McLaren Northern Michigan X-Ray Order Form
McLaren Northern Michigan X-Ray Order Form
Patient's Name Last:
First:
Is there any chance that the patient is pregnant? Y N Insurance Information
MI:
STAT READ Cheboygan Patient Phone Daytime Phone:
Date of Birth Petoskey LTPC
Male Female Gaylord
Cell:
Please Complete/Print/Sign and Fax to Central Scheduling: Fax 231.487.7920-Tel 231.487.3100-Toll Free 866.487.3100 Reason for Exam/Signs and Symptoms:
ICD-10 Code(s):
CHEST
Chest 2v (PA & lat) Chest 1v (AP or PA) Chest 2v w/ Apical Lordotic Chest 4v (PA & lat w/obliques) Chest Insp & Exp w Lateral Ribs Right w PA Chest Ribs Left w PA Chest Ribs Bilateral w PA Chest Decubitus Chest L R Sternum
ABDOMEN
AP Single View (KUB)
AP & Upright/Decubitus Acute Abd w 1v Chest VP Shunt Evaluation Babygram Other (Specify in free text box) Free Text Box: (include any special
instructions)
UPPER EXTREMITY
Finger(s) 1 2 3 4 5 L R
Hand
L R
Bone Age
L R
Wrist
L R
Wrist with Scaphoid View
L R
Forearm
L R
Elbow Survey (AP & lat)
L R
Elbow Trauma (4 views)
L R
Humerus
L R
Shoulder
L R
Scapula
L R
LOWER EXTREMITY
Toe(s) 1 2 3 4 5 L R
Foot
L R
Calcaneus (Heel)
L R
Ankle Survey (2 views)
L R
Ankle Complete (4 views)
L R
Tib-Fib
L R
Knee Survey (AP & lat only) L R
Knee 3 Views
L R
Knee Complete (4 views)
L R
Femur
L R
Hip Complete
L R
SPINE
Cervical AP & Lat (Min. 4 views
if Swimmers/Fuchs view is needed to see C-1 / C-7)
Cervical AP & Lat Only (post-op)
Cervical AP & Lat w Obliques
Cervical Comp (w obl, flex & ext)
Thoracic w Swimmers View
Thoraco-Lumbar Spine
Lumbar AP & Lat Only (post-op) Lumbar Lateral (Flex & Ext Only) Lumbar Min. 4 Views
(includes AP, AP sacrum, lat & spot)
Lumbar AP & Lat w Obliques
Clavicle AC Joints Infant Upper (Under 18 mos) Other (Specify in free text box)
HEAD
Skull Complete
L R L R
Pelvis
Lumbar Complete w Obliques and Flex & Ext
SI Joints
Sacrum/Coccyx
Infant Lower (Under 18 mos) L R Neck Soft Tissue AP & Lat
Other (Specify in free text box)
Other (Specify in free text box)
To be Scheduled: Please Call 231.487.3100
Scoliosis Standing
Leg Length
L R
Cystogram
Lap Band Adjustment
Voiding Cystogram (VCUG)
Bone Survey Complete
Skull PA & Lateral
Hysterosalpingogram
T-Tube Injection
Skull for Pressure Valve Check
IVP w Tomograms
Sniff Test
Facial Bones Complete
Nephrostogram
Arthrogram No CT/MRI
Mandible Orthopantogram (Panorex) Nasal Bones
Hip Injection
L R
(please specify medications in free text box)
Lumbar Puncture Under Fluoro
Shoulder Wrist L R Barium Enema Single
Contrast Barium Enema Air Contrast
Orbits / Pre MRI / Foreign Body Orbits Trauma Sinuses ? Waters View Only Sinuses Complete Other (Specify in free text box)
Cervical Myelogram w CT
Thoracic Myelogram w CT
Lumbar Myelogram w CT Therapeutic Spinal Injection Procedure
In "Free Text Box", please indicate type of injection, laterality, levels or other important clinical information. Consultation with Radiologist recommended.
RFN (Please specify levels in free text)
TMJ X-Ray with tomography
Water Soluble Enema Enema via Colostomy Esophagram (Barium Swallow) Small Bowel Series Upper GI Air Contrast (Routine) Upper GI Single Contrast Video Swallow Other (Specify in free text box)
Form Filled out by: Today's Date & Time:
Physician signature: _
Office Phone: Exam Date & Time:
(Sign after printing)
MNM 721.293 - Rev: 3/19/2018
*F721293*
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- bronchoscopy and associated procedures coding in icd 10
- 932 chest imaging cpt hcpcs and diagnoses codes
- clinical documentation improvement
- mclaren northern michigan x ray order form
- tavr criteria procedure pre post care
- radiology coding aapc
- radiology ordering guide
- outpatient clinical document improvement
- 2021 x ray cpt codes rba
- justification of exposure including referral criteria and