Lake Cumberland Regional Hospital Advanced Imaging Order Guides

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 �

CENTRAL SCHEDULING: 606-678-3545 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.

2.

3.

4.

5.

6.

7.

Patient Name Patient DOB Procedure Diagnosis – Medical Necessity if required, please include actual symptoms in addition to ICD codes Physician signature List appropriate body part and contrast medium 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

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BODY PART

CT Brain/Head

CT Orbit

CT (W=With Contrast, WO=Without Contrast, W&WO=With and Without Contrast = Combined) PROCEDURE CPT INDICATION(S) EXAM Sites where CODE PREP/PREREQUISITES available CT Brain/Head 70450 None Hospital, • Alzheimer’s WO Contrast McCreary Imaging • Dementia Center • Mental Status Changes • CVA • Stroke • TIA • Confusion • Memory Loss • Headache (less than 7 days) • Trauma CT Brain/Head 70460 NPO 2 hours Hospital, • Tumor/Mass W&WO McCreary Imaging • Cancer/Metastases (METS) Contrast Center • Seizure • Vascular Lesions • Dizziness/Vertigo • Multiple Sclerosis (MS) • Neurofibromatosis • Adenoma • Headache (more than 7 days) • Meningioma • Infection/Meningitis/Mastoiditis CT Orbit 70480 None Hospital, • Facial pain WO Contrast McCreary Imaging • Trauma Center CT Orbit 70481 NPO 2 hours Hospital, • Vision changes W Contrast McCreary Imaging • Optic neuritis Center • Ocular Mass • Graves Disease LifePoint Health Sensitive Information

BODY PART

PROCEDURE

CT Internal Auditory Canal (IAC)

CT IAC, Temporal Bones W&WO Contrast

CT Sinus /Facial Bones

CT Sinus/Facial Bones WO Contrast

CPT CODE 70482

70486

CT Sinus/Facial Bones W/Contrast

CT Pituitary (MRI Unless Contraindicated)

CT Brain/Head W&WO Special views Skull

70470

INDICATION(S) • • • • • • • • •

Cholesteatoma Trauma/Ear Injury Hearing Loss Tinnitus Vertigo Trigeminal Neuralgia Sinusitis Endoscopic Surgery Osteomata Evaluation

• • • • •

Infection Redness/Swelling Tumor Elevated Prolactin Sella Lesion

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EXAM PREP/PREREQUISITES NPO 2 hours

Sites where available Hospital, McCreary Imaging Center

None

Hospital, McCreary Imaging Center

NPO 2 hours

NPO 2 hours

Hospital, McCreary Imaging Center

BODY PART

PROCEDURE

CT Soft Tissue Neck

CT Soft Tissue Neck W/Contrast

CPT CODE 70492

CT Soft Tissue Neck W/WO Contrast

TMJ

CT Chest

CT Chest

INDICATION(S) • • • •

Cancer Staging Infection Pain Tumor/Mass

• •

Parotid stone (W/WO) Parotid infection (W/WO)

*CT Soft Tissue should not be done without unless contraindicated • Jaw Pain • Locking Jaw • Trauma

CT Maxofacial WO Contrast

70486

LDCT Lung Screening

71271

•

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

CT Chest W&WO Contrast

71270

•

Appropriate for known cancer or Radiologist recommendation only

Chest WO Contrast

71250

•

Low-Dose CT (LDCT) Cancer Screening, 3–6month Follow-up F/U Nodule Contrast Dye Contraindication

• •

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EXAM PREP/PREREQUISITES NPO 2 hours

Sites where available Hospital, McCreary Imaging Center

NPO 2 hours

None

Hospital, McCreary Imaging Center

None

Hospital, McCreary Imaging Center

NPO 2 hours

Hospital, McCreary Imaging Center

None

Hospital, McCreary Imaging Center

BODY PART

PROCEDURE

CT Chest

Chest W Contrast

CT Abdomen (ABD)

CPT CODE 71260

CT Chest, High Res. WO Contrast

71250

CT Abdomen W&WO Contrast

74170

INDICATION(S) • Mediastinal abnormality • Hilar abnormality • Hemoptysis • Abn CXR • Lung CA/Mets • Mass Tumor • Abscess • Pleural Effusion • Chronic Effusion • Chronic Dyspnea • Asbestosis • Bronchiectasis • Fibrosis • Interstitial Lung Disease • Pleural Plaques • Sarcoidosis Adrenal Protocol: • Adrenal Mass Liver Protocol: • Liver Mass/Lesion • Elevated Liver Enzymes • Hepatitis • Cirrhosis • Liver Hemangioma (MRI Preferred)

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EXAM PREP/PREREQUISITES NPO 2 hours

Sites where available Hospital, McCreary Imaging Center

None

Hospital, McCreary Imaging Center

NPO 2 hours

Hospital, McCreary Imaging Center

NPO 2 hours

Hospital, McCreary Imaging Center

BODY PART

CT Abdomen (ABD)

PROCEDURE

CPT CODE

CT Abdomen W&WO Contrast

INDICATION(S) Pancreatic Protocol: • Pancreatic Mass • Pancreatitis • Pseudocyst (1st Exam Performed) Renal Mass Protocol: • Any Renal Pathology except Kidney Stones;

EXAM PREP/PREREQUISITES NPO 2 hours

Sites where available Hospital, McCreary Imaging Center

NPO 2 hours

Hospital, McCreary Imaging Center

NPO 2 hours

Hospital, McCreary Imaging Center

NPO 2 hours

Hospital, McCreary Imaging Center

Note: To include Kidneys, Ureters, & Bladder (CT Urogram), use 74178 Abdomen/Pelvis CT Without & With Contrast

CT Abdomen W Contrast

74160

Follow-Up Pancreatic CT (After Initial WO&W Scan)

• • • • • •

Upper Abdominal Pain Gallbladder Hepatitis/Cirrhosis Chronic Pancreatitis Mass Splenomegaly

