RADIOLOGY ORDERING GUIDE - Capitol Imaging Services

MRI General – ExtremitiesBODY PARTREASON FOR EXAMIV CONTRASTPROCEDURE TO PRE CERTCPT CODEExtremity/Non-Joint:Arm, Hand, FingerToe, Foot, Lower leg,FemurStress / FractureMuscle / Tendon TearNoMRI non-joint w/o contrastUpper ExtremityLower ExtremityLower Extremity732187371873718Extremity/Joint:Shoulder, Elbow, WristHip, Knee, AnkleArthritisAVN (Avascular Necrosis)Stress / FractureInternal DisplacementJoint Pain (Specify Joint)Labral TearMeniscus TearMuscle TearTendon TearLigament TearCartilage TearOsteochnodritis Dissecans (OCD)NoMRI joint w/o contrastUpper ExtremityLower Extremity7322173721Extremity/Joint:Shoulder, Elbow, WristHip, atory ArthritisSeptic ArthritisTumor / Mass / Cancer / MetastasisPost Operative Knee / InfectionYesMRI joint w/o & w/contrastUpper ExtremityLower Extremity7322373723Morton’s NeuromaMRI ArthrogramBODY PARTREASON FOR EXAMLabral TearLigament Tear – further sensitive / specificassessmentLoose BodiesOsteochondral Defect StabilityCartilage DefectsTriangular Fibrocartilage / Ligament tears of the wrist Post Operative Indications: Post Operative Rotator Cuff Repair Post Operative Labral Repaid Post Operative Cartilage Repair Post Operative Meniscus Repair Post Operative Ligament Repair (elbow/wrist, etc.)INTRAARTICULAR CONTRASTYesPROCEDURE TO PRE CERTCPT CODEMRI joint w/o & w/contrastLower extremity w/o & w/contrastUpper extremity w/o & w/contrast7372373223(NOTE: If a patient has had a MRI w/ocontrast at DIS within 30 days, then anorder can be for “with only.”)

MRI Angiography (MRA/MRV) – Head & NeckBODY PARTREASON FOR EXAMIV CONTRASTPROCEDURE TO PRE CERTCPT CODEMRA HeadStrokeCVATIAAneurysmAVM (Arteriovenous Malformation)NoMRA head/brain w/o contrast70544Surgery Hx of Aneurysm Clips / Dissection /Vessel InjuryYesMRA head/brain w/o & w/contrast70546MRV HeadVenous ThrombosisNoMRA head/brain w/o contrast70544MRA Arch & GreatVesselsStrokeCVATIASubclavian StealAVM (Arteriovenous Malformation)AneurysmYesMRA neck w/o & w/contrast70549YesMRA neck w/o & w/contrast70549MRA NeckDissection / vessel injuryStrokeCVATIASubclavian StealAVM (Arteriovenous Malformation)AneurysmMRI Angiography (MRA) – ChestBODY PARTREASON FOR EXAMIV CONTRASTPROCEDURE TO PRE CERTCPT CODEMRA ChestThoracic Aorta (other than heart)AneurysmCoarctationVascular AnomaliesDissectionThoracic Outlet SyndromePulmonary EmbolismAVM (Arteriovenous Malformation)Subclavian VesselsYesMRA chest w/o & w/contrast71555

MRI Angiography (MRA) – Abdomen & PelvisBODY PARTREASON FOR EXAMIV CONTRASTPROCEDURE TO PRE CERTCPT CODEMRA AbdomenRenal Artery StenosisRenal FailureNoMRA abdomen w/o contrast74185MRA AbdomenAAA (Abdominal Aortic Aneurysm)DissectionMesenteric IschemiaRenal Artery StenosisYesMRA abdomen w/o & w/ contrast74185Pre Liver TransplantPre Kidney TransplantRenal MassYesOrder two exams:MRA abdomen w/o & w/ contrastMRI abdomen w/o & w/ contrast7418574183AVM (Arteriovenous Malformation)May-Thurner SyndromeVenous OcclusionYesMRA pelvis w/o & w/ contrast72198YesOrder two exams:MRA Pelvis w/o & w/ contrastMRI pelvis w/o & w/ contrast7219872197Order three exams:MRA Abdomen w/o & w/ contrastMRA lower extremity w/o & w/ contrast leftMRA lower extremity w/o & w/ contrast right741857372573725Order three exams:MRA Abdomen w/o & w/ contrastMRA lower extremity w/o & w/ contrast leftMRA lower extremity w/o & w/ contrast right741857372573725MRA extremity w/o & w/ contrastUpper ExtremityLower Extremity7322573725MRA PelvisAneurysmPelvic CongestionMRA Run-Off(peripheral)ClaudicationCold FootPainGangreneUlcerMRA Run-Off(peripheral)Renal FailureRenal Artery StenosisMRA ExtremityArterial Occlusion / StenosisAneurysmVenous Occlusion / ThrombosisYesNoYes

