indeterminate

Imaging Results

• Dense Breasts

• Mass

• Lesion

• High risk for Breast Cancer

• Breast Cancer Staging Pre-Op and/or FU Chemotherapy

• BRCA Positive

• Nipple discharge

• Enlarged lymph nodes

• Metal Removal

• MRI screening clearance

• Hydrate 24-48 hrs prior

• IF Diabetic/Kidney Failure: Creatine and BUN done at most 6 weeks (about 1 and a half months) prior (Kidney function)

• If patient is menstruating still, they need to be 710 day following (14 days with Radiologist approval)

• If a patient is taking an estrogen-based hormone, they must be off for 30 days before the exam.

BODY PART PROCEDURE

Implant Integrity MRI

BREAST

Breast Bilateral W/O Contrast (always done without for implant integrity, contrast not needed to see this)

Includes: Breast tissue, Nipple, axillary lymph nodes, Implant (saline or silicone) 77047

• Silicone Implant Evaluation/Leak/Rupture (No Hx of Breast Cancer)

• Saline Implant Evaluation/Leak/Rupture (No Hx of Breast Cancer)

• Metal Removal

• MRI screening clearance

• If patient is menstruating still, they need to be 710 day following (14 days with Radiologist approval)

Yes Hospital, IMC Open

BODY PART

MRI Upper Extremity (Non-Joint) W/O Contrast

Includes: Humerus, Forearm, Hand, Finger 73218

Note: This is not to evaluate for breast cancer or lumps

1. Include Specific Body Part on Order: Scapula, Humerus, Forearm, Hand, Finger

2. Include Laterality on Order: Left or Right or Bilateral

3.Include Indication:

• Fracture

• Muscle/Tendon/Nerve Injury or Tear (For Bicep tear order a humerus always to cover retraction)

• If a patient is taking an estrogen-based hormone, they must be off for 30 days before the exam.

• Metal Removal

• MRI screening clearance

Yes

All magnets: Hospital, IMC Open

BODY PART PROCEDURE CPT

73220

MRI Upper Extremity (Non-Joint)

MSK

W&W/O Contrast Includes: Humerus, Forearm, Hand, Finger

MRI Upper Extremity (Joint)

W/O Contrast Includes: Shoulder, Elbow, Wrist 73221

MSK

INDICATION(S)

1. Include Specific Body Part on Order: Scapula, Humerus, Forearm, Hand, Finger

2. Include Laterality on Order: Left or Right or Bilateral

3. Include Indication:

• Mass/Tumor

• Infection

• Abscess

• Inflammation (-itis)

• Cancer or Metastases (Mets)

• Metal Removal

• MRI screening clearance

• Hydrate 24-48 hrs prior

• IF Diabetic/Kidn ey Failure:

Creatine and BUN done at most 6 weeks (about 1 and a half months) prior (Kidney function)

Yes

MRI Upper Extremity (Joint)

All magnets: Hospital, IMC Open

1. Include Specific Body Part on Order: Shoulder, Elbow, Wrist

2. Include Laterality on Order: Left or Right or Bilateral

3. Include Indication:

• Muscle/Tendon/Nerve Injury or Tear

• Fracture

• Osteoarthritis

• Cartilage Injury

• Avascular Necrosis (AVN)

1. Include Specific Body Part on Order: Shoulder, Elbow, Wrist

• Metal Removal

• MRI screening clearance Yes

All magnets: Hospital, IMC Closed, IMC Open

• Metal Removal Yes

All magnets: LifePoint Health Sensitive Information

BODY PART PROCEDURE CPT

W/O Contrast ARTHROGRAM ONLY

(X-ray charges for the contrast)

73722

MRI Upper Extremity (Joint)

W&W/O Contrast

Includes: Shoulder, Elbow, Wrist

73223

2. Include Laterality on Order: Left or Right or Bilateral

3. Include Indication:

• Post-op

• SLAP or Ligament Tear

1. Include Specific Body Part on Order: Shoulder, Elbow, Wrist

2. Include Laterality on Order: Left or Right or Bilateral

3. Include Indication:

• Mass/Tumor

• Infection

• Inflammation (-itis)/Inflammatory Arthritis

• Cancer or Metastases (Mets)

