2013 CPT Code Reference Guide. T F imaginghealthcare.com

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1 2013 Reference Guide T F imaginghealthcare.com

2 MRI brain - post fossa w/ & w/o contrast (IAC w/ & w/o) MRI brain (pituitary protocol) w/ & w/o contrast MRI brain (seizure protocol) w/ & w/o contrast Bell s Palsy Hearing loss Vertigo Hormone abnormalities Pituitary Seizures - multiple early onset MRI brain and orbits w/ & w/o contrast MRI brain w/ & w/o contrast MRI brain w/o contrast Loss of vision Optic neuritis Bell s Palsy Dizziness Meningitis Metastatic brain disease Seizures Ataxia Dementia Traumatic brain injury (chronic) Ocular mass or tumor Visual disturbance Brain tumor Headaches (depends on associated clinical history) Multiple sclerosis Vertigo CVA Headaches (depends on associated clinical history) 70553, HEAD/NECK & NEURO MRI brain w/o contrast and consider MRA head Personal or family history of aneurysm Severe headache Subarachnoid hemorrhage 70551, MRI face, orbit, neck w/ & w/o contrast Tumor, mass, swelling, or infection of the soft tissue neck 70543

3 MRI abdomen w/ & w/o contrast Abdominal pain Any complaint related to liver, spleen, pancreas or kidneys MRI ABDOMEN & PELVIS MRA abdomen w/ or w/o contrast *If exam includes history of gall stones, gall bladder disease, bile duct dilation, cholangitis, biliary tumor or pancreatitis include MRCP. MRI abdomen w/ & w/o contrast w/ MRCP MRI abdomen and pelvis w/ & w/o contrast Hypertension Renal artery stenosis Common bile duct or gallbladder concerns Pancreatic duct Crohn s disease Inflammatory bowel disease Ischemic bowel disease , Abdomen w/ & w/o Pelvis w/ & w/o MRI pelvis w/o contrast Coccyx fracture Pubic arthralgia Sacroiliitis Stress fracture (Pelvis) Pelvic fracture Sacral fracture Sports hernia MRI pelvis and prostate gland w/ & w/o contrast Prostate cancer screening, staging or follow up 72197

4 MRI pelvis female GYN w/ & w/o contrast Adenomyosis Cervical cancer Dermoid Family history of uterine Fibroid or ovarian malignant tumor Infection or tumor Ovarian disease Post menopausal bleeding UFE planning Uterine mass Vaginal cancer PELVIS MRI pelvis w/ & w/o contrast Non-gynecological tumor or infection Non-specific pelvic pain MRI cervical spine w/ & w/o contrast Demyelination MS Suspected tumor of cervical spinal cord MRI cervical spine w/o contrast MRI lumbar spine w/ & w/o contrast *If prior lumbar surgery (within 10 years), r/o infection, or bone mets then MRI lumbar spine w/ & w/o contrast. Benign cervical spine Cervical neck pain Compression fracture (Cervical Spine) Degenerative disc disease Disk herniation radiculopathy Low back pain longer than 6 weeks Neuro impairment SPINE MRI lumbar spine w/ & w/o contrast Failed back syndrome Pathologic compression fracture (Lumbar Spine) 72158

5 SPINE MRI lumbar spine w/o contrast MRI thoracic spine w/o contrast Compression fracture Disk herniation Radiculopathy Degenerative disk disease Low back pain Sciatica Compression fracture benign (Thoracic Spine) Degenerative disk disease Disk herniation Thoracic back pain MRI arthrogram (knee only) Ankle pain with concern for unstable osteochondral lesion Hip pain with concern for labral tear Knee pain with concern for unstable osteochondral Knee pain with prior arthroscopy MRI joint LOWER extremity w/ contrast Arthro injection Fluoro guidance OTHER MRI arthrogram (shoulder only) Elbow pain with concern for ligament or intra articular injury including unstable osteochondral lesions Shoulder pain after dislocation or concern for labral tear Shoulder pain after rotator cuff or labral repair Wrist pain with concern for ligament or intra articular injury MRI joint UPPER extremity w/ contrast Arthro injection Fluoro guidance MRI extremity LOWER w/o contrast Fracture to non-joint extremity Lipoma Myositis Nonspecific pain Soft tissue injury Stress response MRI extremity UPPER w/o contrast Fracture to non-joint extremity Lipoma Myositis Nonspecific pain Soft tissue injury Stress response 73218

