Imaging Services Order Guide Medicare Guidelines Require Explicit Written and Signed Provider Orders

2021 Imaging Services Order Guide Medicare guidelines require explicit written and signed provider orders. This guide was created to assist you in ordering and authorizing exams accurately. Please obtain insurance authorizations before scheduling imaging studies.

Call one of our licensed/certified technologists if you have questions or comments.

NOTE: Please DO NOT call the department to schedule an appointment.

CENTRALIZED SCHEDULING ...... 509-248-9592 GENERAL X-RAY ...... 509-895-0509 COMPUTED TOMOGRAPHY (CT) ...... 509-895-0507 MAGNETIC RESONANCE IMAGING (MRI) ...... 509-895-0505 NUCLEAR MEDICINE ...... 509-575-8099 `OHANA MAMMOGRAPHY ...... 509-574-3863 ULTRASOUND ...... 509-249-5154 VASCULAR ULTRASOUND–Memorial Heart & Vascular ...... 509-574-0243 VASCULAR STAT REFERRALS–Memorial Heart & Vascular . . . .509-494-0551 CARDIOVASCULAR SERVICES–Memorial Heart & Vascular . . . 509-574-0243 BONE DENSITY–Lakeview Campus ...... 509-972-1170 PROVIDER EMERGENCY ...... 509-248-7380 Option 0

Consultation of a Clinical Decision Support Mechanism is required to determine if advanced diagnostic imaging services (CT, MRI, Nuclear Medicine, PET) adheres to Appropriate Use Criteria. Order must include Decision Support Number (DSN), G-Code, and Modifier. PHONE | 509-895-0507 PHONE | 509-895-0507 2 3 CT/CAT Scan/Computed Tomography FAX | 509-576-6982 CT/CAT Scan/Computed Tomography FAX | 509-576-6982

*If patient is over 400 lbs., please call the CT department at 509-895-0507. *If patient is over 400 lbs., please call the CT department at 509-895-0507. Consultation of a Clinical Decision Support Mechanism is required. Order must include DSN, G-Code, and Modifier. Consultation of a Clinical Decision Support Mechanism is required. Order must include DSN, G-Code, and Modifier.

BODY PART SYMPTOMS (REASON FOR EXAM) ORDER/PERFORM CPT CODE(S) BODY PART SYMPTOMS (REASON FOR EXAM) ORDER/PERFORM CPT CODE(S)

Bleed • Dizziness • Headache • Fracture • Fainting History of Cancer • Small Bowel Disease (Crohn’s) HEAD • Fresh CVA • Trauma (<1 week) • Dementia, Without IV Contrast 70450 • Large Bowel Disease • Abscess • Diverticulitis ABDOMEN & PELVIS (Routine) Memory Loss, TIA • Generalized Abdominal Pain • Hemochromatosis (CT Appendix) With IV Contrast 74177 • Infection • Mass • Leukemia • Lymphoma • Weight (CT Enterography) Note: Radiologist’s protocol is to not do “with IV Loss • Hx of Hepatitis B or C • Gross Hematuria HEAD contrast only” unless a “without” IV contrast study With IV Contrast 70460 • Cirrhosis • Appendix has been performed within last 30 days. ABDOMEN & PELVIS (CT KUB) F/U CVA • Hx of Seizures • Vision Problems (Long Flank Pain • Kidney Stones • Hematuria with pain Without IV Contrast 74176 HEAD Without & With IV Contrast 70470 (CT RENAL CALC) Term) • F/U Trauma (>1 week) • Metastatic Disease ABDOMEN & PELVIS ORBITS Fracture • Foreign Body Without IV Contrast 70480 Hematuria without pain Without & With IV Contrast 74178 (CT Urography) ORBITS Abscess • Infection • Mass With IV Contrast 70481 CTA HEAD Aneurysm • AVM • Bleed With IV Contrast 70496 SINUS Sinusitis Without IV Contrast 70486 CTA NECK Stenosis • Aneurysm With IV Contrast 70498 Temporal Bones/IACs Foreign Body • Trauma • Cholesteatoma Without IV Contrast 70480 70496 CTA HEAD & NECK Aneurysm • Stenosis With IV contrast Temporal Bones/IACs Abscess • Infection • Mass With IV Contrast 70481 70498 Mastoids Mastoiditis Without IV Contrast 70480 CTA CHEST Dissection • Widened Mediastinum • Aneurysm With IV Contrast 71275 Facial Bones Fracture • Parotid Stone • Trauma Without IV Contrast 70486 CTA PE Chest Pain • Pulmonary Embolus (Pulmonary Angio) • Shortness of Breath (SOB) • Positive D-dimer With IV Contrast 71275 Facial Bones Abscess • Infection • Mass With IV Contrast 70487 (PE Study) • Blood clot in lungs 70491 CTA ABDOMEN Renal Artery Stenosis With IV Contrast 74175 Always done with IV contrast unless Creatinine Note: CPT Mesenteric Artery Abnormality • Celiac Artery NECK (Soft Tissue) level too high or involving Thyroid. Please call With IV Contrast 70490 used if CTA ABDOMEN & PELVIS With IV Contrast 74174 Disease • Dissection • Suspected AAA • Known AAA 509-895-0507 for instructions. done without IV contrast) 71275 CTA CHEST/ABDOMEN PELVIS Dissection • Aneurysm • AAA With IV Contrast 74174 SPINE: Fracture • HNP (Lumbar) • Pain Cervical 72125 (C) CTA ABDOMEN W/RUNOFF • Trauma • Pain in Arms (Cervical) Without IV Contrast Claudication • Pain • Non-healing Ulcers Thoracic 72128 (T) (CTA Runoff) With IV Contrast 75635 • Radiculopathy • Peripheral Vasular Disease Lumbar 72131 (L) (CTA Lower Extremity) CHEST High Resolution Pulmonary Fibrosis • Interstitial Lung Disease Without IV Contrast 71250 73201 (Upper) EXTREMITY: (Specify Body Part) Abscess • Cellulitis • Infection • Mass With IV Contrast 73701 (Lower) • Abnormal Chest X-Ray • Abscess • COPD • CHF CHEST (Routine) • Infection • Lung CA • Lymphadenopathy • Mass With IV Contrast 71260 73200 (Upper) EXTREMITY: (Specify Body Part) Fracture • Pain Without IV Contrast • METS • Pneumonia 73700 (Lower)