• Osteomyelitis

• MRI screening clearance Hospital, IMC Closed, IMC Open

• Metal Removal

• MRI screening clearance

• Hydrate 24-48 hrs prior

• IF Diabetic/Kidn ey Failure: Creatine and BUN done at most 6 weeks (about 1 and a half months) prior (Kidney function)

Yes

All magnets: Hospital, IMC Closed, IMC Open

MRI Lower Extremity (Non-Joint)

W/O Contrast

Includes: Femur, Tib-Fib, Foot

73718

1. Include Specific Body Part on Order: Femur, TibFib, Foot

2. Include Laterality on Order: Left or Right or Bilateral

3. Include Indication:

• Fracture

• Muscle/Tendon/Nerve Injury or Tear

• Metal Removal

• MRI screening clearance Yes

All magnets: Hospital, IMC Closed, IMC Open

BODY PART PROCEDURE CPT

MSK

MRI Lower Extremity (Non-Joint) W&W/O

Contrast Includes: Femur, Tib-Fib, Foot 73720

MRI Lower Extremity (Joint) W/O

Contrast Includes: Hip, Knee, Ankle 73721

MSK

INDICATION(S)

1. Include Specific Body Part on Order: Femur, TibFib, Foot

2. Include Laterality on Order: Left or Right or Bilateral

3.Include Indication:

• Mass/Tumor

• Infection

• Abscess

• Inflammation (-itis)

• Cancer or Metastases (Mets)

• Metal Removal

• MRI screening clearance

• Hydrate 24-48 hrs prior

• IF Diabetic/Kidn ey Failure:

Creatine and BUN done at most 6 weeks (about 1 and a half months) prior (Kidney function) Yes

All magnets: Hospital, IMC Closed, IMC Open

MRI Lower Extremity

1. Include Specific Body Part on Order: Hip, Knee, Ankle

2. Include Laterality on Order: Left or Right or Bilateral

3. Include Indication:

• Muscle/Tendon/Nerve Injury or Tear

• Fracture

• Osteoarthritis

• Cartilage Injury

• Avascular Necrosis (AVN)

1. Include Specific Body Part on Order: Hip, Knee, Ankle

• Metal Removal

• MRI screening clearance Yes

All magnets: Hospital, IMC Closed, IMC Open

• Metal Removal Yes

All magnets:

LifePoint Health Sensitive Information

MSK

(Joint) W/O

Contrast

(X-ray charges for the contrast) 73722

ARTHROGRAM

ONLY

MRI Lower Extremity (Joint)

W&W/O

Contrast Includes: Hip, Knee, Ankle

2. Include Laterality on Order: Left or Right or Bilateral

3. Include Indication:

• Post-op

• SLAP or Ligament Tear

1. Include Specific Body Part on Order: Hip, Knee, Ankle

2. Include Laterality on Order: Left or Right or Bilateral

3. Include Indication:

• Mass/Tumor

• Infection

• Inflammation (-itis)/Inflammatory Arthritis

• Cancer or Metastases (Mets)

• MRI screening clearance Hospital, IMC Closed, IMC Open

• Labral (SLAP) Tear

• Rotator cuff Tear

• TFC injury/Tear

• Ligament Injury

• Metal Removal

• MRI screening clearance

• Hydrate 24-48 hrs prior

• IF Diabetic/Kidn ey Failure: Creatine and BUN done at most 6 weeks (about 1 and a half months) prior (Kidney function)

Yes

All magnets: Hospital, IMC Closed, IMC Open

(All W/O Contrast )

X-ray charges for the contrast

• Cartilage injury or repair

• Loose Bodies

• Post-Op Meniscus Wrist 73222

• OCD

Ankle

MRA Head/Brain or COW

W/O Contrast

MRA

70544

MRA

Carotid/Arch/Gre at Vessels or Neck

W/O Contrast 70549

MRV MRV Head/Brain

W/O Contrast

• CVA

• Aneurysm

• AVM

• Headache

• TIA

Note: If Head/Brain and Neck MRA Ordered Both Must Be PreAuthorized • Metal Removal • MRI screening clearance Yes

