CT Ordering Guide t.com



MRI Standard Operating Procedures

|Body Part |Reason For Exam |IV Contrast |Procedure to Pre-Cert |CPT Code |

| |Alzheimer’s | | | |

| |Confusion | | | |

| |CVA | | | |

| |Dementia | | | |

| |Dizziness |No |MRI Without Contrast |70551 |

| |Headache w/o Focal Symptoms | | | |

| |Memory Loss | | | |

| |Mental Status Changes | | | |

| |Stroke | | | |

| |TIA | | | |

| |Trauma | | | |

| |Vertigo | | | |

|Brain |Vision Changes | | | |

| | | | | |

| |Adenoma | | | |

| |Cranial Nerve Lesions | | | |

| |HIV | | | |

| |Infection | | | |

| |Multiple Sclerosis |Yes |MRI With & Without Contrast |70553 |

| |Neurofibromatosis | | | |

| |Seizures | | | |

| |Tumor/Mass/Cancer/Mets | | | |

| |Vascular Lesions | | | |

|“IAC” |IAC/Hearing Loss |Yes | | |

|“Pituitary” |Elevated Prolactin |Yes |MRI With & Without Contrast |70553 |

|“Pituitary” |Pituitary Lesion |Yes | | |

| | | | | |

| |To guide surgery planning, | | | |

| |radiation therapy, or other | | | |

| |surgical treatments for the brain, | | | |

| |such as laser ablation; for | | | |

| |preoperative planning to localize | | |70555 |

| |language dominance and for | |fMRI |96020 |

| |functional localization of memory; | | | |

| |to localize abnormal brain | | | |

| |functionfor epilepsy surgery | | | |

| |Stroke | | | |

|MRA Brain |CVA | | | |

| |TIA |No |MRA Brain Without Contrast |70544 |

| |Aneurysm | | | |

| |Arterial Venous | | | |

| |Alzheimer’s | | | |

| |Dementia |No |MRI Spectroscopy Without Contrast |76390 |

|Brain Spectroscopy |Seizures | | | |

| |Encephalopathy | | | |

| |Ischemia | | | |

| |Hypoxia | | | |

| |Brain Injury | |MRI Spectroscopy With and/or Without |76390 |

| | |Yes |Contrast | |

| |Tumor/Mass/Cancer/Mets | | | |

| |Infection | | | |

| |Multiple Sclerosis | | | |

| |Toxic Metabolic (peds) | | | |

|Body Part |Reason For Exam |IV Contrast |Procedure to Pre-Cert |CPT Code |

| | | | | |

|MRV Brain |Venous Thrombosis |No |MRA Without Contrast |70544 |

| | | | | |

| |Demyelination/Multiple | | | |

| |Diplopia | | | |

| |Dysthyroid Eye Disease | | | |

|Orbits |Exopthalmos | | | |

| |Grave’s Disease |Yes |MRI Orbits/Face/Neck With & Without |70543 |

| |Proptosis | |Contrast | |

| |Pseudotumor | | | |

| |Sclerosis | | | |

| |Trauma | | | |

| |Tumor/Mass/Cancer/Mets | | | |

| |Vascular Lesions | | | |

| | | | | |

| | | | | |

| |Infection | | | |

|Neck |Tumor/Mass/Cancer/Mets |Yes |MRI Orbits/Face/Neck With & Without |70543 |

| |Vocal Cord Paralysis | |Contrast | |

| | | | | |

| |Aneurysm | | | |

| |Arterial Venous Malformation | | | |

|MRA Neck |CVA |Yes |MRA Neck With & Without Contrast |70549 |

| |Stroke | | | |

| |Subclavian Steal | | | |

| |TIA | | | |

| | | | | |

| | | | | |

| |Aneurysm(Neck specific) | | | |

|MRA Arch & Great Vessels |Arterial Venous Malformation |Yes |MRA Neck With & Without Contrast |70549 |

