Requested Exam Date and Time: ________________ Location
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Order Form www.mrispecialistsofthecarolinas.com Scheduling 704-671-5969 Fax 704-671-7755 Requested Exam Date and Time: ___________________________________ Location: □ Gastonia (M/Th/F) □ Belmont (T/W) Scheduled Date and Time:___________________________________________ (Please arrive 20 minutes early) Authorization #: ___________________________________________ Insurance:_________________________________________ When obtaining authorizations, select location preferred using the following numbers: Group NPI 1356324487 Tax ID # 560988142 Patients Full Name: ____________________________________ D.O.B.: ____________Height:________ Weight:________________ Social Security# _____________________ Home Phone #_________________ Other Phone: _______________________________ Ordering Physician: _____________________________ Physician signature: _____________________________________________ Scheduled by: _____________________________ Phone:________________________ Email: _______________________________ Previous studies / location:_____________________________________________________ Send CD with Patient?:______________ Special Instructions / Needs:_____________________________________________________________________________________ Please list relevant surgery:_____________________________________________________________________________________ History of Cancer?:____________________________________________________________________________________________ Metal objects in body?:____________________________________ □ Pacemaker? □ Aneurysm clip? □ Implant? □ Stent? □ Orbital x-rays required for History of metal work □ Claustrophobia (prescribed medications require driver) □ Any chance of Pregnancy? If so, date of LMP:_______________ □ Allergies:__________________________________________ ___________________________________________________________________________________________________________ Diagnosis/Symptoms:___________________________________ ______________________________________________________ ______________________________________________________ HEAD / NECK: MRI BRAIN CPT ICD-9 □ MRI - brain w/o 70551 ____ □ MRI - brain with 70552____ ___________ □ MRI - brain w/o & w 70553_______________ □ MRI - other – IAC / Pituitary / Trigeminal___________________ HEAD / NECK: MRI ORBIT FACE & NECK □ □ □ □ MRI - TMJ 70336_______________ MRI - orbit, face, neck w/o 70540_______________ MRI - orbit, face, neck with 70542_______________ MRI - orbit, face, and neck w/o & w 70543_______________ MAGNETIC RESONANCE ANGIOGRAPHY, HEAD □ □ □ □ MRA - head w/o MRA - neck w/o 70547_______________ MRA - neck with 70548_______________ MRA - neck w/o & w SPINE: MRI SPINAL CANAL □ □ □ □ □ □ □ □ □ □ □ 70544_______________ 70549_______________ MRI - C-spine w/o 72141_______________ MRI - C-spine with 72142_______________ MRI - C-spine w/o & w 72156_______________ MRI - L-spine w/o 