1

Sutter Standard Operating Procedures

{00241664 v.1} Policies Page X of X Department Policy: XX-XXX

Sutter Health and Affiliates Administrative Policies and Procedures

Modifying Imaging Procedure Orders to Meet the Needs of the Patient

Department: Medical Foundation Radiology / Diagnostic Imaging Policy: 00-000

Origination Date: 07/01/2012 Revised Date: Next Review Date:

Approved by:

Diagnostic Imaging Oversight Committee -

June 1st, 2012

System Management Team

POLICY

Radiologists practicing in Sutter Health affiliated Medical Foundation imaging departments are permitted to modify the test design and/or order alternative procedures for ambulatory patients within specified limits detailed in relevant Standard Operating Procedures (SOPs) or Radiology Protocols without specific notification to or additional orders from the referring/ordering provider. The patient’s medical and physical condition, the imaging department’s equipment and the training and expertise of the imagers will be used in determining the optimal study(ies) to be performed.

PURPOSE Sutter Health Medical Foundation imaging departments and breast centers require the ability to efficiently generate and fulfill orders and provide optimal patient care while remaining in compliance with payor guidelines. SCOPE This policy applies to Sutter Health affiliated Medical Foundations. Note: In the hospital setting, radiologists may modify or give orders according to their privileges and the hospital’s general policies on documenting physician orders.

PROCEDURES Ordering physicians who use Epic are presented with the following question which authorizes the Medical Foundation imaging department to modify the order if needed per imaging protocol: “Radiologist may modify the order per protocol to meet the clinical needs of the patient?” The default answer is “Yes,” to authorize modifications to test orders. Ordering providers who do not want the radiologist to make any changes can change the response to “No.” External ordering physicians are informed by affiliate imaging departments of Sutter Health radiologists’ ability to use SOPs and protocols to modify the test design of radiology procedures and their ability to limit their orders to only particular studies. Unless otherwise specified by the external ordering physician, Sutter Health users transcribing radiology procedure orders for

{00241664 v.1} Policies Page X of X Department Policy: XX-XXX

external ordering providers will respond “Yes” to the ordering question of “Radiologist may modify the order per protocol to meet the clinical needs of the patient?” For breast imaging studies, follow the Standard Operating Procedures for breast imaging results and recommended actions outlined in the attached Breast Imaging Standard Operating Procedure. For all imaging studies, radiologists may modify the following aspects of test design to optimally meet the clinical needs of the patient based on presenting clinical history, signs and symptoms:

• Use or non-use of contrast • Laterality of exam • Number and type of views • CT slice thickness • Imaging of adjacent or alternate body part

The radiologist should include the reason for the modification in the report to the ordering provider.

The radiologist may modify an order with clear and obvious errors that would be apparent to a reasonable layperson, such as the patient receiving the test (e.g., x-ray of wrong foot ordered), without notifying the treating physician/practitioner, Test design does not include adding tests using a different modality, except in the case of breast imaging, which is covered by a specific SOP. If the radiologist determines than another imaging procedure using a different modality than the one ordered is needed, the imaging department staff will contact the ordering physician for new orders. References: Medicare Benefit Policy Manual, Ch. 15, sec. 80.6.4 Palmetto GBA article Standard Operating Procedures (SOPs) for Diagnostic Testing http://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Jurisdiction%201%20Part%20B~Browse%20by%20Topic~General~7X9NRW2052?open&navmenu=%7C%7C Attachment: Breast Imaging Standard Operating Procedure

Page #1 of 6

CT Standard Operating Procedures

Body Part Reason For Exam IV Contrast Procedure to Pre-Cert CPT Code Head/Brain

Alzheimer’s Bleed, Hemorrhage CVA, Stroke Headaches Hydrocephalus Memory Loss, Confusion Shunt Check Trauma Vertigo, Dizziness* Headache w/Associated Neurologic Signs* Infection* Mass/Tumor* Metastatic Staging* *MRI PREFERRED HIV Melanoma Toxoplasmosis

No

Yes

Yes

CT Head, Brain Without Contrast CT Head, Brain With Contrast CT Head, Brain Without and With Contrast

70450 70460 70470

CTA Brain (Head)

Aneurysm AVM (Arterio/Venous Malformation CVA TIA Vascular Malformation

Yes

CTA Brain

75671

Orbit

Foreign Body Fracture Graves Disease Trauma Abscess Exopthalmus Mass Pain Pseudo Tumor Retinoblastoma

No

Yes

Yes

CT Orbit Without Contrast CT Orbit With Contrast CT Orbit without & with Contrast

70480 70481 70482

Sinus Limited

Sinusitis (billing will apply modifier 52) *This is for limited exam ONLY*

No

CT Sinus Screen (same CPT code as sinus complete)

70486

Sinus Full Osteomeatal Complex

Osteomeatal Complex Functional Endoscopic Sinus Surgery

No

CT Sinus Complete

70486

Page #2 of 6

Body Part Reason For Exam IV Contrast Procedure to Pre-Cert CPT Code Temporal Bone

Cholesteotoma Hearing Loss, Conductive* Trauma *Sensory neuro hearing loss, order MRI with and without contrast

No

CT Inner Ears, Temporal Bones

70480

CTA Carotid

Bruit Carotid Stenosis CVA TIA

Yes

CTA Carotid

75662

Spine Cervical/Thoracic

Trauma, Fracture, Fusion Assess Bony Degenerative Changes *MRI recommended for disc herniation, Mets or infection

No

CT Cervical Spine Without Contrast CT Thoracic Spine Without Contrast

72125

72128

Spine Lumbar/Sacral

Trauma, Fracture, Fusion, Pars Defect - *MRI recommended for disc herniation, mets, infection.

No

CT Lumbar Spine Without Contrast

72131

Neck/Parotid

All necks should be ordered with contrast unless there is renal failure Parotid Mass Gland Infection of Parotid Parotid Stone

Yes

Yes

CT Neck, Parotid With Contrast CT Neck, Parotid Without and With Contrast

70491

70492

Neck/Parotid/Nasopharynx

If elevated creatinine, order without contrast.

No

CT Neck Without Contrast

70490

Axilla

Mass, Chest Wall Mass

Yes

CT Chest with Contrast

71260

Page #3 of 6

Body Part Reason For Exam IV Contrast Procedure to Pre-Cert CPT Code Chest

All chest are ordered with contrast except for these indications Renal Failure F/U Nodules (Contrast needed for 1st exam, then all F/U nodules without contrast.) Tracheal Stenosis Asbestosis COPD Cough Esophageal CA Hemoptysis Lymphoma Lung CA Lung Nodule Mass Pneumonia Sarcoidosis

No

Yes

CT Chest Without Contrast CT Chest With Contrast

71250

71260

Chest, High Resolution

Bronchiectasis Fibrosis Interstitial Disease Pleural Plaques

No

CT Chest Without High Resolution

71250

CTA Chest & Abd Thoracic Aortic Dissection

Aneurysm Aortic Dissection Thoracic Aortic

Yes

CTA Chest and Abdomen (Please authorize BOTH codes)

71275 75635

CTA Chest ( PE Study)

AAA / Aortic Dissection Chest Pain / Dyspnea + D Dimers DVT Hemoptysis Pulmonary Hypertension Shortness of Breath Tachypnea

