Detailed Order Request Checklists for Chest (Thoracic) Exams

Size: px

Start display at page:

Download "Detailed Order Request Checklists for Chest (Thoracic) Exams"

Georgiana Leonard
7 years ago
Views:

1 Next Generation Solutions Detailed Order Request Checklists for Chest (Thoracic) Exams 8600 West Bryn Mawr Avenue South Tower Suite 800 Chicago, IL Appropriate.Safe.Affordable 2015 AIM Specialty Health

2 Contents Getting ready to place an order... 3 INFORMATION YOU LL NEED FOR CHEST EXAM ORDER REQUESTS... 3 Chest CT, MRI, CTA (Noncoronary) and MRA... 4 THORACIC AORTIC ANEURYSM AND DISSECTION... 4 Chest CT and MRI... 4 CHEST WALL DEFORMITY... 4 CHEST WALL MASS... 4 HEMOPTYSIS... 4 PULMONARY NODULE... 4 Chest CT... 4 BULLOUS EMPHYSEMA... 4 COUGH... 4 FEVER OF UNKNOWN ORIGIN... 5 INFECTIONS AND INFLAMMATORY... 5 INTERSTITIAL LUNG DISEASE... 5 LUNG CANCER SCREENING... 5 MALIGNANCY... 5 PERSISTENT PNEUMONIA... 6 PNEUMONIA COMPLICATIONS... 6 PNEUMOTHORAX... 6 PREOPERATIVE OR PREPROCEDURE... 6 UNEXPLAINED WEIGHT LOSS... 6 Chest MRI... 7 MALIGNANCY... 7 MEDIASTINAL OR HILAR MASS... 7 CT (NONCORONARY) CTA AND MRA... 7 ATHEROMATOUS DISEASE... 7 NEOPLASM... 7 PREOPERATIVE OR PREPROCEDURE... 7 PULMONARY EMBOLISM

3 Getting ready to place an order Knowing what information you'll need for each order saves time. Our cardiology order request checklists can help you identify and collect the information you need to have available when entering an order request. We recommend that you print a copy or save it to your computer to keep it handy when you're preparing to submit an order with AIM Specialty Health. INFORMATION YOU LL NEED FOR CHEST EXAM ORDER REQUESTS For ALL chest exam order requests, you will need: Patient first and last name Ordering provider first and last name CPT code and the name of the exam you re requesting Diagnostic code (ICD9) or name of your patient s diagnosis The name and location of the facility where the exam will be performed For MOST chest exam order requests, you may also need: Reason or indication for ordering this exam Physician s plan for the patient (e.g., preoperative imaging) Current or past treatment history Patient s pertinent medical history (e.g., aortic diseases, lung diseases, cancer, or syndromes) Chest x-ray date and results (very important, most exams will ask for this) Other imaging or lab tests, date, and results The patient s current physical exam, signs, and symptoms. Are signs or symptoms new or worsening? Duration of symptoms? Complete smoking history 3

4 Chest CT, MRI, CTA (Noncoronary) and MRA THORACIC AORTIC ANEURYSM AND DISSECTION Established or suspected Prior imaging; type, date, and results Preoperative or postoperative, date of surgery Surveillance New or worsening symptoms For transcatheter aortic valve implantation/replacement (TAVI or TAVR)? Chest CT and MRI CHEST WALL DEFORMITY Preoperative Measurement of Haller index (HI) Evaluate for cardiac displacement Evaluate chest deformity Evaluation Nuss bar length design Postoperative evaluation Prior chest x-ray, date, result, and nondiagnostic? CHEST WALL MASS Prior chest x-ray or ultrasound, date, result, and nondiagnostic? HEMOPTYSIS Chest x-ray, date, result (nondiagnostic?) PULMONARY NODULE New or worsening signs or symptoms Prior CT or MRI to evaluate nodule within past six months? Change in nodule within past two years? Initial evaluation or periodic surveillance Chest CT BULLOUS EMPHYSEMA Established or suspected Prior chest x-ray New or worsening symptoms COUGH Prior chest x-ray, date, result, and nondiagnostic? Is the patient immunocompromised? Duration of cough: 4 weeks or less 4

5 Greater than 4 weeks Unresponsive to medical treatment? Other causes for cough have been excluded FEVER OF UNKNOWN ORIGIN Is the patient immunocompromised? Duration of fever Less than 3 weeks 3 or more weeks Standard work up for fever Chest x-ray or other Laboratory studies: complete blood count (CBC), chemistry including liver enzymes, and blood cultures Urinalysis INFECTIONS AND INFLAMMATORY Initial diagnosis? Follow up of existing condition? Chest x-ray within the past 4 weeks? Change is patient s clinical status? Surveillance Evaluation Preoperative Postoperative After therapy INTERSTITIAL LUNG DISEASE Established diagnosis of pulmonary fibrosis or interstitial lung disease? Abnormal physical exam findings Abnormal symptoms Abnormal testing: pulmonary function tests (PFT), pulse oximetry, other imaging (chest x-ray) Predisposing factors or known medical conditions Surveillance New or worsening symptoms Evaluation after therapy LUNG CANCER SCREENING Pack year history Signs and symptoms of lung cancer Prior CT in the past one year Candidate for curative surgery Smoking history, years since the patient quit MALIGNANCY Confirmed diagnosis? Initial staging Surgical resection 5

6 Restaging or treatment evaluation Periodic surveillance Change in clinical status Suspected diagnosis based on: Symptoms or physical exam findings Other testing abnormalities Tracheobronchial lesion of bronchoscopy Sputum cytology positive for malignancy Paraneoplastic syndrome Abnormal imaging date and results (including chest x-ray) Renal mass? Surgical resection planned? PERSISTENT PNEUMONIA Chest x-ray for pneumonia done? Recurrent pneumonia Persistent after medical treatment Recurrent within six months Due to suspected obstruction PNEUMONIA COMPLICATIONS Is patient immunosuppressed? Chest x-ray is nondiagnostic PNEUMOTHORAX Recurrent or unexplained? PREOPERATIVE OR PREPROCEDURE For transcatheter aortic valve implantation/replacement (TAVI or TAVR)? Prior chest CT within 60 days? UNEXPLAINED WEIGHT LOSS Amount of weight loss Less than 10% Greater than 10% Interval of six months? Testing done to evaluate weight loss: Complete history and physical exam Laboratory abnormalities Stool hemoccult Chest x-ray 6

7 Chest MRI MALIGNANCY Confirmed diagnosis MEDIASTINAL OR HILAR MASS Contraindication to CT? Prior CT chest, date, results (inconclusive?) Reason for mass Vascular invasion by tumor Detection of spine extension from a chest mass Differentiate a mass from vascular structure CT (NONCORONARY) CTA AND MRA ATHEROMATOUS DISEASE Penetrating atherosclerotic aortic ulce) NEOPLASM Concern about vascular involvement? PREOPERATIVE OR PREPROCEDURE Prior chest CT within 60 days? For transcatheter aortic valve implantation/replacement (TAVI or TAVR)? PULMONARY EMBOLISM Is patient receiving medical treatment for pulmonary embolism? 7

2011 Radiology Diagnosis Coding Update Questions and Answers

2011 Radiology Diagnosis Coding Update Questions and Answers How can we subscribe to the Coding Clinic for ICD-9 guidelines and updates? The American Hospital Association publishes this quarterly newsletter.