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General Ultrasound SCHAFFER, SCHONHOLZ & DROSSMAN, LLP 488 Madison Avenue Suite 1220 New York, NY 10022 • Tel 212.755.7656 Fax 212.688.9474 PATIENT REFERRAL INFORMATION GENERAL ULTRASOUND Patient’s Name: Patient’s DOB: Patient’s Medicare#: Referring Physician’s Name & Address: Referring Physician’s Signature: Date: X CODE ABDOMINAL ULTRASOUND X CODE ABDOMINAL ULTRASOUND (cont’d) X CODE RENAL SONOGRAPHY 76700 Abdominal Ultrasound R19.01 Right upper quadrant abdominal swell, mass & lump 76770 Renal Ultrasound R10.819 Abdominal tenderness, unspec site R10.811 Right upper quadrant abdominal tenderness N30.01 Acute cystitis w/hematuria R94.5 Abnormal results of liver function studies R10.11 Right upper quadrant pain R31.1 Benign essential microscopic hematuria R10.0 Acute abdomen R10.821 Right upper quadrant rebound abdominal tenderness N20.0 Calculus of Kidney K80.18 Calculus of gallbladder w/other cholecystitis w/o obstr R10.9 Unspec abdominal pain N28.1 Cyst of kidney, acquired R10.83 Colic R10.10 Upper abdominal pain, unspec N30.91 Cystitis, unspec w/hematuria K57.93 Diverticulitis intest, part unsp w/o perf/abscess w/bld R31.0 Gross hematuria K57.92 Diverticulitis intest, part unsp w/o perf/abscess w/o bld R31.9 Hematuria Unspec K57.80 Diverticulitis intest, part unsp w/perf/abscess w/o bld X CODE PELVIC ULTRASOUND N99.521 Infection of other external stoma of urinary tract K57.32 Diverticulitis lrg intest w/o perf/abscess w/o bleed 76830 Pelvic Transvaginal Ultrasound N99.531 Infection of other stoma of urinary tract K57.81 Diverticulitis of intest, part unsp w/perf/abscess w/bld 76856 Pelvic Transabdominal Ultrasound O23.31 Infection of other parts of urinary tract in preg, 1st trim K57.33 Diverticulitis of lrg intest w/o perf/abscess w/bleed D27.1 Benign neoplasm of left ovary O23.32 Infection of other parts of urinary tract in preg, 2nd tri K57.21 Diverticulitis of lrg intest w/perf/abscess w/bleed D27.0 Benign neoplasm of right ovary O23.33 Infection of other parts of urinary tract in preg, 3rd trim K57.20 Diverticulitis of lrg intest w/perf/abscess w/o bld D27.9 Benign neoplasm of unspec ovary O23.30 Infection of other parts of urinary tract in preg, unsp tri K57.00 Diverticulitis of sm intest w/perf/abscess w/o bld D06.9 Carcinoma in situ of cervix, unspec N30.11 Interstitial cystitis (chronic) w/hematuria K57.13 Diverticulitis of sml intest w/o perf/abscess w/bleed D06.0 Carcinoma in situ of endocervix N30.41 Irradiation cystitis w/hematuria K57.01 Diverticulitis of sml intest w/perf/abscess w/bld D06.1 Carcinoma in situ of exocervix P39.3 Neonatal UTI K57.53 Diverticulitis sml & lrg intest w/o perf/abscess w/bleed D06.7 Carcinoma in situ of other parts of cervix N30.21 Other chronic cystitis w/hematuria K57.52 Diverticulitis sml & lrg intest w/o perf/abscess w/o bld N80.6 Endometriosis in cutaneous scar N30.81 Other cystitis w/hematuria K57.41 Diverticulitis sml & lrg intest w/perf/abscess w/bleed N80.2 Endometriosis of fallopian tube R31.2 Other microscopic hematuria K57.40 Diverticulitis sml & lrg intest w/perf/abscess w/o bleed N80.5 Endometriosis of intestine O86.29 Other UTI following delivery K57.12 Diverticulitis sml intest w/o perf/abscess w/o bleed N80.1 Endometriosis of ovary Z87.440 Personal history of urinary (tract) infections R10.816 Epigastric abdominal tenderness N80.3 Endometriosis of pelvic peritoneum N02.6 Recurrent hematuria w/dense deposit dis R10.13 Epigastric pain N80.4 Endometriosis of rectovaginal septum & vagina N02.7 Recurrent hematuria w/diff crescentic glomerulonephri R10.826 Epigastric rebound abdominal tenderness N80.0 Endometriosis of uterus N02.4 Recurrent hematuria w/diff endocap prolif glomerul R10.84 Generalized abdominal pain N80.9 Endometriosis, unspec N02.2 Recurrent hematuria w/diff membr glomerulonephritis R10.817 