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BODY PART

PROCEDURE

CPT CODE

CT Pelvis

CT Pelvis (Soft Tissue) W Contrast

72194

CT Pelvis W/WO (Cystogram)

CT ABD & Pelvis

INDICATION(S) • • • • • •

Cancer Mass/Tumor Fibroid Endometriosis Infection Trauma

• • • •

Fistula Tumor/Mass Fracture SI Joints

CT Pelvis (Bony) WO Contrast

72192

CT ABD & Pelvis WO Contrast

74176

•

Kidney Stones

CT ABD & Pelvis W Contrast

74177

• • • • • •

Trauma Bowel Perforation Abdominal Pain Cancer Staging Mass Appendicitis, Crohn’s/Ulcerative Colitis/Diverticulitis/Abscess/Acute Pancreatitis Hematoma

•

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EXAM PREP/PREREQUISITES NPO 2 hours

Available at site Hospital, McCreary Imaging Center

NPO 2 hours None

Hospital, McCreary Imaging Center

None

Hospital, McCreary Imaging Center

NPO 2 hours

Hospital, McCreary Imaging Center

BODY PART

PROCEDURE

CPT CODE

CT ABD & Pelvis

CT ABD & Pelvis W&WO Contrast

74178

INDICATION(S) • • • • •

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

CT Cervical Spine WO Contrast

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.

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EXAM PREP/PREREQUISITES NPO 2 hours

Available at site

None

Hospital, McCreary Imaging Center

NPO 2 hours

Hospital, McCreary Imaging Center

BODY PART

PROCEDURE

CPT CODE

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

CT Thoracic Spine WO Contrast

72128

•

CT Thoracic Spine W/WO

CT Lumbar Spine W Contrast CT Lumbar Spine W/W/O

• • • • • •

CT Thoracic Spine W Contrast

CT Lumbar Spine WO Contrast

INDICATION(S)

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

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

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EXAM PREP/PREREQUISITES None

Available at site Hospital, McCreary Imaging Center

NPO 2 hours

None

NPO 2 hours

Hospital, McCreary Imaging Center

BODY PART

PROCEDURE

CT Upper CT Extremity: Extremity All Bone CT Is (Shoulder, Humerus, Elbow, Performed Radius/Ulna, Without Wrist, Hand) Contrast Except WO Contrast For Tumor Evaluation CT Upper when MRI is Extremity (Shoulder, contraindicated.

CPT CODE

INDICATION(S)

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 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

73201

Humerus, Elbow, Radius/Ulna, Wrist, Hand) W Contrast

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

73700

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EXAM PREP/PREREQUISITES None

Available at site

NPO 2 hours

Hospital, McCreary Imaging Center

None

Hospital, McCreary Imaging Center

Hospital, McCreary Imaging Center

BODY PART

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

CT Heart

PROCEDURE

CPT CODE

INDICATION(S)

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

Calcium Score

75571

• •

Screening Hyperlipidemia

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EXAM PREP/PREREQUISITES NPO 2 hours

Available at site

None

Hospital only

Hospital, McCreary Imaging Center

BODY PART

PROCEDURE CTA Head or COW W&WO

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

CTA Neck W&W/O (Carotid Artery)

CPT CODE 70496

70498

CTA Chest (PE or Aorta Study)

71275

CTA ABD

74175

INDICATION(S)

EXAM PREP/PREREQUISITES 2 hours

Available at site Hospital, McCreary Imaging Center

• • • • • •

Aneurysm Arterio-Venous Malformation (AVM) Bruit CVA (Stroke) TIA Vascular Tumor

• • • • • • • •

Dissection Stroke Carotid Stenosis Arterio-Venous Malformation (AVM) Bruit CVA (Stroke) TIA Vascular Tumor

2 hours

Hospital, McCreary Imaging Center

• • • • • • • • • • •

Pulmonary Embolism Shortness of breath (SOB) Vascular Evaluation Chest Pain CardioMerge Thoracic aorta Aneurysm Coarctation Aortic Dissection Pre-kidney transplant Renal Artery Stenosis (RAS)

2 hours

Hospital, McCreary Imaging Center

2 hours

Hospital,

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

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

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McCreary Imaging Center

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

CTA Abdominal Aorta & Run Off

75635

• • •

Claudication Peripheral Artery Disease (PAD) Peripheral Vascular Disease (PVD)

2 hours

Hospital, McCreary Imaging Center

CTA ABD & Pelvis

74174

Hospital, McCreary Imaging Center

73206

AAA Crossing Vessels Mesenteric Vessel Evaluation Renal Artery Stenosis (RAS) Stent Obstruction/Leak/Malfunction Ischemic Bowel Vascular disease Ischemia Upper arterial emboli

2 hours

CTA Upper Extremity

• • • • • • • • •

2 hours

Hospital, McCreary Imaging Center

CTA Lower Extremity

73706

• • • •

Peripheral Artery Disease Peripheral Vascular Disease Ischemia Stenosis Evaluation

2 hours

Hospital, McCreary Imaging Center

CTA Heart

75574

• • • •

Coronary Artery Disease (CAD) Bypass graft evaluation Abnormal Echocardiogram Chest Pain

4 hours solid food

Hospital Only

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

No caffeine or smoking 24 hours prior Must follow Medication Prep according to Protocol Heart Rate below 70

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

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8 hours

Hospital, McCreary Imaging Center

Myelography – Performed and Interpreted by Same Provider BODY PART PROCEDURE CPT CODE

Myelogram With CT to Follow

Cervical Spine

72240 (Precert 72240 & 72126)

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

INDICATION(S)

If MRI Contraindicated and/or as suggested by MRI

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EXAM PREP/PREREQUISITES NPO after midnight Blood thinners withheld No contrast Allergy 300lb weight limit NPO after midnight Blood thinner withheld No contrast Allergy 300lb weight limit NPO after midnight Blood thinners withheld No contrast Allergy 300lb weight limit NPO after midnight Blood thinners withheld No contrast Allergy 300lb weight limit

Available at site Yes

Yes

Yes

Yes

CENTRAL SCHEDULING: 606-678-3545 ADVANCED-IMAGING ORDERING GUIDE FLUOROSCOPY 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.