72148_______________ MRI - L-spine with 72149_______________ MRI - L-spine w/o & w 72158_______________ MRI - T-spine w/o 72146_______________ MRI - T-spine with 72147_______________ MRI - T-spine w/o & w 72157_______________ MRI – sacrum______________________________________ MRI – other________________________________________ MRI EXTREMITIES /JOINT * □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ R R R R R R R R R R R R R R □L □L □L □L □L □L □L □L □L □L □L □L □L □L CPT ICD-9 MRI - upper extremity (OTJ) w/o 73218________________ MRI - upper extremity (OTJ) with 73219________________ MRI - upper extremity (OTJ) w/o & w 73220________________ MRI - upper extremity (joint); w/o 73221________________ MRI - upper extremity (joint); with 73222________________ MRI - upper extremity (joint); w/o & w 73223________________ MRA -upper extremity, with or w/o 73225________________ MRI - lower extremity (OTJ) w/o 73718________________ MRI - lower extremity (OTJ) with 73719________________ MRI - lower extremity (OTJ) w/o & w 73720________________ MRI - lower extremity (joint); w/o 73721________________ MRI - lower extremity (joint); with 73722________________ MRI - lower extremity (joint); w/o & w 73723________________ MRA -lower extremity, with or w/o 73725________________ MRI – other: _______ _________________________________________ BODY : CHEST □ MRI - chest w/o □ MRI - chest with □ MRI - chest w/o & w □ MRA – chest / aorta___________________ __ 71550________________ 71551________________ 71552________________ 71555________________ BODY : ABDOMEN/ PELVIS □ □ □ □ □ □ □ □ MRI - abdomen; w/o 74181________________ MRI - abdomen; with 74182________________ MRI - abdomen; w/o & w 74183________________ MRA - abdomen, with or w/o 74185________________ MRI - pelvis w/o 72195________________ MRI - pelvis with 72196________________ MRI - pelvis w/o & w 72197________________ MRA - pelvis with or w/o 72198________________ Contrast requires a Creatinine for anyone over 60, diabetes, kidney disease, chemotherapy, etc… This can be done onsite prior to start of exam. Extremities / Joints with history of infection, abscess, ulcer, cyst or mass usually require contrast agent per radiologist. Federal Necessity: Federal Regulations require that only the tests that are necessary for diagnosis and treatment of a patient’s condition be ordered. The ICD-9 code is required to prove medical necessity. ICD-9 DESCRIPTION MRI TEMPOROMANDIBULAR JOINT TOTAL 524.60 TEMPOROMANDIB JT DIS NOS 526.9 JAW DISEASE NOS 718.08 ARTIC CARTIL DIS-JT NEC MRI ORBIT FACE & NECK TOTAL 190.1 MALIGN NEOPL ORBIT 784.2 SWELLING IN HEAD & NECK 785.6 ENLARGEMENT LYMPH NODES 524.60 TEMPOROMANDIB JT DIS NOS 784.0 HEADACHE 225.2 BEN NEO CEREBR MENINGES 193. MALIGN NEOPLE THYROID MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; 433.10 CARTD ART OCC NO INFARC 784.0 HEADACHE 747.81 CEREBROVASCULAR ANOMALY 437.3 NONRUPT CEREBRAL ANEURYM 436. CVA 780.4 DIZZINESS AND GIDDINESS 434.91 CEREBR ART OCC W INFARC 435.9 TRANS CEREB ISCHEMA NOS 437.1 AC CEREBROVASC INSUF NOS 348.8 BRAIN CONDITIONS NEC 780.39 OTHER CONVULSIONS 433.30 MUL PRECER OCC NO INFARC 331.9 CEREB DEGENERATION NOS 348.0 CEREBRAL CYSTS MRI – BRAIN 784.0 436.0 780.4 433.10 780.39 331.9 348.8 434.91 437.1 437.3 474.81 348.0 348.4 780.99 721.0 435.9 346.90 437.1 331.7 434.90 721.00 191.2 478.1 389.10 191.3 780.99 434.91 162.9 346.90 722.4 780.2 172.9 721.8 225.0 781.0 793.0 722.2 340. 