Yes

CTA Chest

71275

Page #4 of 6

Body Part Reason For Exam IV Contrast Procedure to Pre-Cert CPT Code Abdomen

F/U for patients with renal cell carcinoma in renal failure - *Recommend MRI Abdominal Pain (generalized) Epigastric pain LUQ Pain Mass Pancreatitis Pseudocyst RUQ Pain

No

Yes

CT Abdomen Without Contrast CT Abdomen With Contrast

74150

74160

Abdomen and/or Kidney

Adrenal Mass- (MR preferred) Cirrhosis— (MR preferred) Embolization Hepatoma, Hepatitis Liver Hemangioma- (MR preferred) Radiofrequency Ablation

Yes

CT Abdomen Without and With Contrast

74170

Abdomen and/or Kidney and Pelvis (if ordering pelvis, both codes must be authorized)

Carcinoid Kidney Cyst vs. Mass - (MRI Preferred) Painless Hematuria Melanoma

Yes

CT Abdomen Without and With Contrast CT Pelvis With Contrast

74170

72193

Abdomen/Pelvis

Hematuria Stone (Stone Study) Abdominal Pain (upper & lower quardrants) Abscess Appendicitis Cancer Staging (except melanoma & carcinoid)* Colitis/ IBD Crohns / Ulcerative Diverticulitis Hematuria Hernia (i.e. ventral, umbilical, inguinal)** Mass *For certain CA’s, some insurance companies will not cover CT pelvis (i.e. breast & lung CA) ** Non covered indication for upper quadrant.

No

Yes

CT Abdomen Without Contrast AND CT Pelvis Without Contrast CT Abdomen With Contrast AND CT Pelvis With Contrast

74176

74177

Page #5 of 6

Body Part Reason For Exam IV Contrast Procedure to Pre-Cert CPT Code Pelvis (Routine)

Cancer Staging Cysts Infection Mass Pain

Yes

CT Pelvis With Contrast Note: Symptoms must be in pelvis or lower abdomen to be covered by Medicare.

72193

Pelvis

Bone Infection Infection* Tumor/Mass/Cancer/Mets *Recommend MRI

Yes

CT Pelvis Without and With Contrast Note: Must be in pelvic region (lower abdomen) to be a covered service of Medicare.

72194

CT Urogram

Carcinoma Kidney and/or Bladder Transitional Cell

Yes

CT Abdomen and Pelvis With and Without Contrast

74170

CTA Abdomen & Run Off

Peripheral Artery Disease (PAD)

Yes

CT Abdomen and Run Off (Please authorize BOTH codes.)

75635 73706

Pubic Arch Study Protocol

Prostate Treatment Planning

No

CT Pelvis Without Contrast

72192

Pelvis Hips

Fracture Non Union Arthritis

No

CT Pelvis Without Contrast

72192

Extremity Foot Toe Ankle Calf Knee Thigh Femur Lower Leg Finger Hand Wrist Forearm Elbow Humerus

Arthritis Femoral Anteversion Fracture Fusion Loose body Malunion Malignment Knee (indicate Lt, Rt, or Bil) Non Union Osteochondral lesion

No

CT Without Contrast Lower Extremity Upper Extremity

73700

73200

Extremities

Infection* Tumor/Mass/Cancer/Mets *Recommend MRI

Yes

CT Without and With Contrast –Lower CT Without and With Contrast –Upper

73702

73202

Page #6 of 6

Body Part Reason For Exam IV Contrast Procedure to Pre-Cert CPT Code CT Angiography - Extremities

Arterial Stenosis – Lower Claudication -extremity Ischemia - extremity Peripheral Artery Disease

Yes

CT Angiography Lower Extremity Upper Extremity

73706

73206

CT Arthrography

Cartilage Abnormally Labrum Abnormality Loose Bodies Meniscus Abnormally

Yes

CT With Contrast Lower Extremity with Contrast Upper Extremity with Contrast Fluoro Guided Joint Injection *Please state which joint in comments

73701

73201

76000

Diagnostic Imaging Services Policy and Procedure

{00241664 v.1}Page 1 of 5

TITLE: Breast Imaging Standard Operating Procedure

APPROVED BY: Diagnostic Imaging Oversight Committee

CHAPTER: Sutter Epic Weblinks SECTION: Specialty/Clinical Topic>Radiology

ISSUED: 7/1/2011 Updated: 01/06/2012

REVIEWED: DIOC Chair

REPLACES: N/A PAGE 1/4

Purpose - These operating procedures allow Sutter Health imaging departments and breast centers to efficiently generate and fulfill compliant orders for indicated breast imaging and diagnostic studies as needed based upon radiologist recommendations.

Sutter Health imaging departments and breast centers will recommend additional breast imaging and diagnostic studies, including mammography, breast ultrasound, Breast MRI and image guided breast aspiration and/or biopsy, based upon the clinical history, physical findings and/or Breast Imaging Reporting and Data System (BI-RADS) classification as developed by the American College of Radiology.

What is the Breast Imaging Reporting and Database System (BI-RADS)?

The American College of Radiology (ACR) has established a uniform system for radiologists to describe and manage mammogram findings. The system includes seven standardized Categories, or Assessments. Each BI-RADS Category has an associated recommended Follow-up plan to assist radiologists and other physicians in appropriately managing a patient’s care.

Breast Imaging Reporting and Database System (BI-RADS)

Category Assessment Follow-up

0 Need additional imaging evaluation Additional imaging needed before a category can be assigned

1 Negative Continue routine screening mammograms (for women over age 40)

2 Benign (noncancerous) findingj Continue routine screening mammograms (for women over age 40)

3 Probably benign Receive a 6-month follow-up mammogram or ultrasound, then every 6-12 months for 1-2 years.

4 Suspicious abnormality Requires biopsy 5 Highly suggestive of malignancy

(cancer) Requires biopsy

6 Known biopsy-proven malignancy (cancer)

Assure that treatment for known cancer is completed.

Diagnostic Imaging Services Policy and Procedure

{00241664 v.1}Page 2 of 5

Additional information about BI-RADS is available on the ACR Web site at http://www.acr.org/Quality-Safety/Resources/BIRADS/Mammography or by calling the ACR at 1–800–ACR–LINE (1–800–227–5463).

