Radiology Ordering & Physician Services Toolkit

RADIOLOGY ORDERING & PHYSICIAN SERVICES TOOLKIT PREPARED IN 2014

Goals of this Toolkit

1. TO HELP REFERRING PHYSICIANS ORDER THE RIGHT TEST AT THE RIGHT TIME

2. TO MINIMIZE TIME CONSUMING RE-ORDERS AND RE-PRECERTING

3. TO IMPROVE PATIENT CARE

4. TO PROVIDE VALUABLE RESOURCES TO PATIENTS

5. TO PREPARE FOR ICD10 CHANGES & DOCUMENTATION CHALLENGES

6. TO PROVIDE ELECTRONIC FORMS AND DOCUMENTS TO REFERRING PHYSICIANS

7. TO REDUCE DENIALS TO THE HOSPITAL AND RADIOLOGISTS

CONTACT RADIOLOGY WITH ANY QUESTIONS

Contact Name Responsibility Phone Number Email

Michael Langenberg University Radiology (865) 803-2973 [email protected] Administrator Allen Gilbert University Radiology I/T (865) 661-9060 [email protected]

Denise Ruggles University Radiology Admin (865) 584-7376 [email protected] Support Shannon Buck Radiology Department (865) 305-9048 [email protected] Manager (XRay, MRI, Ultrasound) Brett Hines Radiology Department (865) 305-6939 [email protected] Manager (CT, Nuclear Medicine, PET CT) Donna Johnson Radiology Support Manager TBD TBD

TBD IR Nurse Manager (865) 305-9067 TBD

Cristina Whitehead IR / NIR Clinic Coordinator (865) 558-0225 [email protected]

Let us know how we can help you! Table of Contents

1. Section 1 - Radiology Ordering Quick Tips

2. Section 2 – Common Radiology Protocols

3. Section 3 - “The Radiology Man” Diagram

4. Section 6 – Radiology Departmental Order Form

5. Section 7 - Comprehensive Imaging Ordering Guide

6. Section 8 – CT Abdomen Pelvis Ordering Guide

7. Section 9 – CT Chest Ordering Guide

8. Section 10 - MRI Brain Ordering Guide

9. Section 4 – Patient Preparation Instructions

10. Section 5 – Patient Maps Radiology Ordering Quick Tips Physicians please provide all or as much of the following when ordering Imaging Studies Information “MUST HAVE” DESCRIPTION

1. LOCATION Provide as much as possible the specific anatomical sites requiring imaging (left right, upper, outer, etc), Laterality, Quadrant of Organ, Location of the Bone, Individual Vessel Occluded, Graft vs Native

2. SEVERITY Indicate on the order whether it is Acute or Chronic, Traumatic or Non- Traumatic, Open or Closed, With or Without Hemorrhage, With or without perforation

3. CONTEXT / SIGNS Provide ALL SIGNS AND SYMPTOMS patient is experiencing relevant to this SYMPTOMS imaging exam, Relevant prior procedures and previous treatments, underlying conditions, history of…, what is the intent of imaging study… imaging ordered for what condition?

4. STORY Provide as much information to let radiology know what was the patient doing? Where did event happen? What was patient’s status at the time?

*Information obtained from Coding Strategies, Inc. “Embrace ICD10” presentation on February 14, 2014 Radiology Protocols

Please Note – All CPT Codes Must be Precerted even if Ordered as a “Protocol”

COMMON IMAGING PROTOCOLS

PROTOCOL – CT Studies CPT Code to CPT Description Precert Renal Protocol 74178 CT Abdomen/Pelvis with and without Contrast

CT Stone Study/Urinary Tract 74176 CT Abdomen/Pelvis without Contrast

Urogram 74178 & CT Abdomen/Pelvis with and without Contrast

76376 3D Reformatted CT Images

Liver (Hepatic) Protocol 74170 CT Abdomen with and without Contrast

CT Enterography 74177 CT Abdomen/Pelvis with Contrast

Pancreatic Protocol 74170 CT Abdomen with and without Contrast

Pulmonary Embolism (PE) Protocol 71275 CTA Chest

Parathyroid Protocol 70492 CT Neck Soft Tissue with and without Contrast

CT Dissection Study 71275 & CTA Chest and CTA Abdomen

74175 MRI PROTOCOLS

PROTOCOL – MRI Studies CPT Code to CPT Description Precert Carotid Protocol 70549 MRA Neck with and without Contrast

