Updated 2016 Radiology Order Standards: Complete Provider/Offi ce Contact Information Pre-authorization Information Indication (reason) for study CT Ordering Guide Previous adverse contrast events

BODY Coronary CT W and W/O Contrast ...... CPT Code 75574 Prep: NPO 2 hours for all studies W Contrast • Coronary artery disease/Bypass graft evaluation • Chest pain suspected cardiac Chest CT W/O Contrast ...... CPT Code 71250 Heart CT W Contrast (Morphology) ...... CPT Code 75572 • Lung Nodules (may be done W Contrast if ordering MD desires) • Pulmonary venous mapping • Pneumonia (may be done W Contrast if ordering MD desires) • Pulmonary vein evaluation • Pleural effusion (may be done W Contrast if ordering MD desires) • Gated TAVI (if in conjunction with Angiography Abd and Pel CT • Interstitial Lung Disease (Hi Res Chest) W and W/O Contrast W/ 3D Reconstruction, CPT Code 74174) • COPD Abdomen CT W/O Contrast ...... CPT Code 74150 Chest CT W Contrast ...... CPT Code 71260 • Adrenal mass detection • Lung (may be done W/O Contrast if ordering MD desires) • Chest Wall Mass Abdomen CT W Contrast ...... CPT Code 74160 • Mediastinal Mass/Abnormality • Empyema • Liver Mass Characterization/Surgical Planning • Hilar Mass/Abnormality • (PE) • Hepatitis/Cirrhosis/Cholangiocarcinoma • Aneurysm Follow-Up (size only) • Chest Pain • Post treatment HCC (not for metastatic surveillance) (may be done W Contrast if ordering MD desires) • Coarctation of the aorta • Dissection (chest only, no 3D) Abdomen CT W and W/O Contrast ...... CPT Code 74170 • Renal Mass or Pancreatic Mass Characterization/Surgical Planning Chest CT W and W/O Contrast ...... CPT Code 71270 • Liver chemo embolization or RFA • Dissection (if in conjunction with Abdomen and Pelvis CT W Contrast, CPT Code 74177) • Adrenal Mass characterization Angiography, Chest CT W and W/O Contrast W/ 3D Reconstruction . . . . CPT Code 71275 Abdomen and Pelvis CT W/O Contrast ...... CPT Code 74176 • Aortic or mitral valve • Renal Stone/RP bleed • Thoracic outlet syndrome • Abdomen and pelvis patient who cannot have contrast • Chronic PE Abdomen and Pelvis CT W Contrast ...... CPT Code 74177 • Pulmonary AVM • Abdominal Pain/Abdominal mass/Malignancy • Nausea and vomiting/Weight loss/Fever • Pre and Post Operative sternal anatomy (redo sternotomy; Damiano protocol) • Diverticulitis/Appendicitis/Abscess/Acute pancreatitis • CT Enterography Chest CT W/O Contrast W/ 3D Reconstruction ...... CPT Code 71250 & 76377 • Dissection • Trauma/Bowel perforation • Any other indication that is not already listed (BODY – continued inside) • Airway imaging (inc. TBM), Tracheal stenosis, Tracheal malacia (Tracheal Tree) • Redo sternotomy for patients who cannot have contrast • Aortic or mitral valve for patients who cannot have contrast

To schedule any radiology exam, call 314-362-7111

BODY (continued) NEURO Prep: NPO 2 hours for all studies W Contrast Prep: NPO 2 hours for all studies W Contrast Abdomen and Pelvis CT W and W/O Contrast ...... CPT Code 74178 Head CT W/O Contrast ...... CPT Code 70450 • Ischemic Bowel • Headache/Trauma/Stroke/TIA • GI bleeding • Dizziness/Intracranial bleed

Angiography Abdomen CT W and W/O Contrast Head CT W and W/O Contrast ...... CPT Code 70470 W/ 3D Reconstruction ...... CPT Code 74175 • Mass/Metastatic disease • Pre Liver transplant/Portal vein embolization • Hepatic resection candidates Neck CT W Contrast ...... CPT Code 70491 • Living Liver Donor • Neck Mass/Malignancy Staging/Malignancy follow