There are certain clinical situations that BI-RADS do not address, where it is clinically appropriate for the radiologist to modify the referring physician's order based on prior history or patient current conditions, the radiologist may change the patient's referral order to the appropriate study under the general SOP permission given by the referring physician. Examples include:

1. Patients that present with orders for screening mammograms who report a palpable abnormality or history of prior abnormal breast imaging study

2. Patients who present with a diagnostic mammogram order with no signs or symptoms or history of breast cancer that should undergo screening mammography

3. Patient with a palpable abnormality whose diagnostic mammogram order does not include breast ultrasound and for which ultrasound is indicated

Diagnostic Imaging Services Policy and Procedure

{00241664 v.1}Page 3 of 5

PALPABLE BREAST LUMPS and FOCAL BREAST PAIN WORKFLOW

Patient < 30 Patient > 30

Diagnostic US first. Add diagnostic mammogram based on radiologist recommendations

Diagnostic mammogram and likely US

Specific imaging findings

BI-RADS 0 Assessment incomplete

Need to complete additional imaging or obtain and review prior studies

BI-RADS 1 & 2 Negative / benign

BI-RADS 3 Probably benign

BI-RADS 4 & 5 Suspicious

Follow-up by PCP, continued routine screening

Follow up as specified by radiologist

Image guided core needle biopsy

If not available refer to surgeon for excisional biopsy

Biopsy results reviewed by radiologist & communicated to PCP

Diagnostic Imaging Services Policy and Procedure

{00241664 v.1}Page 4 of 5

Discordant Malignant

Atypia Benign

6 month possible follow-up mammo or U/S

Refer to surgeon Re-biopsy Refer to surgeon

{00241664 v.1} Policies Page X of X Department Policy: XX-XXX

SCREENING MAMOGRAM – WORKFLOW

BI-RADS Category 1 & 2

Image guided core needle biopsy

Follow radiology advice for follow up imaging

Follow up by PCP continue routine screening

If not available or amenable, refer to surgeon for excisional biopsy

Biopsy results reviewed by radiologist and communicated to PCP

Malignant Atypia Benign

Refer to surgeon Refer to surgeon 6 month follow-up mammo/ultrasound possible

BI-RADS Category 0 & 3

BI-RADS Category 4 & 5

Page #1 of 7

MRI Standard Operating Procedures

Body Part Reason For Exam IV Contrast Procedure to Pre-Cert CPT Code Brain

Alzheimer’s Confusion CVA Dementia Headache w/o Focal Symptoms Memory Loss Mental Status Changes Seizures Stroke TIA Trauma Adenoma Cranial Nerve Lesions Dizziness Elevated Prolactin HIV IAC/Hearing Loss Infection Multiple Sclerosis Neurofibromatosis Pituitary Lesion Tumor/Mass/Cancer/Mets Vascular Lesions Vertigo Vision Changes To guide surgery planning, radiation therapy, or other surgical treatments for the brain, such as laser ablation; for preoperative planning to localize language dominance and for functional localization of memory; to localize abnormal brain functionfor epilepsy surgery

No

Yes

MRI Without Contrast MRI With & Without Contrast fMRI

70551

70553

70555 96020

MRA Brain

Stroke CVA TIA Aneurysm Arterial Venous

No

MRA Brain Without Contrast

70544

Brain Spectroscopy

Alzheimer’s Dementia Seizures Encephalopathy Ischemia Hypoxia Brain Injury Tumor/Mass/Cancer/Mets Infection Multiple Sclerosis

No

Yes

MRI Spectroscopy Without Contrast MRI Spectroscopy With and/or Without Contrast

76390

76390

Page #2 of 7

Body Part Reason For Exam IV Contrast Procedure to Pre-Cert CPT Code MRV Brain

Venous Thrombosis

No

MRA Without Contrast

70544

Orbits

Demyelination/Multiple Diplopia Dysthyroid Eye Disease Exopthalmos Grave’s Disease Proptosis Pseudotumor Sclerosis Trauma Tumor/Mass/Cancer/Mets Vascular Lesions

Yes

MRI Orbits/Face/Neck With & Without Contrast

70543

Neck

Infection Pain Tumor/Mass/Cancer/Mets Vocal Cord Paralysis

Yes

MRI Orbits/Face/Neck With & Without Contrast

70543

MRA Neck

Aneurysm Arterial Venous Malformation CVA Stroke Subclavian Steal TIA

Yes

MRA Neck With & Without Contrast

70549

MRA Arch & Great Vessels

Aneurysm Arterial Venous Malformation CVA Stroke Subclavian Steal TIA

Yes

MRA Neck With & Without Contrast

70549

Spine: Cervical

Arm/Shoulder Pain and/or Weakness Degenerative Disease Disc Herniation Neck Pain Radiculopathy Post-op (any hx cervical surgery) Abscess/Infection Discitis Multiple Sclerosis Myelopathy Osteomyelitis Syrinx Tumor/Mass/Cancer/Mets Vascular Lesions/AVM

No

Yes

MRI Cervical Spine Without Contrast MRI Cervical Spine With & Without Contrast

2141

72156

Page #3 of 7

Body Part Reason For Exam IV Contrast Procedure to Pre-Cert CPT Code Spine: Thoracic

Back Pain Compression Fracture (no hx cancer/mets) Degenerative Disease Disc Herniation Radiculopathy Trauma Vertebroplasty Planning (no hx of cancer/mets) Compression Fracture (with hx of cancer/mets) Post-op (any hx thoracic surgery) Abscess/Infection AVM Discitis Multiple Sclerosis Myelopathy Osteomyelitis Syrinx Tumor/Mass/Cancer/Mets Vascular Lesions Vertebroplasty Planning (with hx of cancer/mets)

No Yes

MRI Thoracic Without Contrast MRI Thoracic With & Without Contrast

72146

72157

Spine: Lumber

Back Pain Compression Fracture (no hx cancer/mets) Degenerative Disease Disc Herniation Radiculopathy Sciatica Spondylolithesis Stenosis Trauma Vertebroplasty (no hx of cancer/mets) Postop (any hx lumbar surgery) Abscess/Infection Compression Fracture (with hx of cancer/mets) Discitis Osteomyelitis Post-op (any hx lumbar surgery) Tumor/Mass/Cancer/Mets Vertebroplasty Planning (with hx of cancer/mets)

No

Yes

MRI Lumbar Without Contrast MRI Lumbar With & Without Contrast

72148

72158

Page #4 of 7

Body Part Reason For Exam IV Contrast Procedure to Pre-Cert CPT Code Chest Mediastinum

Tumor/Mass/Cancer/Mets

Yes

MRI Chest/Mediastinum With & Without Contrast

71552

MRA Chest

Aneurysm Arterial Venous Malformation Coarctation Dissection Pulmonary Embolism Thoracic Aorta (other than the heart) Thoracic Outlet Syndrome Vascular Anomalies Subclavian Vessels

Yes

MRA Chest With or Without Contrast

71555

MRV Chest

Arterial Venous Malformation Venous Occlusion/ Thrombosis

Yes

MRA Chest With or Without Contrast

71555

Breast

Implant Rupture Abnormal Mammogram Abnormal Ultrasound Dense Breast/High Risk Mass/Lesion/Cancer Palpable Mass

No

Yes

MRI Breast Without Contrast Bilateral Unilateral (specify breast) MRI Breast Bilateral With & or Without Contrast MRI Breast Unilateral With & or Without Contrast (Specify Side)

77059 77058

77059

77058

Brachial Plexus

Brachial Plexus Injury Nerve Avulsion Tumor/Mass/Cancer/Mets

Yes

MRI Chest/Mediastinum With & Without Contrast

71552

Cardiac

Anomalous Coronary

Artery -CCTA

If looking for Valve Insuffciency/Regurgilation, ASD/VSD and the patient is unable to receive a contrast agent. ARVD Mass Myocardial Infarction Pericardial Disease Sarcoldosis Viability Valve Insuffciency/Regurgilation Atrial/Ventricular Septal Defect

No

No

Yes

No

Morphology & Function Without Contrast Morphology & Function Without Contrast; With Flow/Velocity Quantification Morphology & Function Without and With Contrast and Further Sequences Morphology & Function Without Contrast; With Flow/Velocity Quantification

