Diagnostic Imaging Department - (208) 359-6508 Scheduling Requests (208) 359-6508 Fax Orders# (208) 359-6504

DATE ORDERED:________________________________________ Patient Name: Daytime Phone: Ordering Physician: Indication for Procedure:

DOB: Work Phone: Physician Signature: Pregnant? YES

GENERAL RADIOLOGY Abdomen

FLUOROSCOPY Myelography

M / F

NO

EDC:

70150 Facial Bones Complete

74220 Esophagus/Barium Swallow

70160 Nasal Bones Complete

74230 Esoph. Swallowing Function (Speech)

70360 Neck, Soft Tissue

74247 UGI (Air Contrast)

IV CONTRAST ALERTS (RADIOLOGY) Contrast Allergy Y N High Risk: Creatinine:______________ A creatinine is required within 30 days for the following patients Pre-Existing Renal Insufficiency (HX Cr>1.5) History of kidney disease as an adult; inc. tumor or transplant Family histroy of kidney failure Prior renal surgery Diabetes treated with insulin or other prescribed medications Paraproteinemia syndromes or diseases (e.g. Multiple Myeloma) Collagen vascular disease (e.g. scleroderma, lupus) Taking metfromin or metformin-containing drug combinations Chronic or high dose use of non-steroidal anti-inflammatory drugs Regular use of nephrotoxic medications such as aminoglycosides Age 60 or older CT SCAN 76377 3D Processing (check in addition to exam)

74241 UGI (Single Contrast)

70450 Head w/o Contrast

74000 Abdomen/KUB 1 View

72265 Lumbar Myelogram

74020 Abdomen 2 View (Supine & Erect)

72132 CT L-Spine post Myelo

74022 Abdomen Series(Supine, Erect, PA Chest)

72240 Cervical Myelogram 72126 CT C-Spine post Myelo

Chest / Ribs

72126 Lumbar Puncture

71020 Chest PA & Lateral

72126 Vertebroplasty

Urinary Tract

71010 Chest 1 View (PA) 71101 Ribs, Uni. w/ PA Chest

R

L

71111 Ribs, Bilat. w/ PA Chest

74400 IVP limited 74455 VCUG (Voiding Cystourethrogram) 74430 Cystogram

Head & Neck

Gastrointestinal Tract

Spine & Pelvis 72050 72040 72072 72110 72114 72100 72170 72220 72090

Cervical Spine Complete Cervical Spine Limited Thoracic Spine Complete Lumbosacral Spine Complete Lumbosacral SpineComp. w Flex/Ext Lumbosacral Spine Limited Pelvis, AP Sacrum & Coccyx Scoliosis Series

74249 74250 74251 74280 74270

UGI w/ Small Bowel Follow Through Small Bowel Follow Through Barium Enema (Air Contrast) Barium Enema (Single Contrast)

Lower Extremity (specify R or L)

BREAST DIAGRAM

Bone Length Hips, Bilateral Hip, Uni Femur Knee Complete Knee Limited Tibia & Fibula Ankle Complete 73630 Foot Complete 73650 Calcaneus, Heel

R

L

R R R R R R

L L L L L L

R R

L L

76700 Abdominal Complete

73660 Toe-Specify Digit_____

R

L

76705 Abdominal Limited

77073 73520 73510 73550 73564 73560 73590 73610

R

L

70460 70496 70480 70481 70486 70487 70490 70491 70498 71250 71260 71275 74176 74177 74175 72191 70486 73200

mark pain / palpable lesion 73700

ULTRASOUND

76770 Renal

Upper Extremity (specify R or L)

* * * * * * * * * * *

(Retroperitoneal Complete)

74262

IAC/ Sella/ Orbits w/o contrast IAC/ Sella/ Orbits w contrast Maxiofacial w/o contrast Maxiofacial w contrast

Soft Tissue Neck w/o Contrast Soft Tissue Neck w Contrast CTA Neck Chest w/o Contrast High Res. Chest w Contrast CTA Chest - Pulmonary Abdomen/Pelvis w/o Contrast Abdomen/Pelvis w Contrast CTA Abdomen CTA Pelvis Sinus Upper Extremity R L specify:_____________ Lower Extremity R L specify:_____________ CT Colon Diagnostic w/ contrast

MRI

73000 Clavicle

R

L

73010 Scapula

R

L

76830 Pelvic Transvaginal ONLY

70548 MRA Neck w IV Gad

73030 Shoulder Complete 73060 Humerus

R R

L L

76856 76830 Pelvic Transabd. & Transvag. 76801 OB 1st Trimester

70336 TMJ 70553 Pituitary w & w/o IV Gad

73080 Elbow Complete 73090 Forearm 73110 Wrist Complete

R R R

L L L

76805 OB Complete 76813 OB Nuchal Translucency Screening (NT) 76815 OB Limited

70553 IAC w & w/o IV Gad 72141 Cervical Spine 72156 Cervical Spine w & wo IV Gad

73130 Hand Complete

R

L

76816 OB Follow-Up

72146 Thoracic Spine

73140 Finger-Specify Digit___

R

L

76817 OB Transvaginal

72157 Thoracic Spine w & wo IV Gad

76870 Scrotum

72148 Lumbar Spine

76536 Thyroid 93306 Echocardiography Complete

72158 Lumbar Spine w & wo IV Gad 72195 Pelvis

78306 Bone Scan Whole Body 78300 Bone Scan Limited R L specify:_______________ 78315 Bone Scan 3 Phase R L specify:_______________ 78223 HIDA Scan w/ E.F. 78452 SPECT Myocardial perfusion, multiple study 78707 Renal Flow/ Function 78014 Parathyroid 78014 Thyroid Uptake & Scan 78014 Gastic Emptying

UNLISTED EXAMS / COMMENTS

Rev. 02/13

93308 93350 93880 76882 93922 93970 93971 93965 76645

Echocardiography/Bubble Study Echocardiography w/ Stress Carotid Extremity Non-Vascular R L specify:____________ Ankle/Brachial Index w/ Exercise Venous Bilateral Venous Unilateral R L Venous Reflux R L Breast R L

* see Breast Diagram for Diagnostics Biopsy - Specify Type:

SAFETY PRECAUTIONS Pacemaker Claustrophobia Hx of metal grinding or welding Prev. surgery of area to be imaged

70551 Brain w/o IV Gad

76775 Aorta (Retroperitoneal Limited) 76856 Pelvic Transabdominal ONLY

NUCLEAR MEDICINE

Notes:

Head w Contrast CTA Head

70553 Brain w & wo IV Gad 70544 MRA Brain w/o IV GAD

72197 77059 73221 73222 73221 73222 73221 73222 73721 73722

Pelvis w & wo IV Gad Hand/ Finger Shoulder Shoulder w/ Joint Injection Elbow Elbow w/ Joint Injection Wrist Wrist w/ Joint Injection Hip Hip w/ Joint Injection

73721 73722 73721 73722 73718

Knee Knee w/ Joint Injection Ankle Ankle w/ Joint Injection Foot

IV CONTRAST ALERTS- Cr within 3 mos High Risk - Creatinine__________ * Age 60 or older * Renal disease; inc. tumor or transplant * Dialysis or Renal Insufficiency * Hx of liver disease/transplant or pending * Hx of Diabetes - insulin or medication treated * Organ transplant * Multiple Myeloma R R R R R R R R R

L L L L L L L L L

R R R R R

L L L L L

Notes: _________________________________

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