Angiography Abd and Pel CT Sinus CT W/O Contrast ...... CPT Code 70486 W and W/O Contrast W/ 3D Reconstruction...... CPT Code 74174 • Acute or chronic Sinusitis/Nasal cavity polyps • Pre and Post endoluminal grafting/TAVI • TRAM fl ap surgical planning Orbits CT W/O Contrast ...... CPT Code 70480 • Living Renal Donor • Trauma/black eye/visual defects • Gated TAVI (if in conjunction with Heart CT W Contrast (Morphology), CPT Code 75572) Abdomen and Pelvis CT Maxillofacial CT W/O Contrast ...... CPT Code 70486 W/O Contrast W/ 3D Reconstruction ...... CPT Code 74176 & 76377 • Trauma/ black eye/facial contusion/jaw injury • Pre and post endoluminal grafting-for patients who cannot have contrast Maxillofacial CT W Contrast ...... CPT Code 70487 Chest, Abdomen and Pelvis CT W Contrast ...... CPT Code 71260 &74177 • Facial weakness/Neoplasm/Malignancy/Cellulitis/Abscess • Malignancy Staging/Malignancy follow-up Temporal Bones CT W/O Contrast ...... CPT Code 70480 Angiography Chest, Abdomen and Pelvis CT • Ear Disorder/Deafness/Acute Mastoiditis W and W/O Contrast W/ 3D Reconstruction...... CPT Code 71275 & 74174 • Trauma/ear injury • Pre and Post endoluminal grafting • Intraparenchymal hematoma Chest, Abdomen, and Pelvis CT Head CTA...... CPT Code 70496 W/O Contrast W/ 3D Reconstruction ...... CPT Code 71250, 74176 & 73677 • Intracranial Aneurysm/Stenosis/Dissection • Pre and post endoluminal grafting for patients who cannot have contrast • (SAH)/Arteriovenous malformation (AVM) Virtual Colonoscopy Diagnostic CT W/O Contrast ...... CPT Code 74261 • Failed colonoscopy Head and Neck CTA ...... CPT Code 70496 and 70498 • Patients that cannot be sedated or cannot stop blood thinners for conventional colonoscopy • Extracranial Aneurysm/Stenosis/Dissection • Subarachnoid hemorrhage (SAH)/Arteriovenous malformation (AVM) Urogram CT Abdomen and Pelvis • Penetrating neck injury W and W/O Contrast W/ 3D Reconstruction...... CPT Code 74178 & 76377 • Cervical Spine fracture • Hematuria Angiography, Abdominal Aorta CT Spine CT W/O Contrast. . . .CPT Code 72125 (C-Spine) or 72128 (T-Spine) or 72131(L-Spine) with Lower Extremity Runoff, W Contrast W/ 3D Reconstruction ...... CPT Code 75635 • Radiculopathy/Trauma/Pain • CT AIF / Bypass evaluation/Cold leg/Leg ischemia

