Southeast X-Ray, Inc.
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List: Stephenson
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Name: Mandible (Default) [Edit] [Delete]
CPT: 70100
MANDIBLE:
Multiple views of the mandible reveal no evidence for fracture or other significant bone or soft
tissue abnormality.
IMPRESSION: Negative mandible.
Name: MANDIBLE (Default) [Edit] [Delete]
CPT: 70110
MANDIBLE:
Multiple views of the mandible reveal no evidence for fracture or other significant bone or soft
tissue abnormality.
IMPRESSION: Negative mandible
Name: Facial Bones (Default) [Edit] [Delete]
CPT: 70140
FACIAL BONES:
Bony structures show no distinct fracture. Infraorbital wall appears intact. Paranasal sinus is
clear.
IMPRESSION: Negative facial series.
Name: FACIAL (Default) [Edit] [Delete]
CPT: 70150
FACIAL BONES:
Bony structures show no distinct fracture. Infraorbital wall appears intact. Paranasal sinus is
clear.
IMPRESSION: Negative facial series.
Name: NASAL (Default) [Edit] [Delete]
CPT: 70160
NASAL BONES:
The nasal bone shows no fracture line or abnormal configuration. Anterior nasal spine is intact.
Nasal septum midline.
IMPRESSION: No evidence of nasal fracture.
Name: ORBITS (Default) [Edit] [Delete]
CPT: 70200
ORBITS:
Multiple views of the orbits reveal no fracture or other significant bony abnormality. The soft
tissues are not remarkable.
IMPRESSION: Negative orbits.
Name: SINUS (Default) [Edit] [Delete]
CPT: 70220
PARANASAL SINUS SERIES:
The maxillary, ethmoid, frontal and sphenoid sinuses are clear. No air-fluid level. Nasal septum
midline.
IMPRESSION: Negative sinus series.
Name: Skull (Default) [Edit] [Delete]
CPT: 70250
SKULL SERIES:
Multiple views of the skull demonstrate no evidence of fracture. No focal lesion. The sella has
normal shape. No abnormal calcification.
IMPRESSION: Normal skull examination.
Name: SKULL (Default) [Edit] [Delete]
CPT: 70260
SKULL:
Multiple views of the skull demonstrate no evidence of fracture. No focal lesion. The sella has
normal shape. No abnormal calcification.
IMPRESSION: Normal skull examination.
Name: MRI TMJ [Edit] [Delete]
CPT: 70336
MRI TEMPOROMANDIBULAR JOINTS:
COMPARISON: INDICATIONS: TECHNIQUE: Multiplanar images were obtained on a 3
Tesla Siemens ultrahigh field MRI scanner without intravenous contrast, utilizing a series of
customized pulse sequences. FINDINGS: Right Temporomandibular Joint: Condyle: Coronoid:
Joint/Bursa: Disk: Cartilage: Left Temporomandibular Joint: Condyle: Coronoid: Joint/Bursa:
Disk: Cartilage:
IMPRESSION:
Name: Sft Tissue Neck (Default) [Edit] [Delete]
CPT: 70360
SOFT TISSUE NECK:
AP and lateral view of the soft tissues of the neck demonstrate normal appearance of airway.
Epiglottis is normal. Aryepiglottic folds appear normal. No tonsillar hypertrophy, adenoidal
hypertrophy or lingual tonsillar hypertrophy. No abnormal calcifications.
IMPRESSION: Negative soft tissue neck.
Name: CT HEAD FULL AR [Edit] [Delete]
CPT: 70450
CT HEAD:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16channel spiral CT scanner without intravenous contrast. Additional isotropic multiplanar
reconstructions were obtained in the sagittal and coronal planes. FINDINGS: Intracranial space:
Ventricles: Cerebrum: Cerebellum: Brain stem: CV junction: Temporal bones: Parasellar region:
Skull: Nasal vault: Nasal septum: Nasopharynx: Sinuses: Maxillary: Ethmoid: Frontal: Sphenoid:
OMU regions:
IMPRESSION:
Name: CT HEAD WO AR [Edit] [Delete]
CPT: 70450
CT HEAD WITHOUT CONTRAST:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16channel spiral CT scanner without intravenous contrast. Additional isotropic multiplanar
reconstructions were obtained in the sagittal and coronal planes. FINDINGS: Intracranial space:
Ventricles: Cerebrum: Cerebellum: Brain stem: CV junction: Temporal bones: Parasellar region:
Skull: Paranasal sinuses:
IMPRESSION:
Name: CT HEAD W/WO AR [Edit] [Delete]
CPT: 70470
CT HEAD WITH AND WITHOUT CONTRAST:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a16channel spiral CT scanner without intravenous contrast. Additional isotropic multiplanar
reconstructions were obtained in the sagittal and coronal planes. CONTRAST: A 20 ga.