Liver (Hepatic) Protocol 74183 MRI Abdomen with and without Contrast

Stroke Protocol 70553 & MRI Brain with and Without Contrast

70544 & MRA Head without Contrast

70549 MRA Neck with and without Contrast University Radiology CPT Code Guidelines for MRI and CT

MRI Head and Neck CT Head and Neck TMJ 70336 Brain wo Contrast 70450 Orbits w Contrast 70481 Brain wo Contrast 70551 Brain w Contrast 70460 Orbits w/wo Contrast 70482 Brain w/wo Contrast 70553 Brain w/wo Contrast 70470 Temporal Bones wo Contrast 70480 Neck Soft Tissue wo Contrast 70540 Sinus Complete 70486 Temporal Bones w Contrast 70481 MRI Orbits, Pituitary, Neck Soft Tissue w/wo Contrast 70543 Maxillofacial wo Contrast 70486 Temporal Bones w/wo Contrast 70482 Cranial Nerve, IAC’s Maxillofacial w Contrast 70487 Neck Soft Tissue wo Contrast 70490 Orbits, Pituitary, Cranial Nerve IAC’s Maxillofacial w/wo Contrast 70488 Neck Soft Tissue w Contrast 70491 w/wo Contrast 70543 Orbits wo Contrast 70480 Neck Soft Tissue w/wo Contrast 70492 MRI Chest CT Chest Chest wo Contrast 71550 Chest w/o Contrast 71250 Chest w/wo Contrast 71552 Chest w Contrast 71260 MRI Breast Chest w/wo Contrast 71270 Breast Unilateral with and/or without Contrast 77058 Chest CTA/ PE Study 71275 Breast Bilateral with and/or without Contrast 77059 Cardiac CTA w Calcium Scoring 75574 Cardiac CTA w/o Calcium Scoring 75574 MRI Spine Calcium Scoring 75571 Cervical wo Contrast 72141 Thoracic Spine wo Contrast 72146 CT Spine Lumbar Spine wo Contrast 72148 Cervical Spine w/o Contrast 72125 C Spine w/wo Contrast 72156 Thoracic Spine w/o Contrast 72128 T Spine w/wo Contrast 72157 Lumbar Spine w/o Contrast 72131 L Spine w/wo Contrast 72158 CT Abdomen and Pelvis Abdomen/Pelvis w/o Contrast 74176 (Stone Study) MRI Abdomen Abdomen/Pelvis w Contrast 74177 Abdomen wo Contrast 74181 Abdomen/Pelvis w/wo Contrast 74178 Abdomen w/wo Contrast 74183 Abdomen w MRCP 74183 CT Abdomen Only Abdomen w/o Contrast 74150 MRI Pelvis Abdomen w Contrast 74160 Pelvis wo Contrast 72195 Abdomen w/wo Contrast 74170 Pelvis w/wo Contrast 72197 MRI Angiography CT Pelvis Only MRA Head wo Contrast 70544 Pelvis w/o Contrast 72192 MRA Head w Contrast 70545 Pelvis w Contrast 72193 MRA Neck wo Contrast 70547 Pelvis w/wo Contrast 72194 MRI Arthogram MRA Neck w Contrast 70548 CT Urogram Shoulder 23350, 73222 MRA Chest w or wo Contrast 71555 CT Urogram 74178 Elbow 24220, 73222 MRA Renal Artery w or wo Contrast 74185 Wrist 25246, 73222 MRA Runoff w or wo Contrast 73725 CT Angiography Hip 27093, 73722 Coronary Calcium Score 75571 Knee 27370, 73722 Cardiac CTA without Calcium Score 75574 Ankle 27648, 73722 MRI Upper Extremity Cardiac CTA w Calcium Score 75574 Other than Joint wo Contrast 73218 Head w/wo Contrast 70496 Other than Joint with Contrast 73219 Neck w/wo Contrast 70498 Other than Join w/wo Contrast 73220 Abdomen 74175 Joint wo Contrast 73221 Lower Extremities w/wo Contrast 73706 Joint w/wo Contrast 73223 CTA Runoff 75635 Pelvis w/wo Contrast 72191 CT Extremities MRI Lower Extremity Upper Ext wo Contrast 73200 Other than Joint wo Contrast 73718 Upper Ext w Contrast 73201 Other than Joint with Contrast 73719 Upper Ext w/wo Contrast 73202 Other than Join w/wo Contrast 73720 Lower Ext wo Contrast 73700 Joint wo Contrast 73721 Lower Ext w Contrast 73701 Joint with Contrast 73722 Lower Ext w/wo Contrast 73702 Joint w/wo Contrast 73723

Call 865-305-8080 to schedule and appointment. UniveRsity OF tennessee MeDical centeR 1924 alcOa Hwy : knOxville, tn 37920 scHeDUling: 865-305-8080 Fax: 865-305-6131

Radiology order form

Name: MR #: DOB: Date of Service: Precert# / Authorization#: Ordering Physician: Ordering MD Signature:______Phone: Reason for Exam: Fax: Signs and Symptoms: DX Code(s):

Report is Stat /Call Back #: ______

MrI ProCedures (Precert required) MrI Head and Neck MrI Chest MrI Arthogram MrI upper extremity

TMJ 70336 Chest wo Contrast 71550 Left Right Joint: Brain wo Contrast 70551 Chest w/wo Contrast 71552 Shoulder 23350, 73222 Left Right Brain w/wo Contrast 70553 MRI Abdomen Elbow 24220, 73222 Stroke Brain Only wo Contrast 70551 Other than Joint wo Contrast 73218* Abdomen wo Contrast 74181 Wrist 25246, 73222 Stroke Protocol w/wo Contrast 70553, Other than Joint w/wo Contrast 73220* Abdomen w/wo Contrast 74183 Hip 27093, 73722 70544, 70549 Joint wo Contrast 73221* Abdomen w MRCP (wo Contrast) 74181 Knee 27370, 73722 Joint w/wo Contrast 73223* Multiple Sclerosis w/wo Contrast 70553 Ankle 27648, 73722 Neck Soft Tissue wo Contrast 70540 MRI Pelvis MRI Lower Extremity Neck Soft Tissue w/wo Contrast 70543 Pelvis wo Contrast 72195 MRI Angiography Orbits, Pituitary, Cranial Nerve IAC’s Pelvis w/wo Contrast 72197 MRA Head wo Contrast 70544 Joint: w/wo Contrast 70543 MRI Cardiac MRA Neck wo Contrast 70547 Left Right MRA Neck w/wo Contrast 70549 MRA Other than Joint wo Contrast 73718* MRI Spine Morphology and Function w/wo Chest w or wo Contrast 71555 MRA Other than Joint w/wo Contrast 73720* Cervical wo Contrast 72141 Contrast 75561 Pelvis w or wo Contrast 72198 MRA Joint wo Contrast 73721* Cervical w/wo Contrast 72156 Velocity Flow Mapping wo Contrast Abdomen w or wo Contrast 74185 MRA Joint w/wo Contrast 73723* Thoracic wo Contrast 72146 75557, 75565 Renal Artery w or wo Contrast 74185 Thoracic w/wo Contrast 72157 MRI Breast *Recommend w/wo Extremity for 1) Infection MRA Lower Ext w or wo Contrast 73725 Lumbar wo Contrast 72148 Breast Unilateral w and/or wo Contrast 77058 2) Tumor of Soft Tissue Lumbar w/wo Contrast 72158 Breast Bilateral w and/or wo Contrast 77059 CT Procedures (Available at Turkey Creek, Precert Required) CT Head and Neck Radiology Protocoled Studies CT Abdomen CT Angiography Head wo Contrast 70450 Renal Protocol 74178 Abdomen wo Contrast 74150 CTA Head 70496 Head w/wo Contrast 70470 Kidney Stone Study/Urinary Tract 74176 Abdomen with Contrast 74160 CTA Neck 70498 Sinus Complete 70486 Urogram 74178,76376 Abdomen w/wo Contrast 74170 CTA Chest 71275 Maxillofacial wo Contrast 70486 Dual Phase Liver (Hepatic) 74170 CTA Abdomen 74175 Maxillofacial with Contrast 70487 CT Enterography 74177 CT Pelvis CTA Pelvis 72191 Orbits wo Contrast 70480 Pancreatic 74170 CTA Abdomen and Pelvis 74174 Pelvis wo Contrast 72192 Orbits with Contrast 70481 Parathyroid 70492 CTA Runoff 75635 (abdominal aorta and Pelvis with Contrast 72193 Temporal Bones wo Contrast 70480 PE Study 71275 bilateral iliofemoral lower extremity runoff) Pelvis w/wo Contrast 72194 Temporal Bones with Contrast 70481 Dissection Study 71275, 74175 CTA Upper Extremitites 73206 Neck Soft Tissue wo Contrast 70490 CTA Lower Extremities 73706 Neck Soft Tissue with Contrast 70491 CT Myelogram CT Abdomen and Pelvis *Also Precert 62284 and 77003 for injection Abdomen Pelvis wo Contrast 74176 CT Extremities Neck Soft Tissue w/wo Contrast 70492 Cervical Spine with Contrast 72126 Abdomen Pelvis with Contrast 74177 Left Right Thoracic Spine with Contrast 72129 Abdomen Pelvis w/wo Contrast 74178 Upper Ext wo Contrast 73200 CT Spine Lumbar Spine with Contrast 72132 Upper Ext with Contrast 73201 Cervical Spine wo Contrast 72125 Virtual Colonography Upper Ext w/wo Contrast 73202 Thoracic Spine wo Contrast 72128 Cardiac CT Diagnostic CT Colonography wo Lower Ext wo Contrast 73700 Lumbar Spine wo Contrast 72131 Calcium Score 75571 Contrast 74261 Lower Ext with Contrast 73701 Coronary CT Angiography 75574 CT Chest Diagnostic CT Colonography w Lower Ext w/wo Contrast 73702 CT of Heart for Structure & Morphology 75572 Contrast (IV) 74262 Chest wo Contrast 71250 CT of Heart for Structure & Morphology with Screening CT Colonography 74263 3D Reformats Chest w Contrast 71260 Known Congenital Heart Disease 75573 3D Reformats 76377 Other Radiology Requests Radiology procedure not listed, Special protocol requests, Specific area of interest, Additional patient instructions