CHEST (Routine) New Nodule • Follow-up Nodule • Rib Fracture Without IV Contrast 71250 CT rarely performs studies without and with IV contrast—unless stated as in the above options. CHEST Calcium Screening Without IV Contrast 75571 Please call CT department before ordering a study without and with IV contrast. ABDOMEN Hernia Without IV Contrast 74150 Who needs a Creatinine level? (Note: If a creatinine result is needed, please provide written order.) Anyone having a CT with IV contrast study who is 60 and older or: Abdominal Pain • Elevated Liver Function Test 1. Is diabetic ABDOMEN • Pancreas Involvement • Abscess • Infection With IV Contrast 74160 2. Has history of kidney disease (including dialysis, solitary kidney, kidney transplant, kidney cancer, kidney failure, kidney surgery) • Enlarged Organs 3. Has history of hypertension requiring medication PELVIS Bony Abnormality • Hernia Without IV Contrast 72192 If the Patient’s GFR is between 30 and 45, they will require IV hydration. We require signed provider orders prior to scheduling these patients. PELVIS Pain • Abscess • Infection • Mass With IV Contrast 72193 Orders for “Prevention of Contrast Induced Nephropathy Radiology Procedures” can be found on Yakima Memorial Abscess • Infection • Mass • METS • Pain Memorial’s Homepage/Applications/Order sets/General Contrast –Induced Nephropathy Prevention order set or use CHEST/ABDOMEN/PELVIS With IV Contrast 71260 & 74177 • Lymphadenopathy • Hx of Cancer the following link: https://www.yakimamemorial.org/pcinrp Pregnancy: The possibility of pregnancy will require a negative pregnancy test result to proceed with exam. Oral Contrast: When necessary or required, patients will be given oral contrast 1 hour prior to their scheduled procedure. General X-Ray Standard Views FAX | 509-248-7395 4 General X-Ray Standard Views FAX | 509-248-7395 5