angiocath was placed in the right antecubital fossa for contrast infusion. 100 cc Optiray 300 were
utilized. [<80>] cc were administered intravenously via power injector. No reaction. BRAIN:
FINDINGS: Intracranial space: Ventricles: Cerebrum: Cerebellum: Brain stem: CV junction:
Temporal bones: Parasellar region: Skull: Paranasal sinuses:
IMPRESSION:
Name: CT TEMP BONE AR [Edit] [Delete]
CPT: 70480
CT TEMPORAL BONES:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16channel spiral CT scanner without intravenous contrast. Additional isotropic multiplanar
reconstructions were obtained in the sagittal and coronal planes. FINDINGS: RIGHT: EAC:
Mastoid: Middle ear: Ossicles: Cochlea: Labyrinth: IAC: CPA cistern: TMJ: LEFT: EAC:
Mastoid: Middle ear: Ossicles: Cochlea: Labyrinth: IAC: CPA cistern: TMJ:
IMPRESSION:
Name: CT HEAD FULL AR [Edit] [Delete]
CPT: 70486
CT HEAD :
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16channel spiral CT scanner without intravenous contrast. Additional isotropic multiplanar
reconstructions were obtained in the sagittal and coronal planes. FINDINGS: Intracranial space:
Ventricles: Cerebrum: Cerebellum: Brain stem: CV junction: Temporal bones: Parasellar region:
Skull: Nasal vault: Nasal septum: Nasopharynx: Sinuses: Maxillary: Ethmoid: Frontal: Sphenoid:
OMU regions:
IMPRESSION:
Name: CT LIM SINUS AR [Edit] [Delete]
CPT: 70486
CT LIMITED SINUS:
COMPARISON: INDICATION: TECHNIQUE: Selected scans were performed on through the
sinuses16-channel spiral CT scanner without intravenous contrast. FINDINGS: Nasal vault:
Nasal septum: Sinuses: Maxillary: Ethmoid: Frontal: Sphenoid:
IMPRESSION:
Name: CT MXF AR [Edit] [Delete]
CPT: 70486
CT MAXILLOFACIAL:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on 16channel spiral CT scanner without intravenous contrast. Additional isotropic multiplanar
reconstructions were obtained in the sagittal and coronal planes. Maximum intensity projection
2D and volume rendered 3D reconstructions were obtained and performed on a separate Vitrea
workstation. FINDINGS: Facial bones: Orbital rims: Orbital floors: Orbital walls: Nasal bones:
Zygomatic arches: Pterygoid plates: Mandibular rami and condyles: Mandibular symphysis:
Nasal septum: Globes: Optic nerves: Extraocular muscles: Lacrimal glands: Nasal vault:
Nasopharynx: Sinuses: Maxillary: Ethmoid: Frontal: Sphenoid: OMU regions: Temporal bones:
Sella turcica:
IMPRESSION:
Name: CT SIN 4 CUT AR [Edit] [Delete]
CPT: 70486
CT SINUSES 4 CUT:
COMPARISON: INDICATION: TECHNIQUE: Limited scans were performed through all
sinuses on a 16-channel spiral CT scanner without intravenous contrast. FINDINGS: Maxillary:
Ethmoid: Frontal: Sphenoid:
IMPRESSION:
Name: CT SINUS AR [Edit] [Delete]
CPT: 70486
CT SINUSES:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on 16channel spiral CT scanner without intravenous contrast. Additional isotropic multiplanar
reconstructions were obtained in the sagittal and coronal planes. FINDINGS: Nasal vault: Nasal
septum: Sinuses: Maxillary: Ethmoid: Frontal: Sphenoid: OMU regions: Nasopharynx: Temporal
bones:
IMPRESSION:
Name: CT SOFT NECK AR [Edit] [Delete]
CPT: 70491
CT SOFT TISSUE NECK:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16
channel spiral CT scanner during intravenous administration of nonionic contrast. Additional
isotropic multiplanar reconstructions were obtained in the sagittal and coronal planes. Contrast:
100 cc Optiray 300 were utilized. __ cc were administered intravenously via power injector. No
reaction. FINDINGS: Nasal Vault: Nasopharynx: Oral Cavity: Oropharynx: Hypopharynx:
Larynx: Salivary Glands: Parotid: Submandibular: Lymph Nodes: Thyroid Gland: Carotid
Spaces: Bones: Thoracic Inlet:
IMPRESSION:
Name: CTA BRAIN AR [Edit] [Delete]
CPT: 70496
CTA BRAIN:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16
channel spiral CT scanner with dynamic bolus intravenous injection of nonionic contrast and
acquisition of images. Additional maximum intensity projection 2D and volume rendered 3D
reconstructions were obtained and performed on a separate Vitrea workstation. CONTRAST: A
20 ga. angiocath was placed in the right antecubital fossa for contrast infusion. 100 cc Optiray
350 were utilized. __ cc were administered intravenously via power injector. No reaction. CT
ANGIOGRAM OF THE BRAIN: Distal internal carotid arteries: Carotid siphons: Supraclinoid
internal carotid arteries: Middle cerebral arteries: Anterior cerebral arteries: Circle of Willis:
Basivertebral arteries: Posterior cerebral arteries: CONCLUSIONS: BRAIN: FINDINGS:
Intracranial space: Ventricles: Cerebrum: Cerebellum: Brain stem: CV junction: Temporal
bones: Parasellar region: Skull: Paranasal sinuses:
IMPRESSION:
Name: CTA NECK AR [Edit] [Delete]
CPT: 70498
CTA NECK:
COMPARISON: INDICATIONS: TECHNIQUE: Volumetric scans were performed on a 16
channel spiral CT scanner with dynamic bolus intravenous injection of nonionic contrast and
acquisition of images. Additional maximum intensity projection 2D and volume rendered 3D
reconstructions were obtained and performed on a separate Vitrea workstation. Contrast: A 20
Ga. angiocath was placed in the right antecubital fossa for contrast infusion. 100 cc Optiray 350
were utilized. __ cc were administered intravenously via power injector. No reaction. CT
ANGIOGRAM OF THE NECK: FINDINGS: Aortic arch: Innominate system: Left common
carotid system: Left subclavian system: CONCLUSIONS: CT SOFT TISSUE NECK:
FINDINGS: Nasal Vault: Nasopharynx: Oral Cavity: Oropharynx: Hypopharynx: Larynx:
Salivary Glands: Parotid: Submandibular: Lymph Nodes: Thyroid Gland: Carotid Space: Bones:
Thoracic Inlet:
IMPRESSION:
Name: MRIOBTFACEWO AR [Edit] [Delete]
CPT: 70540
MRI ORBIT/FACE WITHOUT CONTRAST:
COMPARISON: INDICATIONS: TECHNIQUE: Multiplanar images were obtained on a 3
Tesla Siemens ultrahigh field MRI scanner without intravenous contrast, utilizing a series of
customized pulse sequences. FINDINGS: Orbits and Contents: Paranasal Sinuses: Nasopharynx:
Maxilla/Zygoma: Oropharynx: Tongue: Mandible/TMJ: Salivary Glands:
IMPRESSION:
Name: MRINECK W/WO AR [Edit] [Delete]
CPT: 70543
MRI SOFT TISSUE NECK WITH AND WITHOUT CONTRAST:
COMPARISON: INDICATION: TECHNIQUE: Multiplanar images were obtained on a 3 Tesla
Siemens ultrahigh field MRI scanner both before and after intravenous contrast administration,
utilizing a series of customized pulse sequences. Contrast: FINDINGS: Nasal Vault:
Nasopharynx: Oral Cavity: Oropharynx: Hypopharynx: Larynx: Salivary Glands: Parotid:
Submandibular: Lymph Nodes: Thyroid Gland: Carotid Spaces: Bones: Thoracic Inlet:
IMPRESSION:
Name: MRA BRAIN AR [Edit] [Delete]
CPT: 70544
MRA BRAIN:
COMPARISON: INDICATIONS: TECHNIQUE: Multiplanar magnetic resonance arteriograms
were obtained on 3 Tesla Siemens ultrahigh field MRI scanner without intravenous contrast,
utilizing a series of customized pulse sequences. Image processing performed on an independent
workstation included maximum intensity projections and 3-D volume rendering of the imaged
vasculature. FINDINGS: Distal internal carotid arteries: Carotid siphons: Supraclinoid internal
carotid arteries: Middle cerebral arteries: Anterior cerebral arteries: Circle of Willis:
Basivertebral arteries: Posterior cerebral arteries:
IMPRESSION:
Name: MRV BRAIN WO AR [Edit] [Delete]
CPT: 70544
MRV BRAIN WITHOUT CONTRAST:
COMPARISON: INDICATIONS: TECHNIQUE: Multiplanar magnetic resonance venograms
were obtained on 3 Tesla Siemens ultrahigh field MRI scanner without intravenous contrast,
utilizing a series of customized pulse sequences. Image processing performed on an independent
workstation included maximum intensity projections and 3-D volume rendering of the imaged
vasculature. FINDINGS: Superior sagittal sinus: Septal veins: Thalamostriate veins: Internal
cerebral veins: Basal veins of Rosenthal: Great vein of Galen: Straight sinus: Transverse sinuses:
Sigmoid sinuses: Superior petrosal sinuses: Cavernous sinuses: Inferior petrosal sinuses: Internal
jugular veins:
IMPRESSION:
Name: MRA CAR AR [Edit] [Delete]
CPT: 70548
MRA CAROTIDS:
COMPARISON: INDICATIONS: TECHNIQUE: Multiplanar magnetic resonance arteriograms
were obtained on 3 Tesla Siemens ultrahigh field MRI scanner with intravenous contrast,
utilizing a series of customized pulse sequences. Image processing performed on an independent
workstation included maximum intensity projections and 3-D volume rendering of the imaged
vasculature. Contrast: FINDINGS: Aortic arch: Innominate system: Left common carotid
system: Left subclavian system:
IMPRESSION:
Name: MRIBRAIN WO AR [Edit] [Delete]
CPT: 70551
MRI BRAIN WITHOUT CONTRAST:
COMPARISON: INDICATIONS: TECHNIQUE: Multiplanar images were obtained on a 3
Tesla Siemens ultrahigh field MRI scanner without intravenous contrast, utilizing a series of
customized pulse sequences. FINDINGS: Intracranial space: Ventricles: Cerebrum: Cerebellum:
Brainstem: CV junction: Temporal bones: Parasellar region: Major vessels: Skull: Paranasal
sinuses: Orbits and contents:
IMPRESSION:
Name: MRIBRAINWMRA AR [Edit] [Delete]
CPT: 70551
MRI BRAIN WITH MRA :
COMPARISON: MRA brain same date. INDICATIONS: TECHNIQUE: Multiplanar images
were obtained on a 3 Tesla Siemens ultrahigh field MRI scanner without intravenous contrast,
utilizing a series of customized pulse sequences. FINDINGS: Intracranial space: Ventricles:
Cerebrum: Cerebellum: Brainstem: CV junction: Temporal bones: Parasellar region: Skull:
Paranasal sinuses: Orbits and contents:
IMPRESSION:
Name: MRI IAC [Edit] [Delete]
CPT: 70553
MRI BRAIN INTERNAL AUDITORY CANAL:
COMPARISON: INDICATIONS: TECHNIQUE: Multiplanar images were obtained on a 3
Tesla Siemens ultrahigh field MRI scanner both before and after intravenous contrast
administration, utilizing a series of customized pulse sequences. High-resolution thin section
acquisitions were performed through the internal auditory canals. Contrast: FINDINGS:
Intracranial space: Ventricles: Cerebrum: Cerebellum: Brainstem: CV junction: Temporal bones:
Parasellar region: Major vessels: Skull: Paranasal sinuses: Orbits and contents:
IMPRESSION:
Name: MRIBRAINW/WO AR [Edit] [Delete]
CPT: 70553
MRI BRAIN WITH AND WITHOUT:
COMPARISON: INDICATIONS: TECHNIQUE: Multiplanar images were obtained on a 3
Tesla Siemens ultrahigh field MRI scanner both before and after intravenous contrast
administration, utilizing a series of customized pulse sequences. Contrast: FINDINGS:
Intracranial space: Ventricles: Cerebrum: Cerebellum: Brainstem: CV junction: Temporal bones:
Parasellar region: Major vessels: Skull: Paranasal sinuses: Orbits and contents:
IMPRESSION:
Name: CHEST 1 VIEW (Default) [Edit] [Delete]
CPT: 71010
CHEST; SINGLE VIEW:
The heart and mediastinum appear normal. The lungs are clear without infiltrate, consolidation,
or interstitial prominence. No effusion. Bony structures appear normal.