75557

75557

75565

75561

75561

75565

Page #5 of 7

Body Part Reason For Exam IV Contrast Procedure to Pre-Cert CPT Code Abdomen

Abnormal Enzymes Fetal MRI MRCP (Biliary/Pancreatic Ducts, Stones, Jaundice) Abdominal Pain Abscess/Ascites Adrenal Mass Liver Pancreatic Mass/Lesion Renal Lesion Tumor/Mass/Cancer/Mets

No

Yes

MRI Abdomen Without Contrast MRI Abdomen With & Without Contrast

74181 74183

MRA Abdomen

AAA(abdominal aortic aneurysm) Dissection Mesenteric Ischemia Renal Artery Stenosis Pre Liver Transplant Pre Kidney Transplant Renal Mass

Yes

Yes

MRA Abdomen With or Without contrast Order 2 Studies MRA Abdomend With or Without Contrast MRI Abdomen With Or Without Contrast

74185 74185 74183

MRV Abdomen

Venous Anomaly Venous Occlusion Venous Thrombosis

Yes

MRA Abdomen With or Without Contrast

74185

Pelvis

Fracture MRI Defecogram Muscle/Tendon Tear Urethral Diveticulum Abscess Adenomyosis Embolization Endometrioma Fibroid Osteomyetits Plexopathy Pre/Post Fibroid Prostate Cancer Septic Arthritis Tumor/Mass/Cancer/Mets Ulcer

No

Yes

MRI Pelvis Without Contrast MRI Pelvis With & Without Contrast

72195

72197

MRA Pelvis Or MRV Pelvis

Aneurysm AVM (artriovenous malformation) May Thurner Syndrome Pelvic Congestion Venous Occlusion Aneurysm Pelvic Congestion

Yes

Yes

MRA Pelvis With or Without Contrast Order 2 Exams: MRA Pelvis With or Without Contrast MRI Pelvis With and Without Contrast

72198

72198

72197

Page #6 of 7

Body Part Reason For Exam IV Contrast Procedure to Pre-Cert CPT Code MRA Peripheral (Run-off)

Claudication Cold foot Gangrene Pain Ulcer

Yes

Order 3 Exams: MRA Abdomen with/without contrast & MRA Lower Extremity with/without contrast LEFT & MRA Lower Extremity with/without contrast RIGHT

74185

73725

73725

MRA Extremity or MRV Extremity

Aneurysm Arterial Occlusion/Stenosis Venous Occlusion

Yes

MRA Extremity with & without contrast Upper Extremity

Lower Extremity

73225

73725

Extremity, Non-Joint Arm Hand Finger Femur Lower Leg Foot Toe

Fracture Muscle/Tendon tear Stress Fracture Abscess Cellultis Fasciitis Myositis Osteomyelitis Soft Tissue Tumor/Mass/ Cancer/Mets Ulcer

No

Yes

MRI Non-Joint Without Contrast Lower-Extremity Upper-Extremity MRI Non-Joint Without & With Contrast Lower-Extremity Upper-Extremity

73718

73218

73720

73220

Extremity, Joint Shoulder Elbow Wrist Hip Knee Ankle Foot

Arthritis AVN (Avascular Necrosis) Cartilage Tear Fracture Internal Derangement Joint Pain (specify joint) Labral Tear Ligament Tear Meniscus Tear Muscle Tear Osteochondritis Dessicans (OCD) Stress Fracture Sprain/Strain Tendon Tear

No

MRI Joint Without Contrast Lower-Extremity Upper-Extremity

73721

73221

Extremity, Joint Shoulder Elbow Wrist Hip Knee Ankle

Abscess Cellulitis Fasciitis Inflamatory Arthritis Myositis Osteomyelitis Septic Arthritis Tumor/Mass/Cancer/Mets Ulcer

Yes

MRI Joint Without & With Contrast Lower-Extremity Upper-Extremity

73723

73223

Page #7 of 7

Body Part Reason For Exam IV Contrast Procedure to Pre-Cert CPT Code MR Arthrography

Labral Tear Loose Bodies OCD Stability Post-op shoulder Post-op meniscus repair

Yes

MRI Joint with Contrast-Order 2 Exams Lower Extremity With Contrast Upper Extremity With Contrast Fluoroscopy Guided Joint

Injection Please state which joint in

comments

73722 73222 76000

NUCLEAR MEDICINE STUDIES STANDARD OPERATING PROCEDURES 1. Bone Scan: ( Order the following as: 78315 – 3 Phase Bone scan with option to do 78320 - Tomographic SPECT) RADO255 with RAD025 A. Procedure for evaluating bone disorders including:

• Skeletal Pain (bone or joint pain) / Fracture (For skeletal injuries/fractures it is preferable to image 48 hours or more after the injury) • Inflammatory / Septic Arthritis • Cellulitis / Osteomyelitis • Renal Osteodystrophy • Avascular Necrosis / Aseptic Necrosis • Skeletal Lesions / Primary Bone Tumors • Prosthetic Infection or Loosening or Painful Prosthesis • Arthritis / Heterotopic Ossification • Reflex Sympathetic Dystrophy

-- 3 Phase Bone scan includes imaging Single or Multiple regions or as a Whole Body exam. -- SPECT may be used by the Nuclear Medicine physician after reviewing initial set of images -- Three Phase Bone Scans are performed on pediatric patients, unless contraindicated. B. Skeletal Metasases: (78306 -Whole Body Bone) RAD0259 -- SPECT may be performed if indicated by radiologist after reviewing initial set of images. 2. Bone Marrow Scan: (78104 – Whole Body) RADO252 Procedure for evaluation of regional bone marrow abnormalities.

• Diagnosis of osteomyelitis in conjunction with an 111In WBC scan. • Diagnosis of prosthetic infection versus normal marrow accumulation at site of prosthetic. • Avascular Necrosis / Bone Infarction

3. Brain Tumor Imaging: (78607 – Tomographic SPECT) RAD0267

• Screening of patients suspected of having primary and/or metastatic brain tumors • To determine the viable tumor burden in patients with known gliomas.

-- Baseline tumor burden prior to therapy -- Follow residual tumor burden following treatment

-- Evaluation of patients suspected of having tumor versus infection (gallium utilized) 4. Cardiac Shunt Study: Right to Left (78428 – Cardiac Shunt Detection) RAD0271

• Detection, evaluation and quantitation of intra-cardiac shunts • Follow-up from surgery for correction of intracardiac shunts.

5. Gallium Inflamation and Infection Scan: (Order the following as: 78806 – Whole Body) RAD0243

• To localize source of fever in patients with fever of unknown origin (FUO) or elevated WBC count. • Diagnosis and follow-up of retroperitoneal fibrosis

(Order the following as: 78807—Tomographic SPECT RAD0338

• Detection of pulmonary and mediastinal inflammation/infection, especially in the immunocompromised patient. • Evaluation and follow-up of active lymphocytic or granulomatous inflammatory processes, such as sarcoidosis or tuberculosis. • Diagnosing osteomyelitis and/or disk space infection. (67 Ga is preferred over labeled leukocytes for disk space infection and vertebral osteomyelitis, and orthopedic

hardware). • Evaluation and follow-up of drug-induced pulmonary toxicity (e.g., bleomycin, amiodarone). • Follow-up post surgery / transplant for infection / osteomyelitis.