BODY PART STANDARD VIEW(S) CODES BODY PART STANDARD VIEW(S) CODES HEAD/NECK Shoulder w/ Recent Trauma AP (Internal/External Rotation) and “Y” View 73030 Skull (Limited) AP & Lateral 70250 Humerus AP & Lateral 73060 Skull (Complete) AP, PA, Towne, RT & LT Laterals 70260 Elbow AP, Lateral & Oblique 73080 Orbits PA, Waters, Lateral & Blowout 70200 Radius/Ulna AP & Lateral 73090 Facial Bones PA, Waters, Lateral, SMV 70150 Wrist PA, Lateral & Oblique 73110 Sinuses (Limited) Waters 70210 Hand PA, Lateral & Oblique 73130 Sinuses (Complete) (Routine) Waters, Lateral, SMV & Caldwell 70220 Finger PA, Lateral & Oblique 73140 Mandible PA, Towne, SMV, RT & LT Laterals 70110 Pediatric (<1y/o) Upper Extremity AP & Lateral 73092 Nasal Bones PA, Waters, Lateral 70160 LOWER EXTREMITY Neck for Soft Tissue Lateral, AP 70360 Hip AP Pelvis & Lateral Hip 73502 THORAX HIP (Bilateral) AP Pelvis & Lateral of Both Hips 73522 Chest PA & LT Lateral 71046 Femur AP & Lateral 73552 Ribs (Unilateral) AP & Oblique & Below Diaphragm 71100 Knee AP & Lateral 73560 Ribs (Bilateral) AP & Both Obliques & Below Diaphragm 71110 Knee (Bilateral Standing) Standing AP view only 73565 Sternum RAO & Lateral 71120 Lower Leg (Tibia/Fibula) AP & Lateral 73590 Sternoclavicular Joints PA & Both Obliques 71130 Ankle AP, Lateral & Oblique 73610 SPINE Foot AP, Lateral & Oblique 73630 Scoliosis Study (Only done at Yakima Memorial Memorial) 72081 Os Calcis (Heel) AP & Lateral 73650 Cervical Spine (2 or 3 views) (Routine) AP, Lateral, & Odontoid 72040 Toe AP & Oblique 73660 Cervical Spine Series (5 views) AP, Lateral, Odontoid & Both Obliques (or specify other views) 72050 Pediatric (<1y/o) Lower Extremity AP & Lateral 73592 Cervical Spine (7 views) AP, Lateral, Odontoid, Both Obliques, Flexion & Extension 72052 OTHER Scanogram (Leg Length) Thoracic Spine Series AP & Lateral 72070 AP Bilateral Hips, Knees & Ankles (Valley Imaging can only do Supine) 77073 (Only performed at Yakima Valley Memorial) Thoracolumbar Spine AP & Lateral 72080 Bone Age Study PA of LT Hand 77072 AP, Lateral, Coned-Down of L5/S1 Lumbar Spine Series (Routine) 72100 AP & Lateral Skull • Lateral C-Spine • Lateral L-Spine • AP Chest Lumbar Spine (5 views) AP, Lateral, Coned-Down L5/S1, & Both Obliques or Flexion & Extension 72110 • AP Humeri • AP Forearms • PA Hands • AP Femurs • AP Lower Legs Bone Survey (Infant/child) 77076 Lumbar Spine (7 views) AP, Lateral, Coned-Down L5/S1, Both Obliques, and Flexion & Extension 72114 • AP Pelvis (to include mid lumbar spine) • AP Feet • Thorax (AP, Lateral, Right & Left Obliques) to include ribs Lumbar Spine (2 views) Flexion & Extension only or Side-to-Side only 72120 AP & Lateral Skull • Lateral C-Spine • AP & Lateral L-Spine Pelvis AP 72170 Bone Survey (Complete) • AP Pelvis • Lateral Thoracic Spine • Obliques of Ribs • AP Femurs 77075 Sacrum/Coccyx AP’s & Lateral 72220 • AP Lower Legs (to include ankles) • AP Bilateral Humerus SI Joints AP & Both Obliques 72202 PROCEDURES only done at Yakima Valley Memorial ABDOMEN Barium Swallow/Esophagus 74220 Abdomen/KUB AP of Kidneys, Ureters & Bladder 74018 Upper GI 74246 Abdomen (2 views) AP & Upright 74019 Small Bowel Follow Through 74250 PA chest, upright abdomen, supine abdomen and a LT lateral decub 74246 (UGI), Abdomen Series 74022 Upper GI w/ Small Bowel Follow Through abdomen 74248 (SB) UPPER EXTREMITY Colon 74270 Air Contrast Colon 74280 Clavicle AP 73000 Lumbar Puncture 77003, 62270 Scapula AP & Lateral 73010 62302, 77003, AC Joints AP Weight Bearing & AP Non-Weight Bearing 73050 Cervical Myelogram 72126 Shoulder AP Internal & External Rotation 73030 62304, 77003, Lumbar Myelogram 72132 PHONE | 509-895-0505 PHONE | 509-895-0505 MRI/Magnetic Resonance Imaging FAX | 509-576-6982 6 MRI/Magnetic Resonance Imaging FAX | 509-576-6982 7 *If patient is over 400 lbs., please call the MRI department at 509-895-0505. *If patient is over 400 lbs., please call the MRI department at 509-895-0505. Consultation of a Clinical Decision Support Mechanism is required. Order must include DSN, G-Code, and Modifier. Consultation of a Clinical Decision Support Mechanism is required. Order must include DSN, G-Code, and Modifier.

BODY PART SYMPTOMS (REASON FOR EXAM) ORDER/PERFORM CPT CODE(S) BODY PART SYMPTOMS (REASON FOR EXAM) ORDER/PERFORM CPT CODE(S)

