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Requested Exam Date and Time: ___________________________________ Location: □ Gastonia (M/Th/F) □ Belmont (T/W)

Scheduled Date and Time:___________________________________________ (Please arrive 20 minutes early)

Authorization #: ___________________________________________ Insurance:_________________________________________

When obtaining authorizations, select location preferred using the following numbers: Group NPI 1356324487 Tax ID # 560988142

Patients Full Name: ____________________________________ D.O.B.: ____________Height:________ Weight:________________

Social Security# _____________________ Home Phone #_________________ Other Phone: _______________________________

Ordering Physician: _____________________________ Physician signature: _____________________________________________

Scheduled by: _____________________________ Phone:________________________ Email: _______________________________

Previous studies / location:_____________________________________________________ Send CD with Patient?:______________

Special Instructions / Needs:_____________________________________________________________________________________

Please list relevant surgery:_____________________________________________________________________________________

History of Cancer?:____________________________________________________________________________________________

Metal objects in body?:____________________________________ □ Pacemaker? □ Aneurysm clip? □ Implant? □ Stent?

□ Orbital x-rays required for History of metal work □ Claustrophobia (prescribed medications require driver)

□ Any chance of Pregnancy? If so, date of LMP:_______________ □ Allergies:__________________________________________

___________________________________________________________________________________________________________

Diagnosis/Symptoms:___________________________________

______________________________________________________

______________________________________________________

HEAD / NECK: MRI BRAIN CPT ICD-9

□ MRI - brain w/o 70551 ____

□ MRI - brain with 70552____ ___________

□ MRI - brain w/o & w 70553_______________

□ MRI - other – IAC / Pituitary / Trigeminal___________________

HEAD / NECK: MRI ORBIT FACE & NECK

□ MRI - TMJ 70336_______________

□ MRI - orbit, face, neck w/o 70540_______________

□ MRI - orbit, face, neck with 70542_______________

□ MRI - orbit, face, and neck w/o & w 70543_______________

MAGNETIC RESONANCE ANGIOGRAPHY, HEAD

□ MRA - head w/o 70544_______________

□ MRA - neck w/o 70547_______________

□ MRA - neck with 70548_______________

□ MRA - neck w/o & w 70549_______________

SPINE: MRI SPINAL CANAL

□ MRI - C-spine w/o 72141_______________

□ MRI - C-spine with 72142_______________

□ MRI - C-spine w/o & w 72156_______________

□ MRI - L-spine w/o 72148_______________

□ MRI - L-spine with 72149_______________

□ MRI - L-spine w/o & w 72158_______________

□ MRI - T-spine w/o 72146_______________

□ MRI - T-spine with 72147_______________

□ MRI - T-spine w/o & w 72157_______________

□ MRI – sacrum______________________________________

□ MRI – other________________________________________

MRI EXTREMITIES /JOINT * CPT ICD-9

□ R □ L MRI - upper extremity (OTJ) w/o 73218________________

□ R □ L MRI - upper extremity (OTJ) with 73219________________

□ R □ L MRI - upper extremity (OTJ) w/o & w 73220________________

□ R □ L MRI - upper extremity (joint); w/o 73221________________

□ R □ L MRI - upper extremity (joint); with 73222________________

□ R □ L MRI - upper extremity (joint); w/o & w 73223________________

□ R □ L MRA -upper extremity, with or w/o 73225________________

□ R □ L MRI - lower extremity (OTJ) w/o 73718________________

□ R □ L MRI - lower extremity (OTJ) with 73719________________

□ R □ L MRI - lower extremity (OTJ) w/o & w 73720________________

□ R □ L MRI - lower extremity (joint); w/o 73721________________

□ R □ L MRI - lower extremity (joint); with 73722________________

□ R □ L MRI - lower extremity (joint); w/o & w 73723________________

□ R □ L MRA -lower extremity, with or w/o 73725________________

□ MRI – other: _______ _________________________________________

BODY : CHEST

□ MRI - chest w/o 71550________________

□ MRI - chest with 71551________________

□ MRI - chest w/o & w 71552________________

□ MRA – chest / aorta___________________ __ 71555________________

BODY : ABDOMEN/ PELVIS

□ MRI - abdomen; w/o 74181________________

□ MRI - abdomen; with 74182________________

□ MRI - abdomen; w/o & w 74183________________

□ MRA - abdomen, with or w/o 74185________________

□ MRI - pelvis w/o 72195________________

□ MRI - pelvis with 72196________________

□ MRI - pelvis w/o & w 72197________________

□ MRA - pelvis with or w/o 72198________________

Contrast requires a Creatinine for anyone over 60, diabetes, kidney disease, chemotherapy, etc… This can be done onsite prior to start of exam.

← Extremities / Joints with history of infection, abscess, ulcer, cyst or mass usually require contrast agent per radiologist.

Federal Necessity: Federal Regulations require that only the tests that are necessary for diagnosis and treatment of a patient’s condition be ordered. The ICD-9 code is required to prove medical necessity.

ICD-9 DESCRIPTION

MRI TEMPOROMANDIBULAR JOINT TOTAL

524.60 TEMPOROMANDIB JT DIS NOS

526.9 JAW DISEASE NOS

718.08 ARTIC CARTIL DIS-JT NEC

MRI ORBIT FACE & NECK TOTAL

190.1 MALIGN NEOPL ORBIT

784.2 SWELLING IN HEAD & NECK

785.6 ENLARGEMENT LYMPH NODES

524.60 TEMPOROMANDIB JT DIS NOS

784.0 HEADACHE

225.2 BEN NEO CEREBR MENINGES

193. MALIGN NEOPLE THYROID

MAGNETIC RESONANCE ANGIOGRAPHY, HEAD;