2.

3.

4.

5.

6.

7.

Patient Name Patient DOB Procedure Diagnosis – Medical Necessity if required, please include actual symptoms in addition to ICD codes Physician signature List appropriate body part and contrast medium 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 300 lbs LifePoint Health Sensitive Information

Fluoroscopy – Performed and Interpreted by Same Provider BODY PART

PROCEDURE

CPT CODE

Upper GI (UGI)

UGI

74240

UGI w/ Small Bowel

74245

Esophagram/ Barium Swallow

Esophagram

74220

Modified Barium Swallow (MBS) Barium Enema (BE)

MBS

Follow Through

INDICATION(S)

EXAM PREP/PREREQUISITES NPO after midnight

Available at site Yes

• • • • •

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

NPO after midnight

Yes

300lb weight limit

Yes

Bowel Prep Clear Liquid Diet 24 hours prior to exam

Yes

BE

74270

• • • •

Crohn’s Disease Ulcerative Colitits IBS Incomplete Colonoscopy

BE with Air Contrast

74280

• • •

Change in Bowel Habits Abdominal Pain Rectal Bleeding

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•

BODY PART

PROCEDURE

CPT CODE

Small Bowel Series

Small Bowel Series

74250

Sniff Test

Sniff Test

74430

Port Patency

Port Patency

Hysterosalpin gogram Voiding Urethrocysog raphy VCUG IVP

Suspected diverticulitis

INDICATION(S)

EXAM PREP/PREREQUISITES NPO after Midnight

Available at site Yes

No Prep

Yes

No Contrast Allergy

Yes

• • • • • • •

Strictures Suspected Crohns Abdominal Pain Change in Bowel Habits Abnormal XRay Difficulty breathing Eval for unilateral diaphragm paralysis

75809

• •

No blood Return Restarting Chemotherapy

HSG

74740

• •

Infertility Therapeutic

None

Yes

VCUG

74455

• •

Recurrent UTIs Concern for Reflux

None

Yes

IVP

74400

• • • •

Recurrent UTIs Hx of Kidney Stones Flank pain Hematuria

NPO after midnight

Yes

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Arthrogram – Performed and Interpreted by Same Provider BODY PART PROCEDURE CPT CODE

Arthrogram With MRI to Follow (unless contraindicated)

INDICATION(S)

Shoulder

73040 (Precert 73040 & 73222 )

• • •

Rotator cuff tear Limited ROM Pain

Hip

73525 (Precert 73525 & 73722)

• • •

Limited ROM Labral Tear Pain

• • •

Pain Limited ROM Meniscus Tear

• •

Pain Limited Rom

Knee

Wrist

73580 (Precert 73580 & 73722) 73115 (Precert 73115 & 73222)

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EXAM PREP/PREREQUISITES NPO after midnight Blood thinners withheld No contrast Allergy

Available at site Yes

NPO after midnight Blood thinner withheld No Contrast Allergy

Yes

NPO after midnight Blood thinners withheld No contrast Allergy

Yes

NPO after midnight Blood thinners withheld No contrast Allergy

Yes

CENTRAL SCHEDULING: 606-678-3545 ADVANCED-IMAGING ORDERING GUIDE MRI 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.

2.

3.

4.

5.

6.

7.

Patient Name Patient DOB Procedure Diagnosis – Medical Necessity if required, please include actual symptoms in addition to ICD codes Physician signature List appropriate body part and contrast medium 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

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 LifePoint Health Sensitive Information

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 PROCEDURE CPT INDICATION(S) CODE MRI Brain/Head W/O Contrast Includes: Whole brain Brain stem

BRAIN

70551

MRI Brain/Head W&W/O Contrast Includes: Whole Brain Brain stem

70553

• • • • • • • • • • • • • • • • • • • • •

Alzheimer’s, Mental Status Changes Confusion Memory Loss Dementia Headaches Stroke CVA TIA 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

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EXAM 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)

AVAIBLE AT SITE Yes All magnets: Hospital, IMC Closed, IMC Open

Yes All magnets: Hospital, IMC Closed, IMC Open

BODY PART

PROCEDURE

CPT CODE

MRI Orbits W&W/O Contrast

BRAIN

Includes: Eyeball, Optic muscles Optic nerve

MRI Face/Paranasal Sinuses W&W/O Contrast

BRAIN

Includes: All Facial Bones, All Sinuses

70543

INDICATION(S)

EXAM PREP/PREREQUISITE

• • • • • •

Graves’ disease Exophthalmos/Proptosis Diplopia/Double-vision Visual field Defect Optic Neuritis Optic Nerve Lesion/Tumor/Infection

• •

• • •

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)

70543

•

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)

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• •

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)

AVAIBLE AT SITE Yes All magnets: Hospital, IMC Closed, IMC Open

Yes All magnets: Hospital, IMC Closed, IMC Open

BODY PART

PROCEDURE

CPT CODE

MRI Soft Tissue Neck W&W/O Contrast

NECK

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

70543

MRI Pituitary or IAC (Ear) W&W/O Contrast

BRAIN

Includes: Pituitary gland & its stalk All bones of the ear & nerves

70553

INDICATION(S)

EXAM PREP/PREREQUISITE

Vocal Cord Paralysis Infection Pain Tumor/Mass Cancer or Metastases (Mets)

• •

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)

LifePoint Health Sensitive Information

• •

• •

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)

AVAIBLE AT SITE Yes All magnets: Hospital, IMC Closed, IMC Open

Yes All magnets: Hospital, IMC Closed, IMC Open

BODY PART

PROCEDURE

CPT CODE

INDICATION(S) IAC/Ear: • Hearing Loss (SNHL) • Tinnitus • Vertigo • Acoustic Neuroma • Trauma • Dizziness

EXAM PREP/PREREQUISITE • • • •

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)