Headaches • Memory Loss • Dizziness ANKLE (mid foot through Pain • Achilles Tendon tear • Posterior Tibial BRAIN Without IV Contrast 70551 Without IV Contrast 73721 • Seizures • Confusion • Stroke • Trauma calcaneus) Tendon tear • Sprain • F/U Fracture Tumor • METS • Mass • Known M.S. • Bell’s ANKLE (mid foot through BRAIN Without & With IV Contrast 70553 Mass • Osteomyelitis • Cellulitis Without & With IV Contrast 73723 Palsy • Facial Nerve • Acoustic Neuroma calcaneus) ORBITS Optic Nerve Pathology Without & With IV Contrast 70543 FOOT (toes through Plantar Fasciitis • Pain • F/U Fracture Without IV Contrast 73718 mid foot) MRA BRAIN Aneurysm • 3rd–7th Nerve Palsy Without IV Contrast 70544 FOOT (toes through Osteomyelitis • Neuroma • Abscess Without & With IV Contrast 73720 MRA NECK Stenosis • Aneurysm • Dissection Without & With IV Contrast 70549 mid foot) • Mass • Cellulitis NECK (soft tissue) Lump • Mass • Vocal Cord Paralysis Without & With IV Contrast 70543 MRI ARTHROGRAM SPINE: Shoulder 73222 (Shoulder) Pain • Sciatica • Stenosis • Radiculopathy 72141 (C) Cervical Wrist 73222 (Wrist) • HNP • Fracture • Hx of Surgery (Cervical or Without IV Contrast 72146 (T) Thoracic Hip Internal Derangement • Labrum Ligament Tears Direct Joint Injection 73722 (Hip) Thoracic) • Metastatic Bone Disease 72148 (L) Lumbar (Note: Knee and Ankle must 73722 (Knee) be scheduled at Yakima 73722 (Ankle) SPINE: 72156 (C) Valley Memorial) Cervical Infection • Abscess, Syrinx • Hx of Lumbar Without & With IV Contrast 72157 (T) Thoracic Surgery within 5 yrs Placenta Accreta • Pain during pregnancy 72158 (L) PELVIS (Female) Without IV Contrast 72195 Lumbar • Bicornuate Uterus SPINE SURVEY Myeloma • Metastatic disease Without IV Contrast 72148 Detection of Gynecologic Problems PELVIS (Female) • Malignancy • Pelvic Pain • Pelvic Mass Without & With IV Contrast 72197 Abdominal Pain • Detection of bile duct or Without IV Contrast ABDOMEN (MRCP) 74181 including Ovarian Cysts or Fibroids gallbladder stones (NPO for 4 hours) Renal/Liver/Pancreas Lesion • Mass Without & With IV Contrast PELVIS Pain • Fracture • Metastatic disease Without IV Contrast 72195 ABDOMEN 74183 • METS • Cirrhosis (NPO for 4 hours) PELVIS Mass • Abscess • Infection Without & With IV Contrast 72197 Complications from crohn’s disease inflammation 74183 MRI Enterography Without and With IV Contrast SACRUM Pain • Fracture • Malignancy Without IV Contrast 72195 • Inflammatory bowel disease 72197 S.I. JOINTS Pain • Sacrolitis Without IV Contrast 72195 BREAST Implant Rupture Without IV Contrast 77047 Multiple Myeloma Myeloma • Evaluate Bone Marrow Only Without Contrast 77084 Breast cancer • BRCA 1 & 2 BREAST Without and With IV Contrast 77049 • Dense Breast Tissue MRI rarely performs studies with IV contrast only. Refer to MRI department before ordering a study with IV contrast. HUMERUS RADIUS/ULNA Pain • Trauma • Fracture • Muscle/Tendon Tear Without IV Contrast 73218 Who needs a Creatinine Blood Result? (Note: If Creatinine result is needed, please provide written order.) HUMERUS RADIUS/ULNA Infection • Osteo • Abscess • Mass • Tumor Without & With IV Contrast 73220 Anyone having an MRI utilizing IV Contrast study who: SHOULDER, ELBOW, WRIST Pain • Trauma • Fracture • Muscle/Tendon Tear Without IV Contrast 73221 1. Is diabetic 2. Has history of kidney disease (including dialysis, solitary kidney, kidney transplant, kidney cancer, kidney failure, SHOULDER, ELBOW, WRIST Infection • Osteo • Abscess • Mass • Tumor Without & With IV Contrast 73223 kidney surgery) FEMUR, TIBIA/FIBULA Pain • Trauma • Fracture • Muscle/Tendon Tear Without IV Contrast 73718 3. Has history of hypertension requiring medication Anyone having an MRI must be competent to sign MR screening form and contrast form. FEMUR, TIBIA/FIBULA Infection • Osteo • Abscess • Mass • Tumor Without & With IV Contrast 73720 Patients who are breast feeding may want to “pump & dump” for 24 hours after the exam if Gadolinium is injected. HIP, KNEE Pain • Trauma • Fracture • Muscle/Tendon Tear Without IV Contrast 73721 Please document on order if patient uses a wheelchair or needs moving/lifting assistance. HIP, KNEE Infection • Osteo • Abscess • Mass • Tumor Without & With IV Contrast 73723 PHONE | 509-575-8099 PHONE | 509-575-8099 8 9 Nuclear Medicine FAX | 509-575-8624 Nuclear Medicine FAX | 509-575-8624

Consultation of a Clinical Decision Support Mechanism is required. Order must include DSN, G-Code, and Modifier. Consultation of a Clinical Decision Support Mechanism is required. Order must include DSN, G-Code, and Modifier.

BODY PART SYMPTOMS (REASON FOR EXAM) ADDITIONAL INFO CPT CODE(S) BODY PART SYMPTOMS (REASON FOR EXAM) ADDITIONAL INFO CPT CODE(S)