Nuclear Medicine – Bone ScanTESTCOMMON INDICATIONCPT CODEBone Scan – Whole BodyPrimary or Metastatic tumors – initial evaluation or follow upPathologic fracturesPain of suspected musculoskeletal etiologyPaget’s diseaseArthritisEvaluation abnormal findings by other imaging modalitiesEvaluation abnormal lab findings, elevated alkaline phosphataseUnexplained bone or back pain78306Bone Scan – 3 Phase(triple phase)Stress or occult fracturesMusculoskeletal traumaAvascular NecrosisProsthetic Joint evaluation for loosening or infectionNon-Union fracturesOsteomyelitisCharcot’s jointReflex Sympathetic Dystrophy (RSD)78315Bone Scan SPECTSpondylosisSpondylolisthesisSpinal fractures in pediatric patientsOsteoid Osteoma78320Nuclear Medicine – BrainTESTCOMMON INDICATIONCPT CODEBrain SPECTAlzheimer’s diseaseDementiaMemory LossCerebrovascular diseaseLyme’s diseaseSeizureBrain Death78607

Nuclear Medicine – Hepatobiliary (Gallbladder)TESTCOMMON INDICATIONCPT CODEHepatobiliary Imaging with SPECT,flow and static imagingAdenomaFocal Nodular Hyperplasia78206Hepatobiliary System Imaging(Gallbladder Scan, HIDA Scan)Acute CholecystitisEvaluate Bile LeakChronic Cholecystitis78226Hepatobiliary System Imaging w/Pharmacologic Intervention(Gallbladder Scan w/ CCK)Acute CholecystitisChronic Cholecystitis78227Nuclear Medicine – Abscess ImagingTESTCOMMON INDICATIONCPT CODEGallium ScanSarcoid / SarcoidosisFever of Unknown OriginVertebral OsteomyelitisWhole Body78806SPECT 78807IN-111 White Blood Cell ScanInfectionOsteomyelitisInfection of prosthetic jointEvaluation of vascular graft infectionRenal infectionBowel AbscessEvaluation of diabetic ulcerLimited 78805Whole Body78806Nuclear Medicine – Thyroid Uptake & ScanTESTCOMMON INDICATIONCPT CODEI-131 Thyroid single uptake & scanDetection of substernal thyroid tissue78018

Nuclear Medicine – Gastrointestinal ScansTESTCOMMON INDICATIONCPT CODEGastric Reflux StudyGastro-Esophageal RefluxAspiration78262Gastric Emptying ScanNausea, VomitingGastroparesisFeeling of fullnessDumping SyndromeGastric outlet obstruction78264Meckels ScanMeckel’s diverticulum78290Liver Imaging SPECT with VascularFlowAdenomaFocal Nodular HyperplasiaAccessory SpleenTrauma to Liver or Spleen78206Hemangioma Imaging – SPECT withVascular FlowCavernous Hemangioma78206Nuclear Medicine – Renal / Bladder / Testicular ScanTESTCOMMON INDICATIONCPT CODERenal Scan Flow and FunctionEvaluate renal perfusion and function78707Diuretic Renal Scan Flow andFunctionUrinary tract obstruction78708Captopril Renal ScanRenovascular Disease HypertensionRenal Artery Stenosis78708Renal SPECT – (DMSA Renal)Parenchymal scarringPyelonephritisCortical Lesion78710Nuclear Medicine – Parathyroid ScanTESTCOMMON INDICATIONCPT CODEParathyroid ScanPrimary HyperparathyroidismIncreased PTH levelsHypercalcemiaParathyroid AdenomaParathyroid Hyperplasia78070

