imaging services order guide - memorial's valley imagingimaging services order guide medicare...

Virginia Mason Memorial / Valley Imaging / `Ohana / Lakeview / Yakima Heart Center

Imaging Services Order GuideMedicare guidelines require explicit written and signed provider orders. This guide was created to assist you in ordering and authorizing exams accurately. Please obtain insurance authorizations before scheduling imaging studies.

Call one of our licensed/certified technologists if you have questions or comments.

CENTRALIZED SCHEDULING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509-248-9592GENERAL X-RAY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509-895-0509COMPUTED TOMOGRAPHY (CT) . . . . . . . . . . . . . . . . . . . . . . 509-895-0507MAGNETIC RESONANCE IMAGING (MRI) . . . . . . . . . . 509-895-0505NUCLEAR MEDICINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509-575-8099`OHANA MAMMOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509-574-3863ULTRASOUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509-249-5154VASCULAR ULTRASOUND–Yakima Heart Center . . . . . . . . . 509-574-0243VASCULAR STAT REFERRALS–Yakima Heart Center . . . . . . 509-494-0551 CARDIOVASCULAR SERVICES–Yakima Heart Center . . . . . 509-574-0243BONE DENSITY–Lakeview Campus . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509-972-1 1 70

Your patient’s Imaging Studies/Results are available ONLINE at https://imaging.yakimamemorial.org/hrs Please call the Virginia Mason Memorial HelpDesk at 509-575-8175 for a Username and Password.

Consultation of a Clinical Decision Support Mechanism is required to determine if advanced diagnostic imaging services (CT, MRI, Nuclear Medicine, PET) adheres to Appropriate Use Criteria. Order must include Decision Support Number (DSN), G-Code, and Modifier.

Imaging Services 2020

https://imaging.yakimamemorial.org/hrs

2

BODY PART SYMPTOMS (REASON FOR EXAM) ORDER/PERFORM CPT CODE(S)

HEADBleed • Dizziness • Headache • Fracture • Fainting • Fresh CVA • Trauma (<1 week) • Dementia, Memory Loss, TIA

Without IV Contrast 70450

HEADNote: Radiologist’s protocol is to not do “with IV contrast only” unless a “without” IV contrast study has been performed within last 30 days.

With IV Contrast 70460

HEAD F/U CVA • Hx of Seizures • Vision Problems (Long Term) • F/U Trauma (>1 week) • Metastatic Disease Without & With IV Contrast 70470

ORBITS Fracture • Foreign Body Without IV Contrast 70480

ORBITS Abscess • Infection • Mass With IV Contrast 70481

SINUS Sinusitis Without IV Contrast 70486

Temporal Bones/ IACs Foreign Body • Trauma • Cholesteatoma Without IV Contrast 70480

Temporal Bones/ IACs Abscess • Infection • Mass With IV Contrast 70481

Mastoids Mastoiditis Without IV Contrast 70480

Facial Bones Fracture • Parotid Stone • Trauma Without IV Contrast 70486

Facial Bones Abscess • Infection • Mass With IV Contrast 70487

NECK (Soft Tissue)Always done with IV contrast unless Creatinine level too high or involving Thyroid. Please call 509-895-0507 for instructions.

With IV Contrast

70491

Note: CPT 70490 used if done without IV contrast)

SPINE: Cervical Thoracic Lumbar

Fracture • HNP (Lumbar) • Pain • Trauma • Pain in Arms (Cervical) • Radiculopathy

Without IV Contrast 72125 (C)72128 (T)72131 (L)

CHEST High Resolution Pulmonary Fibrosis • Interstitial Lung Disease Without IV Contrast 71250

CHEST (Routine)• Abnormal Chest X-Ray • Abscess • COPD • CHF • Infection • Lung CA • Lymphadenopathy • Mass • METS • Pneumonia


CHEST (Routine) New Nodule • Follow-up Nodule • Rib Fracture Without IV Contrast 71250

ABDOMEN Hernia Without IV Contrast 74150

ABDOMENAbdominal Pain • Elevated Liver Function Test • Pancreas Involvement • Abscess • Infection • Enlarged Organs


PELVIS Bony Abnormality • Hernia Without IV Contrast 72192

PELVIS Pain • Abscess • Infection • Mass With IV Contrast 72193

CHEST/ABDOMEN/PELVIS Abscess • Infection • Mass • METS • Pain • Lymphadenopathy • Hx of Cancer With IV Contrast 71260 & 74177

CT/CAT Scan/Computed Tomography*If patient is over 400 lbs., please call the CT department at 509-895-0507.

PHONE / 509-895-0507FAX / 509-576-6982

Consultation of a Clinical Decision Support Mechanism is required. Order must include DSN, G-Code, and Modifier.