PARATHYROID WITH LUNG QUANTITATIVE Elevated Calcium/PTH PTH and Calcium level 78072 Pre- or post-operative evaluation 78598 SPECT-CT (vent or perf) Lab results: TSH, T3 and T4 History of Cancer • Evaluation of bone pain Hyperthyroidism or hypothyroidism Recent images/reports from other Image results from other modalities WHOLE-BODY BONE • Elevated alkaline phosphatase • Arthritis 78306 • Thyroid nodule function evaluation modalities THYROID UPTAKE AND • R/O Paget’s Disease • Graves’ disease • Sub acute thyroiditis Prep: No CT with contrast in past 78014 SCAN SPECT BONE Low Back pain • Pars Fracture • Stress Recent images/reports from other • Evaluation of heterogeneity of function 6 weeks, off thyroid medication 78830 within the thyroid gland • Abnormal TSH, T3, T4 4 weeks, off anti-thyroid SPECT-CT BONE Fracture • Degenerative disc disease modalities medication 4 days. Osteomyelitis • Cellulitis • Avascular Necrosis Recent images/reports from other THREE PHASE BONE • Bone infarcts • Loosening of prosthesis 78315 Lab results: TSH, T3 and T4 modalities • Stress Fracture Image results from other modalities THYROID 78013 Fracture w/o hardware Recent images/reports from other Thyroid nodule function evaluation Prep: No CT with contrast in past 6 weeks, LIMITED BONE 78300 SCAN ONLY Bone pain in specific area modalities off thyroid medication 4 weeks, off anti-thyroid medication 4 days. Recent images/reports from other MULTIPLE AREAS Bone pain in more than one area 78305 modalities THYROID Thyroid carcinoma Prep: No CT with contrast in past 6 78018 WHOLE-BODY SCAN Post ablation evaluation weeks, off thyroid medication 6 weeks Cardio-toxic chemo MUGA Pre-chemo LVEF evaluation 78472 THYROID ABLATION Thyroid cancer Please refer to Endocrinologist Congestive heart failure THYROID THERAPY Hyperthyroidism Please refer to Endocrinologist NM CARDIAC Evaluate viable cardiac tissue 78452 VIABILITY (TL-201) Bile leak • Evaluation of the biliary Image results from other modalities BILIARY PATENCY 78226 system after surgery • Biliary atresia Prep: NPO 4 hours RENAL WITH LASIX Image results from other modalities Evaluation of hydronephrosis 78708 WASHOUT Prep: Well hydrated. Image results from other modalities BILIARY WITH Acute or chronic cholecystitis, bile gastritis, 78227 RENAL FLOW AND Evaluation of kidney function Image results from other modalities EJECTION FRACTION RUQ pain, adbominal pain Prep: No narcotic pain meds for 24 hours. 78707 NPO 4 hours before exam FUNCTION Flank pain Prep: Well hydrated. GASTRIC BLEEDING Active gastrointestinal bleeding Results from Colonoscopy 78278 RENAL WITH Image results from other modalities R/O Renal artery stenosis 78709 CAPTOPRIL Prep: No ACE inhibitors last 3 days. Nausea/Vomiting • Med/Surg Image results from other modalities evaluation of effectiveness IN-111 78830 Neuroendocrine tumors (carcinoid) GASTRIC EMPTY • Gastroesophageal reflux (pre-surgical) Prep: Nothing to eat or drink 4 hours prior, 78264 OCTREOTIDE 78804 • Persistent symptoms no narcotic pain meds 48 hours prior, no gastric emptying meds 48 hours prior. Tremor/Gait Disturbance following upper GI surgery. DATSCAN 78830 Parkinsonian Syndrome MECKEL’S Prep: Patient should fast 3 hours prior Hematochezia,R/O Meckels Diverticulum 78290 DIVERTICULUM to scan • Abnormal or equivocal exercise stress test Contraindications for exercise • Able to exercise with a goal of meeting • Ventricular pre-excitation Evaluation of Cirrhosis, hepatitis • Focal 85% of max predicted HR * If unable to • Uninterpretable ECG (V-paced rhythm, LIVER IMAGING EXERCISE NUCLEAR Nodular hyperplasia • Assess function of 78201 meet target HR, patient will be converted to LBBB, >1mm ST depression) 78452 (static only) STRESS TEST reticuloendothelial system a vasodilator test. • Severe hypertension • Likely to have poor echo images Hepatic Cavernous Hemangioma —with vascular flow 78830 • Symptomatic Evaluation of liver vascular flow • Exercise contraindicated or unable to Contraindications for vasodilator LIVER AND SPLEEN Evaluation of Cirrhosis • Hepatitis exercise or achieve 85% max predicted HR • 2nd degree or 3rd degree AV Block 78215 VASODILATOR (static only) • Residual splenic tissue after splenectomy (document why) • Uninterpretable baseline • Severe hypotension NUCLEAR STRESS 78452 ECG (including LBBB, ventricular paced —with vascular flow Evaluation of liver vascular flow 78216 TEST rhythm, >1 mm ST depression) • Likely to LUNG V/Q R/O Pulmonary Embolism • Chest pain/ Chest x-ray within 24 hours. 78582 have poor echo images • Symptomatic (vent/perfusion) shortness of breath with positive D-dimer NUCLEAR MEDICINE Ischemic cardiomyopathy— LUNG PERFUSION 78452 Evaluation of pulmonary perfusion 78580 VIABILITY STUDY evaluate viable cardiac tissue ONLY Consultation of a Clinical Decision Support Mechanism is required. Order must include DSN, G-Code, and Modifier. PHONE | 509-248-5154 PHONE | 509-248-5154 Ultrasound FAX | 509-576-6982 10 Ultrasound FAX | 509-576-6982 11

BODY PART ORGANS INCLUDED SYMPTOMS (REASON FOR EXAM) CPT CODE(S) BODY PART SYMPTOMS (REASON FOR EXAM) ADDITIONAL INFO CPT CODE(S)