BRAIN

MRI TMJ W/O Contrast Includes: TMJ joints

70336

• • • •

Jaw Pain Locking Jaw Jaw Popping/Clicking Difficulty Opening Jaw

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• •

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

AVAIBLE AT SITE Yes

All magnets: Hospital, IMC Closed, IMC Open

Yes All magnets: Hospital, IMC Closed, IMC Open

BODY PART

PROCEDURE

CPT CODE

MRI Chest/Mediastinum W&W/O Contrast **or** W/O Contrast

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

MRI ABD W/O Contrast

ABDOMEN

Includes: Pancreas, Spleen, Appendix (If pregnant) General View of organs

74181

INDICATION(S) Brachial Plexus Injury (Please Specify) Nerve Avulsion Tumor/Mass Cancer or Metastases (Mets) Avascular Necrosis Trauma 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 • • • • • • • • • •

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EXAM PREP/PREREQUISITE • • • •

• •

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)

Metal Removal MRI screening clearance

AVAIBLE AT SITE Yes All magnets: Hospital, IMC Closed, IMC Open

Yes All magnets: Hospital, IMC Closed, IMC Open

BODY PART

PROCEDURE

CPT CODE

MRCP W/O Includes: Biliary Duct/Veins, Gallbladder, Pancreas

ABDOMEN

74181

MRI ABD W&W/O Contrast Includes: Kidneys, Adrenals, Spleen, Ureters 74183

INDICATION(S)

EXAM PREP/PREREQUISITE

• • • • •

Stones Jaundice Pancreatic Mass Biliary Obstruction Pancreatitis

• •

Metal Removal MRI screening clearance

• • • • • • •

Tumor/Mass/Cancer Abdominal Pain Abscess Ascites Renal lesions Pyelonephritis Hematuria

• •

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)

LifePoint Health Sensitive Information

• •

AVAIBLE AT SITE Yes All magnets: Hospital, IMC Closed, IMC Open Yes All magnets: Hospital, IMC Closed (Except Adrenals), IMC Open

BODY PART

PROCEDURE

CPT CODE

MRI Liver W&W/O Contrast

ABDOMEN

SPINE

Includes: Liver (3phase), Arteries, Veins

74183

MRI C-Spine W/O Contrast Includes: Vertebral body, Spinal cord, Disc space

72141

INDICATION(S) • • • • • •

• • • • • • • •

Liver Mass Tumor Cyst Lesion Hepatomegaly Cirrhosis

Pain or Weakness in Neck/Arm/Shoulder Degenerative Disc Disease Disc Herniation Stenosis Post-Op Evaluation Radiculopathy Trauma Fracture

LifePoint Health Sensitive Information

EXAM PREP/PREREQUISITE • • • •

• •

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

AVAIBLE AT SITE Yes Hospital, IMC Open

Can NOT be done on IMC Closed

Yes All magnets: Hospital, IMC Closed, IMC Open

BODY PART

PROCEDURE

CPT CODE

MRI C-Spine W&W/O Contrast

SPINE

Includes: Vertebral body, Spinal cord, Disc space

72156

Includes: Vertebral body, Spinal cord, Disc space

72146

EXAM PREP/PREREQUISITE • •

• • •

Syrinx Infection/Discitis Cancer or Metastases Compression Fracture with History of Cancer Tumor/Mass Myelopathy Multiple Sclerosis (MS)

• • • • • • • • •

Pain Degenerative Disc Disease Disc Herniation Stenosis Post-Op Evaluation Radiculopathy Trauma Fracture Vertebroplasty Planning

• •

• • • •

MRI T-Spine W/O Contrast

SPINE

INDICATION(S)

LifePoint Health Sensitive Information

• •

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

AVAIBLE AT SITE Yes All magnets: Hospital, IMC Closed, IMC Open

Yes All magnets: Hospital, IMC Closed, IMC Open

BODY PART

PROCEDURE

CPT CODE

MRI T-Spine W&W/O Contrast

SPINE

Includes: Vertebral body, Spinal cord, Disc space

72157

MRI L-Spine W/O Contrast

SPINE

Includes: Vertebral body, Spinal cord, Disc space

72148

INDICATION(S)

EXAM PREP/PREREQUISITE • •

• • • •

Syrinx Infection/Discitis Cancer or Metastases Compression Fracture with History of Cancer Tumor/Mass Abscess Myelopathy Multiple Sclerosis (MS)

• • • • • • • • •

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)

LifePoint Health Sensitive Information

• •

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

AVAIBLE AT SITE Yes All magnets: Hospital, IMC Closed, IMC Open

Yes All magnets: Hospital, IMC Closed, IMC Open

BODY PART

PROCEDURE

CPT CODE

MRI L-Spine W&W/O Contrast

SPINE

PELVIS

Includes: Vertebral body, Spinal cord, Disc space

MRI Bony Pelvis W/O Contrast Includes: Pelvis, Hips, Sacrum, SI Joints

INDICATION(S)

EXAM PREP/PREREQUISITE • •

72158

• • • •

Syrinx Infection/Discitis Cancer or Metastases Compression Fracture with History of Cancer Tumor/Mass Abscess Myelopathy Multiple Sclerosis (MS)

72195

• • • • •

Muscle/tendon Tear/AVN Hip Pain Fracture Pubalgia/sports hernia Bone Infarct

• •

• • • •

LifePoint Health Sensitive Information

• •

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

AVAIBLE AT SITE Yes All magnets: Hospital, IMC Closed, IMC Open

Yes All magnets: Hospital, IMC Closed, IMC Open

BODY PART

PROCEDURE

CPT CODE

MRI Pelvis Soft Tissue – Female W&W/O Contrast

PELVIS

Includes: Uterus, Ovaries, Cervix

72197

MRI Pelvis Soft Tissue – Male W&W/O Contrast

PELVIS

Includes: Prostate, Seminal Vesicles, Testes, Urethra

72197

INDICATION(S)

EXAM PREP/PREREQUISITE

• • • • • • •

Fibroid Endometriosis Tumor/Mass Cancer or Metastases (Mets) Infection Abscess Congenital Abnormalities

