CT & PET/CT Scheduling Guidelines LVHN (5846) Fax:
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1 CHEST CT (x-ray is almost always required) Nodules Abnormal cxr, ancillary finding, f/u study WO No HRCT: Interstitial lung disease, i.e. asbestosis, sarcoidosis, TB SOBOE, dry cough, Abnormal PFT WO No Suspected pulmonary embolus / Follow-up PE resolution Chest pain, cough, HR, SOB, dyspnea, Hemoptysis W No Persistent unresolved cough of at least 2 weeks w normal x ray Cough W No Unresolved pneumonia documented after antibiotics (4 weeks) Chest pain, cough W No Suspected/known tumor/mass evaluation, staging, restaging, Abnormal Weight loss, abnormal tumor marker, pain, f/u W No chest xray Unexplained abnormalities on chest x ray Abnormal cxr, ancillary finding, f/u study W No Aortic Root Dilation SOB, fatigue, weakness, fainting, Abn chest xray, FU eval W No Thoracic aneurysm, Other cardiac indications Chest pain, SOB WO&W No G0297 CT LUNG SCREENING Asymptomatic, meets screening requirements WO No ABDOMEN CT (Superior to diaphragm to the level of the iliac bifurcation) CT & PET/CT Scheduling Guidelines LVHN (5846) Fax: Key: W - With; WO - Without; WO&W - Without and With CT & PET/CT scanners have low dose software which reduces body radiation by 40% and head dose by 30%. Per ICD-10 requirements, please include as much specificity as possible when documenting the reason for the exam, including signs and symptoms Adrenal mass Adrenal mass unknown WO&W Yes Adenoma (known) Adrenal mass diagnosis is established WO No Epigastric mass, GI Bleed Upper abdominal pain, Heartburn, GERD W Yes Cirrhosis Vomiting blood, jaundice, confusion, incr. LFTs WO&W Yes Renal Mass; Abn ancillary findings; Abn U/S Blood in urine, LBP, unexplained weight loss WO&W Yes Hemangioma; ONLY if MRI cannot be performed Abnormal LFTs, F/U liver mass WO&W Yes Patient has history of partial Nephrectomy-evaluating kidneys Renal CA, polycystic kidney disease WO&W Yes
2 PELVIS CT (Iliac crests to sympysis pubis) Trauma Pain WO No F/U Fracture Pain WO No Abnormal xray Pain WO No Pelvic mass, Inguinal hernia Pain, Palpable mass W Yes ABDOMEN / PELVIS CT (Superior to diaphragm through the symphysis-pubis) Suspected retroperitoneal hematoma/hemorrhage Abdominal pain; hypotension, anemia WO No Suspected stone in kidneys, bladder and ureters Abdominal pain; flank pain, hematuria WO No Clinical signs suggestive of diverticulitis, colitis, Crohn's, IBD Abdominal pain, diarrhea W Yes Clinical signs suggestive of appendicitis Abdominal pain, nausea, vomiting, fever W Yes Lymphadenopathy, assessment of lymphomas Swollen enlarged lymph nodes W Yes F/U of complication/medical treatment of abdominal/pelvic (bowel obstruction) Abdominal pain, distension, vomiting, nausea W Yes Pancreatitis, suspected necrosis or pseudocyst Severe abdominal pain, nausea, vomiting WO&W Yes Hematuria Blood in urine WO&W Yes Hydronephrosis Elevated creatinine,electrolyte imbalance WO&W Yes Abdominal Aortic Aneurysm (Stent Graph protocol) Abdominal pain, rapid HR, abdominal rigidity WO&W No UROGRAM-NO oral-please indicate on the script History of kidney stones, flank pain, hematuria WO&W No DIAGNOSTIC VIRTUAL COLONOSCOPY Incomplete colonoscopy WO Yes EXTREMITIES CT Upper: Position of known fracture Pain and swelling around area, loss of function WO No Joint Arthritis, pain WO No Arthrogram Pain, decreasing ROM W No Lower: Position of known fracture Pain and swelling around area, loss of function WO No Joint Pain WO No Arthrogram Pain, "clicking" W No Leg Length Studies: Leg length discrepancy Scoliosis, One leg is shorter, gait problems, pain in back/legs WO No Cellulitis Swelling, Redness W No
