631-444-5544 ORTHOPEDICS

ORTHOPEDICS

631-444-5544

PATIENT LAST NAME

PATIENT FULL FIRST NAME

CLINICAL INDICATIONS/SIGNS/SYMPTOMS (NOT RULE/OUT):

TODAY¡¯S DATE

DATE OF BIRTH

ICD-10:

PHYSICIAN SIGNATURE (REQUIRED)

patients :

PHYSICIAN NAME (PRINTED OR STAMPED)

call to make an appointment

MRI (magnetic resonance imaging)

16

MRI Chest: No IV Contrast 71550

Pectoralis Tear

Sternal Trauma

SC Joint Pain

Brachial Plexus

29 MRI Upper Extremity Joint: No IV Contrast 73221

R

R

R

L Shoulder Indications:

Joint Pain

L Elbow

Arthritis

L Wrist

Bursitis

Fracture

Labral Tear

Ligament Tear

Tendon Tear

L Shoulder Indications:

L Elbow

Abscess

L Wrist

Tumor

Infection

Mass

Osteomyelitis

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CT (computed tomography)

X-RAY

84 CT Cervical Spine: No IV Contrast 72125

85 CT Thoracic Spine: No IV Contrast 72128

86 CT Lumbar Spine: No IV Contrast 72131

120

87 CT

30 MRI Upper Extremity Joint: Pre + Post IV Contrast 73223

R

R

R

34

35

36

37

38

R

Fracture

Pain

X-Ray Head

Humerus

Elbow

Forearm

Wrist

Hand

Fingers

Sinus

Orbits For Foreign Body

Orbits-Complete

Right Ribs

Left Ribs

Sternum

Sternoclavicular Joints

X-Ray Chest Bilateral Ribs

Chest

122

L Upper Extremity: No IV Contrast 73200

Clavicle

Shoulder

Scapula

Skull

Nasal Bones

Facial Bones

X-Ray Spine

124

Cervical AP, LAT, APOM

Add Obliques

Add Lateral Flexion/Extension

Add AP Right & Left Lateral Bending

Thoracic AP, LAT

89 CT Arthrogram R L Upper Extremity

Add Obliques

Other: ________

Shoulder

Elbow

Wrist

Indications:

R L Humerus

Lumbar AP, LAT

73201/23350 73201/24220 73201/25246

Fracture

Obtain Lumbar Films Upright

R L Forearm

Muscle Tear

Add Obliques

R L Hand

90 CT R L Lower Extremity: No IV Contrast 73700

Add Lateral Flexion/Extension

Tendon Tear

R L Finger Specify#:

Hip

Tib/Fib

Add AP Bending To R & L

Fracture

Femur

Ankle

MRI Upper Extremity Non-Joint: Pre + Post IV Contrast 73220

Knee

Foot

R L Humerus

Indications: Pain

Sacrum/Coccyx

Knee W/ Patella Tracking

Toes

R L Forearm

Tumor

Scoliosis Series (Always Upright)

Indicate Degrees:________

R L Hand

Infection

R L Finger Specify#:

Osteomyelitis

91 CT R L Lower Extremity: Post IV Contrast Only 73701 125 X-Ray Extremities

MRI Lower Extremity Joint: No IV Contrast 73721

Hip

Tib/Fib

Foot

R L BILATERAL

Tumor

R L Hip Indications:

Meniscal Tear

Femur

Ankle

Toes

Clavicle

Infection

R L Knee

Pain

Ligament Tear

Knee

A/C Joints Humerus

R L Ankle

Fracture

Cartilage Tear

Elbow

Shoulder

Internal Derangement

Instability

92 CT Arthrogram R L Lower Extremity

Forearm

Scapula

Labral Tear

Hip

Knee

Ankle

Other: ________

Wrist

MRI Lower Extremity Joint: Pre + Post IV Contrast 73723

Hand

73701/27093 73701/27370 73701/27648

Bone Age

R L Hip

Indications:

Osteomyelitis

Finger

Specify

#:

R L Knee

Tumor

Cellulitis

78 CT Pelvis: No Oral, No IV Contrast 72192

Pelvis

Weight-Bearing

R L Ankle

Infection

Bony Pelvis

Sacrum/Coccyx

Hip

Weight-Bearing

MR Arthrogram Lower Extremity Joint

SI Joints

Femur

R L Hip Arthrogram 73722/27093

R L Knee Arthrogram 73722/27369

Knee

Weight-Bearing

83 CTA Runoff: No Oral, Post IV Contrast Only 75635

R L Ankle Arthrogram 73722/27648

Tibia/Fibula

Claudication

Occlusion

MRI Lower Extremity Non-Joint: No IV Contrast 73718

Ankle

Stenosis

Indications:

R L Femur/Thigh

Calcaneus

Fracture

R L Tib/Fib / Calf

Foot

Weight-Bearing

93

Other

Muscle

Tear

R L Foot

Toe

Specify

#:

Tendon

Tear

R L Toe Specify#:

126 Skeletal Xray Survey

MRI Lower Extremity Non-Joint: Pre + Post IV Contrast 73720

R L Femur/Thigh

Indications:

127 Other

220 Bone Scan¨CWhole Body 78306

R L Tib/Fib / Calf

Tumor

31 MR Arthrogram Upper Extremity Joint:

R L Shoulder Arthrogram 73222/23350

R L Elbow Arthrogram 73222/24220

R L Wrist Arthrogram 73222/25246

32 MRI Upper Extremity Non-Joint: No IV Contrast 73218

33

PHYSICIAN ADDRESS

88 CT R

Tumor

Infection

L Upper Extremity: Post IV Contrast Only 73201

Clavicle

Shoulder

Scapula

Humerus

Elbow

Forearm

Wrist

Hand

Fingers

NUCLEAR MEDICINE

R

R

L Foot

L Toe Specify#:

27 MRI Pelvis: No IV Contrast 72195

Pelvic Pain

Sacral/Coccyx Pain

Soft Tissue Mass

Osteomyelitis

221 Bone Scan 3 Phase 78315 Region

SI Joint Pain

222 Bone Scan Spect 78320 Region

39 MRA ABD/PEL and Lower Extremity Runoff: Post IV Contrast

74185, 72198, 73725, 73725

Claudication

40 MRI Cervical Spine: No IV Contrast 72141

Neck Pain

Numbness

Radiculopathy

Disc Herniation

Trauma

41 MRI Cervical Spine: Pre + Post IV Contrast 72156

Syrinx

Discitis

Multiple Sclerosis

Tumor/Mass

Osteomyelitis

Pain

Disc Herniation

Radiculopathy

Trauma

Compression Fracture

Syrinx

Discitis

Multiple Sclerosis

Tumor/Mass

Osteomyelitis

Lower Back Pain

Numbness

Trauma

Disc Herniation

Radiculopathy

Leg Pain

Discitis

Post-Op

Tumor/Mass

42 MRI Thoracic Spine: No IV Contrast 72146

43 MRI Thoracic Spine: Pre + Post IV Contrast 72157

44 MRI Lumbar Spine: No IV Contrast 72148

45 MRI Lumbar Spine: Pre + Post IV Contrast 72158

46 Other

223

Other

ULTRASOUND

108 Extremity Doppler Ultrasound

Venous for DVT Upper

Lower

Bilateral 93970

Right 93971

Left 93971

Pain

Edema

Difficulty walking

Shortness of breath

Arterial Upper

Bilateral 93930

Right 93931

Arterial Lower

Bilateral 93925

Right 93926

Atherosclerosis

Claudication

Pelvic Pain

109 US Extremity 76881

Body Part:

119 Other

R

DEXA

160

161

162

Left 93931

Left 93926

L

Dexa Hips, Lumbar, Wrist 77080

Dexa Hips, Lumbar 77080

Dexa with LVA 77085

Indications:

INTERVENTIONAL

176 MSK

Shoulder

Elbow

Wrist

Hip

Knee

Ankle

Foot

177 MSK

Shoulder

Elbow

Wrist

Hip

Knee

Ankle

178 Other

Fluoro-Guided

RT LT

Injection 77002/20610

Injection 77002/20605

Injection 77002/20605

Injection 77002/20610

Injection 77002/20610

Injection 77002/20605

Injection 77002/20605

Ultrasound-Guided RT LT

Aspiration Injection 20611

Aspiration Injection 20606

Aspiration

Injection 20611 Ganglion 20612

Aspiration Injection 20611

Aspiration Injection 20611

Aspiration Injection 20606

Aspiration

Aspiration

Aspiration

Aspiration

Aspiration

Aspiration

Aspiration

CONTRAST GUIDE

MRI MUSCULOSKELETAL

BODY PART

Extremity, Non Joint:

Forearm

Thigh

Hand / Finger Lower Leg

Humerus

Foot / Toes

Extremity, Non Joint:

Forearm

Thigh

Hand/Finger Lower Leg

Humerus

Foot / Toes

Extremity, Joint:

Shoulder

Hip

Elbow

Knee

Wrist

Ankle

Extremity, Joint:

Shoulder

Hip

Elbow

Knee

Wrist

Ankle

Joint: Arthrogram

Chest - MSK

CPT

REASON FOR EXAM

PROCEDURE TO PRE-CERT

EXAM

number

Fracture / Stress Fracture

Muscle / Tendon Tear

73218/73718 32/37

MRI Joint Non Contrast

Upper Extremity / Lower Extremity

(Venous Injection)

Abscess

Cellulitis

Morton¡¯s Neuroma

Arthritis

Cartilage Tear

Fracture/Stress Fracture

Internal Derangement

Osteomyelitis

Soft Tissue

73220/73720 33/38

Tumor/Mass

Ulcer

Joint Pain

Ligament Tear

73221/73721 29/34

Meniscal Tear

Muscle / Tendon Tear

MRI Joint Pre and Post IV Contrast

Upper Extremity / Lower Extremity

(Venous Injection)

Abscess

Cellulitis

Osteomyelitis

Tumor / Mass

Ulcer

MRI Joint Post Contrast

Intra-articular Injection

AC Joint Pain

Sternum

SC Joint Pain

Brachial Plexus

Scapula

MRI Non-Joint Non Contrast Upper

Extremity / Lower Extremity

MRI Non-Joint Pre and Post IV Contrast

Upper Extremity / Lower Extremity

MRI Chest Non Contrast

73223/73723 30/35

73222/73722 31/36

71550

16

MRI SPINE

REASON FOR EXAM CPT EXAM

number

BODY PART PROCEDURE TO PRE-CERT

Spine: Cervical

Spine: Cervical

Spine: Thoracic

Spine: Thoracic

Spine: Lumbar

Spine: Lumbar

Degenerative Disease

Disc Herniation

Extremity Pain/Weakness

MRI Cervical Spine Pre and Post IV Contrast Discitis

Mass/Lesion

Back Pain

MRI Thoracic Spine Non Contrast

Compression Fx

Disc Herniation

MRI Thoracic Spine Pre and Post IV Contrast Discitis

Mass/Lesion

Back Pain

MRI Lumbar Spine Non Contrast

Compression Fx

Disc Herniation

Osteomyelitis

MRI Lumbar Spine Pre and Post IV Contrast

Post Lumbar Surgery ( ................
................

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