Nuclear Medicine – I-131 Whole Body ScansTESTCOMMON INDICATIONCPT CODEI-131 Whole Body ScanThyroid Cancer78018I-131 Thyrogen Whole Body ScanThyroid Cancer78018I-123 Thyrogen (Low Risk) WholeBody ScanThyroid Cancer78018I-131 Thyrogen Whole Body ScanThyroid Cancer78018I-131 Follow up Whole Body ScanPost therapyThyroid Cancer78018Nuclear Medicine – Tumor ImagingTESTCOMMON INDICATIONCPT CODEOctreotide scanPrimary and Metastatic Neuroendocrine tumors bearing somatostatin receptorsCarcinoidIslet Cell llary thyroid Undifferentiated APUDoma78803 and78804Prostascint ScanRising PSA post radical prostatectomyNewly diagnosed Prostate Cancer patients with high risk for metastatic disease78803 and78804

Ultrasound – NeckBODY PARTREASON FOR EXAMNeck, face, soft tissueMassAbnormalities detected on other imaging (CT/MRI/PET/NUCLEAR)Enlarged thyroid glandMultinodular goiterAbnormal lab tests (elevated calcium levels/abnormal thyroid blood work)History thyroid cancerHyper or hypothyroidismFollow up patient on suppressionCarotid ArterySyncopeHemiplegiaDifference in arm blood pressureAphasiaAtaxiaReversible ischemic neurological deficit (RND)BruitVertigo/dizziness (non medicare)Memory loss (non medicare)Dementia (non medicare)Transient ischemic attach (T*A0Cerebral vascular attack (CVA)Amaurosis FugaxTransient visual lossTransient retinal occlusionCarotid traumaPREPCPT CODENone76536No turtlenecks, high collar shirts, necklacesor ties9388093882Ultrasound – Chest (including Breast)BODY PARTREASON FOR EXAMPREPCPT CODEChestPleural effusionSuperficial MassNone76604BreastAbnormal mammographic findings (differentiate cyst from solid lesion)Palpable massTargeted area of painNipple dischargeInfection (abscess)Implants – with clinical indications (non medicare)Aorta (retroperitoneal limited)None76641(unilateral)76642(limited)Aortic aneurysm (follow up to AAA)Pulsatile aortaBruitNPO 6 hours prior76775G0389BODY PARTREASON FOR EXAMPREPCPT CODEComplete AbdomenCirrhosis or hepatic disease 9hepatitis/portal hypertension)Abdominal distention (fluid collection) ascitesPain sonal history of cancer: MetastasisObstructive symptoms of the biliary system (jaundice)Abnormal diagnostic tests 9follow up to CT/MRI)Gastroesophageal reflux (GERD)SplenomegalyAbnormal liver functions (elevated LFT’s/fatty liver)HepatomegalyNPO 6 hours prior76700Ultrasound – Abdomen

Ultrasound – PelvisBODY PARTREASON FOR EXAMComplete PelvisPain (pelvic or adnexal tenderness)Ovarian cystOvarian torsionFibroid uterusEnlarged uterus or ovaryAdnexal abnormalitiesDysfunctional uterine bleedingPost menopausal bleedingPercocious pubertyPolycystic ovary disease (PCOD)Limited physical exam (MD unable to perform pelvic agiaAbnormal diagnostic test (follow up to CT/MRI0Localization of intrauterine contraceptive deviceExcessive bleeding, pain or signs of infection after pelvic surgery, deliveryor abortionTransvaginalPain (pelvic or adnexal tenderness)Ovarian cystOvarian torsionFibroid uterusEnlarged uterus or ovaryAdnexal abnormalitiesDysfunctional uterine bleedingPost menopausal bleedingPrecocious pubertyPolycystic ovary disease (PCOD)Limited physical exam (MD unable to perform pelvic agiaAbnormal diagnostic test (follow up to CT/MRI0Localization of intrauterine contraceptive deviceExcessive bleeding, pain or signs of infection after pelvic surgery, deliveryor abortionLimited Pelvis (bladder)Urinary retentionPost void residualEnlarged prostateBladder outlet pididymitisHydrocele (swelling)Undescended testesPREPCPT CODEFill bladder with 32 oz. of water 45 minutesprior to appointment. DO NOT VOID.76856None76830Fill bladder with 32 oz. of water 45 minutesprior to appointment. DO NOT VOID.76857None76870 and93975