• Bruit

• Dissection

• Carotid Stenosis

• Stroke • CVA

• TIA

• AVM

Note: If Head/Brain and Neck MRA Ordered Both Must Be PreAuthorized

• Evaluation for thrombosis

• Drowsiness & Confusion accompanying headache

• Metal Removal

• MRI screening clearance

Closed, IMC Open

• Metal Removal Yes

BODY PART PROCEDURE CPT CODE

INDICATION(S)

PREP/PREREQUISITES

Available at site

70544 • Tumor in the cerebral venous sinus • MRI screening eclearance Hospital, IMC Open *Can NOT be done on IMC Closed LifePoint Health Sensitive Information

ADVANCED-IMAGING ORDERING GUIDE NUCLEAR MEDICINE

FOR PATIENT SAFETY:

Valid Order MUST Contain:

1. Patient Name

2. Patient DOB

3. Procedure

4. Diagnosis – Medical Necessity if required, please include actual symptoms in addition to ICD codes

5. Physician signature

6. List appropriate body part and contrast medium

7. Auth if required

If Allergy to Contrast:

1. Provide patient with a prescription for prednisone and Benadryl

2. Fax copy of Allergy Prep Order and Procedure Order to Central Scheduling

1. Provide patient with a Lab Order for creatinine with GFR

2. Fax Creatinine Results with GFR and Procedure Order to Central Scheduling—Creatinine result must be within 30 days of scheduled procedure

If Hydration is Needed:

1. Fax hydration order and Procedure Order to Central Scheduling

Table Weight Limit for General NM studies is 400 lbs

Table Weight Limit for Cardiac NM studies is 350 lbs

Nuclear Medicine

BODY PART

Hepatobiliary 78227 (W Gallbladder W/EF) (Most Common) 78226 (Gallbladder No EF)

Gastric Emptying 78264

ABDOMEN

78265 (W Small Bowel)

• Chronic Cholecystitlis

• Anything not covered by CPT 78226

• Patient should have nothing to eat or drink for 4 hours prior to the exam.

ABDOMEN

Renal W Flow

78708 (W

Pharm & Quant Meas)

78707 (W/O Pharm & Quant Meas)

GI Bleed

Liver Scan

• Acute (Active) Cholecystitlis

• Bile Leak

• Cystic Duct Obstruction post sx.

• Nausea

• Vomiting

• Gastroparesis

• Patient should have nothing to eat or drink for 4 hours prior to the exam.

Hospital

• Renal Artery Stenosis

• Renal Function/Perfusion

• Hydronephrosis

• Atrophic Kidney

• Contrast Reaction

• Transplant

• Renal Failure

• Rectal Bleeding

*Bright Red Blood*

• Lesions/Mass/Tumor/Cyst

• Cirrhosis

• Hepatitis

• No Prep Hospital

CHEST

Liver Spec

Meckel’s Scan

Lung V/Q 78582 (Vent & Perf)

78580 Perfusion only

Myocardial Perfusion (Rest/Stress) 78452

Myocardial Amyloidosis SPECT/CT

78830

• Hemangioma Recommendation Per Radiologist

• Suspect Mecklel’s Diverticulum

• No Prep

Hospital

MUGA 78472

• Pulmonary Embolus

• Pulmonary Perfusion

• Qualitative Lung Analysis

• Pulmonary Hypertension

•

• CAD

• Chest Pain

• SOB

• EKG Changes

• Detection of transthyretin-related cardiac amyloidosis (ATTR)

• Per Cardiologist Recommendation Only

• Chemo Work-UP

• CHF

• Decreased LVEF

• Dyskinesis

Thyroid Uptake 78012

Thyroid Uptake & Scan 78014

Thyroid Scan 78013

• Goiter

• Hyperthyroidism

• Hypothyroidism

• Abnormal Thyroid Values

• Thyroid Nodule

LifePoint Health Sensitive Information

• NPO 6 hours

• No Intestinal Irritants (Laxatives, Barium Studies or Aspirin for 3 days

• No Prep

Patient needs to have recent CXR less than 24 hours old.