433.10 CARTD ART OCC NO INFARC

784.0 HEADACHE

747.81 CEREBROVASCULAR ANOMALY

437.3 NONRUPT CEREBRAL ANEURYM

436. CVA

780.4 DIZZINESS AND GIDDINESS

434.91 CEREBR ART OCC W INFARC

435.9 TRANS CEREB ISCHEMA NOS

437.1 AC CEREBROVASC INSUF NOS

348.8 BRAIN CONDITIONS NEC

780.39 OTHER CONVULSIONS

433.30 MUL PRECER OCC NO INFARC

331.9 CEREB DEGENERATION NOS

348.0 CEREBRAL CYSTS

MRI – BRAIN

784.0 HEADACHE

436.0 CVA

780.4 DIZZINESS AND GIDDISNESS

433.10 CAROTD ART OCC NO INFARC

780.39 OTHER CONVULSIONS

331.9 CEREB DEGENERATION NOSE

348.8 BRAIN CONDITIONS NEC

434.91 CEREBR ART OCC W INFARC

437.1 AC CEREBROVASC INSUF NOS

437.3 NONRUPT CEREBRAL ANEURYM

474.81 CEREBROVASCULAR ANOMALY

348.0 CERBRAL CYSTS

348.4 COMPRESSION OF BRAIN

780.99 OTHER GENERAL SYMPTOMS

721.0 CERVICAL SPONDYLOSIS

435.9 TRANS CEREB ISCHEMIA NOS

346.90 MIGRAINE NOS/NOT INTRACBL

437.1 AC CEREBROVASC INSUF NOS

331.7 CEREB DEGEN IN OTH DIS

434.90 CEREBR ART OCC NO INFARC

721.00 CERVICAL SPONDYLOSIS

191.2 MAL NEO TEMPORAL LOBE

478.1 NASAL & SINUS DIS NEC

389.10 SENSORNEUR HEAR LOSS NOS

191.3 MAL NEO TEMPORAL LOBE

780.99 OTHER GENERAL SYMPTOMS

434.91 CEREBR ART OCC W INFARCT

162.9 MAL NEO BRONCH/LUNG NOS

346.90 MIGRAINE NOS/NOT INTRCBLE

722.4 CERVICAL DISC DEGEN

780.2 SYNCOPE AND COLLAPSE

172.9 MALIG MELANOMA SKIN NOS

721.8 SPINAL DISCORDERS NEC

225.0 BENIGN NEOPLASM BRAIN

781.0 ABN INVOLUN MOVEMENT NEC

793.0 ABN FINDING-SKULL & HEAD

722.2 DISC DISPLACEMENT NOS

340. MUTILPLE SCLEROSIS

780.4 DIZZINESS AND GIDDINESS

780.39 OTHER CONVULSIONS

225.2 BEN NEO CEREBR MENINGES

348.8 BRAIN CONDITIONS NEC

784.0 HEADACHE

198.3 SEC MAL NEO BRAIN/SPINE

191.9 MALIG NEO BRAIN NOS

784.2 SWELILNG IN HEAD & NECK

191.1 MALIG NEO FRONTAL LOBE

331.9 CEREB DEGENERATION NOS

227.3 BENIGN NEO PITUITARY

348.9 BRAIN CONDISTIONS NOS

225.1 BENIGN NEO CRANIAL NERVE

747.81 CEREBROVASCULAR ANOMALY

191.0 MALIGN NEOPLE CEREBRUM

348.0 CEREBRAL CYSTS

174.9 MALIGN NEOPLE BRAST NOS

253.8 PITUITARY DISCORDER NEC

781.2 ABNORMALITY OF GAIT

433.10 CARTD ART OCC NO INFARC

437.3 NONRUPT CEREBRAL ANEURYM

437.9 CEREBROVASC DISEASE NOS

436. CVA

388.30 TINNITUS NOS