DIGITAL MAMMogrAPHy Name: MR #: Screening Bilateral Screening Mammogram with DOB: Diagnosis (Required): two view film study of each breast Date of Service: Precert# / Authorization#: G0202

Ordering Physician: Phone: Unilateral Screening Mammogram with two view study of single breast Ordering Physician Signature: Fax: G0202 -52 Right Left

Ultrasound Procedures Diagnostic Ultrasound Ultrasound Continued Female Ultrasound Diagnostic Mammogram, Bilateral Abdominal Complete 76700 Pelvic Complete 76856 Pelvic Complete 76856 (to include mammographic imaging, Abdominal Limited 76705 Pelvic Limited 76857 with Transvaginal 76830 ultrasound, or biopsy as deemed Organ Follow-up Retroperitoneal 76770 with Transvaginal if indicated 76830 necessary by the radiologist. G0204 Gall Bladder Retroperitoneal Limited 76775 Transvaginal 76830 Liver Bladder 76857 Breast 76645 Diagnostic Mammogram, Spleen Chest 76604 1st Trimester, Transabdominal 76801 Unilateral (to include mammographic Pancreas Soft Tissue Abd Mass/Hernia 76705 Male Ultrasound imaging, ultrasound, or biopsy as Kidney Thyroid, Head/Neck 76536 deemed necessary by the radiologist. Scrotal 76870 Billiary Extremity Non-Vascular 76880 G0206 Right Left Prostate 76872 Aorta IVC Ultrasound OB Neonatal Ultrasound Reason for Exam/ B-scan/real time, Single or Neonatal Head 76506 Abdominal Limited 76705 Other Requests First Gestation 76805 Neonatal Spine 76800 Up Left Quad Low Left Quad OB Limited 76815 Neonatal Hip Dynamic 76885 Up Right Quad Low Right Quad Follow-up, Transabdominal, Neonatal Hip Static 76886 Other Ultrasound Requests Per Fetus 76816 OB Transvaginal 76817 BONE DENSITY DEXA Scan 77080 Nuclear Medicine Procedures (Available at Turkey Creek, Precert Required) Nuc Med Cardiovascular Nuc Med Endocrine Nuc Med Gastrointestinal Nuc Med Tumor/ Infection/ Cardiac Shunt Imaging 78428 Parathyroid Exam 78070 Liver-Spleen SPECT 78205 Inflammation Cardiac 1st Pass, Single 78481 123I Thyroid Uptake Scan 78012,13,14 Hepatobiliary, including GBEF 78227 Tumor Imaging; Limited 78800 Cardiac 1st Pass, Multiple 78483 Thyroid CA; Neck/Chest 78015 Thyroid GE Reflux 78262 Tumor Imaging; WB 78802 Vascular Flow Imaging 78445 CA; WB 78018 Gastric Emptying 78264 Tumor Imaging; Spect 78803 DVT Imaging; Peptide (AcuTect) 78456 Thyroid CA; Uptake 78020 GI Bleeding Scan 78278 Infection Imaging; Limited 78805 Heart MPS; SPECT; Single Study 78451 131I Thyroid Therapy 79005 Meckel’s 78290 Infection Imaging; WB 78806 Heart MPS; SPECT; Multiple Study 78452 131I Thyroid Therapy w Imaging 79005 & 78018 Shunt Patency 78291 Infection Imaging; Spect 78807 131 Heart MPS; PET; Single Study 78491 I Mets Survey 78018 Nuc Med Musculoskeletal Nuc Med Genitourinary 38792 Heart MPS; PET; Multiple Study 78492 Sentinel Node wo Imaging Limited Area Bone Scan 78300 Renal Perfusion / Function 78707 78195 MUGA; Single Study 78472 Sentinel Node w Imaging Multiple Area Bone Scan 78305 Renal Perfusion / Function w Lasix 78708 MUGA; Multiple Study 78473 Nuc Med Head & CNS Whole Body Bone Scan 78306 Renal Perfusion / Function w ACE 78709 Nuc Med Respiratory Brain Limited w Flow 78601 Three Phase Bone Scan 78315 Renal Scan; Spect 78710 Perfusion Lung Scan 78580 Brain Complete w Spect 78607 Bone SPECT 78320 Ureteral Reflux Scan 78740 Ventilation/Perfusion Lung Scan 78582 Cisternogram 78630 Nuc Med Other Other Nuc Med Requests Quantitative Ventilation/Perfusion 78598 Cerebral Shunt Evaluation 78645 Urea Breath TST C-14; Collection 78267 CSF Leak 78650 Urea Breath TST C-14; Analysis 78268 X-Ray Procedures (Available at Turkey Creek) X-Ray Head and Neck X-Ray Spine X-Ray Lower Extremity X-Ray Upper Extremity Mandible; Complete 70110 Cervical Spine 2/3 Views 72040 Left Right Left Right Facial Bones; Complete 70150 Cervical Spine Complete 72052 Hip; 2 Views 73510 Clavical 73000 Nasal Bones; Complete 70160 Thoracic Spine 2 Views 72070 Hips; Bilateral, w / AP Pelvis 73520 Shoulder 73030 Orbits; Complete 70200 Lumbar Spine 2/3 Views 72100 Hips / Pelvis; Infant 73540 AC Joints 73050 Sinus; Less than 3 Views 70210 Lumbar Spine 4 Views 72110 Femur; 2 Views 73550 Humerus; 2 Views 73060 Sinus; Complete 70220 Lumbar Complete w/ Bending 72114 Knee; 3 Views 73562 Elbow; 3 Views 73080 Skull; Less than 4 Views 70250 Bilateral Standing Knees 73565 Forearm; 2 Views 73090 X-Ray Flouroscopy Skull; Complete 70260 Tibia/Fibula; 2 Views 73590 Wrist; Complete 73110 Barium Swallow 74220 Neck; Soft Tissue 70360 Lower Ext. Infant; 2 Views 73592 Hand; 3 Views 73130 Modified Barium Swallow 74230 Ankle; 3 Views 73610 Fingers; Minimum 2 Views 73140 Single Contrast Upper GI 74241 X-Ray Chest Calcaneus; 2 Views 73650 Double Contrast Upper GI 74247 Arthography Chest; 2 Views 71020 Toes; Minimum 2 Views 73660 Small Bowel Series 74251 Left Right Ribs; Unilateral, 2 Views 71100 Foot; 3 Views 73630 Barium Enema, Diagnostic 74280 Ankle 73615 Ribs; Bilateral; 3 Views 71110 Barium Enema, Therapeutic 74283 Hip 73525 Sternum; 2 Views 71120 X-Ray Abdomen Defecography 74270 Wrist 73115 Sternoclavicular Joints 71130 Abdomen; Single View 74000 Shoulder 73040 Cystogram 74430 Abdomen; Supine & Erect 74020 Knee 73580 Other X-Ray Requests Hysterosalpingogram 74740 Acute Abdomen Series Complete 74022 Sinus Tract Study 76080 Elbow 73085 Myelogram - See CT Myelogram TMJ 70332

