CT Scan Reference Guide

Transcription

1 Diagnostic Imaging A Department of Rutland Regional Medical Center CT Scan Reference Guide 10/01/2017 Safety Questions for Exams with IV Contrast...Page 3 CPT Code Scan Ranges: Head...Pages 4-5 Neck/Spine...Pages 6-7 Chest...Pages 8-9 Abdomen and Pelvis...Pages Extremities...Pages Angiography...Pages CT Referral/Order Form*...Pages 16 *The CT Referral/Order Form (#4809) may be found online at

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3 Diagnostic Imaging A Department of Rutland Regional Medical Center Safety Questions for Exams with IV Contrast Is the patient allergic to CT contrast or x-ray dye?... Yes No If yes, please describe: Are pre-medications ordered?... Yes No LAB: Creatinine ordered if patient over 60 and/or diabetic?... Yes No GFR result: If GFR below 30 and Creatinine above 1.8, consult Creatinine result: with Radiologist and place note on order. Is the patient pregnant?... Yes No If yes, please consult with Radiologist Is Weight charted for today s visit?... Yes No Note: IV contrast is dosed by weight: Does the patient have a removable insulin pump, monitor or chemo pump?... Yes No Note: All removable pumps must be removed prior to CT Scan. Venous Access: Does the patient have a power injectable venous access?... Yes No (port, midline, PICC)? Does the patient require any special accommodations for the exam?... Yes No Lift needed Difficulty hearing Need caregiver Requires extra time for exam Difficulty lying flat on back Traveling from facility: Other (describe): Page 3

4 CPT Code Scan Ranges Head 70450, 70460, , , Page 4

5 CPT Code Acceptable S/S Procedure to Pre-Cert o Trauma/MVA head lac o Headaches worst of life o CVA, Stroke o Bleed, Hemorrhage o Seizure o Unexplained Memory Loss, Confusion o Vertigo, Dizziness o Shunt Check o Hydrocephalus CT Head, Brain Head o Metastatic Staging o Mass/ Tumor o Infection o Headache w. Associated Neurologic Signs CT Head, Brain CTV o Sagittal Sinus thrombosis o Venous thrombosis * 100cc 30 sec delay CT Brain o Melanoma o HIV o Toxoplasmosis CT Head, Brain Without and With contrast o Trauma/Right or Left o Fracture/Right or Left o Foreign Body CT Orbit o Hearing Loss, Conductive o Cholesteatoma o Mastoiditis o Trauma * For sensory neuro hearing loss, order MRI with contrast* CT Inner Ears, Temporal Bones o Pseudo Tumor o Mass o Infection/Cellulitis o Abscess CT Orbit o Sinusitis o Nasal Polyp CT Sinus o Trauma o Fracture CT Facial Bones o Infection o Cellulitis o Mass CT Facial Bones Page 5

6 CPT Code Scan Ranges Neck/Spine 70490, 70491, 70492, Page 6

7 CPT Code Acceptable S/S Procedure to Pre-Cert o Mass o Infection o Cancer Workups o Soft Tissue o Parotid Mass o Vocal Chord Paralysis o Voice Changes CT Neck * Only order if elevated creatinine o Mass o Infection o Cancer Workups o Soft Tissue o Parotid Mass o Vocal Chord Paralysis o Voice Changes CT Neck Neck/Spine * If elevated creatinine, order o Infection of Submandibular Gland o Infection of Parotid Gland o Parotid Stone / Submandibular Stone CT Soft Tissue Neck Without and o Trauma, Fracture, Fusion o Assess Bone Degenerative Changes * MRI recommended for disc herniation, mets, infection CT Cervical Spine o Trauma, Fracture, Fusion o Assess Bone Degenerative Changes * MRI recommended for disc herniation, mets, infection CT Thoracic Spine o Trauma, Fracture, Fusion o Assess Bone Degenerative Changes * MRI recommended for disc herniation, mets, infection CT Lumbar Spine Page 7