780.4 780.39 225.2 348.8 784.0 198.3 191.9 784.2 191.1 331.9 227.3 348.9 225.1 747.81 191.0 348.0 174.9 253.8 781.2 433.10 437.3 437.9 436. 388.30 782.0 435.9 345.90 191.6 253.9 348.5 350.1 723.1 780.93 781.3 431. 368.8 HEADACHE CVA DIZZINESS AND GIDDISNESS CAROTD ART OCC NO INFARC OTHER CONVULSIONS CEREB DEGENERATION NOSE BRAIN CONDITIONS NEC CEREBR ART OCC W INFARC AC CEREBROVASC INSUF NOS NONRUPT CEREBRAL ANEURYM CEREBROVASCULAR ANOMALY CERBRAL CYSTS COMPRESSION OF BRAIN OTHER GENERAL SYMPTOMS CERVICAL SPONDYLOSIS TRANS CEREB ISCHEMIA NOS MIGRAINE NOS/NOT INTRACBL AC CEREBROVASC INSUF NOS CEREB DEGEN IN OTH DIS CEREBR ART OCC NO INFARC CERVICAL SPONDYLOSIS MAL NEO TEMPORAL LOBE NASAL & SINUS DIS NEC SENSORNEUR HEAR LOSS NOS MAL NEO TEMPORAL LOBE OTHER GENERAL SYMPTOMS CEREBR ART OCC W INFARCT MAL NEO BRONCH/LUNG NOS MIGRAINE NOS/NOT INTRCBLE CERVICAL DISC DEGEN SYNCOPE AND COLLAPSE MALIG MELANOMA SKIN NOS SPINAL DISCORDERS NEC BENIGN NEOPLASM BRAIN ABN INVOLUN MOVEMENT NEC ABN FINDING-SKULL & HEAD DISC DISPLACEMENT NOS MUTILPLE SCLEROSIS DIZZINESS AND GIDDINESS OTHER CONVULSIONS BEN NEO CEREBR MENINGES BRAIN CONDITIONS NEC HEADACHE SEC MAL NEO BRAIN/SPINE MALIG NEO BRAIN NOS SWELILNG IN HEAD & NECK MALIG NEO FRONTAL LOBE CEREB DEGENERATION NOS BENIGN NEO PITUITARY BRAIN CONDISTIONS NOS BENIGN NEO CRANIAL NERVE CEREBROVASCULAR ANOMALY MALIGN NEOPLE CEREBRUM CEREBRAL CYSTS MALIGN NEOPLE BRAST NOS PITUITARY DISCORDER NEC ABNORMALITY OF GAIT CARTD ART OCC NO INFARC NONRUPT CEREBRAL ANEURYM CEREBROVASC DISEASE NOS CVA TINNITUS NOS SKIN SENATION DISTURB TRANS CEREB ISCHEMIA NOS EPILEPSY NOS-NOT INTRACT MAL NEO CEREBELLUM NOS PITUITARY DISORDER NOS CEREBRAL EDEMA TRIGEMINAL NEURALGIA CERVICAL GIA MEMORY LOSS LACK OF COORDINATION INTRACEREBRAL HEMORRHAGE VISUAL DISTURBANCES NEC ICD-9 MRI CHEST 786.6 425.4 786.05 786.6 358.00 424.1 786.05 162.9 212.1 427.9 785.1 786.05 425.4 427.1 780.2 424.0 212.7 401.9 423.9 424.1 427.31 429.3 478.32 578.1 784.2 423.9 425.9 427.2 427.69 511.9 746.89 785.6 DESCRIPTION CHEST SWELLING/MASS/LUMP PRIM CARDIOMYOPATHY NEC SHORTNESS OF BREATH CHEST SWELLING/MASS/LUMP MYASTENIA GRAVIS WITHOUT (ACUTE) EXACERBATION AORTIC VALVE DISORDER SHORTNESS OF BREATH MAL NEO BRONCH/LUNG NOS BENIGN NEO LARYNX CARDIAC DYSRHTHMIA NOS PALPITATIONS SHORTNESS OF BREATH PRIM CARDIOMYOPATHY NEC PAROX VENTRIC TACHCARD SYNCOPE AND COLLAPSE MITRAL VALVE DISORDER BENIGN NEOPLASM HEART HYPERTENSION NOS PERICARDIAL DISEASE NOS AORTIC VALVE DISORDER VOCAL PARAL UNILAT TOTAL BLOOD IN STOOL SWELLING IN HEAD & NECK MALIG NEO