3CT/CAT Scan/Computed Tomography


ABDOMEN & PELVIS (Routine) (CT Appendix) (CT Enterography)

History of Cancer • Small Bowel Disease (Crohn’s) • Large Bowel Disease • Abscess • Diverticulitis • Generalized Abdominal Pain • Hemochromatosis • Infection • Mass • Leukemia • Lymphoma • Weight Loss • Hx of Hepatitis B or C • Gross Hematuria • Cirrhosis • Appendix


ABDOMEN & PELVIS (CT KUB) (CT RENAL CALC) Flank Pain • Kidney Stones • Hematuria with pain Without IV Contrast 74176

ABDOMEN & PELVIS (CT Urography) Hematuria without pain Without & With IV Contrast 74178

CTA HEAD Aneurysm • AVM • Bleed With IV Contrast 70496

CTA NECK Stenosis • Aneurysm With IV Contrast 70498

CTA HEAD & NECK Aneurysm • Stenosis With IV contrast 7049670498

CTA CHEST Dissection • Widened Mediastinum • Aneurysm With IV Contrast 71275

CTA PE (Pulmonary Angio) (PE Study)

Chest Pain • Pulmonary Embolus • Shortness of Breath (SOB) • Positive D-dimer • Blood clot in lungs


CTA ABDOMEN Renal Artery Stenosis With IV Contrast 74175

CTA ABDOMEN & PELVIS Mesenteric Artery Abnormality • Celiac Artery Disease • Dissection • Suspected AAA • Known AAA With IV Contrast 74174

CTA CHEST/ABDOMEN PELVIS Dissection • Aneurysm • AAA With IV Contrast 7127574174

CTA ABDOMEN W/RUNOFF (CTA Runoff) (CTA Lower Extremity)

Claudication • Pain • Non-healing Ulcers • Peripheral Vasular Disease With IV Contrast 75635

EXTREMITY: (Specify Body Part) Abscess • Cellulitis • Infection • Mass With IV Contrast 73201 (Upper)73701 (Lower)

EXTREMITY: (Specify Body Part) Fracture • Pain Without IV Contrast 73200 (Upper)73700 (Lower)

CT rarely performs studies without and with IV contrast—unless stated as in the above options. Please call CT department before ordering a study without and with IV contrast. Who needs a Creatinine level? (Note: If a creatinine result is needed, please provide written order.)

Anyone having a CT with IV contrast study who is 60 and older or:1. Is diabetic2. Has history of kidney disease (including dialysis, solitary kidney, kidney transplant, kidney cancer, kidney failure, kidney surgery)3. Has history of hypertension requiring medication

If the Patient’s GFR is between 30 and 45, they will require IV hydration. We require signed provider orders prior to scheduling these patients.Orders for “Prevention of Contrast Induced Nephropathy Radiology Procedures” can be found on Virginia Mason Memorial’s Homepage/Applications/Order sets/General Contrast –Induced Nephropathy Prevention order set or use the following link: https://www.yakimamemorial.org/pcinrp

Pregnancy: The possibility of pregnancy will require a negative pregnancy test result to proceed with exam.Oral Contrast: When necessary or required, patients will be given oral contrast 1 hour prior to their scheduled procedure.

*If patient is over 400 lbs., please call the CT department at 509-895-0507.

PHONE / 509-895-0507FAX / 509-576-6982


https://www.yakimamemorial.org/pcinrp

4General X-Ray Standard Views

BODY PART STANDARD VIEW(S) CODESHEAD/NECKSkull (Limited) AP & Lateral 70250

Skull (Complete) AP, PA, Towne, RT & LT Laterals 70260

Orbits PA, Waters, Lateral & Blowout 70200

Facial Bones PA, Waters, Lateral, SMV 70150

Sinuses (Limited) Waters 70210

Sinuses (Complete) (Routine) Waters, Lateral, SMV & Caldwell 70220

Mandible PA, Towne, SMV, RT & LT Laterals 70110

Nasal Bones PA, Waters, Lateral 70160

Neck for Soft Tissue Lateral, AP 70360

THORAXChest PA & LT Lateral 71046

Ribs (Unilateral) AP & Oblique & Below Diaphragm 71100

Ribs (Bilateral) AP & Both Obliques & Below Diaphragm 71110

Sternum RAO & Lateral 71120

Sternoclavicular Joints PA & Both Obliques 71130

SPINEScoliosis Study (Only done at Virginia Mason Memorial) 72081

Cervical Spine (2 or 3 views) AP, Lateral, & Odontoid 72040

Cervical Spine Series (Routine) (5 views) AP, Lateral, Odontoid & Both Obliques (or specify other views) 72050

Cervical Spine (7 views) AP, Lateral, Odontoid, Both Obliques, Flexion & Extension 72052

Thoracic Spine Series AP & Lateral 72070

Thoracolumbar Spine AP & Lateral 72080

Lumbar Spine Series (Routine) AP, Lateral, Coned-Down of L5/S1 72100

Lumbar Spine (5 views) AP, Lateral, Coned-Down L5/S1, & Both Obliques or Flexion & Extension 72110

Lumbar Spine (7 views) AP, Lateral, Coned-Down L5/S1, Both Obliques, and Flexion & Extension 72114