Abdominal Pain • History of Cancer • Nausea & Needs to be ordered with US abdomen complete or 76981 & Abd Assessment of liver fibrosis risk, Pancreas • Liver • Gallbladder Vomiting • Mass • Enlarged Organs • Abnormal limited if not completed within the past 1 month. Comp 76700 US ELASTOGRAPHY longitudinal monitoring of liver US ABDOMEN • Common Bile Duct • Right Kidney Labs • Weight Loss 76700 or disease. Prep: NPO for 8 hours; no alcohol 12 hours prior • Left Kidney • Aorta • Spleen Prep: NPO for 8 hours; small sips of water with to study Abd Ltd 76705 medication acceptable Unknown dates • Confirm viability • AFI evaluation RUQ Pain • Jaundice • Suspected Gallstones US PREGNANCY Uterus • Ovaries • Any additional • Placental location • Fetal position 76815 US ABDOMEN Limited Pancreas • Liver • Cirrhosis • History of gallstones • Elevated liver LIMITED concerns noted on the order Prep: Drink 32oz. of water 1 hour prior 76705 for Liver/Gallbladder • Gallbladder • Common Bile Duct function tests • Hepatitis B or C to exam; DO NOT VOID Prep: NPO for 8 hours; small sips of water acceptable Re-evaluation of fetal size • Re-evaluation of organ Soft tissue mass in the abdominal wall • Soft tissue systems suspected or confirmed to be abnormal on Uterus • Ovaries • As indicated on US ABDOMEN Limited mass on the lower back • Hernia, umbilical hernia US PREGNANCY previous scan • Re-evaluation of anatomy not seen Area indicated on order 76705 order for fetal/pregnancy evalua- 76816 for hernia or mass or higher in the abdomen FOLLOW-UP well on previous anatomic survey tion Prep: None Prep: Drink 32oz. of water 1 hour prior to exam; DO NOT VOID RLQ pain • Elevated WBC US PREGNANCY Funneling • Cerclage • Preterm labor • Hx of US APPENDIX RLQ Appendix area Pt must have a normal BMI to have 76705 Transvaginal cervix 76817 TRANSVAGINAL preterm labor • Shortened Cervix on previous exam the appendix evaluated by Ultrasound US BIOPHYSICAL Biophysical profile Decreased fetal movement • Post Dates Pregnancy 76819 US CAROTID Only done at YVM Heart & Vascular PROFILE evaluation of the fetus • Irregular Non-Stress Test US EXTREMITY Palpable Soft Tissue Lump on an extremity Area indicated on order 76882 76705 NON-VASCULAR • Abscess US PYLORIC Pylorus Projectile Vomiting • Weight Loss Doppler STENOSIS Please order doppler as indicated • Failure to Thrive Flank pain • Hematuria • Polycystic Kidneys 93975 US KIDNEYS/ Right Kidney • Left Kidney • Bladder 76770 RETROPERITONEAL Prep: Drink 32oz. of water 1 hour prior to exam. 76870 If able to hold the bladder, it helps the exam US SCROTUM/ Bilateral Testicles • Scrotum Pain • Swelling • Mass Doppler TESTICLES Please order doppler as indicated • Location of Testicle (undescended) 93975 Inguinal hernia or hx of inguinal hernia US PELVIS LIMITED Inguinal area indicated on order 76857 • Groin pain to eval for hernia US SPINE (INFANT) Spine • Area of dimple Sacral Dimple • Skin Tag 76800 US THYROID/ Thyroid • Neck area indicated on Abnormal Thyroid Function 76536 Uterus • Ovaries Pelvic Pain • Ovarian Cysts • Abnormal Vaginal 76856 SOFT TISSUE NECK order • Palpable Mass • Enlargement Bleeding • Ovarian Cancer Screening • Polycystic Transvaginal US VEIN (UPPER OR ovary syndrome • Clinically Suspected Adnexal Only done at YVM Heart & Vascular US PELVIS Please order transvaginal as 76830 LOWER EXTREMITY) indicated Mass • Endometrial Evaluation Prep: Drink 32oz. of water 1 hour prior Doppler Increased head circumference Please order doppler as indicated to exam; DO NOT VOID 93975 Follow up abnormality seen on last exam US NEONATAL HEAD Intracranial Anatomy 76506 (US VENTRICLE) Exam is conducted through the anterior Uterus • Ovaries • Pregnancy Determine Location of Pregnancy (Intrauterine or fontanel, please indicate on the order if the US PREGNANCY Extrauterine) • Fetal Dates • Confirm Viability 76801 anterior fontanel is patent. 1ST TRIMESTER WITH Please order transvaginal as • Evaluate Bleeding or Pain Transvaginal Ovaries • Follicles • Uterus Infertility • Baseline for infertility workup TRANSVAGINAL indicated Prep: Drink 32oz. of water 1 hour prior 76817 US FOLLICLE STUDY 76830 • Endometrium Transvaginal evaluation of follicles to exam; DO NOT VOID Aorta Known AAA • Family history of AAA • History of Anatomic Survey of the fetus • Anatomy US AORTA 93978 Only scheduled at tobacco use • Pulsating abdominal mass This exam can only be billed one time in a YVM Heart & Vascular US PREGNANCY Uterus • Placenta • Anatomical pregnancy—use for anatomical survey only 76805 POST 1ST TRIMESTER survey of the fetus Once-in-a-lifetime exam—Male or female and US AAA SCREENING Prep: Drink 32oz. of water 1 hour prior Aorta + family history of AAA, or male 65-75 yo and 76706 MEDICARE PART B to exam; DO NOT VOID lifetime tobacco use > 100 cigarettes US RETROPERITONEAL Aorta • IVC • Left Kidney Follow-up on a single organ only after 76775 LIMITED • Right Kidney a complete study has been done. PHONE | 509-574-0243 Mammography/Bone Densitometry/Body Composition 12 Heart & Vascular FAX | 509-574-0257 13 STAT REFERRALS | 509-494-0551 PHONE | 509-574-3863 FAX | 509-249-8649 Outpatient Vascular Ultrasound Services BODY PART SYMPTOMS (REASON FOR EXAM) ORDER/PERFORM CPT CODE(S) * This form is not intended to represent a comprehensive list of all appropriate indications .