3 SPINE CT (Due to radiation exposure, levels must be indicated) Cervical C 1 - C Fractures Pain, trauma, fall, bruising and swelling WO No Scoliosis Curving spine, shoulders/hips are uneven, LBP WO No Tumor: if MRI is contraindicated Pain, weight loss, fatigue W No Tumor: if MRI was recently completed eval for bone Pain, weight loss, fatigue WO No Post-op Studies Pain, f/u surgical eval WO No Thoracic T 1 - T Fractures Pain, trauma, fall, bruising and swelling WO No Scoliosis Curving spine, shoulders/hips are uneven, LBP WO No Tumor: if MRI is contraindicated Pain, weight loss, fatigue W No Tumor: if MRI was recently completed eval for bone Pain, weight loss, fatigue WO No Post-op Studies Pain, f/u surgical eval WO No Lumbar L 1 - S Fractures Pain, trauma, fall, bruising and swelling WO No Scoliosis Curving spine, shoulders/hips are uneven, LBP WO No Tumor: if MRI is contraindicated Pain, weight loss, fatigue W No Tumor: if MRI was recently completed eval for bone Pain, weight loss, fatigue WO No Post-op Studies Pain, f/u surgical eval WO No BRAIN / HEAD CT Headache; new, sudden, severe Headache WO No Stroke or TIA, ORDER MRI for ACUTE SYMPTOMS Numbness, weakness, dizziness, trouble speaking WO No Visual Disturbance As stated WO No Hydrocephalus i.e. shunt revision Headache, vomiting, blurred vision WO No Trauma for depressed fracture Pain at site WO No Headaches, Mass (MR is contraindicated) Headaches W No Primary or metastatic tumor, new or follow up (MR is contraindicated) Blurred vision, chronic headaches, R/O mets WO&W No
4 ORBITS CT Trauma Facial/eye pain WO No No Trauma; specific localized facial pain Localized orbital pain, swelling, inflamation W No SINUS CT (When scheduling, please provide your image guided protocol: Brain Lab, Landmark, Stryker) Preoperative Congestion, poplyps, CBS WO No Sinusitis; chronic, failed several courses of antibiotic therapy Facial pain, congestion WO No Osteomyelitis Pain in infected bone, fever, chills W No Sinus-nasal tumor Nasal congestion, pain above or below eyes W No NECK CT (Soft tissue) (Imaging does NOT include vetebral structures - see Cervical Spine) R/O Calculi Pain, dry mouth, bad taste in mouth, swelling WO No Lymphadenopathy Swelling of lymph nodes W No Parotids Dysphagia, vocal changes, aspiration W No Vocal cord lesion, hoarseness, paralysis Hoarseness, breathy sounding W No Salivary gland stones Pain, swelling WO&W No 3D STAND ALONE RECONSTRUCTIONS D Reconstruction, all body parts HEAD CTA Aneurysm Double or loss of vision, headache, eye pain WO&W No NECK CTA Suspected Carotid Stenosis Weakness, numbness, Confusion, dizziness WO&W No CORONARY CTA (CCTA) Equivocal stress test, abnormal imaging Chest pain, cough, SOB, dyspnea WO&W No Pulmonary Vein Stenosis-Pre/Post Ablation SOB, fatigue, rapid heartbeat, fainting, A-fib WO&W No
5 CORONARY CALCIUM SCORING Stand alone calcium scoring Hypercholesterolemia WO No CHEST CTA Evaluation of thoracic aortic aneurysm Most have no symptoms until the aneurysm leaks WO&W No CHEST / ABDOMEN / PELVIS CTA and Dissection Stabbing or sharp chest pain WO&W No ABDOMEN CTA Renal hypertension Blood in urine, hypertension, renal insufficiency WO&W No Renal Artery Stenosis Hypertension WO&W No PELVIS CTA DIEP Trans Flap Preoperative for arterial supply W No ABDOMEN / PELVIS CTA Abdominal Aortic Aneurysm Constant chest/abd & back pain; pulsatile mass WO&W No Iliac Aneurysm Lower abdominal pain, low back pain or groin pain WO&W No Mesenteric Ischemia Abdominal pain WO&W No ABDOMINAL AORTA with RUNOFFS CTA Lower extremity ischemia, Claudication, Foot ulcer Absent pulse in foot, cramping pain, rest pain WO&W No EXTREMITIES CTA Lower extremity ischemia Evaluate swelling, fistula, graft W No Upper extremity ischemia Evaluate swelling, fistula, graft W No
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73725x2 MRA Pelvis Runoff (to ankle) CTA Abdomen with & without CTA Cardiac Brain without 70551
CT CT Myelogram MRI Abdomen without 74150 Cervical 62302 Abdomen / MRCP 74181 Abdomen with 74160 Thoracic 62303 Abdomen / MRCP with & without 74183 Abdomen with & without 74170 Lumbar 62304 Abdomen / Pelvis
AIM 2014 CPT Radiology & Cardiac Codes Requiring Review
AIM 2014 CPT Radiology & Cardiac Codes Requiring Review Modality Body Part CT Head 1 70480 CT orbit, sella or posterior fossa; w/o contrast 1 CT Head 1 70481 CT orbit, sella or posterior fossa; with CT
PLAS/RECON SURGERY PATIENT HEALTH HISTORY
PLAS/RECON SURGERY PATIENT HEALTH HISTORY Chief Complaint - Please describe the problem that brings you into the office today: Allergies 1. Do you have any allergies? if so, please list To Medications?