8 CPT Code Scan Ranges Chest 71250, 71260, Page 8

9 CPT Code Acceptable S/S Procedure to Pre-Cert o Renal Failure Patients CT Chest High Resolution o Interstitial Disease o Fibrosis o COPD o Hemoptysis o Bronchiectasis o Sarcoidosis o Pleural Plaques o Asbestos CT Chest * Specialist ordering o Cough o Pneumonia o Lung CA o Esophageal CA o Lymphoma o Lung Nodule o Mass o Tracheal Stenosis o Chest Wall Mass CT Chest Chest PE o Chest Pain/ Dyspnea o Tachypnea o Shortness of Breath o + D Dimer o Pulmonary Hypertension (PA HTN) CT Chest PE CTV o SVC Thrombosis * 100cc contrast 18G IV 120 second delay CT Chest o Empyema CT Chest Without and Page 9

10 CPT Code Scan Ranges Abdomen & Pelvis 74150, 74160, , 74177, , Page 10

11 CPT Code o Non-Union Fracture Cystogram Enterography CTV o Arthritis o Cancer Staging o Mass o Cysts o Infection o Abscess o Bone Infection o Leakage o Colovesical Fistula o Bladder perforation Acceptable S/S o F/U for patients with renal cell carcinoma in renal failure * MRI recommended * Please list quadrant: RUQ, LUQ o Epigastric Pain o Pseudocyst o Pancreatitis o Adrenal Mass No Oral Prep o Abnormal Ultrasound o Renal Mass No Oral Prep o Liver Hemangioma (MRI preferred) o Hepatitis, Cirrhosis No Oral Prep o Flank Pain, Stone (Stone Study) * Please list a side: Right or Left* Please list quadrant: RUQ, LUQ o Crohn's, Ulcerative Colitis, IBD o Diverticulitis o Abscess o Mass o Hernia (i.e., umbilical, inguinal) o Kidney Cyst vs Mass o Melanoma o Carcinoid o Crohn's Disease, Inflammatory Bowel Disease o GI Bleed o Suspected Partial SBO (Small Bowel Obstruction) o Small Bowel Masses o Celiac Disease * MRI Recommended o Venous Thrombosisis o IVC Clot * 150cc contrast 4-5cc per sec 120 second delay o T-Cell Carcinoma of Kidney and/or Bladder o Defects/Bladder Leakage o Painless hematuria * Specialist ordering Procedure to Pre- Cert CT Pelvis CT Pelvis CT Pelvis CT Abdomen CT Abdomen CT Abdomen Without and CT Abdomen and Pelvis CT Abdomen and Pelvis CT Abdomen and Pelvis CT Abdomen and Pelvis CT Abdomen and Pelvis With and Abdomen & Pelvis Page 11

12 CPT Code Scan Ranges Extremities , , Page 12

13 CPT Code Acceptable S/S Procedure to Pre-Cert o Fracture o Non-Union / Malunion CT Chest (for SC joints) o Fracture o Fusion CT Upper Extremity (includes AC joints) o Non- Union / Malunion o Infection o Tumor / Mass / Cancer / Mets CT Upper Extremity CTV o Venous thrombosis o Infection/abscess o Lymphedema * 150cc contrast 18G unaffected arm, 120 second delay upper, and 180 second delay lower CT Upper Extremity o Fracture o Fusion o Non- Union/ Malunion o Arthritis o Patello Femoral Malalignment (Bilateral) o Anteversion/ Malrotation (Bilateral) CT Lower Extremity o Infection o Tumor/ Mass/ Cancer/ Mets CT Lower Extremity CTV o Venous thrombosis o Infection / abscess o Lymphedema * 150cc contrast 18G unaffected arm, 120 second delay upper, and 180 second delay lower CT Lower Extremity Extremities Page 13