Breast cancer • BRCA 1 & 2 EXAM NAME COMMON INDICATIONS CPT CODES BREAST MRI Without and With IV Contrast 77049 (Done at Valley Imaging) • Dense breast tissue Bruit • Hx of CVA/TIA • Pre-op exam • Numbness, paresthesia • Stenosis of carotid artery 93880 (Complete) CAROTID • Cerebrovascular disease • Subclavian artery stenosis • Vascular grafts/stents DX Bilat–G0204 93882 (Limited) New mass • Nodule • Thickening • Diagnostic Mammogram DX Uni–G0206 • Coronary artery disease • Amaurosis fugax • Syncope and Collapse BREAST Asymmetry Breast Ultrasound Ultrasound Left or 93886 (Complete) TCD See above Right–76642LT or 76642RT 93888 (Limited)

DX Bilat–G0204 TCD EMBOLI MONITORING HX of CVA/TIA • Numbness • Paresthesia • Amaurosis fugax • Syncope and collapse 93892 Diagnostic Mammogram DX Uni–G0206 Abd swelling, mass, lump • Abdominal tenderness • Bruit /weak pulse 93978 (Complete) AORTOILIAC BREAST Discharge Breast Ultrasound Ultrasound Left or Right– • AAA • Aortic ectasia • Vascular grafts/stents • Endograft evaluation 93979 (Limited) Ductogram if indicated 76642LT or 76642RT *One time only, must be initial imaging study of the abdominal aorta Ductogram–77054 Medicare AAA Screening Male or female and + family history of AAA, or DX Bilat–G0204 History of benign biopsy Diagnostic Mammogram or AAA SCREENING Male 65-75 yo and lifetime tobacco use > 100 cigarettes 76706 BREAST DX Uni–G0206 ACC/AHA AUC AAA Screening Guidelines (JACC Vol 60,No. 3,2012) • Family history • Fibrocystic Screening Mammogram Screening–G0202 > 60 years old and family history of AAA, or > 65 years old and current or former smoker Asymptomatic • Routine • Greater than 3 years BREAST Screening Mammogram Screening–G0202 Post prandial abdominal pain • Nausea • Abdominal Bruit • Celiac artery compression post breast cancer treatment MESENTERIC 93976 • Vasc. disorder of intestines • Epigastric pain • Vascular grafts/stents • Abnormal weight loss Hypertension • Abnormal kidney function test • Renal artery stenosis RENAL ARTERY 93975 ** All Diagnostic Mammogram orders must have a signed written or electronic order prior to performing the exam. • Chronic kidney disease • Renal transplant • Vascular grafts/stents ILIOCAVAL (IVC) Shortness of breath • Chest pain • Compression of vein 93978 (Complete) (ABDOMINAL VENOUS) • Abnormal labs (D-dimer) • DVT/ PE • Leg swelling 93979 (Limited) 93925 (LEA BIL) 93926 (LEA UNI) PHONE | 509-972-1170 LOWER EXTREMITY ARTERIAL Pain in lower extremity • PVD • PVD with grafts/stents • Claudication • Ulcer • Bruit/Weak pulse 93978 (AO-IL) Bone Densitometry/Body Composition FAX | 509-249-5319 (LEA) 93922 (Resting ABI) (Performed at Lakeview Campus) 93924 (Exercise ABI) ANKLE BRACHIAL INDEX (ABI) 93922 (Resting/DBI) See above BODY PART SYMPTOMS (REASON FOR EXAM) ORDER/PERFORM CPT CODE(S) DIGIT BRACHIAL INDEX (DBI) 93924 (Exercise ABI)