To schedule any radiology exam, call 314-362-7111 MYELOGRAPHY MUSCULOSKELETAL CT (continued) Prep: NPO 4 hours; may drink clear liquids up to 30 minutes prior to exam Prep: NPO 2 hours for all studies W contrast Myelogram with CT, Cervical Spine...... CPT Code 72240 Upper Extremity (continued) (Precert CPT Code 72240 & 72126) Shoulder CT - W Contrast ...... CPT Code 73201 • Problem cases unresolved by non-invasive imaging • Mass/Tumor • Infection (if concern for septic joint should be aspirated prior to CT) • Patients with contraindications for MR Shoulder CT - W Contrast (Arthrogram only; no IV contrast) ...... CPT Code 73201 • Cervical myelopathy or radiculopathy in which fi ne bone detail is desired • Rotator cuff or labral injury, unable to get MRI • Arthroplasty evaluation • Presurgical planning and mapping Humerus, Arm CT - W/O Contrast ...... CPT Code 73200 Myelogram with CT, Thoracic Spine ...... CPT Code 72255 • Fracture, trauma (Precert CPT Code 72255 & 72129) Humerus, Arm CT - W Contrast ...... CPT Code 73201 • Problem cases unresolved by non-invasive imaging • Mass/Tumor • Infection • Patients with contraindications for MR • Thoracic myelopathy or radiculopathy in which fi ne bone detail is desired Elbow CT - W/O Contrast ...... CPT Code 73200 • Presurgical planning and mapping • Fracture, trauma • Osteoarthritis (OA) • Arthrodesis evaluation • Arthroplasty evaluation Myelogram with CT, Lumbosacral Spine ...... CPT Code 72265 (Precert CPT Code 72265 & 72132) Elbow CT - W Contrast ...... CPT Code 73201 • Problem cases unresolved by non-invasive imaging • Mass/Tumor • Infection (if concern for septic joint should be aspirated prior to CT) • Patients with contraindications for MR Elbow CT - W Contrast (Arthrogram only; no IV contrast) ...... CPT Code 73201 • Lumbar radiculopathy in which fi ne bone detail is desired • Osteochondral lesion (OCD) • Cartilage injury or repair • Loose body • Presurgical planning and mapping Forearm CT - W/O Contrast ...... CPT Code 73200 Myelogram with CT, 2-3 Regions ...... CPT Code 72270 • Fracture, trauma (Precert CPT Code 72270 & depending on the desired level(s) 72126, 72129, and/or 72132) Forearm CT - W Contrast ...... CPT Code 73201 • Problem cases unresolved by non-invasive imaging • Mass/Tumor • Infection • Patients with contraindications for MR Wrist CT - W/O Contrast...... CPT Code 73200 • Complex or nonfocal myelopathy or radiculopathy in which fi ne bone detail is desired • Fracture, trauma • Osteoarthritis (OA) • Arthrodesis evaluation • Presurgical planning and mapping Wrist CT - W Contrast ...... CPT Code 73201 • Mass/Tumor • Infection (if concern for septic joint should be aspirated prior to CT) Wrist CT - W Contrast (Arthrogram only; no IV contrast)...... CPT Code 73201 MUSCULOSKELETAL CT • Ligament injury • Triangular fi brocartilage (TFC) complex injury Prep: NPO 2 hours for all studies W contrast • Articular cartilage injury Chest Hand/Finger(s) CT - W/O Contrast ...... CPT Code 73200 Chest Wall, Clavicle, Sternum CT - W/O Contrast ...... CPT Code 71250 • Fracture, trauma • Osteoarthritis (OA) • Arthrodesis evaluation • Fracture • Trauma Hand/Finger(s) CT - W Contrast ...... CPT Code 73201 Chest Wall, Clavicle, Sternum CT - W Contrast...... CPT Code 71260 • Mass/Tumor • Infection (if concern for septic joint should be aspirated prior to CT) • Mass/Tumor • Infection Pelvis Upper Extremity Pelvis, Sacroiliac (SI) joints, Sacrum CT - W/O Contrast ...... CPT Code 72192 Shoulder CT - W/O Contrast ...... CPT Code 73200 • Fracture, trauma • Osteoarthritis (OA) • Bone stock/bone graft harvest evaluation • Fracture, trauma • Osteoarthritis (OA) • Arthrodesis evaluation • Arthroplasty loosening evaluation Pelvis, Sacroiliac (SI) joints, Sacrum CT - W Contrast ...... CPT Code 72193 • Mass/Tumor • Infection

To schedule any radiology exam, call 314-362-7111 (MUSCULOSKELETAL – continued on back)