| |CVA | | | |

| |Stroke | | | |

| |Subclavian Steal | | | |

| |TIA | | | |

| | | | | |

| | | | | |

| | | | | |

| |Arm/Shoulder Pain and/or | | | |

| |Weakness | | |2141 |

| |Degenerative Disease |No |MRI Cervical Spine Without Contrast | |

| |Disc Herniation | | | |

|Spine: Cervical |Neck Pain | | | |

| |Radiculopathy | | | |

| | | | | |

| |Post-op for tumor | | | |

| |Abscess/Infection | | | |

| |Discitis | |MRI Cervical Spine With & Without | |

| |Multiple Sclerosis |Yes |Contrast |72156 |

| |Myelopathy | | | |

| |Osteomyelitis | | | |

| |Syrinx | | | |

| |Tumor/Mass/Cancer/Mets | | | |

| |Vascular Lesions/AVM | | | |

| | | | | |

|Body Part |Reason For Exam |IV Contrast |Procedure to Pre-Cert |CPT Code |

| | | | | |

| |Back Pain | | | |

| |Compression Fracture (no hx | | | |

| |cancer/mets) |No |MRI Thoracic Without Contrast |72146 |

| |Degenerative Disease | | | |

| |Disc Herniation | | | |

| |Radiculopathy | | | |

| |Trauma | | | |

| |Vertebroplasty Planning (no hx of | | | |

|Spine: Thoracic |cancer/mets) | | | |

| |Compression Fracture (with hx of | | | |

| |cancer/mets) | | | |

| | | | | |

| |Post-op for tumor | | | |

| |Abscess/Infection | | | |

| |AVM | | | |

| |Discitis | | | |

| |Multiple Sclerosis | | | |

| |Myelopathy | |MRI Thoracic With & Without Contrast | |

| |Osteomyelitis |Yes | |72157 |

| |Syrinx | | | |

| |Tumor/Mass/Cancer/Mets | | | |

| |Vascular Lesions | | | |

| |Vertebroplasty Planning (with hx of| | | |

| |cancer/mets) | | | |

| | | | | |

| | | | | |

| |Back Pain | | | |

| |Compression Fracture (no hx | | | |

| |cancer/mets) | | | |

| |Degenerative Disease | | | |

| |Disc Herniation |No |MRI Lumbar Without Contrast |72148 |

| |Radiculopathy | | | |

| |Sciatica | | | |

|Spine: Lumbar |Spondylolithesis | | | |

| |Stenosis | | | |

| |Trauma | | | |

| |Vertebroplasty (no hx of | | | |

| |cancer/mets) | | | |

| | | | | |

| | | | | |

| |Postop (any hx lumbar surgery | | | |

| |within 2 yrs) | | | |

| |Abscess/Infection | | | |

| |Compression Fracture (with hx of | | | |

| |cancer/mets) | | | |

| |Demyelinating |Yes |MRI Lumbar With & Without Contrast |72158 |

| |Discitis | | | |

| |Osteomyelitis | | | |

| |Tumor/Mass/Cancer/Mets | | | |

| |Vertebroplasty Planning (with hx of| | | |

| |cancer/mets) | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

|Body Part |Reason For Exam |IV Contrast |Procedure to Pre-Cert |CPT Code |

| | | | | |

|Chest |Tumor/Mass/Cancer/Mets |Yes |MRI Chest/Mediastinum With & Without | |

|Mediastinum | | |Contrast |71552 |

| | | | | |

| |Aneurysm | | | |