Ultrasound – Urinary TractBODY PARTREASON FOR EXAMPREPCPT CODEKidney (retroperitoneal limited)Flank painChronic renal medical diseaseRenal failureTraumaRenal cancerTraumaRenal cancerPolycystic kidney disease (PCKD)Hydronephrosis (obstruction)Renal StoneElevated lab values (BUN or creatinine)Fill bladder with 32 oz. of water 45 minutesprior to appointment. DO NOT VOID.76775Renal transplantPost renal transplantUrinomaLymphocelePainElevated lab values (creatinine)Poor renal functionNPO 6 hours prior to appointment76776Renal artery stenosisRenal artery aneurysmRenal vein thrombosisHypertensionAbnormal lab values (BUN or creatinine)NPO 6 hours prior to appointment76775 and93975BODY PARTREASON FOR EXAMPREPCPT CODEUpper or Lower Extremity (non vascular)limitedJoint PainTendon pain/tendonitisFluid Collection (Baker’s cyst/Ganglion cyst)MassLigament / tendon / rotator cuff / carpal tunnelNone76882Edema / swellingCalf pain (non medicare)Follow up DVT (site specific)Positive Homan sign (shooting pain with foot dorsiflexion)Trauma to vein (site specific)None93970-93971Claudication / pain with walkingDecreased or absent pulsesGangreneIschemic rest painAtherosclerosisNone93922-93923Aneurysm (femoral, poplitieal or upper extremity)Trauma to artery (site specific)Arterial embolus (site specific)Vein graft surveillancePTFE graftNone93925-9392693930-93931Renal DopplerUltrasound – ExtremityUpper or Lower Extremity Venous DopplerUpper or Lower Extremity Arterial Doppler(PVR)Upper or Lower Extremity Arterial Duplex

Ultrasound – PregnancyBODY PARTREASON FOR EXAMPREPCPT CODEPregnancy First Trimester(14 weeks or less)Normal supervision of pregnancySize and datingVaginal bleedingEctopicNo fetal heart tonesFill bladder with 32 oz. of clear liquids 45minutes prior to appointment. DO NOTVOID.76801Pregnancy After First Trimester(greater than 14 weeks)Normal supervision of pregnancySize greater than datesCervical incompetenceVaginal bleedingSize smaller than datesFill bladder with 32 oz. of clear liquids 45minutes prior to appointment. DO NOTVOID.76805None76817Transvaginal First Trimester(0-12 weeks)Ultrasound – PediatricBODY PARTREASON FOR EXAMPREPCPT CODESpine and contentsSacral dimpleNeoplasm of spinal cord / meningesSpina bifidaCongenital anomalies of spinal cordInjury to spine/cord, birth traumaNone76800Complete AbdomenLimited Abdomen Single Organ orQuadrantLimited PelvisComplete PelvisTraumaHemihypertrophyPainOrgan enlargementAppendicitisLLQ / RLQUrogenital malformationsPrecocious pubertyVaginal dischargeAbnormal bleedingPelvic massOvarian torsionLess than 2 months – NPO for 2 hours priorto exam3 omonts-1 year – NPO 4 hours prior toexam1-8 years – NPO 5 hours prior to exam8 years or older – NPO 6 hours prior toexamLess than 2 months – NPO for 2 hours priorto exam3 omonts-1 year – NPO 4 hours prior toexam1-8 years – NPO 5 hours prior to exam8 years or older – NPO 6 hours prior toexamInfant to 2 years – 8 oz clear liquid 45minutes prior to exam2-6 years – 16 oz clear liquid 45 minutesprior to exam6-12 years – 24 oz clear liquid 45 minutesprior to exam12 years or older – 32 oz clear liquid 45minutes prior to examDO NOT VOID.Infant to 2 years – 8 oz clear liquid 45minutes prior to exam2-6 years – 16 oz clear liquid 45 minutesprior to exam6-12 years – 24 oz clear liquid 45 minutesprior to exam12 years or older – 32 oz clear liquid 45minutes prior to examDO NOT VOID.76705767057685776857

Ultrasound – ProceduresBODY PARTREASON FOR EXAMPREPCPT CODEBreast BiopsyMassLumpTo be discussed at the time of schedulingthe procedure76641-7664276942