Hosital

Hospital

• No Caffeine

• No Heart Medicine Hospital

• No Prep

Hospital

• No Prep

Hospital

• NPO after midnight for Day 1 only

• No Prep

Hospital

NECK Parathyroid

78070 (Planar)

78071 (SPECT)

78072 (SPECT/CT)

I 131 Therapy Treatment

Whole Body Bone Scan 78306

• Parathyroid Adenoma

• Hypercalcemia

• Elevated PTH

• No Prep

*Must have Elevated PTH and Hypercalemia*

Hospital

3-Phase Bone Scan 78315

BONE

SPECT Bone

SPECT/CT Bone

• Hyperthyroidism

• Metastatic Disease

• Response of Therapy

• Paget’s Disease

• Elevated Lab Values

• Bone Pain, Injury > 1 Week

• Trauma

• Osteomyelitis

• Localized Injury >1 Week Ago

• Joint Pain

• Bone Surgery FU

• Trauma

78320 78830

Limited Bone Scan 78300

LYMPHATIC Lymphoscintigraphy 78195

• Degenerative Disc Disease

• Back Pain

• Bone Surgery

• Stress Fracture

• Low Back Pain

• Trauma

• Identifying the lymph node(s) that receive primary lymphatic drainage for surgery (Melanoma & Breast Cancers)

LifePoint Health Sensitive Information

• NPO 4 hours Prior to Exam

• Light Breakfast

• Patient will be injected and then have a 3 hour wait time until scan. Will require to go eat and drink during this time and require to empty bladder immediately before exam.

Hospital

• No Prep

Hospital

BRAIN Brain

ADVANCED-IMAGING ORDERING GUIDE PET

FOR PATIENT SAFETY:

Valid Order MUST Contain:

1. Patient Name

2. Patient DOB

3. Procedure

4. Diagnosis – Medical Necessity if required, please include actual symptoms in addition to ICD codes

5. Physician signature

6. List appropriate body part and contrast medium

7. Auth if required

If Allergy to Contrast:

1. Provide patient with a prescription for prednisone and Benadryl

2. Fax copy of Allergy Prep Order and Procedure Order to Central Scheduling

1. Provide patient with a Lab Order for creatinine with GFR

2. Fax Creatinine Results with GFR and Procedure Order to Central Scheduling—Creatinine result must be within 30 days of scheduled procedure

If Hydration is Needed:

1. Fax hydration order and Procedure Order to Central Scheduling

If Pacemaker, defibrillator, bladder stimulator, spinal stimulator, brain stimulator of any other implanted device:

1. Fax Make, Model and Type (or a copy of patient’s device card) with Procedure Order to Central Scheduling

Skull to MidThigh PET/CT Skull Base to Mid-thigh 78815

Whole Body PET/CT Whole Body 78816

• Any cancer except Melanoma, Brain, and Unknown Primary (Isotope: FDG or Ga-68)

• Cancer of Unknown Primary or Melanoma (Isotope: FDG)

ADVANCED-IMAGING ORDERING GUIDE ULTRASOUND

FOR PATIENT SAFETY:

Valid Order MUST Contain:

1. Patient Name

2. Patient DOB

3. Procedure

4. Diagnosis – Medical Necessity if required, please include actual symptoms in addition to ICD codes

5. Physician signature

6. List appropriate body part and contrast medium

7. Auth if required

If Allergy to Contrast:

1. Provide patient with a prescription for prednisone and Benadryl

2. Fax copy of Allergy Prep Order and Procedure Order to Central Scheduling

1. Provide patient with a Lab Order for creatinine with GFR

2. Fax Creatinine Results with GFR and Procedure Order to Central Scheduling—Creatinine result must be within 30 days of scheduled procedure

If Hydration is Needed:

1. Fax hydration order and Procedure Order to Central Scheduling

If Pacemaker, defibrillator, bladder stimulator, spinal stimulator, brain stimulator of any other implanted device:

1. Fax Make, Model and Type (or a copy of patient’s device card) with Procedure Order to Central Scheduling

BODY PART

ABDOMEN

COMPLETE Includes: Pancreas Liver Gallbladder Bile Ducts Right and Left Kidneys Spleen

Aorta (limited)

IVC (limited

Portal Vein 76700

• Abdominal pain

• Flank pain

• Abnormal laboratory tests

• Abnormality seen on another imaging study

• Follow-up of known or suspected abnormality in the abdomen

• AN ABDOMINAL COMPLETE DOES NOT EXAMINE THE PELVIS OR BOWEL

• When the right upper quadrant only is the primary area of interest, order US Abdomen RUQ.

• When the left upper quadrant only is the primary area of interest, order US Spleen.

• If an abdominal hernia or Ascites is the area of interest, order US Abdominal Limited

PREP/PREREQUISITES

• Patient should have nothing to eat or drink for 6 hours prior to the exam.

Sites where available

• Patient may take medications with a small amount of water Hospital Somerset

BODY PART PROCEDURE

ABDOMEN (RUQ)

Includes:

Pancreas

Liver

Gallbladder

Bile Ducts

ABDOMEN

Right Kidney

Aorta Limited

IVC Limited

Portal Vein 76705

INDICATION(S) EXAM

PREP/PREREQUISITES

• Right upper quadrant pain

• Right flank pain

• Epigastric pain

• Jaundice

• Abnormal liver function tests

• Abnormality seen on another imaging study

• Follow-up of known or suspected abnormality in the right upper quadrant

• If the right upper quadrant area and both kidneys are desired, order US Abdomen Complete.

• When the left upper quadrant only is the primary area of interest, order US Spleen.

• Patient should have nothing to eat or drink for 6 hours prior to the exam.

• Patient may take medications with a small amount of water.

Sites

BODY PART PROCEDURE

ABDOMEN LIMITED

Includes:

Abdomen and peritoneal cavity and Soft Tissue of the Abdomen 76705

ABDOMEN

US APPENDIX

76705

INDICATION(S) EXAM PREP/PREREQUISITES

• Search for free or loculated peritoneal and/or retroperitoneal fluid

• Soft tissue mass on front or back of abdomen

• Suspected hernia

• This exam looks for ascites and soft tissue only. If wanting a RUQ or Single Organ Ultrasound must state.

• Order must identify location

• RLQ pain

• Suspected appendicitis

• This exam looks for appendicitis only this exam does not include the uterus and ovaries. If wanting to evaluate uterus and ovaries a US Pelvis must also be ordered.

• None

BODY PART PROCEDURE

US LIVER WITH ELASTOGRAPHY

Includes: Pancreas Liver

Gallbladder

Bile Ducts

Right Kidney

Aorta Limited

ABDOMEN

IVC Limited

US ABDOMINAL AORTA

Includes:

Aorta and Proximal

Iliac Arteries

76705 +

INDICATION(S) EXAM

PREP/PREREQUISITES

Sites where available

• Hepatic cirrhosis

• Chronic viral hepatitis

•Steatohepatitis

•Fatty liver disease

•Liver staging

• *US of choice to evaluate hepatic fibrosis

• Exam must specify Liver Elastography or just a normal Liver ultrasound will be completed

• Patient should have nothing to eat or drink for 6 hours prior to the exam.

• Patient may take medications with a small amount of water Hospital

76706

• Palpable or pulsatile abdominal mass

• Follow-up of a previously identified abdominal aortic aneurysm

• Screening evaluation for abdominal aortic aneurysm

• Patient should have nothing to eat or drink for 6 hours prior to the exam.

• Patient may take medications with a small amount of water. Hospital Somerset IMC Mccreary

BODY PART PROCEDURE

US RENAL

Includes: Right and Left Kidneys

Urinary Bladder

ABDOMEN

76770 Bilateral

76775 Unilateral

INDICATION(S) EXAM

PREP/PREREQUISITES

Sites where available

US RENAL ARTERY

DOPPLER

93975

Bilateral

93976 Unilateral

• Flank pain

• Abnormal laboratory tests

• Abnormality seen on another imaging study

• Follow-up of known or suspected renal or urinary bladder abnormality

• Hematuria

• If both kidneys and the right upper quadrant area are desired, order US Abdominal Complete.