6. Gallium Tumor Scan: (78804 – Whole Body Mult. Days with 78803-Tomographic SPECT) RAD0395 with RAD0445

• Lymphoma -- Hodgin's Disease (HDL) Sarcoma -- Non Hodgkin's Lymphoma (NHL) Testicular Tumors -- Lung cancer Head and Neck Tumors -- Melanoma Multiple Myeloma -- Hepatocellular carcinoma Neuroblastoma

• Recurrence, Restaging, Management, and outcome of both HD and NHL • Differentiation of brain tumor from infection

7. Gastric Empty Study: (78264 – Gastric Emptying Study) RAD0263 • Determination of possible delayed gastric emptying and quantitation of gastric emptying rate in patients with suspected gastroparesis of other motility problems. • Evaluation of response to therapy in those patients who have proven delayed gastric

emptying. • Evaluation of gastric motility in post-operative or post-radiotherapy patients. • Evaluation of gastric outlet obstruction

8. Hepatobiliary (HIDA) Scan: (78223 – Hepatobiliary Ductal System Imaging w or w/o Pharm. Intervnt.) RAD0299

• Functional assessment of the hepatobiliary system / Or asses the integrity of the hepatobiliary tree. These broad categories include:

-- Suspected acute cholecystitis -- Evaluate for choledochal cyst -- Suspected chronic biliary tract disorders -- Jaundice -- Common bile duct obstruction / Extravasation / Leak -- Gallstone/lithotripsy patients -- Evaluation of congenital abnormalities of the biliary tree -- Evaluation of right upper quadrant pain -- Evaluation of route of biliary drainage in post-op biliary diversion -- Evaluation of biliary atresia vs. neonatal hepatitis

9. Liver and Spleen Scan: (78205 – Liver Imaging SPECT) RAD0324 • This study can be used for determining the size and shape of the liver and spleen. • For suspected focal nodular hyperplasia of the liver. These lesions often have normal or

increased uptake on sulfur colloid imaging.

10. Lymphoscintigraphy: Breast and Melanoma: (78195 -- Lymphatic / Lymph Nodes w/Imaging with option for 78803 --Tomographic SPECT) RAD0330 RAD0445 (38792 – Sentinel Node I.D. w/out Imaging) RAD0330

• Lymphoscintigraphy for Intra-operative Identification of Sentinel Lymph Nodes in conjunction with Breast Carcinoma and Malignant Melanoma with the aid of the intra-operative gamma probe.

• Visualization of lymphatic drainage and assisting in imaging Sentinel Lymph Node position(s) prior to surgery. • Malignant melanomas may be performed with SPECT imaging to assist in localization. • Lymphatic Transport Mapping (Used to plan patient’s therapy) / Lymphedema evaluation

11. Mammoscintigraphy: (78800 – Localization of Tumor, Limited Area) RAD0394

• Evaluate breast cancer in patients in whom mammography is nondiagnostic, equivocal, or difficult to interpret: -- Presence of scar tissue -- Implants -- Dense breast tissue -- Severe dysplastic disease • Assist in identifying multicentric and multifocal carcinomas in patients with tissue

diagnosis of breast cancer.

12. Meckles Diverticulum: (78261 – Gastric Mucosa Imaging) RAD0331 • The indication for a Meckel’s scintiscan is to localize ctopic gastric mucosa in a Meckel’s diverticulum as

the source of unexplained gastrointestinal bleeding. Bleeding Meckel’s diverticula usually occur in young children. The Meckel’s scintiscan should be used when the patient is not actively bleeding. 13. Myocardial Perfusion Scan: Adensosine/Lexiscan (78452 – Myocard. Perfusion Imaging, SPECT – Multiple) RAD0335

• For the detection of coronary artery disease (CAD) and assessing prognosis in patients with symptoms suggestive of CAD. • For risk stratification of post myocardial infarction patients and in patients with unstable angina or chronic CAD. • For cardiac risk stratification prior to non-cardiac surgery in patients with known CAD or those with risk factors for CAD. • For the evaluation of the efficacy of therapeutic interventions in patients with known CAD • Risk stratification of clinically stable patients into low and high-risk groups very early after acute myocardial infarction (>1 day) or early after angioplasty or stenting

(less than 2 weeks). • Inability to perform adequate exercise.

-- Degenerative joint disease (DJD) -- Obesity -- Arthritis -- SOB -- Gait Disturbance -- Vertigo -- Peripheral Vascular Disease (PVD) -- Weakness -- Advanced age -- Stroke

• Patients with Left Bundle Branch Block (LBBB), or Pacemaker. • Concomitant treatment with medications which blunt the heart rate response (beta blockers, calcium channel blockers).

14. Myocardial Perfusion Scan: Exercise (78452 – Myocard. Perfusion Imaging, SPECT – Multiple) RAD0335

• To evaluate the functional capacity of selected patients with valvular heart disease • To evaluate the blood pressure response of patients being treated for systemic arterial hypertension who wish to engage in vigorous dynamic or static exercise • To evaluate asymptomatic males over the age of 40 with two or more risk factors for CAD • To evaluate sedentary male patients >40 years who plan to enter a vigorous exercise program • To evaluate stress induced cardiac arrhythmia

15. Myocardial Infarct Study w/PYP: (78469 – Myoc. Imaging, Infact Tomographic SPECT) RAD0295

• Detection of Acute Myocardial Infarction • Patients with pre-existing ECG abnormalities • Patients with atypical symptoms • Patients who are post-op open heart surgery

Note: Myocardial scanning is not indicated in evaluating a patient with a typical MI. 16. Neuroendocrine Tumor Imaging: (78804 – Whole Body Mult. Days with 78803-Tomographic SPECT) RAD0395 with RAD0445

• Detecting primary and metastic pheochromocytoma in adults. • Improving the diagnosis of neuroblastomas in pediatric patients.

17. Octreoscan: (78804 – Whole Body Mult. Days with 78803-Tomographic SPECT) RAD0395 with RAD0445 A. Detection and localization of a variety of suspected neuroendocrine and some non-neuroendocrine tumors and their metastases B. Staging patients with neuroendocrine tumors. C. Determination of somatostatin-receptor status (patients with somatostatin receptor-positive tumors may be more likely to respond to octreotide therapy). D. Follow-up of patients with known disease to evaluate potential recurrence. E. Staging patients with Neuroendocrine tumors.

• Adrenal medullary tumors ( pheochromocytoma, neuroblastoma, ganglioneuroma) • GEP (gastroenteropancreatic) tumors, e.g., gastrinoma, insulinoma, glucagonoma, VIPoma (vasoactive intestinal polypeptide secreting tumor) and non-functioning GEP tumors • Carcinoid tumors (The following is a partial list as other entities may also demonstrate somatostatin positive receptor uptake.) -- Merkel Cell tumor of the skin -- Paraganglioma -- Small-Cell Lung Carcinoma -- Benign and malignant bone tumors -- Lymphoma (Hodgkin’s and non-Hodgkin’s -- Differentiated thyroid carcinoma (Papillary, follicular, Hürthle cell)

-- Medullary Thyroid Carcinoma -- Melanoma -- Pituitary Adenomas -- Astrocytomas / Meningioma -- Breast Carcinoma -- Non-small cell lung carcinoma 18. Parathyroid Imaging: (78070 – Parathyroid Imaging) RAD0342

• To localize hyperfunctioning parathyroid tissue in primary hyperparathyroidism in patients with newly diagnosed hypercalcemia and elevated PTH levels. • To localize hyperfunctioning parathyroid tissue (usually adenomas) in patients

with persistent or recurrent disease. • To provide localization information prior to parathyroid surgery.

