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Priority

Request for Diagnostic Services

Please Provide All Needed Information to Prevent Service Delays
Multiple Choice
Patient under Hospice Care

RADIOLOGY

OrderRightLeftExamCPT
Ankle (3 view)73610
Chest (1 view)71045
Chest (2 view)71046
Clavicle (2 view)73000
Elbow (3 view)73080
Femur (2 view)73551
Finger(s) (2 view)73140
Foot (3 view)73630
Forearm (2 view)73090
Hand (3 view)73130
Heel/Os Calsis (2 view)73650
Hip (2–3 view)73502
Bilat Hips w/Pelvis73520
Humerus (2 view)73060
Knee (2 view)73560
Pelvis (1 or 2 views)72170
Ribs w/AP Chest71101
Sternum (2 view)71120
Scapula (2 view)73010
Shoulder (2 view)73030
Tib/Fib (2 view)73590
Toes (2 view)73660
Wrist (3 view)73110
Other

EXAMS

OrderRightLeftExamCPT
Abdomen
Abdomen/KUB (1 view)74018
Abdomen (2 view)74019
Skull
Facial Bones70150
Mandible (Limited)70100
Nasal Bones70160
Skull70250
Sinuses70210
Orbits70200
Spine
Cervical Spine (2 view)72040
Thoracic Spine (2 view)72070
Lumbar Spine (2 view)72100
Sacrum/Coccyx (2 view)72220
Sacrum And Coccyx, 2+ Views72200
Electrocardiograph
Electrocardiograph (EKG) W/O Interpretation93005
Other

Medical Necessity: This test is medically necessary for the diagnosis and treatment of the patient. Provide patient's symptoms to warrant exam below.

CARDIAC/ULTRASOUND EXAMS

General Ultrasounds are scheduled exams. Abdominal ultrasounds require 6 hours NPO prior to exam. Pelvic ultrasounds require patient to have a full urinary bladder.

OrderRightLeftExamCPT
Abdominal Ultrasound76700
Abdominal, LTD (RUQ, No Pancreas & Spleen)76705
Ankle Brachial Index (ABI)93922
Breast LTD (Palp Mass or F/U from Abn Mamm Only)76642
Echocardiogram93306
Pelvic Ultrasound76856
Renal/Retroperitoneal76770
Renal Artery76775
Testicular (Scrotum)76870
Thyroid (Head/Neck Tissues)76536
US, ltd, joint/other nonvascular extremitystructure(s)
Enter Body Part below
76882
Dopplers R/O DVT
Venous Extremities Unilateral/Upper93971
Venous Extremities Unilateral/Lower93971
Venous Duplex Scan (Bilateral) Upper93970
Venous Duplex Scan (Bilateral) Lower93970
Arterial Duplex Upper Bilateral93930
Arterial Duplex Unilateral/Upper93931
Arterial Duplex Lower Bilateral93925
Arterial Duplex Lower/Unilateral93926
Carotid Duplex Doppler93880
Other

Condition of the patient that requires the exam to be performed portably

Weak/Non-AmbulatorySuspected Fracture
Hospice PatientSuspected Pneumonia
DementiaUnsteady gait/fall risk
Advanced AgeImmunosuppressive
Physical LimitationsCombative
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