6 MRI joint LOWER extremity w/o contrast Evaluate for bony or soft tissue pathology Internal derangement occult Joint pain MRI joint UPPER extremity w/o contrast MRI w/ & w/o contrast Evaluate for bony or soft tissue pathology Internal derangement occult Joint pain Tumor or infection of extremity UPPER extremity (non-joint) LOWER extremity (non-joint) OTHER

7 CT head, brain w/ & w/o contrast Ataxia Brain tumor CVA Dementia Headaches (Contrast - depends on associated clinical history) HEAD/NECK & NEURO CT head, brain w/o contrast Ataxia CVA Dementia Headaches Normal pressure Traumatic brain injury hydrocephalus (NPH) (acute) (Contrast - depends on associated clinical history) CT maxillofacial w/o contrast Possible fracture Trauma CT orbit w/o contrast Fracture Trauma Swelling CT sinus w/o contrast Facial pain Sinusitis CT soft tissue neck w/ contrast Lymphadenopathy Mass Swelling CT CT soft tissue neck w/o contrast Contraindication to iodine (consider MRI) Salivary gland stone CT temporal bones w/o contrast Earache Hearing loss Cholesteatoma 70480

8 CT angiography chest CT chest interstitial disease evaluation, high-resolution chest w/o contrast Aneurysm Chest pain Dyspnea Pulmonary embolism Ascending aorta or aortic arch dissection Elevated D-Dimer Interstitial lung disease CT chest low dose screening w/o contrast Low dose lung cancer screening CT chest w/ contrast CT chest w/o contrast CT abdomen w/ & w/o contrast (w/ oral contrast, unless specified) CT abdomen w/ contrast (w/ oral contrast, unless specified) Preferred Abnormal chest x-ray Adenopathy Chest pain Cough Dyspnea Follow up for known neoplasm Lung cancer Pleural effusion Pneumonia Pulmonary nodule or mass Nodule follow-up when contrast is contraindicated Contraindication to iodine Adrenal mass Pancreatic mass Renal mass Preferred Adenopathy Pancreatitis Hepatic mass (dedicated liver study) Upper abdominal pain Mass Upper abdominal pain CHEST ABDOMEN CT abdomen w/o contrast (w/ oral contrast, unless specified) Contraindication to iodine (consider MRI) 74150

9 ABDOMEN & PELVIS EXAM TO ORDER CT abdomen/pelvis w/ & w/o contrast* (w/ oral contrast, unless specified) CT abdomen/pelvis w/ contrast (w/ oral contrast, unless specified) CT abdomen/pelvis w/o contrast (w/ oral contrast, unless specified) CT abdomen/pelvis w/o contrast (w/o oral contrast) - renal stone study CT colonography diagnostic Abdominal pain Constipation Lymph node enlargement Preferred Abdominal distension Adenopathy Bowel obstruction or perforation Diverticulitis Mass Cancer Diverticulitis Pelvis pain Abdominal or pelvic pain Contraindication to iodine (consider MRI) Flank pain Suspected renal stones or follow-up Abdominal pain Appendicitis Cancer Constipation Lymph node enlargement Pelvic pain Failed or contraindication to traditional colonoscopy due to: - Rectal bleeding, tortuous colon, or inability to tolerate sedation CT colonography screening Colon cancer screening Family history of colon cancer CT small bowel w/ contrast (w/ oral contrast) CT urogram w/ & w/o contrast Anemia Chronic GI bleed Small bowel mass Dysuria Hematuria Bowel obstruction Crohn s disease Flank pain UTIs *Performing CT Abdomen/Pelvis w/ & w/o contrast is not our recommended study, except for some dedicated oncology cases.

10 CT cervical spine w/o contrast CT lumbar spine w/o contrast CT extremity LOWER w/o contrast CT extremity UPPER w/o contrast Compression fracture Trauma (Cervical Spine) Neck pain Compression fracture (Lumbar Spine) Low back pain Trauma (Lumbar Spine) Fracture Swelling Fracture Swelling Pain Pain SPINE OTHER CT bone density, QCT Osteoporosis Osteopenia 77078

11 US neck soft tissue Palpable head, face or neck mass (describe area) NECK US thyroid or neck Goiter Palpable neck mass (describe on head, face, or neck) Parotid, abnormal thyroid tests Thyroidmegaly CHEST US chest Mediastinum Palpable mass, chest wall and upper back (describe location) Pleura ABDOMEN US abdominal complete Abnormal liver tests Ascites Epigastric pain Fatty liver Hepatitis Jaundice Nausea Pain Test includes the liver, pancreas, gallbladder, kidneys, aorta, and spleen. If abdominal and kidney (renal) are ordered together use abdomen and pelvic LTD (76857) to include bladder images ULTRASOUND US abdominal LTD Inguinal hernia Quadrant pain Single organ evaluation such as liver or gallbladder Palpable mass lower abdominal and lower back (describe location) 76705