CPT only © American Medical Association. ©2012 Order Form may not be reprinted or reproduced without authorization by the author. Radiology Order Form - 932604 (Dev 2/10) To Order an MRI study call 305-8080 University Radiology If you are unsure what MRI to order call 305-8656 MRI & MRA Ordering Guide For more Information visit www.utrad.com

Please use this guide to determine the correct MRI or MRA exam to Order and Precert CPT Code(s) to Body Part Reason for Exam or Exam Indications Procedure to Order & Precert Precert Alzheimers Mental Status Change Confusion Dementia 70551 MRI Brain Without Contrast Memory Loss Stroke / CVA Suspected MS TIA Headaches Dizziness / Vertigo Cranial Nerve Lesions HIV / AIDS Hearing Loss IAC Mass MRI Brain Infection Multiple Sclerosis Neurofibromatosis Pituitary Lesion MRI Brain With and Without Contrast 70553 Elevated Prolactin Seizures Tumor/Mass/Cancer Visual Changes Vascular Lesions AVM Bell’s Palsy Facial Weakness Acoustic Neuroma Metastases MRA Brain Aneurysm or Family History of Aneurysm (Arterial or Venous TIA MRA Brain Without Contrast 70544 Circulation or Circle Stroke / CVA* (Order with MRI Brain W/Out 70551) of Willis) Venous Thrombosis AVM* (Order with MRI Brain W/WOut 70553) MRA Brain Sinus Thrombosis MRA Brain With and Without Contrast 70546 (Venous Circulation) Venous Circulatory Symptoms Alzheimers MRA Neck Mental Status Changes (Arch and Great Stroke/CVA MRA Neck With and Without Contrast 70549 Vessels) TIA Bruit MRI Orbits Trauma MRI Orbits (Face/Neck) Without Contrast 70540

Grave’s Disease MRI Orbits (Face/Neck) Without and With 70543

© Association of University Radiologists, PC Page 1 To Order an MRI study call 305-8080 University Radiology If you are unsure what MRI to order call 305-8656 MRI & MRA Ordering Guide For more Information visit www.utrad.com

Infection Pain MRI Orbits (Face/Neck) Without and With MRI Neck 70543 Tumor / Mass / Cancer / Mets Contrast Vocal Cord Paralysis Arm/Shoulder Pain Degenerative Disease Neck Pain Disc Herniation MRI Cervical Spine Without Contrast 72141

MRI Spine - Radiculopathy Numbness Cervical Syrinx Post Op Fusion Discitis Osteomyelitis MRI Cervical Spine Without and With Contrast 72156 Myelopathy Tumor/Mass/Cancer Back Pain Degenerative Disease Disc Herniation Radiculopathy MRI Thoracic Spine Without Contrast 72146 Trauma Compression Fracture MRI Spine – Discitis Post Op Fusion Thoracic Osteomyelitis Multiple Sclerosis MRI Thoracic Spine With and Without 72157 Myelopathy Syrinx Contrast Tumor/Mass/Cancer Back / Leg Pain Degenerative Disease Disc Herniation Radiculopathy Trauma Compression Fracture MRI Lumbar Spine Without Contrast 72148 MRI Spine – Sciatica Spinal Stenosis Lumbar Spondylolithesis Scoliosis Discitis MRI Lumbar Spine Without and With Contrast 72158 Osteomyelitis