• •

• • • • • •

Enlarged Prostate Tumor/Mass Cancer or Metastases (Mets) Abscess Infection Congenital Abnormalities

• •

LifePoint Health Sensitive Information

• •

• •

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)

AVAIBLE AT SITE Yes All magnets: Hospital, IMC Closed, IMC Open

Yes Hospital Magnet

BODY PART

PROCEDURE

PELVIS

MRI Pelvis Osteo/Mass W&W/O Contrast Includes: Whole Plevis, *Rectum

CPT CODE

72197

INDICATION(S) • • • • • •

Cancer/Metastases (Mets) Wounds Osteomylitis Lesions Lipomas Abscess

*Not true dedicated Rectal Protocol

LifePoint Health Sensitive Information

EXAM PREP/PREREQUISITE • • • •

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)

AVAIBLE AT SITE Yes

All magnets: Hospital, IMC Closed, IMC Open

BODY PART

PROCEDURE

CPT CODE

MRI Bilateral Breast W&W/O Contrast (always bilateral, our facility does not do singular breast images)

BREAST

Includes: Breast tissue, Nipple, axillary lymph nodes

INDICATION(S) •

77049

• • • • • • • •

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

EXAM PREP/PREREQUISITE • • • •

•

•

LifePoin t Health Sensitiv

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.

AVAIBLE AT SITE Yes Hospital, IMC Open

*Can NOT be done on IMC Closed

BODY PART

PROCEDURE

CPT CODE

Implant Integrity MRI Breast Bilateral W/O Contrast

BREAST

(always done without for implant integrity, contrast not needed to see this)

INDICATION(S) • •

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

77047

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

BODY PART

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

MSK

Includes: Humerus, Forearm, Hand, Finger

CPT CODE

73218

Note: This is not to evaluate for breast cancer or lumps 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: • Fracture • Muscle/Tendon/Nerve Injury or Tear (For Bicep tear order a humerus always to cover retraction)

LifePoint Health Sensitive Information

EXAM PREP/PREREQUISITE

AVAIBLE AT SITE

Yes Metal Removal MRI screening clearance Hospital, IMC • If patient is Open 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.

EXAM Available at PREP/PREREQUISITES site • •

• •

Metal Removal MRI screening clearance

Yes All magnets: Hospital, IMC Open

BODY PART

PROCEDURE

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

MSK

CPT CODE

73220

Includes: Humerus, Forearm, Hand, Finger

MRI Upper Extremity (Joint) W/O Contrast

MSK

Includes: Shoulder, Elbow, Wrist MRI Upper Extremity (Joint)

73221

INDICATION(S)

EXAM PREP/PREREQUISITES

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)

•

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

•

LifePoint Health Sensitive Information

• • •

•

•

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) Metal Removal MRI screening clearance

Metal Removal

Available at site Yes

All magnets: Hospital, IMC Open

Yes All magnets: Hospital, IMC Closed, IMC Open

Yes All magnets:

BODY PART

PROCEDURE

CPT CODE

INDICATION(S)

W/O Contrast

73722

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

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

•

ARTHROGRAM ONLY (X-ray charges for the contrast)

MRI Upper Extremity (Joint) W&W/O Contrast

73223

Includes: Shoulder, Elbow, Wrist

MRI Lower Extremity (Non-Joint) W/O Contrast Includes: Femur, Tib-Fib, Foot

73718

LifePoin t Health Sensitiv

EXAM PREP/PREREQUISITES

Available at site

•

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

• • •

•

Metal Removal MRI screening clearance

All magnets: Hospital, IMC Closed, IMC Open

Yes All magnets: Hospital, IMC Closed, IMC Open

BODY PART

PROCEDURE

CPT CODE

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

MSK

Includes: Femur, Tib-Fib, Foot

MRI Lower Extremity (Joint) W/O Contrast

MSK

73720

Includes: Hip, Knee, Ankle MRI Lower Extremity

73721

INDICATION(S)

EXAM PREP/PREREQUISITES

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)

•

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

•

LifePoint Health Sensitive Information

• • •

•

•

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) Metal Removal MRI screening clearance

Metal Removal

Available at site Yes All magnets: Hospital, IMC Closed, IMC Open

Yes All magnets: Hospital, IMC Closed, IMC Open

Yes All magnets:

BODY PART

PROCEDURE

CPT CODE

INDICATION(S)

(Joint) W/O Contrast

73722

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)

ARTHROGRAM ONLY (X-ray charges for the contrast)

MSK

MRI Lower Extremity (Joint) W&W/O Contrast

73723

Includes: Hip, Knee, Ankle

BODY PART

PROCEDURE

MRI Arthrogr aphy

Shoulder Elbow

CPT CODE 73222 23350 73040 73222 24220

INDICATION(S) • • • •

Labral (SLAP) Tear Rotator cuff Tear TFC injury/Tear Ligament Injury LifePoint Health Sensitive Information

EXAM PREP/PREREQUISITES

Available at site

•

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

• • •

EXAM PREP/PREREQUISITES

All magnets: Hospital, IMC Closed, IMC Open

Available at site

BODY PART

(All W/O Contrast ) X-ray charges for the contrast

PROCEDURE Wrist Hip Knee Ankle

MRA Head/Brain or COW W/O Contrast

MRA

CPT CODE 73085 73222 25246 73115 73722 27093 73525 73722 27369 73580 72722 27648 73615

70544

INDICATION(S)

EXAM PREP/PREREQUISITES

• • • •

Cartilage injury or repair Loose Bodies OCD Post-Op Meniscus

• • • • •

CVA Aneurysm AVM Headache TIA

•

• • • • • • •

Bruit Dissection Carotid Stenosis Stroke CVA TIA AVM

•

• •

Evaluation for thrombosis Drowsiness & Confusion accompanying headache

•

•

Metal Removal MRI screening clearance

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

MRA Carotid/Arch/Gre at Vessels or Neck W/O Contrast

MRV

MRV Head/Brain W/O Contrast

70549

•

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

LifePoint Health Sensitive Information

Metal Removal MRI screening clearance

Metal Removal

Available at site

Yes All magnets: Hospital, IMC Closed, IMC Open Yes All magnets: Hospital, IMC Closed, IMC Open Yes

BODY PART

PROCEDURE

CPT CODE 70544

INDICATION(S) •

Tumor in the cerebral venous sinus

EXAM PREP/PREREQUISITES • MRI screening eclearance

Available at site Hospital, IMC Open *Can NOT be done on IMC Closed

LifePoint Health Sensitive Information

CENTRAL SCHEDULING: 606-678-3545 ADVANCED-IMAGING ORDERING GUIDE NUCLEAR MEDICINE 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.