19. Pulmonary Aspiration: Pediatric and Adult (78262 – Gastroesophageal Reflux Study) RAD0285

• Suspected aspiration into the lungs due to gastroesophageal reflux. Pulmonary Aspiration with Gastric Empty Study (78264 – G. E. Study & 78262 – Reflux Study) RAD0263 and RAD0285

• Suspected aspiration into the lungs due to gastroesophageal reflux. • Determination of possible delayed gastric emptying and quantitation of gastric emptying rate in patients with suspected gastroparesis of other motility problems.

-- Diabetics -- Peptic Ulceration -- Cancer of the Stomach -- Tauma

• Evaluation of response to therapy in those patients who have proven delayed gastric emptying.

• Evaluation of gastric motility in post-operative or post-radiotherapy patients. • Evaluation of gastric outlet obstruction

20. Renal Hypertension Study with Captopril: Pediatric and Adult (78708 – Kidney Imaging w/ Vascular Flow and Function, single study with Pharmacologic intervention) RAD0414

• Renovascular hypertension caused by renal hypoperfusion from stenosis. • Renal artery thrombosis in infants / Coarctation of the aorta in infants. • Abrupt or severe hypertension / Hypertension resistant to 3-drug therapy • Bruits in the abdomen or flank • Recurrent pulmonary edema in an elderly hypertensive patient • Worsening renal function during therapy with angiotensin-converting enzyme inhibitors. • Grade 3 or 4 hypertensive retinopathy / Unexplained azotemia • Onset of hypertension under age 30 years or over 55 years. • Hypertension in children / Hypertension in infants with an umbilical artery catheter.

21. Renal With or Without Lasix: Pediatric and Adult (78709 – Kidney imaging with vascular flow and function, multiple studies With and without pharmacological intervention) RAD0319

• To differentiate a true obstruction from a dilated nonobstructed system (stasis) • Ureteropelvic or ureterovesical obstruction as a cause of hydronephrosis • Post-surgical evaluation of a previously obstructed system • Distension of pelvicalyceal system as an etiology of back pain • Assess vascular compromise • Assess differential function

22. Renal / DMSA: (78710 – Tomographic SPECT) RAD0411

• Acute pyelonephritis / Renal Scarring • Evaluate function of renal mass • Solitary or ectopic renal tissue (e.g., pelvic kidney) • Horseshoe and pseudohorseshoe kidneys

23. Renal Transplant Study: (78709 – Kidney imaging with vascular flow and function, multiple studies With and without pharmacological intervention) RAD0319

• To visualize and evaluate renal artery flow (perfusion) and excretion • To aid in the diagnosis of rejection and/or leak

24. Thyroid Scan and Uptake: (78007 – Thyroid imaging, w/ uptake; multiple determinations) RAD0435

• Evaluate for Hyperthyroidism or Hypothyroidism • Evaluate function of a thyroid nodule • Document the existence , the size and location of the thyroid gland or location of ectopic thyroid tissue. • Demonstrate heterogeneity of function within a hyperthyroid gland (Toxic Nodular Goiter) • Post-operative evaluation of the thyroid gland

25. Voiding Cysternogram: (78470 & 78730 – Ureteral reflux study, with bladder residual study) RAD0457 and RAD0448

• Initial evaluation of females with urinary tract infection for reflux • Diagnosis of familial reflux • Evaluation of vesicoureteral reflux after medical management or assessment of the results of antireflux surgery • Serial evaluation of bladder dysfunction (e.g., neurogenic bladder) for reflux

26. White Blood Cell Study: (78806 – Whole Body, with option to do 78807 – Tomographic SPECT) RAD0243 with RAD0338

• To evaluate febrile postoperative patient without localizing signs or symptoms. Fluid collections, ileus, bowel gas, fluid, and/or healing wounds may reduce the specificity of CT and ultrasound to detect site(s) and extent of inflammatory bowel disease. 99mTc-labeled leukocytes may be preferable for this indication.

• To detect acute osteomyelitis (less than one week duration) in conjunction with bone imaging. Gallium imaging is preferred performed in conjunction with bone imaging for chronic infection greater than one week, in the presence of prior surgery or hardware, spine or disc infections and in diabetic patients when degenerative or traumatic changes, neuropathic osteoarthropathy, or prior osteomyelitis have caused increased bone remodeling.

• To detect mycotic aneurysms, vascular graft infections, and shunt infections.

Note: The 99mTc Ceretec WBC study is performed instead of the 111In WBC study when acute appendicitis is suspected, a STAT study is needed, in pediatric population or if 111Indium is not available.

Page #1 of 5

Ultrasound Standard Operating Procedures EPIC Exam to Order Reason for Exam Exam Description CPT Code RAD1199 US AAA Exam Screen Only (Medicare)

Abdominal Aorta AAA Screening

G0389

RAD0459 US Abdomen Complete

Abdominal Pain Cirrhosis r/o Gallstones Hepatitis Nausea Pancreatitis Vomiting Elevated LFT’s

Includes Liver, GB, CBD, Pancreas, Spleen, Kidneys, Upper Abdominal Aorta and IVC

76700

RAD0460 US Abdomen Limited

Abdominal Mass Hernia R/O Ascitis Pyloric Stenosis R/O Gallstones R/O Appendicitis

Single abdominal organ or single quadrant only i.e. Gallbladder

76705

RAD0461 US Abdomen Retroperitoneal

AAA Bladder Mass/CA Chronic Kidney Disease Hematuria Hydronephrosis Renal Insufficiency Renal/kidney Stones UTI

Kidneys Bladder Aorta Iliacs IVC

76770

RAD0462 US Abdomen Retroperitoneal Limited

Aorta/IVC Bladder Only

76775

RAD0465 US Chest

R/O Pleural Fluid Superficial Mass Chest area

76604

RAD1056 or 0770 US Breast

Finding in axilla

Perform 1799 / 1800 US Axilla left or right

76882

Page #2 of 5

EPIC Exam to Order

Reason for Exam

Exam Description

CPT Code

RAD1057 US Extremity Non-Vascular

Mass/Lump R/O popiteal cyst *Not for DVT*

76880

RAD0478 US Fetal Biophys Profile W/O Stress NST

Fetal Assessment of tone, breathing, movement and fluid only

76819

RAD0519 US Head and Brain Neonatal

Neonatal Brain Increasing Head Circumference

Assessment of neonatal brain for Bleed or Ventriculomegaly <12 months or fontanel closes

76506

RAD0494 US Head and Neck Soft Tissue

Abnormal TSH, T3 / T4 Hyperthyroidism Multinodular Goiter Palpable head/neck mass Thyroid nodules