12 US aorta LTD US renal retroperitoneal US pelvic (female) and transvaginal *Patient or doctor may specifically request no transvaginal due to patient age (under 18 years old), pregnancy or comfort. US pelvic (female and male) (No transvaginal included) US pelvic LTD Aorta screening Abdominal aortic aneurysm (AAA) Abnormal kidney labs Calculus of kidney stones Dysuria includes bladder and Flank pain pre & post void measurements Hematuria Hydronephrosis Mass or cyst CKB UTI If clinical history suggests urinary tract pathology, then a complete evaluation of the kidneys and urinary bladder will be included in the exam. Bleeding Bloating Endometriosis Excessive or frequent Female pelvis to view menstruation uterus and ovaries Fibroids Leiomyoma Mass Lower abdominal and pelvic pain Pelvic pain Mass Irregular bleeding Bloating Fibroids Abscess Free fluid Male pelvis bladder Bladder Urinary tract problems Soft palpable mass, To evaluate bladder in pelvic wall and buttocks addition to abdominal US (describe location) , US scrotal Mass Pain Swelling and tenderness 76870, PELVIS

13 VASCULAR EXAM TO ORDER US arterial - lower extremity only *Always includes bilateral extremity unless amputation. US carotid duplex arteries bilateral US extremity venous studies duplex scan of veins, UNILATERAL upper and lower US extremity venous study duplex scan of veins, BILATERAL upper and lower US noninvasive extremity artery bilateral Cellulitis Claudication Edema Extremity pain 93925, PVD or PAD (Peripheral vascular/arterial disease) Bruit Diplopia Hypercholestremia Hyperlipidemia Trauma Vertigo Edema Numbness Swelling in extremity Warm limb Pain in extremity Thrombosis Please indicate upper/lower extremity and right/left. Pain Redness Swelling Tenderness in both legs Please indicate upper/lower extremity and right/left. Claudication Pain US breast Palpable mass to INCLUDE side and location on breast (i.e. right breast palpable 10:00) OTHER US non-vascular extremity LTD Lumps Soft tissue masses on extremities and axilla (document specific area of concern) US spinal canal and contents Tethered cord (pediatric exam) 76800

14 US obstetrical < 14 weeks US transvaginal US obstetrical > 14 weeks Pregnancy LESS than 14 weeks Fetal demise Please include last menstrual period or established estimated date of delivery on all exams (less than 14 weeks). *Preferred exam to include EV for early OB. Pregnancy GREATER than 14 weeks Evaluation of fetal growth Please include last menstrual period or established estimated date of delivery for OB ultrasound more than 14 weeks or for multiple fetus OB ultrasound more than 14 weeks , , PREGNANCY US obstetrical w/ imaging of additional fetus Multiple fetus US obstetrical < 14 weeks (first) (additional) CPT is a registered trademark of the American Medical Association and are subject to change.

15 Annual bilateral diagnostic mammogram Personal history breast cancer - asymptomatic women G0204 Annual screening mammogram All asymptomatic women age 40 and older G0202 Breast ultrasound Palpable mass woman age 29 and younger MAMMOGRAPHY Diagnostic bilateral mammogram (male) Palpable mass Diagnostic bilateral mammogram, breast ultrasound (female) G0204 Symptomatic patients age 30 and older G0204, Unilateral diagnostic mammogram Personal history breast cancer - mastectomy G0206 Consider high-risk screening MRI of breasts in addition to (not as a replacement for) annual screening mammography High Risk Patients: - BRCA 1 or 2 carrier - History of chest radiation from ages Lifetime risk of breast cancer 20-25% or greater - Untested patient w/ 1st degree relative positive for BRCA 1 or MAMMOGRAPHY

16 Our Locations Temecula Valley Hancock Avenue Suite 105 Murrieta, CA Tri-City 3601 Vista Way Bldg A, Ste 101 Oceanside, CA ENCINITAS 477 N. El Camino Real Suite A 102 Encinitas, CA Poway Monte Vista Road Suite A Poway, CA Golden Triangle 4150 Regents Park Row Suite 195 La Jolla, CA Kearny Mesa 7625 Mesa College Drive Suite 103 San Diego, CA HILLCREST-5th Avenue 3366 Fifth Avenue San Diego, CA HILLCREST-Laurel 2466 First Avenue San Diego, CA Alvarado 6386 Alvarado Court Suite 121 San Diego, CA South Bay 333 H Street Suite 1095 Chula Vista, CA V 08.13