2.

3.

4.

5.

6.

7.

Patient Name Patient DOB Procedure Diagnosis – Medical Necessity if required, please include actual symptoms in addition to ICD codes Physician signature List appropriate body part and contrast medium 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 for General NM studies is 400 lbs Table Weight Limit for Cardiac NM studies is 350 lbs LifePoint Health Sensitive Information

Nuclear Medicine BODY PART

PROCEDURE

CPT CODE

Hepatobiliary

78227 (W Gallbladder W/EF) (Most Common)

• •

Chronic Cholecystitlis Anything not covered by CPT 78226

78226 (Gallbladder No EF)

• • •

Acute (Active) Cholecystitlis Bile Leak Cystic Duct Obstruction post sx.

78264

• • •

Nausea Vomiting Gastroparesis

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

• • • • • • •

Renal Artery Stenosis Renal Function/Perfusion Hydronephrosis Atrophic Kidney Contrast Reaction Transplant Renal Failure

• No Prep

GI Bleed

•

• No Prep

Liver Scan

• • •

Rectal Bleeding *Bright Red Blood* Lesions/Mass/Tumor/Cyst Cirrhosis Hepatitis

Gastric Emptying

INDICATION(S)

78265 (W Small Bowel)

ABDOMEN Renal W Flow

78708 (W Pharm & Quant Meas) 78707 (W/O Pharm & Quant Meas)

ABDOMEN LifePoint Health Sensitive Information

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

Available at site Hospital

Hospital

Hospital

Hospital

• No Prep Hospital

Liver Spec

•

Hemangioma Recommendation Per Radiologist

• No Prep

Hospital

Meckel’s Scan

•

Suspect Mecklel’s Diverticulum

• NPO 6 hours • No Intestinal Irritants (Laxatives, Barium Studies or Aspirin for 3 days

Hosital

• • • • •

Pulmonary Embolus Pulmonary Perfusion Qualitative Lung Analysis Pulmonary Hypertension

• No Prep

• • • • •

CAD Chest Pain SOB EKG Changes Detection of transthyretin-related cardiac amyloidosis (ATTR) Per Cardiologist Recommendation Only Chemo Work-UP CHF Decreased LVEF Dyskinesis Goiter Hyperthyroidism Hypothyroidism Abnormal Thyroid Values Thyroid Nodule

• No Caffeine • No Heart Medicine

Lung V/Q

78582 (Vent & Perf) 78580 Perfusion only

CHEST

Myocardial Perfusion (Rest/Stress)

78452

Myocardial Amyloidosis SPECT/CT

78830

MUGA

78472

Thyroid Uptake Thyroid Uptake & Scan Thyroid Scan

78012 78014

•

78013

• • • • • • • • •

LifePoint Health Sensitive Information

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

• No Prep

• No Prep

Hospital

Hospital

Hospital

Hospital

• NPO after midnight for Day 1 only

Hospital Hospital

• No Prep

Hospital

NECK

Parathyroid

78070 (Planar) 78071 (SPECT) 78072

• • •

Parathyroid Adenoma Hypercalcemia Elevated PTH

• No Prep

•

Hyperthyroidism

• NPO 4 hours Prior to Exam

• • • • • • • • • • • • • •

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 Degenerative Disc Disease Back Pain Bone Surgery

• Light Breakfast

• • • •

Stress Fracture Low Back Pain Trauma Identifying the lymph node(s) that receive primary lymphatic drainage for surgery (Melanoma & Breast Cancers)

(SPECT/CT) I 131 Therapy Treatment Whole Body Bone Scan

3-Phase Bone Scan

78306

78315

BONE SPECT Bone

78320

SPECT/CT Bone

78830

Limited Bone Scan

78300

LYMPHATIC Lymphoscintigraphy

78195

LifePoint Health Sensitive Information

*Must have Elevated PTH and Hypercalemia*

• 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

Hospital

Hospital

Hospital

Hospital • No Prep

Hospital

BRAIN

Brain

•

Brain Death Study

LifePoint Health Sensitive Information

• No Prep

Hospital

CENTRAL SCHEDULING: 606-678-3545 ADVANCED-IMAGING ORDERING GUIDE PET 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.

2.

3.

4.

5.

6.

7.

Patient Name Patient DOB Procedure Diagnosis – Medical Necessity if required, please include actual symptoms in addition to ICD codes Physician signature List appropriate body part and contrast medium 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

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 LifePoint Health Sensitive Information

PET-CT: BODY PART Skull to MidThigh Whole Body

PROCEDURE PET/CT Skull Base to Mid-thigh PET/CT Whole Body

CPT CODE 78815

INDICATION(S) •

78816

•

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

LifePoint Health Sensitive Information

EXAM PREP/PREREQUISITES

Available at site

CENTRAL SCHEDULING: 606-678-3545 ADVANCED-IMAGING ORDERING GUIDE ULTRASOUND 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.

2.

3.

4.

5.

6.

7.