782.0 SKIN SENATION DISTURB

435.9 TRANS CEREB ISCHEMIA NOS

345.90 EPILEPSY NOS-NOT INTRACT

191.6 MAL NEO CEREBELLUM NOS

253.9 PITUITARY DISORDER NOS

348.5 CEREBRAL EDEMA

350.1 TRIGEMINAL NEURALGIA

723.1 CERVICAL GIA

780.93 MEMORY LOSS

781.3 LACK OF COORDINATION

431. INTRACEREBRAL HEMORRHAGE

368.8 VISUAL DISTURBANCES NEC

ICD-9 DESCRIPTION

MRI CHEST

786.6 CHEST SWELLING/MASS/LUMP

425.4 PRIM CARDIOMYOPATHY NEC

786.05 SHORTNESS OF BREATH

786.6 CHEST SWELLING/MASS/LUMP

358.00 MYASTENIA GRAVIS WITHOUT (ACUTE)

EXACERBATION

424.1 AORTIC VALVE DISORDER

786.05 SHORTNESS OF BREATH

162.9 MAL NEO BRONCH/LUNG NOS

212.1 BENIGN NEO LARYNX

427.9 CARDIAC DYSRHTHMIA NOS

785.1 PALPITATIONS

786.05 SHORTNESS OF BREATH

425.4 PRIM CARDIOMYOPATHY NEC

427.1 PAROX VENTRIC TACHCARD

780.2 SYNCOPE AND COLLAPSE

424.0 MITRAL VALVE DISORDER

212.7 BENIGN NEOPLASM HEART

401.9 HYPERTENSION NOS

423.9 PERICARDIAL DISEASE NOS

424.1 AORTIC VALVE DISORDER

427.31 VOCAL PARAL UNILAT TOTAL

429.3 BLOOD IN STOOL

478.32 SWELLING IN HEAD & NECK

578.1 MALIG NEO CORPUS UTERI

784.2 AMYLOIDOSIS

423.9 PERICARDIAL DISEASE NOS

425.9 SECOND CARDIOMYOPATH NOS

427.2 PAROX TACHYCARDIA NOS

427.69 PREMATURE BEATS NEC

511.9 PLEURAL EFFUSION NOS

746.89 CONG HEART ANOMALY NEC

785.6 ENLARGEMENT LYMPH NODES

MRI-ABDOMEN/PELVIS

599.2 URETHRAL DIVERTICULUM

719.45 JOINT PAIN-PELVIS

721.3 LUMBOSACRAL SPONDYLOSIS

724.79 DISORDER OF COCCYX NEC

618.0 PROPLAPSE OF VAGINAL WALL

621.8 DISORDERS OF UTERUS NEC

722.2 DISC DISPLACEMENT NOS

616.0 CERVICTIS

218.9 UTERINE LEIOMYOMA NOS

571.5 CIRRHOSIS OF LIVER NOS

585. CHRONIC RENAL FAILURE

477.1 STRICTURE OF ARTERY

719.45 JOINT PAIN-PELVIS

620.2 OVARIAN CYST NEC/NOS

185. MALIGN NEOPL PROSTATE

195.3 MALIGN NEOPL PELVIS

599.7 HEMATURIA

621.8 DISORDERS OF UTERUS NEC

197.7 SECOND MALIG NEO LIVER

593.2 CYST OF KIDNEY, ACQUIRED

571.5 CIRRHOSIS OF LIVER NOS

573.8 LIVER DISORDERS NEC

789.5 ASCITES

593.9 RENAL & URETERAL DIS NOS

789.2 SPLENOMEGALY

574.20 CALCULUS-GB-NO CYSTITIS

593.9 RENAL & URETERAL DIS NOS

MRI-BREAST

611.72 LUMP OR MASS I N BREAST

174.9 MALIGN NEOPLE BREAST NOS

793.80 ABNORMAL MAMMOGRAM, UNSPEC