Dual-Energy X-ray Absorptiometry (DXA), 93930 (UEA BIL) UPPER EXTREMITY ARTERIAL 93931 (UEA UNI) Bruit/ Weak pulse • Pain • PVD • PVD with grafts/stents • Asymmetric brachial BP BONE DENSITY 1 or more sites • Axial Skeleton (eg, hips, DXA Axial Skeleton 77080 (UEA) 93922 (WBI Resting) pelvis, spine) 93923 (Multilevel) Dual-Energy X-ray Absorptiometry (DXA), 93970 (BIL) UPPER EXTREMITY VENOUS (UEV) Pain in arm • Hx of DVT • Shortness of breath • Swelling, mass, lump BONE DENSITY 1 or more sites • Appendicular Skeleton DXA Appendicular Skeleton 77081 93971 (UNI) (peripheral) (eg, radius, wrist, heel) 93970 (BIL) LOWER EXTREMITY VENOUS (LEV) Pain in leg • Swelling • Hx of DVT / PE • Shortness of breath • Ulcer • Abnormal labs (D-dimer) Assessment of therapy response from diet, Body Composition Scan 93971 (UNI) BODY COMPOSITION 76499 exercise, medications, or bariatric surgery (icd-10 code BW0KZZZ) 93970 (Venous BIL) LOWER EXTREMITY REFLUX Varicose veins with pain • Swelling • Venous insufficiency (chronic) • Phlebitis • Ulcer 93971 (Venous UNI) 93978 (Iliocaval) UPPER EXTREMITY VEIN MAP Pre-op exam • PVD • CAD 93971 Prior to vein harvest LOWER EXTREMITY VEIN MAP See above 93971 Prior to vein harvest 93930 (UEA BIL) PRE-OP DIALYSIS ACCESS 93931 (UEA UNI/LTD) Chronic kidney disease • End stage renal disease Prior to hemodialysis access 93970 (Venous BIL) • Kidney failure creation 93971 (Venous UNI) 93923 (Multi level ABI) Swelling • Pain • Complication due to dialysis device, implant and graft DIALYSIS ACCESS (AVG)/ (AVF) 93990 • Difficult cannulation • Prolonged dialysis time PHONE | 509-574-0243 Heart & Vascular FAX | 509-574-0257 14 15 STAT REFERRALS | 509-494-0551

Outpatient Vascular Ultrasound Services * This form is not intended to represent a comprehensive list of all appropriate indications . EXAM NAME COMMON INDICATIONS CPT CODES

93926 (LEA UNI) PSEUDOANEURYM Bruit/Weak pulse • Mass/Lump post procedure • Pain • Complication of artery following a 93971 (Venous UNI) EVALUATION procedure • Swelling • Complication of vein following a procedure 93931 (UEA UNI)

RAYNAUD’S EVALUATION Raynaud’s Syndrome • Cyanosis • Cold extremity • Disturbance of skin sensation • Ulcer (non-pressure) 93923

Outpatient Diagnostic Cardiovascular Services EXAM NAME SUGGESTED USE ADDITIONAL INFO CPT CODES

12 LEAD ELECTROCARDIOGRAM— Establish Cardiac baseline 93010 NO IMAGING

EXERCISE STRESS TEST— Contraindications for exercise NO IMAGING Symptomatic • Normal baseline ECG / RBBB/ LAFB • Ventricular pre-excitation *Start here prior to without baseline ST changes • Able to exercise with • Uninterpretable ECG ( V-paced 93018 ordering stress test a goal of meeting 85% of max predicted HR rhythm, LBBB, >1mm ST depression) with imaging • Severe hypertension

Contraindications for exercise Symptomatic • Abnormal or equivocal exercise stress EXERCISE STRESS ECHO • Ventricular pre-excitation test • Able to exercise • Resting ST changes on 93351 with ultrasound enhancing • Uninterpretable ECG (V-paced ECG • Assess aortic stenosis, mitral reguritation or C8930 (with Definity) agent, if indicated rhythm, LBBB, >1mm ST depression) pulmonary hypertension with exercise • Severe hypertension

Symptomatic • Exercise contraindicated or unable to Contraindications for DOB DOBUTAMINE STRESS ECHO exercise or achieve 85% max predicted HR (document • Underlying dysrhythmias 93351 with ultrasound enhancing why) • Normal or nonspecific baseline ECG • Assess (i.e. atrial fibrillation/v-tach) C8930 (with Definity) agent, if indicated low gradient/ severe aortic stenosis

93306 (Complete) 2D ECHO • Structural Cardiac Assessment 93308 (Limited) with ultrasound enhancing • Include indication on order C8929 (with agent, if indicated Contrast/Definity)

24 or 48 hours HOLTER MONITOR 93227 *defaults to 24 hours unless otherwise specified

EXTENDED HOLTER 3-7 days of continuous patch monitoring 93224 MONITOR 8-14 days of continuous patch monitoring 93248

7-30 days of patient activated recording EVENT RECORDER 93272 *defaults to 7 days unless otherwise specified

Please attach patient demographics, a recent ECG, medication list, and a copy of your signed clinical note clearly indicating the reason for the test and current symptoms in order to establish medical necessity . We cannot schedule testing without this information. If you are unsure of what test to order please contact our office. Appropriate use criteria can be found on our website as well as our referral form . Imaging Services 509-575-8022 | FAX 509-577-5091 2811 Tieton Drive | Yakima, WA 98902 yakimamemorial.org

Valley Imaging 509-248-7380 | FAX 509-248-7395 314 South 11th Avenue, Suite B | Yakima, WA 98902

Heart & Vascular 509-574-0243 | FAX 509-574-0257 406 South 30th Avenue | Yakima, WA 98902

`Ohana Mammography 509-574-3863 | FAX 509-249-5319 1515 West Yakima Avenue | Yakima, WA 98902

Lakeview Bone Density and Body Composition Imaging 509-972-1170 | FAX 509-249-5319 1470 North 16th Avenue | Yakima, WA 98902

For information regarding Yakima Valley Memorial policies, refer to yakimamemorial.org/rights or call 509-469-5411.

REV 07/21