• If wanting a post void residual of the bladder please specify

• If you want wanting to look for RENAL ARTERY STENOSIS. Please order RENAL ARTERY DOPPLER EXAM

•Elevated blood pressure

•Hypertension that is resistant to treatment

•Impaired kidney function

Fluid retention

•Edema (swelling in the ankles and feet)

•Increased protein levels in urine

• None

•Patient should have nothing to eat or drink for 6 hours prior to the exam.

Hospital LifePoint Health Sensitive Information

•Patient may take medications with a small amount of water.

Hospital

Somerset IMC

Mccreary

BODY PART PROCEDURE

ABDOMEN

US SPLEEN 76705

OB/GYN US PELVIC NON OB 76856

TRANSABDOMINAL + 76830

TRANSVAGINAL

INDICATION(S) EXAM

PREP/PREREQUISITES

• Left upper quadrant pain

• Left flank pain

• Abnormality seen on another imaging study

• Follow-up of known or suspected abnormality in the left upper quadrant.

• If the left upper quadrant area and both kidneys are desired, order US Abdomen Complete

• Pelvic pain

• Amenorrhea

• Menorrhagia

• Metrorrhagia

• Menometrorrhagia

• Post-menopausal bleeding

• Follow-up of previously detected abnormality

• Further evaluation of pelvic abnormality detected on another imaging study

•Patient should have nothing to eat or drink for 6 hours prior to the exam.

•Patient may take medications with a small amount of water.

• Patient must have a full bladder.

• Patient should drink four 8-ounce glasses of water prior to the exam. Patient should be FINISHED drinking the water at least one hour before the exam.

• Patient should not void before the exam.

• In lieu of drinking water, patient can have IV fluids.

BODY PART PROCEDURE

OB/GYN OB <14 WEEKS

TRANSABDOMINAL + 76817

TRANSVAGINAL + 76802 For Additional Gestation

INDICATION(S) EXAM

PREP/PREREQUISITES

• Size and dates

• Vaginal bleeding in early pregnancy

• Determine viability/fetal heart beat

• Suspected ectopic pregnancy

• Patient should have a positive pregnancy test before ultrasound is ordered.

• This exam includes evaluation of the maternal uterus and adnexa.

• A transvaginal exam may also be performed per department protocol. A separate exam does not need to be ordered

• Patient must have the results of βHcG test before ultrasound is ordered.

• Patient must have a full bladder.

• Patient should drink four 8-ounce glasses of water prior to the exam. Patient should be FINISHED drinking the water at least one hour before the exam.

• Patient should not void before the exam.

• In lieu of drinking water, patient can have IV fluids.

Sites where available

BODY PART PROCEDURE

CEREBRO

VASCULAR

CAROTID DOPPLER

TEMPORAL ARTERY

93880 Bilateral 93882 Unilateral

INDICATION(S) EXAM PREP/PREREQUISITES

•Weakness

•Headache

•Syncope

•Difference in arm blood pressure

•Bruit

• Vertigo / dizziness

•Memory loss

•Transient ischemic attack (TIA)

•Stroke

•Visual disturbance

•Cerebrovascular accident (CVA)

• Amaurosisfugax

• Giant cell Arteritis

• Head Pain

• Scalp Tenderness

• Jaw Pain

•This exam is usually completed bilaterally, if only wanting to evaluate order needs to state UNILATERAL (RIGHT OR LEFT)

• None

•None Hospital Only

BODY PART PROCEDURE

UPPER EXTREMITIES

Includes:

Subclavian

Axillary

Brachial

Radial and Ulnar

ARTERIAL DOPPLER

LOWER EXTREMITES

Includes:

Common Femoral

Superficial Femoral

Popliteal

Posterior Tibial

Anterior Tibial

Dorsalis Pedis

93930 Bilateral 93931 Unilateral

• Decrease arm pressure

• Cold fingers or toes (poor circulation)