© Association of University Radiologists, PC Page 2 To Order an MRI study call 305-8080 University Radiology If you are unsure what MRI to order call 305-8656 MRI & MRA Ordering Guide For more Information visit www.utrad.com

Please use this guide to determine the correct MRI or MRA exam to Order and Precert CPT Code(s) to Body Part Reason for Exam or Exam Indications Procedure to Order & Precert Precert Post Op HX of Back Surgery Tumor / Mass / Cancer / Mets Tumor/Mass/Cancer Abdominal Pain Post Embolization Hepatitis Hemangioma Cirrhosis Hepatoma Renal Mass or Cyst Transitional Cell Increased Liver MRI Abdomen Carcinoma of Kidney Function Tests Adrenal Mass / Lesion Hematuria (General, Liver, MRI Abdomen With and Without Contrast 74183 Renal, Adrenal, Pheochromocytoma Hypertension Biliary, Pancreas) Jaundice Abnormal Enzymes Stones Biliary Obstruction Pancreatitis Pancreas Mass Painless Jaundice Ampulla Evaluation Cholangiocarcinoma

PSC – Primary Sclerosing Cholangitis Renal Artery Stenosis MRA Abdomen Mesenteric Arterial Hypertension MRA Abdomen With or Without Contrast 74185 Ischemia Fracture Trauma MRI Pelvis (Hip) MRI Pelvis Without Contrast 72195 Hip/Pelvis Pain Muscle /Tendon Tear MRI Pelvis Pain Abscess (Soft Tissue, Uterus, Fibroid Adenomysis Ovaries) Infertility Ovarian Mass Osteomyelitis Septic Arthritis MRI Pelvis With and Without Contrast 72197 Tumor/Mass/Cancer Pre/Post Uterine Fibroid Embolization MRI Pelvis Endometrioma

Continued Decubitis Ulcer

© Association of University Radiologists, PC Page 3 To Order an MRI study call 305-8080 University Radiology If you are unsure what MRI to order call 305-8656 MRI & MRA Ordering Guide For more Information visit www.utrad.com

Please use this guide to determine the correct MRI or MRA exam to Order and Precert CPT Code(s) to Body Part Reason for Exam or Exam Indications Procedure to Order & Precert Precert MRA Pelvis Pelvic Venous Thrombosis MRA Pelvis With and Without Contrast 72198 (Iliac Vessels) Crohn’s Disease Celiac Disease MRI Abdomen With and Without Contrast 74183 MR Enterography Small Bowell Tumor MRI Pelvis With and Without Contrast 72197 Crohn’s Fistulous Disease Fracture MRI Non-Joint Without Contrast: MRI Extremity Stress Fracture Upper Extremity 73218 (Upper) NON JOINT: Muscle or Tendon Tear Lower Extremity 73718 (Lower) Forearms Abscess Myositis Humerus MRI Non-Joint With and Without Contrast: Ulcer Osteomyelitis Lower Leg/Calf Upper Extremity 73220 (Upper) Tumor/Mass/Mets Morton’s Neuroma Femur/Thigh Lower Extremity 73720 (Lower) Plantar Fasciitis Soft Tissue Mass MRI Extremity Arthritis Meniscal Tear JOINT: Avascular Necrosis Muscle Tear MRI Joint Without Contrast: Upper: Stress Fracture Ligament Tear Upper Extremity 73221 (Upper) Hand Joint Pain Cartilage Tear Lower Extremity 73721 (Lower) Wrist Internal Derangement Elbow

Ostochondritis (OCD) Shoulder SC Joint Abscess Osteomyelitis Lower: Ulcer Inflamed Arthritis MRI Joint Without and With Contrast: Foot Cellulitis Septic Arthritis Upper Extremity 73223 (Upper) Ankle Plantar Fasciitis Tumor/Mets/Mass Lower Extremity 73723 (Lower) Knee Myositis Labral Tear Hip (Whole Pelvis) MRA Upper MRA Upper Extremity With or Without Subclavian Tenderness, Redness, Swelling 73225 Extremity Contrast MRA Lower Peripheral Vascular Disease MRA Lower Extremity With or Without 73725

© Association of University Radiologists, PC Page 4 To Order an MRI study call 305-8080 University Radiology If you are unsure what MRI to order call 305-8656 MRI & MRA Ordering Guide For more Information visit www.utrad.com

Please use this guide to determine the correct MRI or MRA exam to Order and Precert CPT Code(s) to Body Part Reason for Exam or Exam Indications Procedure to Order & Precert Precert Extremity Contrast MRI Upper Extremity Joint With and Without 73222 Contrast MR Arthogram Shoulder Instability Ligament Injury (Upper Extremity, Labral Tear TFCC Tear Shoulder, Elbow, Shoulder Injection 23350 Loose Body Wrist) Elbow Injection 24220 Wrist Injection 25246 MRI Lower Extremity Joint With and Without 73722 Contrast MR Arthogram Labral Tear Loose Body (Lower Extremity, Post Surgical Meniscus Retear Hip Injection 27093 Hip, Knee, Ankle) OCD Lesion (Osteochondritis Dissecans) Knee Injection 27370 Ankle Injection 27093 MRI Lumbosacral Leg Pain/Sciatica Lumbar Plexopathy MRI Pelvis Without Contrast 72195 Plexus Radiculopathy Scaral/Coccyx Pain Shoulder Injury MRI Upper Extremity Non-Joint With and MRI Brachial Plexus Nerve Avulsion 73220 Without Contrast Brachial Plexopathy MRI Chest MRI Chest/Mediastinum With and Without Tumor/Mass/Cancer/Mets 71552 (Mediastinum) Contrast MRA Aorta Abdominal Aortic Dissection MRA Abdomen With and Without Contrast 74185 MRA Aorta With Peripheral MRA Abdomen With and Without Contrast Peripheral Vascular Disease 74185 Run-Off MRA Lower Extremity With and Without Claudication 73725 Contrast

Newly Diagnosed Breast Cancer MRI Breast Bi-Lateral With and Without MRI Breast Family History of Breast Cancer 77059 Contrast BRCA 1 and BRCA 2 Genes