City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
Inner Balance Acupuncture
Patient Information Inner Balance Acupuncture 274 Southland Drive, Suite 101, Lexington, KY 40503 859-595-2164 www.acupunctureky.com Name: Today s date: Age: Male Female Marital status: Date of Birth:
LECOM Health Ophthalmology
Patient Name: Date of Birth: New Patient Questionnaire Your answers will be used by your healthcare provider get an accurate history of your medical conditions and ocular concerns. If you are uncomfortable
PATIENT INFORMATION Last Name: First Name: Middle: Date of Birth: EMERGENCY CONTACT INFORMATION PRIMARY INSURANCE INFORMATION
PATIENT INFORMATION Last Name: First Name: Middle: Date of Birth: Gender: SSN: Race: Marital Status: Address Line: City: State: Zip Code: Home Phone: Work Phone: Email Address: Cell Phone: Primary Care
Providence Medical Group
Providence Medical Group To our valued patients: In order to provide you with our full attention when you come for an appointment, we would like to ask you to be aware of the following guidelines. Insurance
Patient Name Date of Birth Age. Other phone ( ) . Other
GASTROINTESTINAL & MINIMALLY INVASIVE SURGERY HEALTH HISTORY QUESTIONNAIRE Date Patient Name _ Date of Birth Age Daytime phone ( ) Other phone ( ) Email How did you hear about us? My doctor Yellow pages
MEDICAL DATA SHEET For Patients 18 years of age and older
MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other
The Rehabilitation Institute Cancer Rehabilitation
DO NOT DRILL The Rehabilitation Institute Cancer Rehabilitation STAR Patient Intake Form Your Name: Date: Your date of birth: Age: Who referred you (if a healthcare provider, please provide address)? Doctors
2012 CPT Radiology Codes Requiring Review Blue Cross and Blue Shield of Louisiana
2012 CPT Radiology Codes Requiring Review Blue Cross and Blue Shield of Louisiana CT Head 70480 CT orbit, sella or posterior fossa; w/o CT Head 70481 CT orbit, sella or posterior fossa; with CT Head 70482
JOHN MICHAEL ROACH, MD
GASTROENTEROLOGY JOHN MICHAEL ROACH, MD 520 N. 4 TH AVE. PASCO, WA 99301 Phone: (509) 546-8383 Name: Date of Birth: First Middle (full) Last m/d/yr Primary care provider: Referring physician: Local Pharmacy:
Broward Oncology Associates, P.A. PATIENT INFORMATION
NAME: BIRTHDATE: AGE: LOCAL ADDRESS (Street city state zip): HOME TELEPHONE# CELL # SOCIAL SECURITY #: - - SEX MARITAL STATUS WHAT IS YOUR HT? WHAT IS YOUR WT? EMPLOYER WORK# SPOUSE'S NAME SPOUSE'S EMPLOYER
Morris Medical Center, P.A.
Today s date: Name : Age Date of Birth Height Weight Right hand dominant Left hand dominant Sex: Male Female Chief Complaints; Current Pain Level (0 ~ 10) 0 1 2 3 4 5 6 7 8 9 10 Average Pain Level (0 ~