611.72 LUMP OR MASS IN BREAST

174.9 MALIGN NEOPL BREAST NOS

233.0 CA IN SITU BREAST

793.80 ABNORMAL MAMMOGRAM, UNSPEC

174.4 MAL NEO BREAST UP-OUTER

676.30 BREAST DIS PREG NEC-UNSP

V10.3 HX OF BREAST MALIGNANCY

V16.3 FAMILY HX-BREAST MALIG

MRI-SPINAL CANAL

721.0 CERVICAL SPONDYLOSIS

722.4 CERVICAL DISC DEGEN

723.0 CERVICAL SPINAL STENOSIS

723.1 CERVICAL GIA

721.8 SPINAL DISORDERS NEC

722.0 CERVICAL DISC DISPLACMENT

722.2 LUMBOSACRAL SPONDYLOSIS

721.3 SYRINGOMYELIA

336.0 CERV SPONDYL W MYELOPATH

721.1 MYELOPATHY NEC

336.8 COMPRESSION OF BRAIN

348.4 LUMB/LUMBOSAC DISC DEGEN

722.52 POSTLAMINECT SYND-CERV

722.81 SPINAL STENOSIS-LUMBAR

724.02 BRACHIAL NEURITIS NOS

723.4 BRACHIAL NEURITIS NOS

344.00 QUADRIPLEGIA NOS

336.0 SYRINGOMYELIA

721.2 THORACIC SPONDYLOSIS

722.11 THORACIC DISC DISPLACMENT

344.1 PARAPLEGIA NOS

721.3 LUMBOSACRAL SPONDYLOSIS

722.4 CERVICAL DIS DEGEN

722.51 THORACIC DISC DEGEN

722.82 POSTLAMINECT SYND-THORAC

721.0 CERVICAL SPONDYLOSIS

721.3 LUMBOSACRAL SPONDYLOSIS

722.52 LUMB/LUMBOSAC DIS DEGEN

ICD-9 DESCRIPTION

721.3 LUMBOSACRAL SPONDYLOSIS

722.52 LUMB/LUMBOSAC DIS DEGEN

722.10 LUBAR DISC DISPLACEMENT

724.02 SPINAL STENOSIS-LUMBAR

722.2 DISC DISPLACEMENT NOS

722.83 POSTLAMINECT SYND-LUMBAR

340. MULTIPLE SCLEROSIS

721.0 CERVICAL SPONDYLOSIS

722.4 CERVICAL DISC DEGEN

721.8 SPINAL DISORDERS NEC

723.1 CERVICALGIA

722.2 DISC DISPLACEMENT NOS

723.0 CERVICAL SPINAL STENOIS

722.81 POSTLAMINECT SYND-CERV

722.0 CERVICAL DISC DISPLACEMENT

336.8 MYELOPATHY NEC

721.1 SYRINGOMYELIA

780.4 CERV SPONDYL W MYELOPATH

336.9 DIZZINESS AND GIDDINESS

225.3 BENIGN NEO SPINAL CORD

348.8 BRAIN CONDITIONS NEC

353.2 CERVICAL ROOT LESION NEC

MRI-ANY JOINT/NON JOINT EXTREMETY

842.12 SPRAIN METACARPOPHALANG

171.2 MAL NEO SOFT ISSUE ARM

228.09 HEMANGIOMA NEC

719.03 JOINT EFFUSION-FOREARM

171.2 MAL NEO SOFT TISSUE ARM

214.8 LIPOMA NEC

238.1 UNC BEHAV NEO SOFT TISSU

719.01 JOINT EFFUSION-SHLDER

782.2 LOCAL SUPRICIAL SWELLING

238.0 UNC BEHAVE NEO BONE

727.05 TENOSYNOV HAND/WRIST NEC

727.41 GANGLION OF JIONT

727.49 BURSAL CYST NEC

831.00 DISLOC SHOULDER NOS-CLOS