© Association of University Radiologists, PC Page 5 To Order an MRI study call 305-8080 University Radiology If you are unsure what MRI to order call 305-8656 MRI & MRA Ordering Guide For more Information visit www.utrad.com

Please use this guide to determine the correct MRI or MRA exam to Order and Precert CPT Code(s) to Body Part Reason for Exam or Exam Indications Procedure to Order & Precert Precert Implant Integrity Issue or Rupture

Common MRI Protocols Precert All: Stroke MRI Brain With and Without Contrast 70553 STROKE Suspected Stroke PROTOCOL MRA Head Without Contrast 70544 TIA MRA Neck With and Without Contrast 70549

CAROTID MRA Neck With and Without Contrast 70549 PROTOCOL

LIVER (HEPATIC) MRI Abdomen With and Without Contrast 74183 PROTOCOL

Crohn’s Disease MR Celiac Disease MRI Abdomen With and Without Contrast 74183 ENTEROGRAPHY Small Bowell Tumor MRI Pelvis With and Without Contrast 72197 Crohn’s Fistulous Disease

© Association of University Radiologists, PC Page 6 To Order a CT or CTA study call 305-8080 University Radiology If you are unsure what CT or CTA to order call 305-9639 CT and CTA Ordering Guide For more Information visit www.utrad.com

Please use this guide to determine the correct CT or CTA exam to Order and Precert CPT Code(s) to Body Part Reason for Exam or Exam Indications Procedure to Order & Precert Precert Hematuria with Pain CT Abdomen/Pelvis Without Contrast 74176 CT Stone Study / Urinary Tract Protocol All Cancer Staging Abdominal Pain Crohns Ulcerative Colitis 74177 IBD Appendicitis CT Abdomen/Pelvis With Contrast Diverticulitis Abscess CT Abdomen/Pelvis

Hernia (ventral, umbilical, inguinal) Cyst vs Mass Hemangioma Painless Hematuria Adrenal Mass Melanoma Carcinoid CT Abdomen/Pelvis With and Without 74178 Hepatoma Contrast Pre and Post Embolization

Transitional Cell Carcinoma of Kidney F/U for patients with Renal CT Abdomen Without Contrast 74150 Cell Carcinoma in Renal Failure Abdominal Pain Mass Epigastric Issues RUQ Pain CT Abdomen With Contrast 74160 CT Abdomen Only LUQ Pain Pseudocyst Pancreatitis Pancreas Mass Liver Mass Liver Protocol CT Abdomen With and Without Contrast 74170 Pancreatic Protocol Adrenal Protocol

CTA Abdomen Crossing Vessels (Renal, Aorta Pre-Op, CTA Abdomen 74175 Nephrectomy Aneurysm Post-Op Stent)

CTA Abdomen Peripheral Artery Disease (PAD) CTA Abdomen (and Run Off) 75635 (Run Off)

© Association of University Radiologists, PC Page 1 To Order a CT or CTA study call 305-8080 University Radiology If you are unsure what CT or CTA to order call 305-9639 CT and CTA Ordering Guide For more Information visit www.utrad.com

Please use this guide to determine the correct CT or CTA exam to Order and Precert CPT Code(s) to Body Part Reason for Exam or Exam Indications Procedure to Order & Precert Precert

Cough Pneumonia Tracheal Stenosis Renal Failure CT Chest Without Contrast 71250 F/U Nodules Suspected Mediastinal / Hilar Adenopathy CT Chest Staging Thoracic Primary Malignancy Complex Pleural Effusion CT Chest With Contrast 71260 Thoracic Trauma Chest Wall Mass Interstitial Disease Fibrosis CT Chest COPD Hemoptysis CT Chest Without and With Contrast 71270 (High Resolution) Bronchiectasis Sarcoidosis --- HIGH RESOLUTION Pleural Plaques Asbestosis Chest Pain/Dyspnea AAA/Aortic Dissection Tachypnea Hemoptysis CTA Chest MRI Orbits (Face/Neck) Without and With Shortness of Breath + D Dimer 71275 (PE Study) Contrast Pulmonary Hypertension

DVT Prostate Treatment Planning CT Pelvis Without Contrast 72192 Cancer Staging Mass in Pelvic Region CT Pelvis Only Cysts in Pelvic Region Pain in Pelvic Region CT Pelvis With Contrast 72193 Infection in Pelvic Region

Order without contrast if elevated creatine CT Neck Without Contrast 70490 CT Neck Submandibular Stone Parotid Stone Infection of Parotid Gland CT Neck Without and With Contrast 70492

© Association of University Radiologists, PC Page 2 To Order a CT or CTA study call 305-8080 University Radiology If you are unsure what CT or CTA to order call 305-9639 CT and CTA Ordering Guide For more Information visit www.utrad.com

Please use this guide to determine the correct CT or CTA exam to Order and Precert CPT Code(s) to Body Part Reason for Exam or Exam Indications Procedure to Order & Precert Precert Parotid Mass Mass Infection Cancer Workups CT Neck With Contrast 70491

Artheromatous Disease Bruit TIA CTA Carotid CVA Vascular Tumor CTA Carotid 75662 Vascular Malformations

Carotid Stenosis Trauma Headaches CVA, Stroke Bleed, Hemorrhage Alzheimers Memory Loss CT Head Without Contrast 70450 Confusion Shunt Check Hydrocephalus Metastatic Staging Vertigo CT Head Dizziness Mass / Tumor Infection CT Head With Contrast 70460 Headache with other Neurological Symptoms

Melanoma HIV CT Head With and Without Contrast 70470 Toxoplasmosis TIA, CVA Vascular Malformation CTA Head / Brain CTA Brain 75671 Aneurysm AVM Trauma Fracture CT Orbit Without Contrast 70480 CT Orbits Foreign Body Graves Disease

© Association of University Radiologists, PC Page 3 To Order a CT or CTA study call 305-8080 University Radiology If you are unsure what CT or CTA to order call 305-9639 CT and CTA Ordering Guide For more Information visit www.utrad.com

Please use this guide to determine the correct CT or CTA exam to Order and Precert CPT Code(s) to Body Part Reason for Exam or Exam Indications Procedure to Order & Precert Precert Pseudo Tumor Mass CT Orbits Exopthalmus Pain CT Orbit With Contrast 70481