Parathyroid Parotid Gland Thyroid

76536

RAD0495 US Hips Infant Dynamic

R/O hip dysplagia requiring physician manipulation

76885

RAD0496 US Hips Infant Static Limited

R/O hip dysplagia. DOES NOT require physician manipulation

76886

RAD0497 US Kidney Transplant

Status of transplanted Kidney with Duplex Scan

76776

Page #3 of 5

EPIC Exam to Order Reason for Exam Exam Description CPT Code RAD0500 US OB Complete Greater than 14 Weeks

If the pt is >or = 14 weeks and this is her 1st US and will not be the detailed scan

Fetal and Maternal Evaluation after 1st trimester

76805

RAD0502 US OB Detailed Single Fetus

Fetal and Maternal evaluation plus detailed fetal anatomic examination. Only used for high-risk pregnancy evaluation by OB specialist – otherwise, use 76805

Detailed anatomy scan usually done between 18 – 22 weeks * Preferably at least 20 weeks

76811

RAD0504 US OB Exam Limited

AFI Cervical Length Fetal Hearbeat Fetal Position Placenta location

Any or all of the reasons for exam

76815

RAD0469 US OB Exam Repeat

Follow-up Fetal Size & AFI Re-evaluation of organ systems suspected to be abnormal

76816

RAD0499 US OB Less than 14 weeks Single Fetus

Fetal and Maternal Evaluation 1st trimester

1st trimester scan – May need OB Transvaginal Obstetric order if really early IUP RAD0518

76801

RAD0503 US OB Multiple Gestation Complete

Fetal and Maternal evaluation plus detailed fetal anatomic examination, transabdominal approach

If the pt is >or = 14 weeks and this is her 1st US and it will not be the detailed scan

76812

RAD0518 US Transvaginal Obstetric

Typically only done during 1st trimester.if not well seen on transabdominal

76817

RAD1175 US OB Nuchal Translucency

First trimester fetal nuchal translucency measurement transabdominal and transvaginal approach

Performed during weeks 11wk2d – 13wk2d

76813

RAD1176 US OB Nuchal Translucency add’l fetus

First trimester fetal nuchal translucency measurement transabdominal and transvaginal approach each add’l fetus

Performed during weeks 11wk2d – 13wk2d

76814

Page #4 of 5

EPIC Exam to Order

Reason for Exam

Exam Description

CPT Code

RAD1237 US Pelvic & Tranvaginal Non-OB

DUB (Dysfunctional Uterine Bleeding) Endometriosis Fibroids Irregular Menses Ovarian Cysts Ovarian Torsion Pelvic Pain

Perfect order for Non-OB Pelvic Ultrasound exams

76856 76830

RAD0505 US Pelvis Complete

DUB (Dysfunctional Uterine Bleeding) Endometriosis Fibroids Irregular Menses Ovarian Cysts Ovarian Torsion Pelvic Pain

Pelvic Ultrasound Non OB Transabdominal approach only

76856

RAD0506 US Pelvic Limited or Follow-up

Rare – follow-up to a recent Pelvic US

76857

RAD0517 US Transvaginal Non OB

Almost always done with US Pelvic Complete

76830

RAD0509 US Scrotum and Testicles

Testicular/scrotal pain Scrotal swelling Testicular Torsion Palpable mass

76870

RAD0514 US Spinal Canal

R/O Tethered Card

Performed on infants with back dimple < 3 months

76800

Page #5 of 5

EPIC Exam to Order Reason for Exam Exam Description CPT Code RAD0236 NIVL Duplex Abd Pelvis Study

RAS Hypertension

Renal Artery Stenosis SMA Study Liver Colorflow

93975

RAD0810 NIVL Duplex Scan Extracranial Arteries

Carotid Bruit Carotid Stenosis CVA/TIA symptoms S/P CEA

Carotid Doppler

93880

RAD 0235 NIVL Venous Duplex Extremity Bilateral

DVT Bilateral Extremities swelling/pain/redness

Venous Doppler Bilateral

93970

RAD1053 NIVL Venous Duplex Extremity Left

DVT Left leg or arm swelling/pain/redness

Venous Doppler Left leg or arm

93971

RAD0774 NIVL Venous Duplex Extremity Right

DVT Right leg or arm swelling/pain/redness

Venous Doppler Right leg or arm

93971

Last rev. 5/7/2012

SMF (Central) RADIOLOGY Protocols for STANDARD OPERATING PROCEDURES

HEAD SKULL < 4 views (limited)

o PA o LAT 70250

4 views or more (complete) o PA o TOWNES o BOTH LATERALS 70260

FACIAL BONES < 3 views (limited)

o UPRIGHT WATERS 70140 3 views or more (complete)

o UPRIGHT WATERS o CALDWELL o LATERAL SMV for zygomas as indicated by pain in that area 70150

NASAL BONES At least 3 views

o UPRIGHT WATERS o BOTH LATERALS 70160

SINUS Less than 3 views

o UPRIGHT WATERS o LATERAL 70210

EYE FOR FB (screening orbits for MRI) 1 view

o WATERS VIEW 70030 TMJ X-RAY indicated for trauma only

o TOWNES o BILATERAL o OPEN SCHULLERS (modified lateral) o CLOSED SCHULLERS 70330

Last rev. 5/7/2012

(CT RECOMMENDED) FOR ALL OTHER COMPLAINTS – Call ordering physician ORBITS At least 4 views

o WATERS o CALDWELL W/ 25-30 degree caudad o LATERAL of affected side o BOTH 3 POINT LANDINGS 70200

MANDIBLE < 4 views (limited)

o LATERAL (only for pediatric teeth) 70100 4 views or more (complete)

o PA o TOWNES o LATERAL o BOTH OBLIQUES 70110

MASTOIDS CT Highly recommended – Call ordering physician NECK SOFT TISSUE LATERAL NECK to include adenoids 70360

SPINE & PELVIS CERVICAL For TRAUMA

o AP o ODONTOID o LATERAL (Incl C-7); SWIMMERS as needed 72040

For PAIN

o AP o ODONTOID o BOTH OBLIQUES, LAT (Incl C-7) SWIMMERS as needed 72050

Complete w/Flexion & Extension

o AP o ODONTOID o BOTH OBLIQUES o LATERAL (Incl C-7); SWIMMERS as needed; o LAT FLEXION

Last rev. 5/7/2012

o LAT EXTENSION 72052 THORACIC AP LATERAL SWIMMERS 72070

LUMBAR For TRAUMA

o AP o LATERAL o CONE OF L4-5 if not open on lateral 72100

For PAIN

o AP o BOTH OBLIQUES o LATERAL o CONE OF L5-S1 if not open on lateral 72110

Complete, including bending views

o AP o LATERAL o BOTH OBLIQUES o CONE OF L5-S1 if not open on latearl o LATERAL FLEXION o LATERAL EXTENSION 72114

LUMBOSACRAL, bending views only

o STANDING AP o NEUTRAL LATERAL o FLEXION LATERAL o EXTENSION LATERAL 72120

THORACOLUMBAR AP LATERAL centered at T-12 / L-1, to includeT-10 TO L-3 72080

SCOLIOSIS UPRIGHT PA T/L to include entire pelvic crests for pelvic tilt & Risser grade

assessment; include separate AP pelvis, only if necessary (72170) UPRIGHT LATERAL T & L SPINE on one projection if possible 72069

*Please note: AP should be standing, with both legs fully extended and patellae facing forward.