840.0 SPRAIN ACROMIOCLAVICULAR

842.00 SPRAIN OF WRIST NOS

719.02 JOINT EFFUSION-UP/ARM

726.19 ROTATOR CUFF DIS NEC

727.04 RADIAL STYLOID TENOSYNOV

729.5 PAIN IN LIMB

719.06 JOINT EFFUSION-L/LEG

719.07 JOINT EFFUSION-ANKLE

727.51 POPLITEAL SYNOVIAL CYST

717.7 CHONDROMALACIA PATELLAE

719.45 JOINT PAIN-PELVIS

719.46 JOINT PAIN-L/LEEG

719.47 JOINT PAIN-ANKLE

733.90 BONE & CARTILAGE DIS NOSE

272.7 LIPIDOSES

355.71 CAUSALGIA OF LOWER LIMB

715.16 LOC PRIM OSTEOART/L-LEG

715.97 OSTEOARTHROS NOS/ANKLE

727.06 TENOSYNOVTISIS FOOT/ANKLE

729.81 SWELLING OF LIMB

730.36 PERIOSTITIS-L/LEG

782.3 EDEMA

717.7 CHRONDROPMALACIA PATELLAE

719.06 JOINT EFFUSION-L/LEG

836.0 TEAR MED MENISC KNEE-CUR

719.45 JOINT PAIN-PELVIS

726.10 ROTATOR CUFF SYND NOS

719.41 JOINT PAIN-SHLDER

719.01 JOINT EFFUSION-SHLDER

726.0 ADHESIVE CAPSULIT SHLDER

719.43 JOINT PAIN-FOREARM

840.9 SPRAIN SHLDER/ARM NOS

715.91 OSTEOARTHR NOS SHLDER

719.03 JOINT EFFUSION-FOREARM

840.4 SPRAIN ROTATOR CUFF

840.6 SPRAIN SUPRASPINATUS

719.42 JOINT PAIN-UP/ARM

726.11 CALCIF TENDITINTIS SHLDER

726.12 BICIPITAL TENOSYNOVITIS

727.43 GANGLION NOS

715.04 GEN OSTEOARTHROS-HAND

715.11 LOC PRIM OSTEOART-SHLDER

171.3 MAL NEO SOFT TISSUE LEG

170.7 MAL NEO LONG BONES LEG

171.9 MAL NEO SOFT TISSUE NOS

782.3 EDEMA

719.06 JOINT EFFUSION-L/LEG

719.07 JOINT EFFUSION-ANKLE

198.5 SECONDARY MALIG NEO BONE

213.7 BEN NEO LONG BONES LEG

214.8 LIPMO NEC

228.01 HEMANGIOMA SKIN

308.9 ACUTE STRESS REACT NOS

719.46 JOINT PAIN-L/LEG

729.5 PAIN IN LIMB

729.81 SWELLING OF LIMB

733.95 STRESS FRACTURE OF OTHER BONE

782.2 LOCAL SUPRFICIAL SWELLING

731.0 OSTEITIS DEFORMANS NOS

733.90 BONE & CARTILAGE DIS NOS

717.2 DERANG POST MED MENISCUS

719.46 JOINT PAIN-L/LEG

719.07 JOINT EFFUSION-ANKLE

727.51 POPLITEAL SYNOVIAL CYST

836.1 TEAR LAT MENISC KNEE-CUR

733.42 ASEPTIC NECROSIS FEMUR

ICD-9 DESCRIPTION

COMERADOAGRAPHY

336.0 SYRINGOMYELIA

348.4 COMPRESSION OF BRAIN

722.81 POSTLAMINECT SYND-CERV

336.8 MYELOPATHY NEC

722.4 CERVICAL DISC DEGEN

349.2 DISORDER OF MENINGES NEC

721.0 CERVICAL SPONDYLOSIS

722.82 POSTLAMINECT SYND-THORAC

344.1 PARAPLEGIA NOS

723.1 CERVICALGIA