14 CPT Code Scan Ranges Angiography , Page 14

15 CPT Code Acceptable S/S Procedure to Pre-Cert o TIA, CVA o Vascular Malformation o Aneurysm o AVM (Arterio/ Venous Malformation) CTA Brain (C2-vertex) o Carotid Stenosis o Bruit o TIA, CVA o Carotid Dissection CTA Carotid (carina-sella turcica) o Thoracic Aortic Dissection o Thoracic Aortic Aneurysm o Coarctation o Aortic Root Dilation CTA Chest o Renal artery aneurysm o Renal artery stenosis o Renal artery stent leak CTA Abdomen (diaphragm-top of pelvis) o Trauma o Arterial Stenosis * 18G IV, unaffected arm, 180cc contrast MAX volume for 24 hours CTA Upper Extremity (arch-fingertips) o Abdominal Aortic Dissection o Mesenteric Ischemia o Bowel Ischemia o Stent Obstruction CTA Abdomen and Pelvis * Thoracic Abdominal Aortic Dissection requires both codes and o Peripheral Artery Disease (PAD) o Ischemia to lower extremities o Arterial stenosis * 18G IV, 180cc contrast MAX volume for 24 hours CTA Aorta-bifem (diaphragm-toes) o Peripheral Artery Disease o Ischemia to Lower Extremity o Known Arterial Stenosis with New Stent * 18G IV, 180cc contrast MAX volume for 24 hours CTA Pelvis and CTA Lower Extremity (iliac crest-toes) CTA Page 15

16 CT Referral/Order Form Last Name: First Name: DOB: MRN#: Patient Phone #: Ordering Provider: Weight: Appointment: Clinical History/Diagnosis: Provider Signature: Date: Time: STANDARD MULTI-PHASE CT ANGIOGRAPHY CHEST CTA Chest-Thoracic Chest with Abdomen/Pelvis with (Painless) Hematuria phase Abdomen/Pelvis Liver 3 phase without (specialist) Renal Stone Pancreas 3 phase (painful) without (specialist) Abdomen with Adrenal 3 phase (specialist) abd w/wo Abdomen without- Mesenteric Ischemia (arterial/venous) Enterography with contrast CTA AAA-Abd/Pelvis PE Chest with CTA Renal Arteries Chest without CTA Pelvis Chest with and w/out (specialist) CTA Aorta-bifem (aorta-toes) CTA Lower Ext (Hip-toes RT or LT) Chest w/out and with PE (specialist) Chest Low Dose Lung CA- G0297 (specialist) BRAIN/SPINE NECK/FACE CTA/UPPER EXTREMITY LOWER EXTREMITY Brain without Temporal Bone (IAC) CTA Brain-COW Ankle without Brain with Face without (sinus) CTA Neck-Carotid Ankle with Brain w/wo Face without (face) CTA Upper Extremity- Foot without C-spine without Face with contrast Foot with T-spine without Orbit without Elbow without Hip without L-spine without Orbit with contrast Elbow with Hip with Recon C-spine Neck Soft Tissue w/ Shoulder without Knee without (trauma) Recon T-spine Neck Soft Tissue w/wo Shoulder with Knee with (trauma) (stone) Recon L-spine Neck without Hand without Pelvis without (trauma) (renal compromised) Hand with Pelvis with Wrist without Wrist with-7320 Form # 4809 Created 07/2017 *1405* Page 1 of 2 Patient Label CT Referral/Order Form Safety Questions for Exams with IV Contrast: Yes No N/A Is the patient allergic to CT contrast or x-ray dye? If yes please describe. Is the patient over 60 or diabetic? If yes, please order a creatinine to be completed 48 hours prior to CT. Does the patient have a power injectable venous access (port, midline, PICC)? Imaging Guided Procedures: (only to be filled out if requesting these procedures below) Drainage: CT guided fluid collection drainage by cath peri or retroperitoneal Biopsy: CT guided needle placement Clinical History: Location/site/nodule/lesion/organ: Outside Imaging? Y N If Yes: date, hospital and location of images. If procedure to be performed same day of request. Is patient NPO? Y N Is patient diabetic? Y N Current Weight(used for patient radiation dose) Is patient on anticoagulation/antiplatelet medications (including aspirin)? Y N last dose: Recent Labs: PTT INR Platelets Date: Labs required? Y N If YES specify specimen type: Nursing Anxiolysis: Y N Submit recent H & P before procedure (H&P should be current within 30 days) Did you discuss with a Radiologist? Yes No Write the name of the Radiologist. Office Use: Notes: Prior Auth # CDS # Form # 4809 Created 07/2017 Page 2 of 2 Patient Label