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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