No shoes 72-inch distance with radiographic ruler down the middle (from top to bottom) Include top of the acetabulum to the talus (this may require > than 72 inches from

Last rev. 5/7/2012

the tube to the imaging plate, depending on patient’s height. Patient may stand on step stool, with handle at side, in order to get the film low enough.

Digital image may require “stitching” to merge it into one film SACRUM & COCCYX 15 DEGREE CEPHALAD AP VIEW OF SACRUM 10 DEGREE CAUDAD VIEW OF COCCYX LATERAL VIEW TO INCLUDE BOTH 72220

SI JOINTS Always Bilateral 20 DEGREE CEPHALAD VIEW OF SACRUM to include both SI joints 45 DEGREE UPSIDE OBLIQUE VIEWS of each SI joint 72202

PELVIS 1-2 views (limited)

o AP PELVIS 72170 At least 3 views (complete)

o AP o LPO o RPO 72190

UPPER EXTREMITIES AC JOINTS *Always Bilateral AP VIEWS bilateral AC JOINTS, with and without weights 73050

STENOCLAVICULAR JOINTS RAO LAO PA CENTERED AT SC JOINTS 71130 CT RECOMMENDED – Call ordering physician

SCAPULA AP “Y” VIEW 73010

SHOULDER Minimum 2 views (complete) for Trauma

o INTERNAL ROTATION o EXTERNAL ROTATION

Last rev. 5/7/2012

o AXILLARY VIEW o TRANSCAPULAR VIEW 73030

Minimum 2 views (complete) for Non-Trauma

o INTERNAL ROTATION o GRASHEY VIEW o AXILLARY VIEW o SUPRASPINATUS OUTLET 73030

CLAVICLE 2 views

o AP o AP WITH 20 – 25 CEPHAL ANGLE 73000

HUMERUS 2 views

o AP o LATERAL 73060

ELBOW AP LATERAL OBLIQUE LATERAL 73080

FOREARM AP LATERAL 73090

WRIST PA OBLIQUE w/45 degree pronation LATERAL SCAPHOID as indicated by pain over snuffbox 73110

HAND PA OBLIQUE w/45 degree pronation LATERAL 73130

FINGER PA OBLIQUE LATERAL 73140

Last rev. 5/7/2012

UPPER EXTREMITY INFANT < 24 months AP LATERAL (Include shoulder to fingers) 73092

LOWER EXTREMITIES

All lower extremity images ordered by podiatry and orthopaedics will be performed as “weight-bearing” exams unless there is recent injury or concern for fracture.

HIP (S) Unilateral

o AP PELVIS 72170 o FROG LATERAL of affected hip (Cross table as indicated) 73500

BILATERAL o AP (may substitute AP Pelvis) o FROG LATERAL both hips 73520

PELVIS & HIPS INFANT (< 24 months) AP Frog leg PELVIS and HIPS 73540

FEMUR AP LATERAL (INCLUDE HIP & KNEE) 73550 (* If 2 films needed for AP & Lat, ensure overlap at midshaft)

KNEE 3 view

o AP (upright weight-bearing, as directed) o LATERAL o SUNRISE 73562

Min 4 views (complete) o AP (upright weight-bearing, as directed) 73564 o LATERAL o TUNNEL o SUNRISE or MERCHANT

AP STANDING *BILATERAL KNEES* 73565 TIB-FIB

Last rev. 5/7/2012

AP LATERAL (Include knee and ankle) 73590

ANKLE AP OBLIQUE LATERAL (Weight Bearing as directed) 73610

FOOT AP OBLIQUE LATERAL (Weight Bearing as directed) 73630

CALCANEUS (HEEL) AP LATERAL 73650

TOES AP OBLIQUE LATERAL 73660

LOWER EXTREMITY INFANT < 24 months AP LATERAL ( Include hips to feet) 73592

CHEST CHEST Single view (for positive PPD test or as ordered)

o PA 71010 o

2 view o PA o LATERAL 71020

PA w/APICAL LORDOTIC 71021 PA w/ BOTH OBLIQUES 71022 CHEST COMPLETE 4 views

o PA o LATERAL o BOTH OBLIQUES 71030

Last rev. 5/7/2012

CHEST DECUBITUS (one or both decubs as ordered) 71035

STERNUM RAO LATERAL 71120

RIBS UNILATERAL RIBS (always includes PA Chest xray)

o UNILATERAL BOTH OBLIQUES using rib technique and mark w/BB o PA CHEST o May also need expiration below diaphragm views 71101

BILATERAL RIBS (always includes PA Chest xray)

o BILAT BOTH OBLIQUES using rib technique and mark w/BB o PA CHEST o May also need expiration below diaphragm views 71111

ABDOMEN ROUTINE 1 VIEW Abdomen

o SUPINE AP (include symphysis) 74000 NOSE TO RECTUM CHILD FOREIGN BODY 1 VIEW AP (child < 8 yrs old) 76010

COMPLETE ABDOMEN W/ERECT and/or DECUB SUPINE UPRIGHT ABDOMEN (Center on diaphragm) DECUBS & SPECIAL VIEWS (as directed) 74020

COMPLETE ABD W/ CXR SUPINE UPRIGHT ABDOMEN (Center on diaphragm) UPRIGHT PA CHEST X-RAY 74022

Last rev. 5/7/2012

MISCELLANEOUS BONE AGE PA ONLY LEFT HAND TO INCLUDE WRIST 77072

INFANT OSSEOUS SURVEY / Battered child series (for suspected child abuse) 77076

Appendicular Skeleton: AP Humeri AP Forearms PA Hands AP Femurs AP Lower Legs (Tib/Fib) AP Feet

*Each must be obtained as a separate exposure to ensure uniform image density and maximize image sharpness; it is NOT acceptable to do single views of an entire upper or lower extremity.*

Axial Skeleton: Chest: AP, Lateral, and Bilateral Obliques, to include all 12 ribs and entire thoracic spine through thoracolumbar junction

Pelvis: AP to iclude the lumbar spine Lumbosacral Spine: Lateral Cervical Spine: Lateral Skull: Frontal (AP) and Lateral

If possible, the exam should be reviewed for completeness and possible inclusion of additional views by the covering Radiologist.

Evaluation of suspected metaphyseal irregularities may require additional coned views of a joint/extremity. Additional Townes and/or oblique views of skull may be necessary in cases of suspected occipital trauma to skull.

SKELETAL / OSSEOUS SURVEY PA & LAT CHEST, LAT SKULL, PELVIS, LATERAL C-T-L SPINES, AP ALL LONG BONES BILATERALLY ( NO LIMITED SURVEYS = ORDER SPECIFIC EXAMS ) 77075

METASTATIC SURVEY PA & LAT CHEST, LAT SKULL, PELVIS, LATERAL C-T-L SPINES, AP LONG BONES 77074

METABOLIC SURVEY (JOINT SURVEY) KNEES & WRISTS AP/LAT 77077

Last rev. 5/7/2012

ARTHRITIS SERIES (Bilat Hands) PA LATERAL NORGAARD VIEW (Allstate view – both hands semi-cupped)