TO OUR HEALTH CARE REFERRAL PROVIDER PARTNERSThis guide to imaging services was developed to help in prescribing and ordering the correct testing for your patients. It includesindications and recommendations to consider as well as CPT codes to use when ordering the appropriate tests at CapitolImaging Services.We want to provide your patients with the highest level of quality imaging. Our physicians are board certified in diagnosticradiology, and some have additional certifications in specialties such as neuroradiology and musculoskeletal radiology. Wetriage studies in order to get the right radiologist to interpret the exam.Our goal is to provide proper and complete imaging. In addition to assuring orders are placed correctly, we tailor examinationsto each patient’s specific condition. It is very important for the radiologist to have information about the specific clinical conditionso that appropriate imaging is performed.When you order a study, including pertinent patient history as well as signs or symptoms is very beneficial. It is also very muchappreciated when you specify a particular entity or condition upon which you would like us to comment in the report.Our goal has always been to provide your patients with a warm welcome, for them to have a pleasant experience and to extenda sincere thank you to each and every one upon completion of their testing. We know patients can be anxious, nervous or evenfrightened of imaging exams, so we do everything we can to make them as comfortable and relaxed as possible.We appreciate your trusting your patients' care to us. Thank you.Capitol Imaging ServicesAdvanced Imaging of Lafayette935 Camellia Blvd #101Lafayette, LA 70508(P) 337-984-2036(F) 337-984-7604Ascension Open MRI2622 S Ruby AveGonzales LA 70737(P) 225-450-6125(F) 225-450-6327Baton Rouge Imaging8044 Summa AveBaton Rouge LA 70809(P) 225-761-7278(F) 225-767-8121Bluebonnet Imaging4570 Bluebonnet Blvd #ABaton Rouge LA 70809(P) 225-298-3223(F) 225-298-5474Central Imaging Center11424 Sullivan Rd Bldg B #CBaton Rouge LA 70818(P) 225-261-7401(F) 225-261-3561Diagnostic Imaging Services71154 Highway 21Covington LA 70433(P) 985-641-2390(F) 985-641-2854Diagnostic Imaging Services1200 Pinnacle Pkwy #5Covington LA 70433(P) 985-641-2390(F) 985-641-2854Diagnostic Imaging Services925 Avenue CMarrero LA 70072(P) 504-883-5999(F) 504-883-5364Diagnostic Imaging Services3434 Houma Blvd #100Metairie LA 70006(P) 504-883-5999(F) 504-883-5364Diagnostic Imaging Services4241 Veterans Blvd #100Metairie LA 70006(P) 504-883-5999(F) 504-883-5364Diagnostic Imaging Services1310 Gause BlvdSlidell LA 70458(P) 985-641-2390(F) 985-641-2854Doctors Imaging4204 Teuton StMetairie LA 70006(P) 504-883-8111(F) 504-883-3555Heritage Diagnostic Center1705 Main Ave SW #CCullman AL 35055(P) 256-734-8175(F) 256-734-6296MR Imaging Systems211 N 3rd St #BAlexandria LA 71301(P) 318-443-7674(F) 318-443-7696Northeast Imaging1703 Lamy LnMonroe LA 71201(P) 318-570-4985(F) 318-450-4040Northwest Imaging1460 E Bert Kouns Ind Loop #708Shreveport LA 71105(P) 318-425-1001(F) 318-425-5001Open MRI of Hammond42078 Veterans AveHammond LA 70403(P) 985-340-1960(F) 985-340-1967OpenSided MRI of New OrleansOne Galleria Blvd #715Metairie LA 70001(P) 504-837-6736(F) 504-837-0835River Bend Imaging490 Belle Terre BlvdLaplace LA 70068(P) 985-359-7226(F) 985-359-0323Vestavia Hills Imaging2017 Canyon Rd #25Vestavia Hills AL 35216(P) 205-824-8262(F) 205-824-8264

Thoracic Spine Abscess / mass / infection Yes No CT thoracic spine w/ contrast 72129 Lumbar Spine Abscess / mass / infection Yes No CT lumbar spine w/contrast 72132 Unless there is a prior contraindication, MRI spine would be a more optimal exam CT General – Chest Chest Bronchiectasis Interstitial Lung DX Follow up pulmonary nodule