Abscess Retinoblastoma CT Orbit Without and With Contrast 70482 Sinusitis CT Sinus (Maxillofacial) Without Contrast CT Sinus Osteomeatal Complex 70486 *CT Sinus Limited will be billed with 52 Modifier Functional Endoscopic Sinus Surgery Trauma Fracture Fusion Bony Degenerative CT Without Contrast CT Spine 72125 Changes - Cervical Spine (Cervical / Thoracic) 72128 *MR Recommended for disc herniation, mets, - Thoracic Spine

infection Trauma Fracture CT Spine Fusion Pars Defect CT Lumbar Spine Without Contrast 72131 (Lumbar / Sacral) *MR Recommended for disc herniation, mets,

infection Hearing Loss Cholesteotoma CT (Orbit) Inner Ears, Temporal Bones CT Temporal Bone Trauma 70480 Without Contrast *Sensory neuro hearing loss; order MRI With Contrast CT Extremities - Foot - Ankle Fracture Fusion - Calf CT Without Contrast - Knee Non-Union Malunion - Lower Extremity 73700 - Thigh Femoral Anteversion Arthritis - Upper Extremity 73200 - Finger Malignment Knee - Hand - Wrist - Arm

© Association of University Radiologists, PC Page 4 To Order a CT or CTA study call 305-8080 University Radiology If you are unsure what CT or CTA to order call 305-9639 For more Information visit www.utrad.com CT and CTA Ordering Guide

Please use this guide to determine the correct CT or CTA exam to Order and Precert CPT Code(s) to Body Part Reason for Exam or Exam Indications Procedure to Order & Precert Precert CT Without and With Contrast Infection CT Extremities - Lower Extremity 73702 Tumor / Mass / Cancer / Mets - Upper Extremity 73202 CT Extremities Abnormality Leg Length CT Leg Lengths 76380 (Leg Lengths) Malrotation Peripheral Artery Disease (PAD) CT Angiography CTA Extremities Ischemia to Lower Extremity - Lower Extremity 73706 Arterial Stenosis – Lower Extremity - Upper Extremity 73206 CT With Contrast 1. Lower Extremity With Contrast OR 73701 CT Arthography Upper Extremity With Contrast 73201 - Hip 2. Fluro Guided Arthogram 76003 Cartilage Abnormality - Knee 3. Choose One Code for body Part Meniscus Abnormality - Ankle - Hip 27093 Labrum Abnormality - Shoulder - Knee 27370 Loose Bodies - Elbow - Ankle 27648 - Wrist -Shoulder 23350 -Elbow 24220 -Wrist 25246

To Order a CT or CTA study call 305-8080 University Radiology If you are unsure what CT or CTA to order call 305-9639 For more Information visit www.utrad.com CT and CTA Ordering Guide

Please use this guide to determine the correct CT or CTA exam to Order and Precert CPT Code(s) to Body Part Reason for Exam or Exam Indications Procedure to Order & Precert Precert Common CT Protocols

Renal Protocol CT Abdomen/Pelvis Without and With 74178 Contrast

CT Stone Study / CT Abdomen/Pelvis Without Contrast 74176 Urinary Tract

Protocol

Precert Both Codes: CT Abdomen/Pelvis With and Without 74178 Urogram Contrast 76376 3D Reformatted CT Images

Liver (Hepatic) CT Abdomen With and Without Contrast 74170 Protocol CT Enterography CT Abdomen/Pelvis With Contrast 74177 Pancreatic Protocol CT Abdomen With and Without Contrast 74170 Pulmonary Embolism CTA Chest 71275 (PE) Protocol Parathyroid CT Neck Soft Tissue Without and With 70492 Protocol Contrast CTA Chest 71275 CT Dissection Study CTA Abdomen 74175

University Radiology Ordering Guide for CT Abdomen and CT Pelvis When to Order a CT Abdomen AND CT Pelvis TOGETHER CT Abdomen / Pelvis CT Abdomen / Pelvis CT Abdomen / Pelvis WITHOUT IV CONTRAST WITH IV CONTRAST W & WITHOUT IV CONTRAST CPT 74176 CPT 74177 CPT 74178 Order when evaluating for: Order when evaluating for: Order when evaluating for:  Hematuria / STONE STUDY  Abdominal Pain (upper and lower  Cyst vs Mass (kidney) quadrants)  Painless Hematuria  Inflammatory Bowel Disease  Transitional Cell Carcinoma of (including Crohns, Ulcerative Kidney Colitis)  CT Renal Mass  Appendicitis  CT Urogram  Abscess  Hernia (ventral, umbilical, inguinal)  CT Enterography

Please Note – In 2011 the AMA COMBINED the CT Abdomen CT Pelvis CPT Codes into singular combined CPT Codes (74176, 74177, and 74178). Although the individual studies for a single CT Abdomen and CT Pelvis still exist, the above codes are designed to capture those cases where the codes (pre 2011) would have been billed together. University Radiology Ordering Guide for CT Abdomen and CT Pelvis When to Order a CT Abdomen ONLY CT Abdomen CT Abdomen CT Abdomen WITHOUT IV CONTRAST WITH IV CONTRAST W & WITHOUT IV CONTRAST CPT 74150 CPT 74160 CPT 74170 Order when evaluating for: Order when evaluating for: Order when evaluating for:  Follow up for patients with Renal  Epigastric issues / evaluation  Pancreatitis Cell Carcinoma in Renal Failure  RUQ Pain  Pancreas Mass (recommend MRI)  LUQ Pain  Liver Mass  Pseudocyst  Adrenal Protocol  CT Dual Phase Liver - Hepatic Protocol  CT Pancreas (Pancreatic Protocol)

NOTE - The UHS Protocol for a CT Abdomen covers from the diaphragm dome (Xiphoid Process) to iliac crests (Belly Button). University Radiology Ordering Guide for CT Abdomen and CT Pelvis

When to Order a CT Pelvis ONLY CT Pelvis CT Pelvis CT Pelvis WITHOUT IV CONTRAST WITH IV CONTRAST W & WITHOUT IV CONTRAST CPT 72192 CPT 72193 CPT 72194 Order when evaluating for: Order when evaluating for: Order when evaluating for:  Prostate Treatment Planning  Cancer Staging (Pubic Arch Study Protocol)  Mass in pelvic region*  Cysts in pelvic region*  Pain in pelvic region*  Infection in pelvic region*