• Arm Numbness

• If wanting to evaluate for Thoracic Outlet Syndrome order

SEGMENTAL PRESSURE UPPER

EXTREMITY and specify for Thoracic Outlet Syndrome

93925 Bilateral 93926 Unilateral

•Claudication/pain with walking

•Decreased or absent pulses

•Arthrosclerosis

• Bruit

•Numbness

• Ulcer on foot or toe (s)

•Discoloration of feet or legs • None

BODY PART PROCEDURE

ANKLE BRACHIAL INDEX

Physiological Testing of Single level of the Ankle

Posterial Tibial Dorsalis Pedis

ARTERIAL DOPPLER

SEGMENTAL PRESSURE LOWER EXTREMITY

Physiological Testing of 3 or More Levels

Including Ankle

Brachial Index

Upper Thigh

Lower Thigh And

Upper Calf Great Toe

93922

INDICATION(S) EXAM PREP/PREREQUISITES

•Claudication/pain with walking

•Decreased or absent pulses

• Arthrosclerosis

• Bruit

•Numbness

• Ulcer on foot or toe (s)

•Discoloration of feet or legs

• None Hospital

93923

• Diminished or Absent Pulses in Lower Extremity

• Non Healing Leg ulcer

• Arterial Disease

• This can be ordered instead of an ARTERIAL DOPPLER LOWER EXTREMITY AND ANKLE BRACHIAL INDEX together.

• None Hospital

BODY PART PROCEDURE

INDICATION(S) EXAM

PREP/PREREQUISITES

Sites

SEGMENTAL

PRESSURE UPPER EXTREMITY 93923

• Diminished or Absent Pulses in Arms

• Arm Pain

• Thoracic Outlet Syndrome

• Suspect Arterial Disease

•This exam is usually completed bilaterally, if only wanting to evaluate order needs to state

UNILATERAL (RIGHT OR LEFT)

ARTERIAL DOPPLER

AV GRAFT/FISTULA

• Check patency or maturity of graft or fistula

• Loss of Thrill

• Swelling

• Please state whether Graft or Fistula, Location and any other pertinent information about the Graft/Fistula

• None

Hospital

LifePoint Health Sensitive Information

• None

Hospital

BODY PART PROCEDURE

LOWER EXTREMITES

93971

Unilateral

93970 Bilateral

VENOUS DOPPLER

UPPER EXTREMITES

93971

Unilateral

93970

Bilateral

•DVT

•Redness

•Lower Extremity Swelling / Pain

• Elevated D-Dimer

•Pulmonary Embolism

• Follow-up for patients with known DVT in leg(s)

• This exam looks for deep vein thrombosis

• If a palpable mass of the leg(s) is the area of interest, order US

EXTREMITY LIMITED

• If a Baker’s Cyst only is suspected, order US EXTREMITY LIMITED • None

• Pain and swelling in arm(s)

• Follow-up for patients with known DVT in arm(s)

• This exam looks for deep vein thrombosis

• If a palpable mass of the arm(s) is the area of interest, order US EXTREMITY LIMITED

• None

BODY PART PROCEDURE

LOWER EXTREMITY

REFLUX/INSUFFIENCY

93971 Unilateral 93970 Bilateral

VENOUS DOPPLER

LOWER EXTREMITY

VEIN MAPPING Includes:

Greater Saphenous Lesser Saphenous 93971 Unilateral 93970 Bilateral

UPPER EXTREMITY

VENOUS VEIN MAPPING Includes: Basilic Vein

Cephalic Vein 93986 Unilateral 93985 Bilateral

SOFT TISSUE

• Varicose Veins

• Non-healing wounds

• Edema

STRUCTURES

• If wanting to evaluate for reflux order must state evaluate for REFLUX or a DVT will be performed