| |Arterial Venous Malformation | | | |

| |Coarctation | | | |

| |Dissection |Yes |MRA Chest With or Without Contrast |71555 |

|MRA Chest |Pulmonary Embolism | | | |

| |Thoracic Aorta (other than the | | | |

| |heart) | | | |

| |Thoracic Outlet Syndrome | | | |

| |Vascular Anomalies Subclavian | | | |

| |Vessels | | | |

| | | | | |

| |Arterial Venous Malformation | |MRA Chest With or Without |71555 |

|MRV Chest |Venous Occlusion/ Thrombosis |Yes |Contrast | |

| | | | | |

| | | |MRI Breast Without Contrast | |

| |Implant Rupture |No |Bilateral |77059 |

| | | |Unilateral (specify breast) |77058 |

| | | | | |

|Breast | | | |77059 |

| |Abnormal Mammogram | |MRI Breast Bilateral With & or Without | |

| |Abnormal Ultrasound |Yes |Contrast | |

| |Dense Breast/High Risk | | |77058 |

| |Mass/Lesion/Cancer | |MRI Breast Unilateral With & or Without | |

| |Palpable Mass | |Contrast (Specify Side) | |

| | | | | |

| |Brachial Plexus Injury |No |MRI Chest/Mediastinum With & Without |71552 |

|Brachial Plexus |Nerve Avulsion | |Contrast | |

| | | | | |

| |Tumor/Mass/Cancer/Mets |Yes | | |

| |Neuropathy | | | |

| | | | | |

| |Anomalous Coronary Artery -CCTA |No |Morphology & Function Without Contrast |75557 |

| | | | | |

| |If looking for Valve | |Morphology & Function Without | |

| |Insuffciency/Regurgilation, ASD/VSD| |Contrast; With Flow/Velocity |75557 |

| |and the patient is unable to | |Quantification | |

|Cardiac |receive a |No | |75565 |

| |contrast agent. | | | |

| | | |Morphology & Function Without and With | |

| |ARVD | |Contrast and Further Sequences | |

| |Mass |Yes | |75561 |

| |Myocardial Infarction | | | |

| |Pericardial Disease | |Morphology & Function Without Contrast; | |

| |Sarcoldosis | |With Flow/Velocity | |

| |Viability | |Quantification | |

| | | | |75561 |

| |Valve Insuffciency/Regurgilation |No | | |

| |Atrial/Ventricular Septal Defect | | |75565 |

|Body Part |Reason For Exam |IV Contrast |Procedure to Pre-Cert |CPT Code |

| | | | | |

| |Abnormal Enzymes | | | |

| |MRCP (Biliary/Pancreatic Ducts, |No |MRI Abdomen Without Contrast |74181 |

| |Stones, Jaundice) | | | |

| | | |MRI Abdomen & Pelvis Without Contrast | |

| |r/o appy or renal stone in pregnant|No | |74181 & 72195 |

|Abdomen |pt. | | | |

| |Fetal MRI | | | |

| | |Yes |MRI Abdomen With & Without |74183 |

| |Abdominal Pain | |Contrast | |

| |Abscess/Ascites | | | |

| |Adrenal Mass | | | |

| |Liver | | | |

| |Pancreatic Mass/Lesion | | | |

| |Renal Lesion | | | |

| |Tumor/Mass/Cancer/Mets | | | |

| | | | | |

| |AAA(abdominal aortic aneurysm) |Yes |MRA Abdomen With or Without contrast |74185 |