Lumbar Spine (2 views) Flexion & Extension only or Side-to-Side only 72120

Pelvis AP 72170

Sacrum/Coccyx AP’s & Lateral 72220

SI Joints AP & Both Obliques 72202

ABDOMENAbdomen/KUB AP of Kidneys, Ureters & Bladder 74018

Abdomen (2 views) AP & Upright 74019

Abdomen Series PA Chest, AP & Upright Abdomen 74022

UPPER EXTREMITYClavicle AP 73000

Scapula AP & Lateral 73010

AC Joints AP Weight Bearing & AP Non-Weight Bearing 73050

Shoulder AP Internal & External Rotation 73030

FAX / 509-248-7395

5General X-Ray Standard Views

BODY PART STANDARD VIEW(S) CODESShoulder w/ Recent Trauma AP (Internal/External Rotation) and “Y” View 73030

Humerus AP & Lateral 73060

Elbow AP, Lateral & Oblique 73080

Radius/Ulna AP & Lateral 73090

Wrist PA, Lateral & Oblique 73110

Hand PA, Lateral & Oblique 73130

Finger PA, Lateral & Oblique 73140

Pediatric (<1y/o) Upper Extremity AP & Lateral 73092

LOWER EXTREMITYHip AP Pelvis & Lateral Hip 73502

HIP (Bilateral) AP Pelvis & Lateral of Both Hips 73522

Femur AP & Lateral 73552

Knee AP & Lateral 73560

Knee (Bilateral Standing) Standing AP view only 73565

Lower Leg (Tibia/Fibula) AP & Lateral 73590

Ankle AP, Lateral & Oblique 73610

Foot AP, Lateral & Oblique 73630

Os Calcis (Heel) AP & Lateral 73650

Toe AP & Oblique 73660

Pediatric (<1y/o) Lower Extremity AP & Lateral 73592

OTHERScanogram (Leg Length) AP Bilateral Hips, Knees & Ankles (Valley Imaging can only do Supine) 77073

Bone Age Study PA of LT Hand 77072

Bone Survey (Infant/child)

AP & Lateral Skull • Lateral C-Spine • Lateral L-Spine • AP Chest • AP Humeri • AP Forearms • PA Hands • AP Femurs • AP Lower Legs • AP Pelvis (to include mid lumbar spine) • AP Feet • Thorax (AP, Lateral, Right & Left Obliques) to include ribs

77076

Bone Survey (Complete)AP & Lateral Skull • Lateral C-Spine • AP & Lateral L-Spine • AP Pelvis • Lateral Thoracic Spine • Obliques of Ribs • AP Femurs • AP Lower Legs (to include ankles) • AP Bilateral Humerus

77075

PROCEDURES only done at Virginia Mason MemorialBarium Swallow/Esophagus 74220

Upper GI 74246

Small Bowel Follow Through 74250

Colon 74270

Air Contrast Colon 74280

Lumbar Puncture 77003, 62270

Cervical Myelogram 62302, 77003, 72126

Lumbar Myelogram 62304, 77003, 72132

FAX / 509-248-7395

6


BRAIN Headaches • Memory Loss • Dizziness • Seizures • Confusion • Stroke • Trauma Without IV Contrast 70551

BRAIN Tumor • METS • Mass • Known M.S. • Bell’s Palsy • Facial Nerve • Acoustic Neuroma Without & With IV Contrast 70553

ORBITS Optic Nerve Pathology Without & With IV Contrast 70543

MRA BRAIN Aneurysm • 3rd–7th Nerve Palsy Without IV Contrast 70544

MRA NECK Stenosis • Aneurysm • Dissection Without & With IV Contrast 70549

NECK (soft tissue) Lump • Mass • Vocal Cord Paralysis Without & With IV Contrast 70543

SPINE:CervicalThoracicLumbar

Pain • Sciatica • Stenosis • Radiculopathy • HNP • Fracture • Hx of Surgery (Cervical or Thoracic) • Metastatic Bone Disease

Without IV Contrast72141 (C)72146 (T)72148 (L)

SPINE:CervicalThoracicLumbar

Infection • Abscess, Syrinx • Hx of Lumbar Surgery within 5 yrs Without & With IV Contrast

72156 (C)72157 (T)72158 (L)

SPINE SURVEY Myeloma • Metastatic disease Without IV Contrast 72148

ABDOMEN (MRCP) Abdominal Pain • Detection of bile duct or gallbladder stones

Without IV Contrast(NPO for 4 hours) 74181

ABDOMEN Renal/Liver/Pancreas Lesion • Mass • METS • Cirrhosis

Without & With IV Contrast(NPO for 4 hours) 74183

MRI Enterography Complications from crohn’s disease inflammation • Inflammatory bowel disease Without and With IV Contrast 74183

72197

BREAST Implant Rupture Without IV Contrast 77047

BREAST Breast cancer • BRCA 1 & 2 • Dense Breast Tissue Without and With IV Contrast 77049

HUMERUS RADIUS/ULNA Pain • Trauma • Fracture • Muscle/Tendon Tear Without IV Contrast 73218

HUMERUS RADIUS/ULNA Infection • Osteo • Abscess • Mass • Tumor Without & With IV Contrast 73220

SHOULDER, ELBOW, WRIST Pain • Trauma • Fracture • Muscle/Tendon Tear Without IV Contrast 73221

