MRI Non-Joint Extremity Questionnaire

Transcription

1 MRI n-joint Extremity Questionnaire INSTRUCTIONS FOR COMPLETING QUESTIONNAIRE: Answer all of the initial questions (Pages 1 and 2) Select the reason for imaging by answering question #6. Based on your answer to question #6, you will be directed to complete one other section of the questionnaire. Answer ONLY the initial questions and the ONE other section as directed based on your answer to question #6. Failure to answer mandatory questions in any part of the questionnaire may lead to technical denial regardless of other answers provided. Chart notes are not required for questionnaire based reviews Follow directions exactly. If the question says select one answer, only one is needed. Selecting more than one can lead to technical denial. Initial Questions 1. (Mandatory) This guideline based review will result in a RECOMMENDATION ONLY to Washington State Department of Labor and Industries. If the recommendation is to approve, PLEASE NOTE THAT services ARE NOT authorized until final determination is made by the Department. 2. (Mandatory) Select the side of the body for this imaging request Right Left Bilateral 3. (Mandatory) Select the body part for this imaging request (NOTE: If you are requesting a JOINT such as knee, elbow, shoulder, please use the MRI Upper Extremity or Lower Extremity questionnaire) Select One Thigh/Femur Lower Leg/Shin Humerus/Upper Arm Forearm 4. (Mandatory) Will you be submitting more than one request for complex imaging for this patient? (STOP: Do not complete the questionnaire. Full review is required for multiple requests. You must submit chart notes for review to avoid delays in final determinations) Continue to next question 5. (Mandatory) Has this patient had an MRI for this same illness/injury within the past 90 days? (STOP: Do not complete the questionnaire. Full review is required for repeat imaging within 90 days. You must submit chart notes for review to avoid delays in final determinations) Continue to next question Initial Questions Page 1 of 6 Questionnaire name: n-joint Extremity MRI Questionnaire Revised 1/1/2017

2 6. (Mandatory) Indicate the reason for imaging by selecting ONLY ONE of the following: Suspected Fracture Answer Section A only Palpable mass of the extremity Answer Section B only Osteomyelitis (known or suspected) Answer Section C only Suspected Abscess Answer Section D only Proceed to the appropriate section (based on your answer above) and answer the questions in ONLY that section. END of INITIAL QUESTIONS proceed to complete ONLY one other section Initial Questions MRI n-joint Extremity Questionnaire Page 2 of 6

3 MRI n-joint Extremity Questionnaire Section A Suspected Fracture (Mandatory) DISCLAIMER: I understand that the answers marked on this questionnaire must be supported by the medical records. 1. (Mandatory) What type of fracture is suspected? Select one Long bone fracture (e.g., femur, tibia, fibula, humerus) Stress fracture type of fracture Other Describe Fracture: 2. Is non-union of a fracture suspected? Select one 3. How long has it been since the initial injury? Select one Less than 12 weeks Between 12 weeks and 6 months Greater than 6 months 4. When was the most recent imaging for this injury done? Select one Only at the time of the initial injury Within the past 2 weeks Greater than 2 weeks but less than 6 weeks ago Greater than 6 weeks ago 5. What kind of imaging was done most recently? Select one Plain film x-rays Bone scan CT Scan MRI END SECTION A Suspected Fracture Section A Page 3 of 6

4 MRI n-joint Extremity Questionnaire Section B Palpable Mass of the Extremity (Mandatory) DISCLAIMER: I understand that the answers marked on this questionnaire must be supported by the medical records. 1. Does the patient have any of the following? Select all that apply Evidence of infection by physical exam Recent trauma by history Palpable mass in the area for which imaging is being requested rmal exam 2. Have plain film x-rays been done? Select one 3. Did the x-rays provide information as to the etiology of the mass? Select one Interpretation pending X-rays not done 6. (Mandatory) Are there recent x-rays which indicate osteomyelitis? Select one Date of x-rays X-ray interpretation pending Date of x-rays or x-rays not done END SECTION B Palpable Mass of the Extremity Section B Page 4 of 6

5 MRI n-joint Extremity Questionnaire Section C Osteomyelitis Known or Suspected (Mandatory) DISCLAIMER: I understand that the answers marked on this questionnaire must be supported by the medical records. 1. Select the clinical indication for the requested imaging. Select one Suspected osteomyelitis Osteomyelitis diagnosed by x-ray, further imaging needed for treatment or preoperative planning Continued symptoms or findings after treatment 2. Is the patient having pain at the site? 3. Does the patient have any of the following findings? Select all that apply Sedimentation rate greater than 30mm/hr Temperature greater than 100.4F (or 38.0C) WBC greater than normal Positive blood cultures C-reactive protein greater than normal ne of the above END SECTION C Osteomyelitis = Known or Suspected Section C Page 5 of 6

6 MRI n-joint Extremity Questionnaire Section D Suspected Abscess (Mandatory) DISCLAIMER: I understand that the answers marked on this questionnaire must be supported by the medical records. 1. Does the patient have any of the following finding on physical exam? Select all that apply Erythema (redness) or swelling at the site Palpable mass Pain at the site rmal exam 2. Does the patient have any of the following findings? Select all that apply Sedimentation rate greater than 30mm/hr Temperature greater than 100.4F (or 38.0C) WBC greater than normal Positive blood cultures C-reactive protein greater than normal ne of the above 3. What kind of imaging was done most recently? Select one Plain film x-rays Bone scan CT scan MRI ne END SECTION D Suspected Abscess Section D Page 6 of 6