Patient Name Patient DOB Procedure Diagnosis – Medical Necessity if required, please include actual symptoms in addition to ICD codes Physician signature List appropriate body part and contrast medium 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

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 LifePoint Health Sensitive Information

Ultrasound BODY PART

PROCEDURE

CPT CODE

ABDOMEN COMPLETE Includes:

ABDOMEN

Pancreas Liver Gallbladder Bile Ducts Right and Left Kidneys Spleen Aorta (limited) IVC (limited Portal Vein

76700

INDICATION(S) • 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

LifePoint Health Sensitive Information

EXAM PREP/PREREQUISITES • 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 where available

Hospital Somerset IMC Mccreary

BODY PART

PROCEDURE

CPT CODE

ABDOMEN (RUQ) Includes:

ABDOMEN

Pancreas Liver Gallbladder Bile Ducts Right Kidney Aorta Limited IVC Limited Portal Vein

76705

INDICATION(S) • 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.

LifePoint Health Sensitive Information

EXAM PREP/PREREQUISITES • 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 where available

Hospital Somerset IMC Mccreary

BODY PART

PROCEDURE

CPT CODE

INDICATION(S)

76705

• Search for free or loculated peritoneal and/or retroperitoneal fluid • Soft tissue mass on front or back of abdomen • Suspected hernia

ABDOMEN LIMITED Includes: Abdomen and peritoneal cavity and Soft Tissue of the Abdomen

• 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

ABDOMEN

US APPENDIX

76705

• 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.

LifePoint Health Sensitive Information

EXAM PREP/PREREQUISITES • None

Sites where available

Hospital Somerset IMC Mccreary

• None

Hospital

BODY PART

PROCEDURE

CPT CODE

US LIVER WITH ELASTOGRAPHY Includes:

ABDOMEN

Pancreas Liver Gallbladder Bile Ducts Right Kidney Aorta Limited IVC Limited

76705 +

Aorta and Proximal Iliac Arteries

• Hepatic cirrhosis • Chronic viral hepatitis •Steatohepatitis •Fatty liver disease •Liver staging • *US of choice to evaluate hepatic fibrosis

EXAM PREP/PREREQUISITES • 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 where available

Hospital

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

US ABDOMINAL AORTA Includes:

INDICATION(S)

76706

• Palpable or pulsatile abdominal mass • Follow-up of a previously identified abdominal aortic aneurysm • Screening evaluation for abdominal aortic aneurysm

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• 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

CPT CODE

76770 Bilateral 76775 Unilateral

ABDOMEN

93975 Bilateral US RENAL ARTERY DOPPLER

93976 Unilateral

INDICATION(S) • 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

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EXAM PREP/PREREQUISITES • None

Sites where available

Hospital Somerset IMC Mccreary

• 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

BODY PART

PROCEDURE

ABDOMEN US SPLEEN

OB/GYN

US PELVIC NON OB

CPT CODE

INDICATION(S)

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

• Left upper quadrant pain • Left flank pain • Abnormality seen on another imaging study • Follow-up of known or suspected 76705 • Patient may take abnormality in the left upper medications with a quadrant. small amount of water.

• If the left upper quadrant area and both kidneys are desired, order US Abdomen Complete • Patient must have • Pelvic pain a full bladder.

• Patient should • Amenorrhea drink four 8-ounce • Menorrhagia glasses of water prior • Metrorrhagia 76856 to the exam. Patient • Menometrorrhagia TRANSABDOMINAL • Post-menopausal bleeding should be FINISHED + • Follow-up of previously detected drinking the water at 76830 least one hour abnormality TRANSVAGINAL before the exam.

• Further evaluation of pelvic • Patient should not abnormality detected on another void before the imaging study exam.

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

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Sites where available

Hospital Somerset IMC Mccreary

Hospital Somerset IMC Mccreary

BODY PART

OB/GYN

PROCEDURE

OB <14 WEEKS

CPT CODE

76801 TRANSABDOMINAL + 76817 TRANSVAGINAL + 76802 For Additional Gestation

INDICATION(S) • 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

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EXAM PREP/PREREQUISITES • 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

Hospital ER and Inpatient Only

BODY PART

PROCEDURE

CAROTID DOPPLER

CPT CODE

93880 Bilateral 93882 Unilateral

CEREBRO VASCULAR

INDICATION(S) •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

TEMPORAL ARTERY

76536

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

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EXAM PREP/PREREQUISITES • None

Sites where available

Hospital Somerset IMC Mccreary

• None

Hospital Only

BODY PART

PROCEDURE

UPPER EXTREMITIES Includes: Subclavian Axillary Brachial Radial and Ulnar

CPT CODE

93930 Bilateral 93931 Unilateral

ARTERIAL DOPPLER LOWER EXTREMITES Includes: Common Femoral Superficial Femoral Popliteal Posterior Tibial Anterior Tibial Dorsalis Pedis

93925 Bilateral 93926 Unilateral

INDICATION(S) • Decrease arm pressure • Cold fingers or toes (poor circulation) • Arm Numbness

EXAM PREP/PREREQUISITES • None

Hospital Somerset IMC Mccreary

• If wanting to evaluate for Thoracic Outlet Syndrome order SEGMENTAL PRESSURE UPPER EXTREMITY and specify for Thoracic Outlet Syndrome • Claudication/pain with walking • Decreased or absent pulses • Arthrosclerosis • Bruit •Numbness • Ulcer on foot or toe (s) •Discoloration of feet or legs

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Sites where available

• None

Hospital Somerset IMC Mccreary

BODY PART

PROCEDURE ANKLE BRACHIAL INDEX

ARTERIAL DOPPLER

Physiological Testing of Single level of the Ankle Posterial Tibial Dorsalis Pedis

CPT CODE

INDICATION(S)

93922

• Claudication/pain with walking • Decreased or absent pulses • Arthrosclerosis • Bruit •Numbness • Ulcer on foot or toe (s) •Discoloration of feet or legs • Diminished or Absent Pulses in Lower Extremity • Non Healing Leg ulcer • Arterial Disease

SEGMENTAL PRESSURE LOWER EXTREMITY Physiological Testing of 3 or More Levels Including Ankle Brachial Index Upper Thigh Lower Thigh And Upper Calf Great Toe

93923

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

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EXAM PREP/PREREQUISITES • None