CORPUS UTERI AMYLOIDOSIS PERICARDIAL DISEASE NOS SECOND CARDIOMYOPATH NOS PAROX TACHYCARDIA NOS PREMATURE BEATS NEC PLEURAL EFFUSION NOS CONG HEART ANOMALY NEC ENLARGEMENT LYMPH NODES MRI-ABDOMEN/PELVIS 599.2 URETHRAL DIVERTICULUM 719.45 JOINT PAIN-PELVIS 721.3 LUMBOSACRAL SPONDYLOSIS 724.79 DISORDER OF COCCYX NEC 618.0 PROPLAPSE OF VAGINAL WALL 621.8 DISORDERS OF UTERUS NEC 722.2 DISC DISPLACEMENT NOS 616.0 CERVICTIS 218.9 UTERINE LEIOMYOMA NOS 571.5 CIRRHOSIS OF LIVER NOS 585. CHRONIC RENAL FAILURE 477.1 STRICTURE OF ARTERY 719.45 JOINT PAIN-PELVIS 620.2 OVARIAN CYST NEC/NOS 185. MALIGN NEOPL PROSTATE 195.3 MALIGN NEOPL PELVIS 599.7 HEMATURIA 621.8 DISORDERS OF UTERUS NEC 197.7 SECOND MALIG NEO LIVER 593.2 CYST OF KIDNEY, ACQUIRED 571.5 CIRRHOSIS OF LIVER NOS 573.8 LIVER DISORDERS NEC 789.5 ASCITES 593.9 RENAL & URETERAL DIS NOS 789.2 SPLENOMEGALY 574.20 CALCULUS-GB-NO CYSTITIS 593.9 RENAL & URETERAL DIS NOS MRI-BREAST 611.72 LUMP OR MASS I N BREAST 174.9 MALIGN NEOPLE BREAST NOS 793.80 ABNORMAL MAMMOGRAM, UNSPEC 611.72 LUMP OR MASS IN BREAST 174.9 MALIGN NEOPL BREAST NOS 233.0 CA IN SITU BREAST 793.80 ABNORMAL MAMMOGRAM, UNSPEC 174.4 MAL NEO BREAST UP-OUTER 676.30 BREAST DIS PREG NEC-UNSP V10.3 HX OF BREAST MALIGNANCY V16.3 FAMILY HX-BREAST MALIG MRI-SPINAL CANAL 721.0 CERVICAL SPONDYLOSIS 722.4 CERVICAL DISC DEGEN 723.0 CERVICAL SPINAL STENOSIS 723.1 CERVICAL GIA 721.8 SPINAL DISORDERS NEC 722.0 CERVICAL DISC DISPLACMENT 722.2 LUMBOSACRAL SPONDYLOSIS 721.3 SYRINGOMYELIA 336.0 CERV SPONDYL W MYELOPATH 721.1 MYELOPATHY NEC 336.8 COMPRESSION OF BRAIN 348.4 LUMB/LUMBOSAC DISC DEGEN 722.52 POSTLAMINECT SYND-CERV 722.81 SPINAL STENOSIS-LUMBAR 724.02 BRACHIAL NEURITIS NOS 723.4 BRACHIAL NEURITIS NOS 344.00 QUADRIPLEGIA NOS 336.0 SYRINGOMYELIA 721.2 THORACIC SPONDYLOSIS 722.11 THORACIC DISC DISPLACMENT 344.1 PARAPLEGIA NOS 721.3 LUMBOSACRAL SPONDYLOSIS 722.4 CERVICAL DIS DEGEN 722.51 THORACIC DISC DEGEN 722.82 POSTLAMINECT SYND-THORAC 721.0 CERVICAL SPONDYLOSIS 721.3 LUMBOSACRAL SPONDYLOSIS 722.52 LUMB/LUMBOSAC DIS DEGEN ICD-9 721.3 722.52 722.10 724.02 722.2 722.83 340. 721.0 722.4 721.8 723.1 722.2 723.0 722.81 722.0 336.8 721.1 780.4 336.9 225.3 348.8 353.2 DESCRIPTION LUMBOSACRAL SPONDYLOSIS LUMB/LUMBOSAC DIS DEGEN LUBAR DISC DISPLACEMENT SPINAL STENOSIS-LUMBAR DISC DISPLACEMENT NOS POSTLAMINECT SYND-LUMBAR MULTIPLE SCLEROSIS CERVICAL SPONDYLOSIS CERVICAL DISC DEGEN SPINAL DISORDERS NEC CERVICALGIA DISC DISPLACEMENT NOS CERVICAL SPINAL STENOIS POSTLAMINECT SYND-CERV CERVICAL DISC DISPLACEMENT MYELOPATHY NEC SYRINGOMYELIA CERV SPONDYL W MYELOPATH DIZZINESS AND GIDDINESS BENIGN NEO SPINAL CORD BRAIN CONDITIONS NEC CERVICAL ROOT LESION NEC MRI-ANY JOINT/NON JOINT EXTREMETY 842.12 SPRAIN METACARPOPHALANG 171.2 MAL NEO SOFT ISSUE ARM 228.09 HEMANGIOMA NEC 719.03 JOINT EFFUSION-FOREARM 171.2 MAL NEO SOFT TISSUE ARM 214.8 LIPOMA NEC 238.1 UNC BEHAV NEO SOFT TISSU 719.01 JOINT EFFUSION-SHLDER 782.2 LOCAL SUPRICIAL SWELLING 238.0 UNC BEHAVE NEO BONE 727.05 