IMPRESSION: Normal one view chest examination.
Name: 2V CHEST (Default) [Edit] [Delete]
CPT: 71020
CHEST; TWO VIEWS:
The heart and mediastinum are normal. The lungs are clear without infiltrate consolidation or
interstitial prominence. No effusion or hyperinflation. Bony structures appear normal.
IMPRESSION: Normal two view chest examination.
Name: 4V CHEST (Default) [Edit] [Delete]
CPT: 71022
CHEST WITH OBLIQUE VIEWS:
The heart and mediastinum are normal. The lungs are clear without infiltrate consolidation or
interstitial prominence. No effusion or hyperinflation. Bony structures appear normal.
IMPRESSION: Normal chest with oblique views.
Name: RIBS (Default) [Edit] [Delete]
CPT: 71100
& RL& RIB SERIES:
The visualized ribs show no fracture or focal lesion. No periosteal reaction or callous formation.
Underlying lung parenchyma is clear with no effusion or pneumothorax.
IMPRESSION: Negative rib series.
Name: RIBS (Default) [Edit] [Delete]
CPT: 71101
& RL& RIB SERIES, INCLUDING FRONTAL VIEW CHEST:
The visualized ribs show no fracture or focal lesion. No periosteal reaction or callous formation.
Underlying lung parenchyma is clear with no effusion or pneumothorax. PA view of the chest
shows no acute infiltrate with normal heart and mediastinum.
IMPRESSION: Negative rib series.
Name: B RIBS (Default) [Edit] [Delete]
CPT: 71110
BILATERAL RIBS:
The visualized ribs show no fracture or focal lesion. No periosteal reaction or callous formation.
Underlying lung parenchyma is clear with no effusion or pneumothorax.
IMPRESSION: Negative rib series.
Name: BI RIBS + CXR (Default) [Edit] [Delete]
CPT: 71111
& RL& RIB SERIES, INCLUDING FRONTAL CHEST VIEW:
The visualized ribs show no fracture or focal lesion. No periosteal reaction or callous formation.
Underlying lung parenchyma is clear with no effusion or pneumothorax. PA view of the chest
shows no acute infiltrate with normal heart and mediastinum.
IMPRESSION: Negative rib series.
Name: Sternum (Default) [Edit] [Delete]
CPT: 71120
STERNUM:
The sternum is intact with no evidence for fracture, displacement or destructive lesion. The
paraspinal soft tissues are unremarkable.
IMPRESSION: Normal sternum.
Name: CT CHEST WO AR [Edit] [Delete]
CPT: 71250
CT CHEST WITHOUT CONTRAST:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16
channel spiral CT scanner. Additional isotropic multiplanar reconstructions were obtained in the
sagittal and coronal planes. FINDINGS: LUNGS: PLEURA: MEDIASTINUM/HILA: HEART:
VESSELS: Aorta: Pulmonary: TRACHEA/BRONCHI: CHEST WALL: BONES:
IMPRESSION:
Name: CT CHEST W/ AR [Edit] [Delete]
CPT: 71260
CT CHEST WITH CONTRAST:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16
channel spiral CT scanner after intravenous administration of nonionic contrast. Additional
isotropic multiplanar reconstructions were obtained in the sagittal and coronal planes.
CONTRAST: Oral contrast FINDINGS: LUNGS: PLEURA: MEDIASTINUM/HILA: HEART:
VESSELS: Aorta: Pulmonary: TRACHEA/BRONCHI: CHEST WALL: BONES:
IMPRESSION:
Name: CTCHEST W/WO AR [Edit] [Delete]
CPT: 71270
CT CHEST WITH AND WITHOUT CONTRAST:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16
channel spiral CT scanner both before and after intravenous administration of nonionic contrast.