SHOULDER, ELBOW, WRIST Infection • Osteo • Abscess • Mass • Tumor Without & With IV Contrast 73223

FEMUR, TIBIA/FIBULA Pain • Trauma • Fracture • Muscle/Tendon Tear Without IV Contrast 73718

FEMUR, TIBIA/FIBULA Infection • Osteo • Abscess • Mass • Tumor Without & With IV Contrast 73720

HIP, KNEE Pain • Trauma • Fracture • Muscle/Tendon Tear Without IV Contrast 73721

HIP, KNEE Infection • Osteo • Abscess • Mass • Tumor Without & With IV Contrast 73723

MRI/Magnetic Resonance Imaging PHONE / 509-895-0505FAX / 509-576-6982

*If patient is over 400 lbs., please call the MRI department at 509-895-0505.Consultation of a Clinical Decision Support Mechanism is required. Order must include DSN, G-Code, and Modifier.

7MRI/Magnetic Resonance Imaging

BODY PART SYMPTOMS (REASON FOR EXAM) ORDER/PERFORM CPT CODE(S)ANKLE (mid foot through calcaneus)

Pain • Achilles Tendon tear • Posterior Tibial Tendon tear • Sprain • F/U Fracture Without IV Contrast 73721

ANKLE (mid foot through calcaneus) Mass • Osteomyelitis • Cellulitis Without & With IV Contrast 73723

FOOT (toes through mid foot) Plantar Fasciitis • Pain • F/U Fracture Without IV Contrast 73718

FOOT (toes through mid foot)

Osteomyelitis • Neuroma • Abscess • Mass • Cellulitis Without & With IV Contrast 73720

MRI ARTHROGRAMShoulderWrist Hip(Note: Knee and Ankle must be scheduled at Virginia Mason Memorial)

Internal Derangement • Labrum Ligament Tears Direct Joint Injection

73222 (Shoulder)73222 (Wrist) 73722 (Hip)73722 (Knee)73722 (Ankle)

PELVIS (Female) Placenta Accreta • Pain during pregnancy • Bicornuate Uterus Without IV Contrast 72195

PELVIS (Female)Detection of Gynecologic Problems • Malignancy • Pelvic Pain • Pelvic Mass including Ovarian Cysts or Fibroids

Without & With IV Contrast 72197

PELVIS Pain • Fracture • Metastatic disease Without IV Contrast 72195

PELVIS Mass • Abscess • Infection Without & With IV Contrast 72197

SACRUM Pain • Fracture • Malignancy Without IV Contrast 72195

S.I. JOINTS Pain • Sacrolitis Without IV Contrast 72195

Multiple Myeloma Myeloma • Evaluate Bone Marrow Only Without Contrast 77084

MRI rarely performs studies with IV contrast only. Refer to MRI department before ordering a study with IV contrast.

Who needs a Creatinine Blood Result? (Note: If Creatinine result is needed, please provide written order.)Anyone having an MRI utilizing IV Contrast study who:

1. Is diabetic2. Has history of kidney disease (including dialysis, solitary kidney, kidney transplant, kidney cancer, kidney failure, kidney surgery)3. Has history of hypertension requiring medication

Anyone having an MRI must be competent to sign MR screening form and contrast form.

Patients who are breast feeding may want to “pump & dump” for 24 hours after the exam if Gadolinium is injected.

Please document on order if patient uses a wheelchair or needs moving/lifting assistance.

PHONE / 509-895-0505FAX / 509-576-6982

*If patient is over 400 lbs., please call the MRI department at 509-895-0505.Consultation of a Clinical Decision Support Mechanism is required. Order must include DSN, G-Code, and Modifier.

8

BODY PART SYMPTOMS (REASON FOR EXAM) ADDITIONAL INFO CPT CODE(S)PARATHYROID WITH SPECT-CT Elevated Calcium/PTH PTH and Calcium level 78072

THYROID UPTAKE AND SCAN

Hyperthyroidism or hypothyroidism • Thyroid nodule function evaluation• Graves’ disease • Sub acute thyroiditis • Evaluation of heterogeneity of function within the thyroid gland • Abnormal TSH, T3, T4

Lab results: TSH, T3 and T4

Image results from other modalities

Prep: No CT with contrast in past 6 weeks, off thyroid medication 4 weeks, off anti-thyroid medication 4 days.

78014

THYROID SCAN ONLY Thyroid nodule function evaluation

Lab results: TSH, T3 and T4


Prep: No CT with contrast in past 6 weeks, off thyroid medication 4 weeks, off anti-thyroid medication 4 days.

78013

THYROID WHOLE-BODY SCAN

Thyroid carcinomaPost ablation evaluation

Prep: No CT with contrast in past 6 weeks, off thyroid medication 6 weeks

78018

THYROID ABLATION Thyroid cancer Please refer to Endocrinologist

THYROID THERAPY Hyperthyroidism Please refer to Endocrinologist

BILIARY PATENCY Bile leak • Evaluation of the biliary system after surgery • Biliary atresia


Prep: NPO 4 hours78226

BILIARY WITH EJECTION FRACTION

Acute or chronic cholecystitis, bile gastritis, RUQ pain, adbominal pain


Prep: No narcotic pain meds for 24 hours. NPO 4 hours before exam

78227

GASTRIC BLEEDING Active gastrointestinal bleeding Results from Colonoscopy 78278

GASTRIC EMPTY

Nausea/Vomiting • Med/Surg evaluation of effectiveness • Gastroesophageal reflux (pre-surgical) • Persistent symptoms following upper GI surgery.