TENOSYNOV HAND/WRIST NEC 727.41 GANGLION OF JIONT 727.49 BURSAL CYST NEC 831.00 DISLOC SHOULDER NOS-CLOS 840.0 SPRAIN ACROMIOCLAVICULAR 842.00 SPRAIN OF WRIST NOS 719.02 JOINT EFFUSION-UP/ARM 726.19 ROTATOR CUFF DIS NEC 727.04 RADIAL STYLOID TENOSYNOV 729.5 PAIN IN LIMB 719.06 JOINT EFFUSION-L/LEG 719.07 JOINT EFFUSION-ANKLE 727.51 POPLITEAL SYNOVIAL CYST 717.7 CHONDROMALACIA PATELLAE 719.45 JOINT PAIN-PELVIS 719.46 JOINT PAIN-L/LEEG 719.47 JOINT PAIN-ANKLE 733.90 BONE & CARTILAGE DIS NOSE 272.7 LIPIDOSES 355.71 CAUSALGIA OF LOWER LIMB 715.16 LOC PRIM OSTEOART/L-LEG 715.97 OSTEOARTHROS NOS/ANKLE 727.06 TENOSYNOVTISIS FOOT/ANKLE 729.81 SWELLING OF LIMB 730.36 PERIOSTITIS-L/LEG 782.3 EDEMA 717.7 CHRONDROPMALACIA PATELLAE 719.06 JOINT EFFUSION-L/LEG 836.0 TEAR MED MENISC KNEE-CUR 719.45 JOINT PAIN-PELVIS 726.10 ROTATOR CUFF SYND NOS 719.41 JOINT PAIN-SHLDER 719.01 JOINT EFFUSION-SHLDER 726.0 ADHESIVE CAPSULIT SHLDER 719.43 JOINT PAIN-FOREARM 840.9 SPRAIN SHLDER/ARM NOS 715.91 OSTEOARTHR NOS SHLDER 719.03 JOINT EFFUSION-FOREARM 840.4 SPRAIN ROTATOR CUFF 840.6 SPRAIN SUPRASPINATUS 719.42 JOINT PAIN-UP/ARM 726.11 CALCIF TENDITINTIS SHLDER 726.12 BICIPITAL TENOSYNOVITIS 727.43 GANGLION NOS 715.04 GEN OSTEOARTHROS-HAND 715.11 LOC PRIM OSTEOART-SHLDER 171.3 MAL NEO SOFT TISSUE LEG 170.7 MAL NEO LONG BONES LEG 171.9 MAL NEO SOFT TISSUE NOS 782.3 EDEMA 719.06 JOINT EFFUSION-L/LEG 719.07 JOINT EFFUSION-ANKLE 198.5 SECONDARY MALIG NEO BONE 213.7 BEN NEO LONG BONES LEG 214.8 LIPMO NEC 228.01 HEMANGIOMA SKIN 308.9 ACUTE STRESS REACT NOS 719.46 JOINT PAIN-L/LEG 729.5 PAIN IN LIMB 729.81 SWELLING OF LIMB 733.95 STRESS FRACTURE OF OTHER BONE 782.2 LOCAL SUPRFICIAL SWELLING 731.0 OSTEITIS DEFORMANS NOS 733.90 BONE & CARTILAGE DIS NOS 717.2 DERANG POST MED MENISCUS 719.46 JOINT PAIN-L/LEG 719.07 JOINT EFFUSION-ANKLE 727.51 POPLITEAL SYNOVIAL CYST 836.1 TEAR LAT MENISC KNEE-CUR 733.42 ASEPTIC NECROSIS FEMUR ICD-9 DESCRIPTION COMERADOAGRAPHY 336.0 SYRINGOMYELIA 348.4 COMPRESSION OF BRAIN 722.81 POSTLAMINECT SYND-CERV 336.8 MYELOPATHY NEC 722.4 CERVICAL DISC DEGEN 349.2 DISORDER OF MENINGES NEC 721.0 CERVICAL SPONDYLOSIS 722.82 POSTLAMINECT SYND-THORAC 344.1 PARAPLEGIA NOS 723.1 CERVICALGIA 741.01 SPIN BIF W HYDRCEPH-CERV 723.0 CERVICAL SPINAL STENOSIS 344.00 QUADRIPLEGIA NOS 336.9 SPINAL CORD DISEASE NOS 722.83 POST LAMINECT SYND-LUMBAR 722.0 CERVICAL DISC DISPLACMNT 225.3 BENIGN NEO SPINAL CORD 322.9 MENINGITIS NOS 721.8 SPINAL DISORDERS NEC 722.2 DISC DISPLACEMENT NOS 756.15 CONGEN FUSION OF SPINE 741.00 SPIN BIF W HYDROCEPH NOS 191.9 MALIG NEO BRAIN NOS 191.1 MALIG NEO FRONTAL LOBE 191.2 MAL NEO TEMPORAL LOBE 348.8 BRAIN CONDISTIONS NEC 784.2 SWELLING IN HEAD & NECK 191.0 MALIGN NEOPL CEREBRUM 191.7 MAL NEO BRAIN STEM 239.6 BRAIN NEOPLASM NOS 780.39 OTHER CONVULSIONS OTHER: This list is not all-inclusive, but is a guide only. All diagnosis codes must be coded to the highest level of specificity. The ordering provider represents that the diagnostic information provided with