Sites where available

Hospital

• None

Hospital

BODY PART

PROCEDURE

SEGMENTAL PRESSURE UPPER EXTREMITY

CPT CODE

93923

INDICATION(S) • Diminished or Absent Pulses in Arms • Arm Pain • Thoracic Outlet Syndrome • Suspect Arterial Disease

• Check patency or maturity of graft or fistula • Loss of Thrill • Swelling 93990

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

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Sites where available

Hospital

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

ARTERIAL DOPPLER

AV GRAFT/FISTULA

EXAM PREP/PREREQUISITES • None

• None

Hospital

BODY PART

PROCEDURE

LOWER EXTREMITES

CPT CODE

INDICATION(S)

93971 Unilateral

• DVT • Redness • Lower Extremity Swelling / Pain • Elevated D-Dimer •Pulmonary Embolism • Follow-up for patients with known DVT in leg(s)

93970 Bilateral

VENOUS DOPPLER

UPPER EXTREMITES

93971 Unilateral 93970 Bilateral

• 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 • 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

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EXAM PREP/PREREQUISITES • None

Sites where available

Hospital Somerset IMC Mccreary

• None

Hospital Somerset IMC Mccreary

BODY PART

PROCEDURE

LOWER EXTREMITY REFLUX/INSUFFIENCY

VENOUS DOPPLER

LOWER EXTREMITY VEIN MAPPING Includes: Greater Saphenous Lesser Saphenous UPPER EXTREMITY VENOUS VEIN MAPPING Includes: Basilic Vein Cephalic Vein

SOFT TISSUE AND SUPERFICIAL STRUCTURES

US CHEST

CPT CODE 93971 Unilateral 93970 Bilateral

93971 Unilateral 93970 Bilateral 93986 Unilateral 93985 Bilateral

76604

INDICATION(S) • Varicose Veins • Non-healing wounds • Edema • 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

EXAM PREP/PREREQUISITES • None

Hospital Somerset IMC

• None Hospital Somerset IMC

•Must Specify Right, Left or Bilateral • Preop planning for Dialysis Graft/Fistula Placement

• None Hospital Somerset IMC

•Must Specify Right, Left or Bilateral • Soft tissue mass on chest (excluding breast) or upper back • Pleural effusion • Order must identify location

LifePoint Health Sensitive Information

Sites where available

• None

Hospital Somerset IMC Mccreary

BODY PART

PROCEDURE

CPT CODE

INDICATION(S) • Soft tissue mass on head or neck – not thyroid related

SOFT TISSUE NECK

SOFT TISSUE AND SUPERFICIAL STRUCTURES

THYROID

US TESTICLES

US EXTREMITY LIMITED

76536

• Order must identify location

76536

•Thyroid Nodule •Hyperthyroidism •Hypothyroidism •Goiter

EXAM PREP/PREREQUISITES • None

• None

76870

• Scrotal pain • None • Testicular trauma • Palpable scrotal mass • Scrotal asymmetry, enlargement, or swelling • Undescended testicle(s

76882

• 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

LifePoint Health Sensitive Information

• None

Sites where available Hospital Somerset IMC Mccreary

Hospital Somerset IMC Mccreary

Hospital Somerset IMC Mccreary

BODY PART

SOFT TISSUE AND SUPERFICIAL STRUCTURES

PROCEDURE

CPT CODE

INDICATION(S) • Breast Mass • Breast Pain • Abnormal Mammogram

US BREAST

76641

PEDIATRIC ABDOMEN FOR PYLORIC STENOSIS

76705

INFANT HIPS (DYNAMIC)

76885

Pediatrics

INFANT SPINE AND CONTENTS

76800

EXAM 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

• Projectile Vomiting

NPO for 2 hours Bring bottle to feed during exam

•Developmental dysplasia of the hip (DDH) •Breech birth •Hip click •Family history of DDH

• None

•Sacral dimple •Spina bifida •Congenital anomalies of spinal cord •Injury to spine/cord, •Birth trauma

• None

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

Sites where available

Somerset IMC

Hospital

Hospital

Hospital

BODY PART

PROCEDURE

NEONATAL HEAD

ULTRASOUND GUIDED PARACENTESIS

CPT CODE

76506

49083

INDICATION(S) •Intracranial hemorrhage •Neonatal seizures •Enlarging head circumference •Hydrocephalus • Ascites

• Pleural effusion

ULTRASOUND GUIDED PROCEDURES

ULTRASOUND GUIDED THORACENTESIS

32555

EXAM PREP/PREREQUISITES • None

Hospital

•Please Coordinate with Ultrasound Department (606) 678-3177 •Will need to consult with Department if patient is on Anticoagulants.

•Need Labs drawn prior to Procedure (PT, PTT, INR, Platelet Count) • If wanting for Diagnostic Purposes need order for Diagnostic Testing of the Fluid

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Sites where available

Hospital

Hospital

BODY PART

PROCEDURE

CPT CODE

INDICATION(S) •Breast Mass

ASPIRATION/BIOPSY ULTRASOUND GUIDED BREAST BIOPSY

ULTRASOUND GUIDED PROCEDURES

ULTRASOUND GUIDED THYROID FINE NEEDLE ASPIRATION/BIOPSY

ULTRASOUND GUIDED BIOPSY/ASPIRATION

19083

EXAM PREP/PREREQUISITES •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 60100

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

76942

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

•Axillary Lymph Node •Groin Lymph Node •Parotid Gland •Neck Mass •Breast Cyst •Superficial Cyst

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Sites where available

Somerset IMC

Hospital

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 convenient date and time for your exam.

RADIOLOGY SERVICES SCHEDULING: PHONE: 606.678.3545 FAX: 606.678.3432

NEXT STEPS

Patients should receive a call within 48 hours after appointment to schedule their imaging services.

If you have not received a call to schedule an exam within 48 hours, please call 606.678.3545 between 7:30am and 5:00pm M-F.

For Offices: Radiology / Imaging Order Guide Scan the QR Code or use URL: https://tinyurl.com/22bu4ee2

LakeCumberlandHospital.com

Arrive for scheduled appointment with insurance cards and identification for registration.