Prep: Nothing to eat or drink 4 hours prior, no narcotic pain meds 48 hours prior, no gastric emptying meds 48 hours prior.

78264

MECKEL’S DIVERTICULUM Hematochezia,R/O Meckels Diverticulum Prep: Patient should fast 3 hours prior

to scan 78290

LIVER IMAGING (static only)

Evaluation of Cirrhosis, hepatitis • Focal Nodular hyperplasia • Assess function of reticuloendothelial system

78201

—with vascular flow Hepatic Cavernous HemangiomaEvaluation of liver vascular flow 78830

LIVER AND SPLEEN (static only)

Evaluation of Cirrhosis • Hepatitis • Residual splenic tissue after splenectomy 78215

—with vascular flow Evaluation of liver vascular flow 78216

LUNG V/Q (vent/perfusion)

R/O Pulmonary Embolism • Chest pain/ shortness of breath with positive D-dimer Chest x-ray within 24 hours. 78582

LUNG PERFUSION ONLY Evaluation of pulmonary perfusion 78580

Nuclear Medicine PHONE / 509-575-8099FAX / 509-575-8624


9Nuclear Medicine

BODY PART SYMPTOMS (REASON FOR EXAM) ADDITIONAL INFO CPT CODE(S)LUNG QUANTITATIVE (vent or perf) Pre- or post-operative evaluation 78598

WHOLE-BODY BONEHistory of Cancer • Evaluation of bone pain • Elevated alkaline phosphatase • Arthritis • R/O Paget’s Disease

Recent images/reports from other modalities 78306

SPECT BONESPECT-CT BONE

Low Back pain • Pars Fracture • Stress Fracture • Degenerative disc disease


THREE PHASE BONEOsteomyelitis • Cellulitis • Avascular Necrosis • Bone infarcts • Loosening of prosthesis • Stress Fracture


LIMITED BONE Fracture w/o hardwareBone pain in specific area


MULTIPLE AREAS Bone pain in more than one area Recent images/reports from other modalities 78305

MUGACardio-toxic chemoPre-chemo LVEF evaluationCongestive heart failure

78472

NM CARDIAC VIABILITY (TL-201) Evaluate viable cardiac tissue 78452

RENAL WITH LASIX WASHOUT Evaluation of hydronephrosis


Prep: No Iodine IV contrast last 24 hours. Well hydrated.

78708

RENAL FLOW AND FUNCTION

Evaluation of kidney functionFlank pain


Prep: No iodine IV contrasts last 24 hours. Well hydrated.

78707

RENAL WITH CAPTOPRIL R/O Renal artery stenosis


Prep: No Iodine IV contrast last 24 hours. No ACE inhibitors last 3 days.

78709

IN-111 OCTREOTIDE Neuroendocrine tumors (carcinoid) 78832

78804

DATSCAN Tremor/Gait Disturbance Parkinsonian Syndrome 78830

PHONE / 509-575-8099FAX / 509-575-8624


10

BODY PART ORGANS INCLUDED SYMPTOMS (REASON FOR EXAM) CPT CODE(S)

US ABDOMENPancreas • Liver • Gallbladder • Common Bile Duct • Right Kidney • Left Kidney • Aorta • Spleen

Abdominal Pain • History of Cancer • Nausea & Vomiting • Mass • Enlarged Organs • Abnormal Labs • Weight Loss

Prep: NPO for 8 hours; small sips of water with medication acceptable

76700

US ABDOMEN Limited for Liver/Gallbladder

Pancreas • Liver • Gallbladder • Common Bile Duct

RUQ Pain • Jaundice • Suspected Gallstones • Cirrhosis • History of gallstones • Elevated liver function tests • Hepatitis B or C

Prep: NPO for 8 hours; small sips of water acceptable

76705

US ABDOMEN Limited for hernia or mass Area indicated on order

Soft tissue mass in the abdominal wall • Soft tissue mass on the lower back • Hernia, umbilical hernia or higher in the abdomen

Prep: None

76705

US APPENDIX RLQ Appendix areaRLQ pain • Elevated WBC

Pt must have a normal BMI to have the appendix evaluated by Ultrasound

76705

US CAROTID Only done at Yakima Heart Center

US EXTREMITY NON-VASCULAR Area indicated on order Palpable Soft Tissue Lump on an extremity

• Abscess 76882

US KIDNEYS/ RETROPERITONEAL Right Kidney • Left Kidney • Bladder

Flank pain • Hematuria • Polycystic Kidneys

Prep: Drink 32oz. of water 1 hour prior to exam. If able to hold the bladder, it helps the exam

76770

US PELVIS LIMITED Inguinal area indicated on order Inguinal hernia or hx of inguinal hernia • Groin pain to eval for hernia 76857

