Www.mrispecialistsofthecarolinas.com
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
-----------------------
Order Form
Scheduling 704-671-5969 Fax 704-671-7755
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