| |Dissection | | | |

| |Mesenteric Ischemia | | | |

|MRA Abdomen |Renal Artery Stenosis | |Order 2 Studies | |

| | | |MRA Abdomend With or Without Contrast | |

| |Pre Liver Transplant |Yes | |74185 |

| |Pre Kidney Transplant | |MRI Abdomen With Or Without Contrast | |

| |Renal Mass | | | |

| | | | |74183 |

| | | | | |

| |Venous Anomaly | |MRA Abdomen With or Without Contrast |74185 |

|MRV Abdomen |Venous Occlusion |Yes | | |

| |Venous Thrombosis | | | |

| | | | | |

| |Fracture | | | |

| |Muscle/Tendon Tear |No |MRI Pelvis Without Contrast |72195 |

| |Urethral Diveticulum | | | |

| |Rectal Cancer | | | |

| | | | | |

| |Placenta Accreta/Previa/Increta | | | |

| | |No |MRI Abdomen & Pelvis Without Contrast |74181 & 72195 |

|Pelvis |Abscess | | | |

| |Adenomyosis | | | |

| |Embolization | | | |

| |Endometrioma | | | |

| |Fibroid | |MRI Pelvis With & Without Contrast | |

| |Osteomyetits |Yes | |72197 |

| |Plexopathy | | | |

| |Pre/Post Fibroid | | | |

| |Prostate Cancer | | | |

| |Septic Arthritis | | | |

| |Tumor/Mass/Cancer/Mets | | | |

| | | | | |

| |Aneurysm | | | |

| |AVM (artriovenous malformation) |Yes |MRA Pelvis With or Without |72198 |

|MRA Pelvis | | |Contrast | |

|Or | | | | |

|MRV Pelvis |May Thurner Syndrome | |Order 2 Exams: | |

| |Pelvic Congestion | |MRA Pelvis With or Without Contrast |72198 |

| |Venous Occlusion |Yes | | |

| | | |MRI Pelvis With and Without Contrast | |

| | | | |72197 |

|Body Part |Reason For Exam |IV Contrast |Procedure to Pre-Cert |CPT Code |

| | |Yes | | |

| |Claudication |Yes |Order 3 Exams: |74185 |

|MRA Peripheral |Cold foot | |MRA Abdomen with/without contrast & | |

|(Run-off) |Gangrene | | | |

| |Pain | |MRA Lower Extremity with/without |73725 |

| |Ulcer | |contrast LEFT & | |

| | | | | |

| | | |MRA Lower Extremity with/without |73725 |

| | | |contrast RIGHT | |

| | | | | |

|MRA Extremity or |Aneurysm | |MRA Extremity with & without contrast | |

|MRV Extremity |Arterial Occlusion/Stenosis |Yes |Upper Extremity | |

| |Venous Occlusion | | |73225 |

| | | |Lower Extremity | |

| | | | |73725 |

| |Fracture | | | |

| |Muscle/Tendon tear | |MRI Non-Joint Without Contrast | |

|Extremity, |Stress Fracture |No |Lower-Extremity | |

|Non-Joint | | | |73718 |

| | | |Upper-Extremity | |

|Arm |Abscess | | |73218 |

|Hand |Cellultis | | | |

|Finger |Fasciitis | |MRI Non-Joint Without & With Contrast | |

|Femur |Myositis |Yes |Lower-Extremity | |

|Lower Leg |Osteomyelitis | | | |

|Foot |Soft Tissue Tumor/Mass/ | |Upper-Extremity |73720 |

|Toe |Cancer/Mets | | | |

| |Ulcer | | |73220 |

| | | | | |

| |Arthritis | | | |

|Extremity, Joint |AVN (Avascular Necrosis) | | | |

| |Cartilage Tear | |MRI Joint Without Contrast | |

|Shoulder |Fracture |No | | |

|Elbow |Internal Derangement | |Lower-Extremity |73721 |

|Wrist |Joint Pain (specify joint) | | | |

|Hip |Labral Tear | |Upper-Extremity |73221 |

|Knee |Ligament Tear | | | |

|Ankle |Meniscus Tear | | | |

|Foot |Muscle Tear | | | |

| |Osteochondritis Dessicans (OCD) | | | |

| |Stress Fracture | | | |

| |Sprain/Strain | | | |

| |Tendon Tear | | | |

| | | | | |

|Extremity, Joint |Abscess | | | |

| |Cellulitis | |MRI Joint Without & With Contrast | |

|Shoulder |Fasciitis | | | |

|Elbow |Inflamatory Arthritis | |Lower-Extremity | |

|Wrist |Myositis |Yes | |73723 |

|Hip |Osteomyelitis | |Upper-Extremity | |

|Knee |Septic Arthritis | | |73223 |

|Ankle |Tumor/Mass/Cancer/Mets | | | |

| |Ulcer | | | |

|Body Part |Reason For Exam |IV Contrast |Procedure to Pre-Cert |CPT Code |

| | | | | |

| | | |MRI Joint with Contrast-Order 2 Exams | |

| | | | | |

| | | |Lower Extremity With Contrast | |

| |Labral Tear |Yes | |73722 |

|MR Arthrography |Loose Bodies | |Upper Extremity With Contrast | |

| |OCD Stability | | |73222 |

| |Post-op shoulder | | | |

| |Post-op meniscus repair | | | |

| | | |Fluoroscopy Guided Joint Injection | |

| | | |Please state which joint in comments |76000 |

| | | | | |

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