US PELVIS

Uterus • Ovaries

Please order transvaginal as indicated

Please order doppler as indicated

Pelvic Pain • Ovarian Cysts • Abnormal Vaginal Bleeding • Ovarian Cancer Screening • Polycystic ovary syndrome • Clinically Suspected Adnexal Mass • Endometrial Evaluation

Prep: Drink 32oz. of water 1 hour prior to exam; DO NOT VOID

76856

Transvaginal 76830

Doppler 93975

US PREGNANCY 1ST TRIMESTER WITH TRANSVAGINAL

Uterus • Ovaries • Pregnancy

Please order transvaginal as indicated

Determine Location of Pregnancy (Intrauterine or Extrauterine) • Fetal Dates • Confirm Viability • Evaluate Bleeding or Pain


76801

Transvaginal 76817

US PREGNANCY POST 1ST TRIMESTER

Uterus • Placenta • Anatomical survey of the fetus

Anatomic Survey of the fetus • Anatomy

This exam can only be billed one time in a pregnancy—use for anatomical survey only


76805

Ultrasound PHONE / 509-248-5154FAX / 509-576-6982

11Ultrasound

BODY PART SYMPTOMS (REASON FOR EXAM) ADDITIONAL INFO CPT CODE(S)

US PREGNANCY LIMITED

Uterus • Ovaries • Any additional concerns noted on the order

Unknown dates • Confirm viability • AFI evaluation • Placental location • Fetal position


76815

US PREGNANCY FOLLOW-UP

Uterus • Ovaries • As indicated on order for fetal/pregnancy evalua-tion

Re-evaluation of fetal size • Re-evaluation of organ systems suspected or confirmed to be abnormal on previous scan • Re-evaluation of anatomy not seen well on previous anatomic survey


76816

US PREGNANCY TRANSVAGINAL Transvaginal cervix Funneling • Cerclage • Preterm labor • Hx of

preterm labor • Shortened Cervix on previous exam 76817

US BIOPHYSICAL PROFILE

Biophysical profile evaluation of the fetus

Decreased fetal movement • Post Dates Pregnancy • Irregular Non-Stress Test 76819

US PYLORIC STENOSIS

Pylorus

Please order doppler as indicatedProjectile Vomiting • Weight Loss • Failure to Thrive

76705

Doppler93975

US SCROTUM/TESTICLES

Bilateral Testicles • Scrotum

Please order doppler as indicatedPain • Swelling • Mass • Location of Testicle (undescended)

76870

Doppler93975

US SPINE (INFANT) Spine • Area of dimple Sacral Dimple • Skin Tag 76800

US THYROID/SOFT TISSUE NECK

Thyroid • Neck area indicated on order

Abnormal Thyroid Function • Palpable Mass • Enlargement 76536

US VEIN (UPPER OR LOWER EXTREMITY) Only done at Yakima Heart Center

US NEONATAL HEAD(US VENTRICLE) Intracranial Anatomy

Increased head circumferenceFollow up abnormality seen on last exam

Exam is conducted through the anterior fontanel, please indicate on the order if the anterior fontanel is patent.

Only scheduled at Virginia Mason Memorial

76506

US FOLLICLE STUDY Ovaries • Follicles • Uterus• Endometrium

Infertility • Baseline for infertility workup

Transvaginal evaluation of follicles76830

US AORTAAorta

Only scheduled at Yakima Heart Center

Known AAA • Family history of AAA • History of tobacco use • Pulsating abdominal mass 93978

US AAA SCREENING MEDICARE PART B Aorta

Once-in-a-lifetime exam—Male or female and + family history of AAA, or male 65-75 yo and lifetime tobacco use > 100 cigarettes

76706

US RETROPERITONEAL LIMITED

Aorta • IVC • Left Kidney • Right Kidney

Follow-up on a single organ only after a complete study has been done. 76775

PHONE / 509-248-5154FAX / 509-576-6982

12Mammography/Bone Densitometry/Body Composition


BREAST MRI Breast cancer • BRCA 1 & 2 • Dense breast tissue Without and With IV Contrast 77049 (Done at Valley Imaging)

BREAST New mass • Nodule • Thickening • Asymmetry

Diagnostic Mammogram Breast Ultrasound

DX Bilat–G0204DX Uni–G0206Ultrasound Left or Right–76642LT or 76642RT

BREAST DischargeDiagnostic Mammogram Breast Ultrasound Ductogram if indicated

DX Bilat–G0204DX Uni–G0206Ultrasound Left or Right–76642LT or 76642RTDuctogram–77054

BREAST History of benign biopsy • Family history • Fibrocystic

Diagnostic Mammogram or Screening Mammogram

DX Bilat–G0204DX Uni–G0206Screening–G0202

BREAST Asymptomatic • Routine • Greater than 3 years post breast cancer treatment Screening Mammogram Screening–G0202

** All Diagnostic Mammogram orders must have a signed written or electronic order prior to performing the exam.

Bone Densitometry/Body Composition(Performed at Lakeview Campus)


BONE DENSITYDual-Energy X-ray Absorptiometry (DXA), 1 or more sites • Axial Skeleton (eg, hips, pelvis, spine)