741.01 SPIN BIF W HYDRCEPH-CERV

723.0 CERVICAL SPINAL STENOSIS

344.00 QUADRIPLEGIA NOS

336.9 SPINAL CORD DISEASE NOS

722.83 POST LAMINECT SYND-LUMBAR

722.0 CERVICAL DISC DISPLACMNT

225.3 BENIGN NEO SPINAL CORD

322.9 MENINGITIS NOS

721.8 SPINAL DISORDERS NEC

722.2 DISC DISPLACEMENT NOS

756.15 CONGEN FUSION OF SPINE

741.00 SPIN BIF W HYDROCEPH NOS

191.9 MALIG NEO BRAIN NOS

191.1 MALIG NEO FRONTAL LOBE

191.2 MAL NEO TEMPORAL LOBE

348.8 BRAIN CONDISTIONS NEC

784.2 SWELLING IN HEAD & NECK

191.0 MALIGN NEOPL CEREBRUM

191.7 MAL NEO BRAIN STEM

239.6 BRAIN NEOPLASM NOS

780.39 OTHER CONVULSIONS

OTHER:

This list is not all-inclusive, but is a guide only. All diagnosis codes must be coded to the highest level of specificity. The ordering provider represents that the diagnostic information provided with EACH test accurately reflects his/her current knowledge of the nature of severity of complaint or condition, and that this information can be substantiated by the patient’s medical record.

MRI Exam Preparation

Due to the strong magnet used in the MRI scanner, it is extremely important for the safety of the patient to obtain accurate information before performing the MRI exam.

The system does not use ionizing radiation, simply radiofrequency waves and magnetic fields.

Here is a link with more specific MRI Safety information:

()

The actual exam time lasts on average 30 to 45 minutes. The complete length of stay from arrival to departure is about one hour.

Registration is completed just prior to the start of the MRI exam. The MRI scan table has a weight limit of 550 pounds.

Please review the following information below.

Patient:

Please bring a copy of your photo ID and insurance card(s).

Please inform us of any types of surgery and/or any known metal or implant inside the body.

Please leave personal belongings at home.

Please limit makeup and jewelry, and please no makeup for Head and Neck exams.

Please try to wear clothes without zippers and metallic embroidery if possible.

Please let us know if you have any special needs while under our care.

Please let us know if you could possibly be pregnant, or are currently breastfeeding.