• Preop planning for Coronary Artery Bypass Graft

•Must Specify Right, Left or Bilateral

• Preop planning for Dialysis Graft/Fistula Placement

•Must Specify Right, Left or Bilateral

None

• Soft tissue mass on chest (excluding breast) or upper back • Pleural effusion

• Order must identify location

None

BODY PART PROCEDURE

SOFT TISSUE NECK

76536

• Soft tissue mass on head or neck

– not thyroid related

• Order must identify location

None

•Thyroid Nodule

•Hyperthyroidism

•Hypothyroidism

•Goiter

SOFT TISSUE AND SUPERFICIAL STRUCTURES

US TESTICLES

76870

None

US EXTREMITY LIMITED

76882

• Scrotal pain

• Testicular trauma

• Palpable scrotal mass

• Scrotal asymmetry, enlargement, or swelling

• Undescended testicle(s • None

• Evaluation of soft tissue masses, swelling, or fluid collection in leg or arm

• Detection of foreign bodies in superficial soft tissues of leg or arm

• Soft tissue mass on buttock

• Order must identify location

• None

BODY PART PROCEDURE

SOFT TISSUE AND SUPERFICIAL STRUCTURES

US BREAST

• Breast Mass

• Breast Pain

• Abnormal Mammogram

76641

PEDIATRIC ABDOMEN FOR PYLORIC STENOSIS

• Projectile Vomiting

76705

INFANT HIPS (DYNAMIC)

Pediatrics

Sites

PREP/PREREQUISITES

If over 30 years of age patient needs Diagnostic Mammo followed by Ultrasound if under 30 years of age

Ultrasound followed by Diagnostic Mammo Somerset IMC

NPO for 2 hours

Bring bottle to feed during exam

INFANT SPINE AND CONTENTS

76885

•Developmental dysplasia of the hip (DDH)

•Breech birth

•Hip click

•Family history of DDH

•Sacral dimple

•Spina bifida

•Congenital anomalies of spinal cord

•Injury to spine/cord,

76800

•Birth trauma

• Per Radiologist Protocol, please also order a single view Lumbar Spine x-ray at the time of the ultrasound

Hospital

• None Hospital

• None

Hospital

BODY PART PROCEDURE

NEONATAL HEAD

ULTRASOUND GUIDED

PARACENTESIS 49083

ULTRASOUND

GUIDED

PROCEDURES

ULTRASOUND GUIDED

THORACENTESIS

INDICATION(S) EXAM

PREP/PREREQUISITES

•Intracranial hemorrhage

•Neonatal seizures •Enlarging

head circumference

•Hydrocephalus

•Ascites

Sites where available

• None Hospital

•Please Coordinate with Ultrasound Department (606)678-3177

•Will need to consult with Department if patient is on Anticoagulants.

32555

• Pleural effusion Hospital

•Need Labs drawn prior to Procedure (PT, PTT, INR, Platelet Count)

•If wanting for Diagnostic Purposes need order for Diagnostic Testing of the Fluid Hospital

BODY PART PROCEDURE

ULTRASOUND GUIDED

PROCEDURES

ASPIRATION/BIOPSY

ULTRASOUND GUIDED BREAST BIOPSY 19083

•Breast Mass

•Please Coordinate with our Nurse Navigator (606)6783787

•If prior Exam are done at outside facility will need prior images and reports from that facility

• Thyroid Nodule

ULTRASOUND GUIDED THYROID FINE NEEDLE

ASPIRATION/BIOPSY

ULTRASOUND GUIDED BIOPSY/ASPIRATION

76942

•Axillary Lymph Node

•Groin Lymph Node

•Parotid Gland

•Neck Mass

•Breast Cyst

•Please Coordinate with Radiology Nurse (606)678-3816

•If prior Exam are done at outside facility will need prior images and reports from that facility Hospital

•Superficial Cyst Hospital

RADIOLOGY SERVICES PATIENT SCHEDULING

Your physician has requested an outpatient exam to be scheduled with Lake Cumberland Regional Hospital. A Scheduling Representative will contact you within 2 business days to arrange a convenientdateandtimeforyourexam.

Patientsshouldreceivea callwithin48hoursafter appointmenttoschedule theirimagingservices.

Ifyouhavenotreceiveda calltoscheduleanexam within48hours, pleasecall606.678.3545 between7:30amand 5:00pmM-F.

Arriveforscheduled appointmentwith insurancecardsand identificationfor registration.