DXA Axial Skeleton 77080

BONE DENSITYDual-Energy X-ray Absorptiometry (DXA), 1 or more sites • Appendicular Skeleton (peripheral) (eg, radius, wrist, heel)

DXA Appendicular Skeleton 77081

FEMUR (1V) VIA DXA Radiologic Examination, Femur, 1 View DXA Femur 1 View 73551

FEMUR (2V) VIA DXA Radiologic Examination, Femur, 2 View DXA Femur 2 View 73552

BONE DENSITY & VERTEBRAL ASSESSMENT

Dual-Energy X-ray Absorptiometry (DXA),1 or more sites • Axial Skeleton (eg, hips, pelvis, spine), including Vertebral Fracture Assessment

DXA Axial Skeleton & Vertebral Fracture Assessment

77085

BODY COMPOSITION Assessment of therapy response from diet, exercise, medications, or bariatric surgery

Body Composition Scan (icd-10 code BW0KZZZ) 76499

VERTEBRAL FRACTURE ASSESSMENT

Vertebral Fracture Assessment via Dual-energy X-ray Absorptiometry (DXA)

Vertebral Fracture Assessment Scan 77086

PHONE / 509-574-3863 FAX / 509-249-8649

PHONE / 509-972-1170FAX / 509-249-5319

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EXAM NAME COMMON INDICATIONS CPT CODES

CAROTIDBruit • Hx of CVA/TIA • Pre-op exam • Numbness, paresthesia • Stenosis of carotid artery • Cerebrovascular disease • Subclavian artery stenosis • Vascular grafts/stents • Coronary artery disease • Amaurosis fugax • Syncope and Collapse

93880 (Complete)93882 (Limited)

TCD See above 93886 (Complete)93888 (Limited)

TCD EMBOLI MONITORING HX of CVA/TIA • Numbness • Paresthesia • Amaurosis fugax • Syncope and collapse 93892

AORTOILIAC Abd swelling, mass, lump • Abdominal tenderness • Bruit /weak pulse • AAA • Aortic ectasia • Vascular grafts/stents • Endograft evaluation


AAA SCREENING

*One time only, must be initial imaging study of the abdominal aortaMedicare AAA Screening

Male or female and + family history of AAA, or Male 65-75 yo and lifetime tobacco use > 100 cigarettes

ACC/AHA AUC AAA Screening Guidelines (JACC Vol 60,No. 3,2012)> 60 years old and family history of AAA, or> 65 years old and current or former smoker

76706

MESENTERIC Post prandial abdominal pain • Nausea • Abdominal Bruit • Celiac artery compression • Vasc. disorder of intestines • Epigastric pain • Vascular grafts/stents • Abnormal weight loss 93976

RENAL ARTERY Hypertension • Abnormal kidney function test • Renal artery stenosis • Chronic kidney disease • Renal transplant • Vascular grafts/stents 93975

ILIOCAVAL (IVC) (ABDOMINAL VENOUS)

Shortness of breath • Chest pain • Compression of vein • Abnormal labs (D-dimer) • DVT/ PE • Leg swelling


LOWER EXTREMITY ARTERIAL (LEA) Pain in lower extremity • PVD • PVD with grafts/stents • Claudication • Ulcer • Bruit/Weak pulse

93925 (LEA BIL)93926 (LEA UNI)93978 (AO-IL)93922 (Resting ABI)93924 (Exercise ABI)

ANKLE BRACHIAL INDEX (ABI)DIGIT BRACHIAL INDEX (DBI) See above 93922 (Resting/DBI)

93924 (Exercise ABI)

UPPER EXTREMITY ARTERIAL (UEA) Bruit/ Weak pulse • Pain • PVD • PVD with grafts/stents • Asymmetric brachial BP

93930 (UEA BIL)93931 (UEA UNI)93922 (WBI Resting)93923 (Multilevel)

UPPER EXTREMITY VENOUS (UEV) Pain in arm • Hx of DVT • Shortness of breath • Swelling, mass, lump 93970 (BIL)93971 (UNI)

LOWER EXTREMITY VENOUS (LEV) Pain in leg • Swelling • Hx of DVT / PE • Shortness of breath • Ulcer • Abnormal labs (D-dimer) 93970 (BIL)93971 (UNI)

LOWER EXTREMITY REFLUX Varicose veins with pain • Swelling • Venous insufficiency (chronic) • Phlebitis • Ulcer93970 (Venous BIL)93971 (Venous UNI)93978 (Iliocaval)

UPPER EXTREMITY VEIN MAP Prior to vein harvest Pre-op exam • PVD • CAD 93971

LOWER EXTREMITY VEIN MAP Prior to vein harvest See above 93971

PRE-OP DIALYSIS ACCESS Prior to hemodialysis access creation

Chronic kidney disease • End stage renal disease • Kidney failure

93930 (UEA BIL)93931 (UEA UNI/LTD)93970 (Venous BIL)93971 (Venous UNI)93923 (Multi level ABI)

DIALYSIS ACCESS (AVG)/ (AVF) Swelling • Pain • Complication due to dialysis device, implant and graft • Difficult cannulation • Prolonged dialysis time 93990

Outpatient Vascular Ultrasound Services* This form is not intended to represent a comprehensive list of all appropriate indications .