MUSCULOSKELETAL CT (continued) Ankle/Hindfoot (specify unilateral or bilateral) CT - W/O Contrast. . . . CPT Code 73700 Prep: NPO 2 hours for all studies W contrast • Fracture, trauma • Osteoarthritis (OA) • Arthrodesis evaluation • Arthroplasty evaluation Lower Extremity Ankle/Hindfoot (specify unilateral or bilateral) CT - W Contrast...... CPT Code 73701 • Mass/Tumor • Infection (if concern for septic joint should be aspirated prior to CT) Hip (specify unilateral or bilateral) CT - W/O Contrast ...... CPT Code 73700 • Fracture, trauma • Osteoarthritis (OA) • Arthrodesis evaluation • Arthroplasty evaluation Ankle, Hindfoot CT - W Contrast (Arthrogram only; no IV contrast) . . . CPT Code 73701 • Osteochondral lesion (OCD) • Cartilage injury or repair • Loose body Hip (specify unilateral or bilateral) CT - W Contrast ...... CPT Code 73701 • Mass/Tumor • Infection (if concern for septic joint should be aspirated prior to CT) Midfoot/Forefoot/Toe(s) (specify unilateral or bilateral) CT - W/O Contrast ...... CPT Code 73700 Hip (specify unilateral or bilateral) CT - W Contrast • Fracture, trauma • Osteoarthritis (OA) • Arthrodesis evaluation (Arthrogram only; no IV contrast) ...... CPT Code 73701 • Labral tear • Articular cartilage injury Midfoot/Forefoot/Toe(s) (specify unilateral or bilateral) CT - W Contrast ...... CPT Code 73701 Thigh, Femur (specify unilateral or bilateral) CT - W/O Contrast...... CPT Code 73700 • Mass/Tumor • Infection (if concern for septic joint should be aspirated prior to CT) • Fracture, trauma 3D Reconstructions at an Independent Workstation Thigh, Femur (specify unilateral or bilateral) CT - W Contrast...... CPT Code 73701 (This code is not body part specifi c; it can be added • Mass/Tumor • Infection as a separate order to any existing study...... CPT Code 76377 Knee (specify unilateral or bilateral) CT - W/O Contrast...... CPT Code 73700 • Osteoarthritis (OA) prior to arthroplasty (commonly shoulder) • Fracture, trauma • Osteoarthritis (OA) • Arthrodesis evaluation • Arthroplasty evaluation • Femoroacetabular impingement (FAI) or hip dysplasia Knee (specify unilateral or bilateral) CT - W Contrast ...... CPT Code 73701 • Fracture (commonly glenoid, pelvic ring or acetabulum) • Mass/Tumor • Infection (if concern for septic joint should be aspirated prior to CT) Premedication for Contrast Allergy Knee (specify unilateral or bilateral) CT - W Contrast • Patients with hives or rash must be pre-medicated for an IV contrast CT scan (not oral contrast). (Arthrogram only; no IV Contrast)...... CPT Code 73701 • Patients with vomiting or dizziness with IV contrast, or shell fi sh allergy do not require premedication. • Meniscus tear or repair • Cartilage injury or repair • Osteochondral lesion (OCD) • Loose body • Patients with anaphylaxis or laryngeal edema should be discussed with radiologist before the exam Leg, Calf, Tibia/Fibula (specify unilateral or bilateral) and/or premedication is ordered. CT - W/O Contrast ...... CPT Code 73700 • Fracture, trauma Premedication Protocol • Prednisone: Leg, Calf, Tibia/Fibula (specify unilateral or bilateral) 50 mg PO (four doses total) to be taken 13 hours, 7 hours and 1 hour prior to appointment. CT - W Contrast ...... CPT Code 73701 • Diphenhydramine (Benadryl) (optional): • Mass/Tumor • Infection 50 mg PO to be taken 1 hour prior to exam.

For questions regarding how to order any of the CT scans or how to reach the appropriate sub-specialty radiologist, please call CT Coordinators at (314) 747-9647 or CT Charge Technologist at (314) 747-9696. To schedule any radiology exam please call Radiology Scheduling at 314-362-7111 or 877-992-7111, 7 a.m.-5:30 p.m. Monday-Friday. Outpatient CT appointments are available 7 a.m.-5:30 p.m. Monday-Friday and 8 a.m.-12 p.m. on Saturdays.

All exams are read by subspecialized radiologists from Washington University’s Mallinckrodt Institute of Radiology.

BJ 14-1195-3688 (05/16)