EACH test accurately reflects his/her current knowledge of the nature of severity of complaint or condition, and that this information can be substantiated by the patient’s medical record. MRI Exam Preparation Due to the strong magnet used in the MRI scanner, it is extremely important for the safety of the patient to obtain accurate information before performing the MRI exam. The system does not use ionizing radiation, simply radiofrequency waves and magnetic fields. Here is a link with more specific MRI Safety information: (http://www.radiologyinfo.org/en/safety/index.cfm?pg=sfty_mr#use) The actual exam time lasts on average 30 to 45 minutes. The complete length of stay from arrival to departure is about one hour. Registration is completed just prior to the start of the MRI exam. The MRI scan table has a weight limit of 550 pounds. Please review the following information below. Patient: Please bring a copy of your photo ID and insurance card(s). Please inform us of any types of surgery and/or any known metal or implant inside the body. Please leave personal belongings at home. Please limit makeup and jewelry, and please no makeup for Head and Neck exams. Please try to wear clothes without zippers and metallic embroidery if possible. Please let us know if you have any special needs while under our care. Please let us know if you could possibly be pregnant, or are currently breastfeeding. Please do not eat or drink anything for 4 hours prior to your exam time for abdomen and/or pelvis related studies only. All other exams do not require fasting. If you feel you are claustrophobic, please discuss with your physician the option of receiving an oral medication to take just prior to your arrival and have a driver bring you to and from your MRI appointment. o The scanner is quite spacious, with a 70 centimeter opening and much shorter overall length, which greatly reduces the claustrophobia effect. o Most exams from the waist down can be done feet first. Head and neck to mid chest usually require to be done head first. Provider: Please provide the following patient information when scheduling: MRI is body part specific. Please list the exact area to be scanned on your order. Date of birth; social security number; phone number. Patient height, weight. Any chance of pregnancy. Previous surgeries, especially to area of interest. History of cancer History of metal or foreign implants within the body from any surgeries or accidents. If the patient has worked around metal (welder, machine shop), he/she must arrive 30 minutes prior to appointment for x-ray clearance (at no charge). Patients with pacemakers, certain types of bio-stimulators, drug infusion devices, or ferrous (magnetic) aneurysm clips cannot have an MRI exam. If patient is claustrophobic please discuss the options of an oral sedative to take prior to the exam time. If patient requires a sedative, referring physician should order prescription (PO meds). Please bring any relevant films and/or reports