CT & PET/CT Scheduling Guidelines LVHN (5846) Fax:

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www.lvhn.org CHEST CT (x-ray is almost always required) 71250 Nodules Abnormal cxr, ancillary finding, f/u study WO No 71250 HRCT: Interstitial lung disease, i.e. asbestosis, sarcoidosis, TB SOBOE, dry cough, Abnormal PFT WO No 71260 Suspected pulmonary embolus / Follow-up PE resolution Chest pain, cough, HR, SOB, dyspnea, Hemoptysis W No 71260 Persistent unresolved cough of at least 2 weeks w normal x ray Cough W No 71260 Unresolved pneumonia documented after antibiotics (4 weeks) Chest pain, cough W No Suspected/known tumor/mass evaluation, staging, restaging, Abnormal 71260 Weight loss, abnormal tumor marker, pain, f/u W No chest xray 71260 Unexplained abnormalities on chest x ray Abnormal cxr, ancillary finding, f/u study W No 71260 Aortic Root Dilation SOB, fatigue, weakness, fainting, Abn chest xray, FU eval W No 71270 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 888.402.LVHN (5846) Fax: 484.884.1909 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. 74170 Adrenal mass Adrenal mass unknown WO&W Yes 74150 Adenoma (known) Adrenal mass diagnosis is established WO No 74160 Epigastric mass, GI Bleed Upper abdominal pain, Heartburn, GERD W Yes 74170 Cirrhosis Vomiting blood, jaundice, confusion, incr. LFTs WO&W Yes 74170 Renal Mass; Abn ancillary findings; Abn U/S Blood in urine, LBP, unexplained weight loss WO&W Yes 74170 Hemangioma; ONLY if MRI cannot be performed Abnormal LFTs, F/U liver mass WO&W Yes 74170 Patient has history of partial Nephrectomy-evaluating kidneys Renal CA, polycystic kidney disease WO&W Yes

PELVIS CT (Iliac crests to sympysis pubis) 72192 Trauma Pain WO No 72192 F/U Fracture Pain WO No 72192 Abnormal xray Pain WO No 72193 Pelvic mass, Inguinal hernia Pain, Palpable mass W Yes ABDOMEN / PELVIS CT (Superior to diaphragm through the symphysis-pubis) 74176 Suspected retroperitoneal hematoma/hemorrhage Abdominal pain; hypotension, anemia WO No 74176 Suspected stone in kidneys, bladder and ureters Abdominal pain; flank pain, hematuria WO No 74177 Clinical signs suggestive of diverticulitis, colitis, Crohn's, IBD Abdominal pain, diarrhea W Yes 74177 Clinical signs suggestive of appendicitis Abdominal pain, nausea, vomiting, fever W Yes 74177 Lymphadenopathy, assessment of lymphomas Swollen enlarged lymph nodes W Yes 74177 F/U of complication/medical treatment of abdominal/pelvic (bowel obstruction) Abdominal pain, distension, vomiting, nausea W Yes 74178 Pancreatitis, suspected necrosis or pseudocyst Severe abdominal pain, nausea, vomiting WO&W Yes 74178 Hematuria Blood in urine WO&W Yes 74178 Hydronephrosis Elevated creatinine,electrolyte imbalance WO&W Yes 74178 Abdominal Aortic Aneurysm (Stent Graph protocol) Abdominal pain, rapid HR, abdominal rigidity WO&W No 74178 UROGRAM-NO oral-please indicate on the script History of kidney stones, flank pain, hematuria WO&W No 74261 DIAGNOSTIC VIRTUAL COLONOSCOPY Incomplete colonoscopy WO Yes EXTREMITIES CT Upper: 73200 Position of known fracture Pain and swelling around area, loss of function WO No 73200 Joint Arthritis, pain WO No 73201 Arthrogram Pain, decreasing ROM W No Lower: 73700 Position of known fracture Pain and swelling around area, loss of function WO No 73700 Joint Pain WO No 73701 Arthrogram Pain, "clicking" W No 77073 Leg Length Studies: Leg length discrepancy Scoliosis, One leg is shorter, gait problems, pain in back/legs WO No 73701 Cellulitis Swelling, Redness W No