*The Pelvic Region as defined by Medicare is the “lower abdomen.” The UHS Protocol for a CT Pelvis covers from the Iliac crest (Belly Button) through Ischial Tuberosities (Upper Thigh)

University Radiology Ordering Guide for CT & CTA of the Chest How to Order a CT Scan of the Chest CT CHEST CT CHEST CT CHEST WITHOUT IV CONTRAST WITH IV CONTRAST W & WITHOUT IV CONTRAST CPT 71250 CPT 71260 CPT 71270 Order when evaluating for: Order when evaluating for: Order when evaluating for: • Lung Nodule(s) • Suspected Mediastinal / Hilar • • Lung Cancer Screening Adenopathy • Chest Metastasis (known extra- • Staging Thoracic Primary thoracic malignancy) Malignancy • Chronic Dyspnea – Suspect Lung • Complex Pleural Effusion Origin (negative Chest Xray) • Thoracic Trauma (high energy • Interstitial Lung Disease, blunt trauma) Bronchiectasis (HRCT Protocol) • Cough • Pneumonia • Tracheal Stenosis/Malacia

*Make sure to include in the order ALL signs and symptoms patient is experiencing. **Consider CTA Chest as an additional Study as well University Radiology Ordering Guide for CT & CTA of the Chest How to Order a CTA Scan of the Chest CTA CHEST CTA CHEST CTA CHEST WITHOUT IV CONTRAST WITH IV CONTRAST W & WITHOUT IV CONTRAST CPT 71275 Order when evaluating for: Order when evaluating for: Order when evaluating for: • • Shortness of Breath, Chest Pain • • Hemoptysis • Pulmonary HTN

PE PROTOCOL *WHEN ORDERING A PE PROTOCOL A CTA CHEST W CONTRAST IS PERFORMED

• Chest Pain – Aortic Dissection**

**Also order with a CTA Abdomen – CPT Code 74175 University Radiology Ordering Guide for MRI of the Brain How to Order an MRI of the Brain* MRI BRAIN MRI BRAIN MRI BRAIN WITHOUT IV CONTRAST WITH IV CONTRAST W & WITHOUT IV CONTRAST CPT 70551 CPT 70552 CPT 70553 Order when evaluating for: Order when evaluating for: Order when evaluating for:  Acqueductal Stenosis  Only done when an MRI of the  Headaches  Altered Mental Status Brain was performed WITHOUT IV  Abscess  Confusion Contrast previously  Aneurysm**  Dementia / Alzheimer’s  AVM / Vascular Lesions  Memory Loss  Dizziness  Psychiatric Disorder  Encephalitis  Trauma  IAC (Hearing Loss, Vertigo)  Indeterminate intracranial lesion  Meningitis  Metastasis/Neoplasm  Multiple Sclerosis  Non traumatic brain hemorrhage  Seizures  Stroke (suspected stroke, TIA)  Tumor  Vascular Malformation** *Make sure to include in the order ALL signs and symptoms patient is experiencing. **Consider MRA as an additional Study as well PATIENT PREPARATION INSTRUCTIONS

CT SCAN

You should wear comfortable, loose-fitting clothing to your exam. You may be given a gown to wear during the procedure.

Metal objects, including jewelry, eyeglasses, dentures and hairpins, may affect the CT images and should be left at home or removed prior to your exam. You should inform the technologist if you have a pacemaker.

You may be asked not to eat or drink anything for a few hours beforehand, especially if a contrast material will be used in your exam. If you have a known allergy to contrast material, or "dye," your doctor may prescribe medications to reduce the risk of an allergic reaction.

Women should always inform their physician and the CT technologist if there is any possibility that they may be pregnant.

Please contact the Radiology Department at 865-305-9060 if you have additional questions.

MRI

You may be asked to wear a gown during the exam or you may be allowed to wear your own clothing if it is loose-fitting and has no metal fasteners.

Guidelines about eating and drinking before an MRI exam vary with the specific exam and also with the facility. Unless you are told otherwise, you may follow your regular daily routine and take food and medications as usual.

Some MRI examinations may require the patient to receive an injection of contrast material into the bloodstream. The contrast material most commonly used for an MRI exam contains a metal called gadolinium.

• pins, hairpins, metal zippers and similar metallic items, which can distort MRI images • removable dental work • pens, pocket knives and eyeglasses • body piercings

Please contact the Radiology Department at 865-305-9060 if you have additional questions. PATIENT PREPARATION INSTRUCTIONS

NUC MED

You may be asked to wear a gown during the exam or you may be allowed to wear your own clothing.

Women should always inform their physician or technologist if there is any possibility that they are pregnant or if they are breastfeeding.

Jewelry and other metallic accessories should be left at home if possible, or removed prior to the exam because they may interfere with the procedure.

In some instances, certain medications or procedures may interfere with the examination ordered.

Please contact the Radiology Department at 865-305-9060 if you have additional questions.

You should wear comfortable, loose-fitting clothing for your ultrasound exam. You may need to remove all clothing and jewelry in the area to be examined.

You may be asked to wear a gown during the procedure.

Preparations depend on the type of ultrasound you are having.

• For a study of the liver, gallbladder, spleen, and pancreas, you may be asked to eat a fat- free meal on the evening before the test and then to avoid eating for eight to 12 hours before the test. • For ultrasound of the kidneys, you may be asked to drink four to six glasses of liquid about an hour before the test to fill your bladder. You may be asked to avoid eating for eight to 12 hours before the test to avoid gas buildup in the intestines. • For ultrasound of the aorta, you may need to avoid eating for eight to 12 hours before the test.

Please contact the Radiology Department at 865-305-9060 if you have additional questions. FOR SERVICES IN THE MAIN RADIOLOGY DEPARTMENT From West Knoxville Travel on I -40 East Take Exit 386B and merge onto US-129/Alcoa Hwy toward Airport/Smokey Mts 1.9 miles Take the Cherokee Trail/UT Medical Center Exit 0.4 miles Please contact the Radiology Department at (865) 305-9060 for additional assistance.