from non CaroMont facilities if possible. Exam Ordering The table weight limit is 550 pounds. An Order Form is also available online and is submitted electronically via secure email. You can also download an Order form (link), and fax it to us at 704 671.7755. It is most common to order exams as either without (w/o) (no contrast) or without & with contrast, when contrast is requested. Normally the only exams ordered as with contrast would be MRA (MR Angiography) of the neck or abdomen or pelvis. MRA of the Head does not require contrast. Arthrograms of the hip or shoulder or of a joint are ordered as with contrast. Currently some newer technology should be available soon which will further improve vessel visualization without the use of contrast materials, which may be beneficial for some patients. Contrast Injection Some exams require the injection of a contrast material to help improve visualization of the brain, spine, and vascular system to name a few. The medication is FDA approved and is considered quite safe. It is administered intravenously usually halfway through the exam. Please be well hydrated on the day of your exam unless we request otherwise. Patients with known diabetes, kidney dysfunction, cancer or anyone over the age of 60 may require us to obtain a simple blood test upon arrival to check the creatinine level as an extra precaution to assure proper usage of the contrast media. We can accept a creatinine level done at another medical office if it has been completed in the past 10 days. Please let us know if you are currently breastfeeding. It is recommended to discontinue this up to 72 hours after contrast injection. Routine Radiologist preferred MRI Exam Protocol for MRISC The best method is to order as ‘MRI ____ with and/or without contrast’ and add a note stating: ‘Contrast at Radiologist discretion’. This allows greater flexibility and does not require another call to the insurance company to change an authorization for example. However the referring physician certainly has the right to order with any specific request as indicated. A patient having a history of known cancer, infection, abscess, cyst, or mass most often require the use of contrast, where the exam should be ordered as ‘without and/or with contrast’. MRI Brain without and with contrast. 70553. Most all brains need to be done without and with contrast MRA Brain without contrast. 70554 MRV Brain without contrast 70554 MRI Cervical Spine without contrast (even with history of cervical surgery). 72141 MRA Neck with contrast. 70548 MRI Lumbar spine without and with contrast for history of low back surgery. 72158 MRI / MRA Abdomen without and with contrast. MRI 74183, MRA 74185 o MRCP does not require contrast. 74181 MRI / MRA Pelvis without and with contrast. MRI 72197, MRA 72198 Basically all MRA exams are without and with contrast except MRA Head, where contrast is not required. MR Arthrography of any joint is always ordered as with contrast. Upper 73222, Lower 73722