SPINE CT (Due to radiation exposure, levels must be indicated) Cervical C 1 - C 7 72125 Fractures Pain, trauma, fall, bruising and swelling WO No 72125 Scoliosis Curving spine, shoulders/hips are uneven, LBP WO No 72126 Tumor: if MRI is contraindicated Pain, weight loss, fatigue W No 72125 Tumor: if MRI was recently completed eval for bone Pain, weight loss, fatigue WO No 72125 Post-op Studies Pain, f/u surgical eval WO No Thoracic T 1 - T 12 72128 Fractures Pain, trauma, fall, bruising and swelling WO No 72128 Scoliosis Curving spine, shoulders/hips are uneven, LBP WO No 72129 Tumor: if MRI is contraindicated Pain, weight loss, fatigue W No 72128 Tumor: if MRI was recently completed eval for bone Pain, weight loss, fatigue WO No 72128 Post-op Studies Pain, f/u surgical eval WO No Lumbar L 1 - S 1 72131 Fractures Pain, trauma, fall, bruising and swelling WO No 72131 Scoliosis Curving spine, shoulders/hips are uneven, LBP WO No 72132 Tumor: if MRI is contraindicated Pain, weight loss, fatigue W No 72131 Tumor: if MRI was recently completed eval for bone Pain, weight loss, fatigue WO No 72131 Post-op Studies Pain, f/u surgical eval WO No BRAIN / HEAD CT 70450 Headache; new, sudden, severe Headache WO No 70450 Stroke or TIA, ORDER MRI for ACUTE SYMPTOMS Numbness, weakness, dizziness, trouble speaking WO No 70450 Visual Disturbance As stated WO No 70450 Hydrocephalus i.e. shunt revision Headache, vomiting, blurred vision WO No 70450 Trauma for depressed fracture Pain at site WO No 70460 Headaches, Mass (MR is contraindicated) Headaches W No 70470 Primary or metastatic tumor, new or follow up (MR is contraindicated) Blurred vision, chronic headaches, R/O mets WO&W No

ORBITS CT 70480 Trauma Facial/eye pain WO No 70481 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) 70486 Preoperative Congestion, poplyps, CBS WO No 70486 Sinusitis; chronic, failed several courses of antibiotic therapy Facial pain, congestion WO No 70487 Osteomyelitis Pain in infected bone, fever, chills W No 70487 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) 70490 R/O Calculi Pain, dry mouth, bad taste in mouth, swelling WO No 70491 Lymphadenopathy Swelling of lymph nodes W No 70491 Parotids Dysphagia, vocal changes, aspiration W No 70491 Vocal cord lesion, hoarseness, paralysis Hoarseness, breathy sounding W No 70492 Salivary gland stones Pain, swelling WO&W No 3D STAND ALONE RECONSTRUCTIONS 76377 3D Reconstruction, all body parts HEAD CTA 70496 Aneurysm Double or loss of vision, headache, eye pain WO&W No NECK CTA 70498 Suspected Carotid Stenosis Weakness, numbness, Confusion, dizziness WO&W No CORONARY CTA (CCTA) 75574 Equivocal stress test, abnormal imaging Chest pain, cough, SOB, dyspnea WO&W No 75572 Pulmonary Vein Stenosis-Pre/Post Ablation SOB, fatigue, rapid heartbeat, fainting, A-fib WO&W No

CORONARY CALCIUM SCORING 75571 Stand alone calcium scoring Hypercholesterolemia WO No CHEST CTA 71275 Evaluation of thoracic aortic aneurysm Most have no symptoms until the aneurysm leaks WO&W No CHEST / ABDOMEN / PELVIS CTA 71275 and 74174 Dissection Stabbing or sharp chest pain WO&W No ABDOMEN CTA 74175 Renal hypertension Blood in urine, hypertension, renal insufficiency WO&W No 74175 Renal Artery Stenosis Hypertension WO&W No PELVIS CTA 72191 DIEP Trans Flap Preoperative for arterial supply W No ABDOMEN / PELVIS CTA 74174 Abdominal Aortic Aneurysm Constant chest/abd & back pain; pulsatile mass WO&W No 74174 Iliac Aneurysm Lower abdominal pain, low back pain or groin pain WO&W No 74174 Mesenteric Ischemia Abdominal pain WO&W No ABDOMINAL AORTA with RUNOFFS CTA 75635 Lower extremity ischemia, Claudication, Foot ulcer Absent pulse in foot, cramping pain, rest pain WO&W No EXTREMITIES CTA 73706 Lower extremity ischemia Evaluate swelling, fistula, graft W No 73206 Upper extremity ischemia Evaluate swelling, fistula, graft W No

PET/CT 78815 Skull Base to Mid Thigh - Breast, Cervical, Colorectal, Esophageal, Head & Neck, Single Pulmonary nodule, Lymphoma, Thyroid, Lung 78816 Whole Body - Melanoma and Myeloma 78608 Alzheimers - Dementia, Refractory seizures after Cancer Revision: March 2018

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