Please do not eat or drink anything for 4 hours prior to your exam time for abdomen and/or pelvis related studies only. All other exams do not require fasting.

If you feel you are claustrophobic, please discuss with your physician the option of receiving an oral medication to take just prior to your arrival and have a driver bring you to and from your MRI appointment.

15 The scanner is quite spacious, with a 70 centimeter opening and much shorter overall length, which greatly reduces the claustrophobia effect.

16 Most exams from the waist down can be done feet first. Head and neck to mid chest usually require to be done head first.

Provider:

Please provide the following patient information when scheduling:

MRI is body part specific. Please list the exact area to be scanned on your order.

• Date of birth; social security number; phone number.

• Patient height, weight.

• Any chance of pregnancy.

• Previous surgeries, especially to area of interest.

• History of cancer

• History of metal or foreign implants within the body from any surgeries or accidents.

• If the patient has worked around metal (welder, machine shop), he/she must arrive 30 minutes prior to appointment for x-ray clearance (at no charge).

• Patients with pacemakers, certain types of bio-stimulators, drug infusion devices, or ferrous (magnetic) aneurysm clips cannot have an MRI exam.

• If patient is claustrophobic please discuss the options of an oral sedative to take prior to the exam time.

• If patient requires a sedative, referring physician should order prescription (PO meds).

• Please bring any relevant films and/or reports from non CaroMont facilities if possible.

Exam Ordering

• The table weight limit is 550 pounds.

• An Order Form is also available online and is submitted electronically via secure email.

• You can also download an Order form (link), and fax it to us at 704 671.7755.

• It is most common to order exams as either without (w/o) (no contrast) or without & with contrast, when contrast is requested.

• Normally the only exams ordered as with contrast would be MRA (MR Angiography) of the neck or abdomen or pelvis. MRA of the Head does not require contrast.

• Arthrograms of the hip or shoulder or of a joint are ordered as with contrast.

• Currently some newer technology should be available soon which will further improve vessel visualization without the use of contrast materials, which may be beneficial for some patients.

Contrast Injection

• Some exams require the injection of a contrast material to help improve visualization of the brain, spine, and vascular system to name a few. The medication is FDA approved and is considered quite safe. It is administered intravenously usually halfway through the exam. Please be well hydrated on the day of your exam unless we request otherwise.

• Patients with known diabetes, kidney dysfunction, cancer or anyone over the age of 60 may require us to obtain a simple blood test upon arrival to check the creatinine level as an extra precaution to assure proper usage of the contrast media. We can accept a creatinine level done at another medical office if it has been completed in the past 10 days.

• Please let us know if you are currently breastfeeding. It is recommended to discontinue this up to 72 hours after contrast injection.

Routine Radiologist preferred MRI Exam Protocol for MRISC

The best method is to order as ‘MRI ____ with and/or without contrast’ and add a note stating: ‘Contrast at Radiologist discretion’. This allows greater flexibility and does not require another call to the insurance company to change an authorization for example. However the referring physician certainly has the right to order with any specific request as indicated.

A patient having a history of known cancer, infection, abscess, cyst, or mass most often require

the use of contrast, where the exam should be ordered as ‘without and/or with contrast’.

• MRI Brain without and with contrast. 70553. Most all brains need to be done without and with contrast

• MRA Brain without contrast. 70554

• MRV Brain without contrast 70554

• MRI Cervical Spine without contrast (even with history of cervical surgery). 72141

• MRA Neck with contrast. 70548

• MRI Lumbar spine without and with contrast for history of low back surgery. 72158

• MRI / MRA Abdomen without and with contrast. MRI 74183, MRA 74185

o MRCP does not require contrast. 74181

• MRI / MRA Pelvis without and with contrast. MRI 72197, MRA 72198

• Basically all MRA exams are without and with contrast except MRA Head, where contrast is not required.

• MR Arthrography of any joint is always ordered as with contrast. Upper 73222, Lower 73722

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Order Form



Scheduling 704-671-5969 Fax 704-671-7755

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