PHONE / 509-574-0243FAX / 509-574-0257STAT REFERRALS / 509-494-0551

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EXAM NAME SUGGESTED USE ADDITIONAL INFO CPT CODES12 LEAD ELECTROCARDIOGRAM— NO IMAGING

Establish Cardiac baseline 93000

EXERCISE STRESS TEST—NO IMAGING *Start here prior to ordering stress test with imaging

Symptomatic • Normal baseline ECG / RBBB/ LAFB without baseline ST changes • Able to exercise with a goal of meeting 85% of max predicted HR

Contraindications for exercise• Ventricular pre-excitation• Uninterpretable ECG ( V-paced rhythm, LBBB, >1mm ST depression)• Severe hypertension

93015

EXERCISE STRESS ECHOwith ultrasound enhancing agent, if indicated

Symptomatic • Abnormal or equivocal exercise stress test • Able to exercise • Resting ST changes on ECG • Assess aortic stenosis, mitral reguritation or pulmonary hypertension with exercise

Contraindications for exercise• Ventricular pre-excitation• Uninterpretable ECG (V-paced rhythm, LBBB, >1mm ST depression) • Severe hypertension

93351

DOBUTAMINE STRESS ECHO with ultrasound enhancing agent, if indicated

Symptomatic • Exercise contraindicated or unable to exercise or achieve 85% max predicted HR (document why) • Normal or nonspecific baseline ECG • Assess low gradient/ severe aortic stenosis

Contraindications for DOB• Underlying dysrhythmias (i.e. atrial fibrillation/v-tach) 93351

2D ECHO with ultrasound enhancing agent, if indicated

• Structural Cardiac Assessment • Include indication on order

933069330893306

EXERCISE NUCLEAR STRESS TEST

• Abnormal or equivocal exercise stress test • Able to exercise with a goal of meeting 85% of max predicted HR * If unable to meet target HR, patient will be converted to a vasodilator test. • Likely to have poor echo images • Symptomatic

Contraindications for exercise• Ventricular pre-excitation • Uninterpretable ECG (V-paced rhythm, LBBB, >1mm ST depression)• Severe hypertension

78452

VASODILATOR NUCLEAR STRESS TEST

• Exercise contraindicated or unable to exercise or achieve 85% max predicted HR (document why) • Uninterpretable baseline ECG (including LBBB, ventricular paced rhythm, >1 mm ST depression) • Likely to have poor echo images • Symptomatic

Contraindications for vasodilator• 2nd degree or 3rd degree AV Block • Severe hypotension

78452

MUGA • Pre-chemo LVEF evaluation • Congestive Heart Failure • Cardio-toxic chemo 78473

NUCLEAR MEDICINE VIABILITY STUDY

Ischemic cardiomyopathy— evaluate viable cardiac tissue 78452

Outpatient Diagnostic Cardiovascular Services


EXAM NAME COMMON INDICATIONS CPT CODES

PSEUDOANEURYM EVALUATION

Bruit/Weak pulse • Mass/Lump post procedure • Pain • Complication of artery following a procedure • Swelling • Complication of vein following a procedure

93926 (LEA UNI)93971 (Venous UNI)93931 (UEA UNI)

RAYNAUD’S EVALUATION Raynaud’s Syndrome • Cyanosis • Cold extremity • Disturbance of skin sensation • Ulcer (non-pressure) 93923

Outpatient Vascular Ultrasound Services* This form is not intended to represent a comprehensive list of all appropriate indications .


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Please attach patient demographics, a recent ECG, medication list, and a copy of your signed clinical note clearly indicating the reason for the test and current symptoms in order to establish medical necessity. We cannot schedule testing without this information. If you are unsure of what test to order please contact our office. Appropriate use criteria can be found on our website as well as our referral form.

Outpatient Diagnostic Cardiovascular Services


EXAM NAME SUGGESTED USE ADDITIONAL INFO CPT CODES

HOLTER MONITOR 24 or 48 hours *defaults to 24 hours unless otherwise specified 93224

EXTENDED HOLTER MONITOR 7 days of continuous patch monitoring 0295T

EVENT RECORDER 7-30 days of patient activated recording *defaults to 7 days unless otherwise specified 93268

509-248-7380 / FAX 509-248-7395314 South 11th Avenue, Suite B / Yakima, WA 98902

509-574-3863 / FAX 509-249-53191515 West Yakima Avenue / Yakima, WA 98902

509-575-8022 / FAX 509-577-50912811 Tieton Drive / Yakima, WA 98902

yakimamemorial.org

02/2020 For information regarding Virginia Mason Memorial policies, refer to yakimamemorial.org/rights or call 509-469-5411.

Bone Density and Body Composition Imaging509-972-1170 / FAX 509-249-5319

1470 North 16th Avenue / Yakima, WA 98902

509-574-0243 / FAX 509-574-0257406 South 30th Avenue / Yakima, WA 98902

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