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 Cancer (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 • Pulmonary embolism (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 • Subarachnoid hemorrhage (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