Generalized abdominal tenderness N92.1 Excessive & frequent menstruation w/irregular cycle N02.3 Recurrent hematuria w/diff mesangial prolif glomerul R10.827 Generalized rebound abdominal tenderness N92.0 Excessive & frequent menstruation w/regular cycle N02.5 Recurrent hematuria w/diff mesangiocap glomerulon R19.00 Intra-abd & pelvic swelling, mass & lump, unspec site N92.4 Excessive bleeding in the premenopausal period N02.1 Recurrent hematuria w/focal & segment glomerul les R19.04 Left lower quadrant abdominal swelling, mass & lump N92.2 Excessive menstruation at puberty N02.0 Recurrent hematuria w/minor glomerular abnormality R10.814 Left lower quadrant abdominal tenderness N83.00 Follicular cyst of ovary N02.8 Recurrent hematuria w/other morphologic changes E10.32 Left lower quadrant pain N80.8 Other endometriosis N02.9 Recurrent hematuria w/unspec morphologic changes R10.32 Left lower quadrant pain N83.8 Other non-inflam disord ovary fallop tube & broad lig N30.31 Trigonitis w/hematuria R10.824 Left lower quadrant rebound abdominal tenderness N83.209 Other ovarian cysts O23.42 Unspec infection of urinary tract in preg, 2nd trimester R19.02 Left upper quadrant abdominal swelling, mass & lump N85.8 Other specified non-inflammatory disorders of uterus O23.40 Unspec infection of urinary tract in preg, unspec trim R10.812 Left upper quadrant abdominal tenderness R10.2 Pelvic & perineal pain O23.41 Unspecified infection of urinary tract in preg, 1st trim R10.12 Left upper quadrant pain N84.0 Polyp of corpus uteri O23.43 Unspecified infection of urinary tract in preg, 3rd trim R10.822 Left upper quadrant rebound abdominal tenderness N95.0 Postmenopausal bleeding N23 Unspecified renal colic R10.30 Lower abdominal pain, unspec O04.88 UTI following (induced) terminat of preg R10.2 Pelvic & perineal pain O08.83 UTI following an ectopic & molar preg R10.815 Periumbilic abdominal tenderness X CODE THYROID ULTRASOUND O03.88 UTI following complete or unspec spont abortion R10.825 Periumbilic rebound abdominal tenderness 76536 Thyroid Ultrasound O86.20 UTI following delivery, unspec R10.33 Periumbilical pain E06.0 Acute thyroiditis O07.38 UTI following failed attempted termination of preg Z85.71 Personal Hx of Hodgkin lymphoma E06.3 Autoimmune thyroiditis O03.38 UTI infect following incomplete spontaneous abort Z85.42 Personal Hx of malignant neopl of other parts of uter E06.2 Chronic thyroiditis w/transient thyrotoxicosis N39.0 UTI site not specified Z85.51 Personal Hx of malignant neoplasm of bladder E06.4 Drug-induced thyroiditis Z85.3 Personal Hx of malignant neoplasm of breast D44.0 Neoplasm of uncertain behavior of thyroid gland Z85.41 Personal Hx of malignant neoplasm of cervix uteri D44.9 Neoplasm of uncertain behavior of unsp endoc gland X CODE TESTICULAR ULTRASOUND Z85.43 Personal Hx of malignant neoplasm of ovary E04.9 Nontoxic goiter, unspec 76870 Testicular Ultrasound Z85.9 Personal Hx of malignant neoplasm, unspec E06.5 Other chronic thyroiditis N44.2 Benign cyst of testis Z85.528 Personal Hx of other malignant neoplasm of kidney E04.8 Other specified nontoxic goiter R1Ø.2 Pelvic & perineal pain R10.829 Rebound abdominal tenderness, unspec site O90.5 Postpartum thyroiditis N5Ø.9 Disorder of male genital organs, unspec R19.03 Right lower quadrant abd swelling, mass & lump E06.1 Subacute thyroiditis R10.813 Right lower quadrant abdominal tenderness E06.9 Thyroiditis, unspec R10.31 Right lower quadrant pain R10.823 Right lower quadrant rebound abdominal tenderness hcss09212015 REFERRING PHYSICIAN: Please complete the Patient Referral section above & place an “X” next to the procedure code & justifiable diagnosis code or provide an alternative diagnosis in the space below each procedure grouping Please see other side for additional information for your patients .
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