Additional isotropic multiplanar reconstructions were obtained in the sagittal and coronal planes.
CONTRAST: Oral contrast FINDINGS: LUNGS: PLEURA: MEDIASTINUM/HILA: HEART:
VESSELS: Aorta: Pulmonary: TRACHEA/BRONCHI: CHEST WALL: BONES:
IMPRESSION:
Name: CTA PULM AR [Edit] [Delete]
CPT: 71275
CTA PULMONARY:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16channel spiral CT scanner both before and after intravenous administration of nonionic contrast.
Additional isotropic multiplanar reconstructions were obtained in the sagittal and coronal planes.
A dedicated CT pulmonary angiogram was performed, and the images were reformatted in
rotation about the longitudinal axis. CONTRAST: A 20 ga. angiocath was placed in the right
antecubital fossa for contrast infusion. 100 cc Optiray 350 were utilized. ___ cc were
administered intravenously via power injector. No reaction. FINDINGS: LUNGS: HEART:
VESSELS: AORTA: PULMONARY: SYSTEMIC: MEDIASTINUM/HILA:
TRACHEOBRONCHIAL TREE: PLEURA: CHEST WALL: UPPER ABDOMEN: BONES:
IMPRESSION:
Name: MRI CHEST WO AR [Edit] [Delete]
CPT: 71550
MRI CHEST WITHOUT CONTRAST:
COMPARISON: INDICATIONS: TECHNIQUE: Multiplanar images were obtained on a 3
Tesla Siemens ultrahigh field MRI scanner without intravenous contrast, utilizing a series of
customized pulse sequences. FINDINGS: LUNGS: HEART: VESSELS: AORTA:
PULMONARY: SYSTEMIC: MEDIASTINUM/HILA: TRACHEOBRONCHIAL TREE:
PLEURA: CHEST WALL: UPPER ABDOMEN: BONES:
IMPRESSION:
Name: C/S (Default) [Edit] [Delete]
CPT: 72040
CERVICAL SPINE:
AP and lateral views of the cervical spine show good alignment throughout with disc spaces
preserved and vertebral body height maintained.
IMPRESSION: Negative cervical spine.
Name: C/S (Default) [Edit] [Delete]
CPT: 72050
CERVICAL SPINE:
Cervical spine 5 views. The vertebral bodies have normal height. Disc spaces are wellmaintained. Alignment is normal. The neural foramina are widely patent. The odontoid appears
normal.
IMPRESSION: Normal 5 view cervical spine.
Name: T/S (Default) [Edit] [Delete]
CPT: 72070
THORACIC SPINE:
The vertebral bodies have normal height and disc spaces are well maintained. There is normal
alignment. No degenerative change.
IMPRESSION: Normal thoracic spine examination.
Name: 3V T/S (Default) [Edit] [Delete]
CPT: 72072
THORACIC SPINE:
The vertebral bodies have normal height and disc spaces are well maintained. There is normal
alignment. No degenerative change.
IMPRESSION: Normal thoracic spine examination.
Name: 4V T/S (Default) [Edit] [Delete]
CPT: 72074
THORACIC SPINE:
The vertebral bodies have normal height and disc spaces are well maintained. There is normal
alignment. No degenerative change.
IMPRESSION: Normal thoracic spine examination.
Name: SPINE (Default) [Edit] [Delete]
CPT: 72100
LUMBOSACRAL SPINE:
The vertebral bodies have normal height and disc spaces are well maintained. Alignment normal.
No degenerative change evident. SI joints appear normal.
IMPRESSION: Negative lumbar spine examination.
Name: L/S (Default) [Edit] [Delete]
CPT: 72110
LUMBOSACRAL SPINE:
Multiple views of the lumbosacral spine show good alignment throughout the lumbar spine with
disc spaces preserved and vertebral body height maintained. The SI joints are unremarkable.
IMPRESSION: Negative lumbar spine.
Name: CT CS WO AR [Edit] [Delete]
CPT: 72125
CT CERVICAL SPINE WITHOUT CONTRAST:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16
channel CT scanner without IV contrast. Additional isotropic multiplanar reconstructions were
obtained in the sagittal and coronal planes. FINDINGS: Vertebrae: Alignment: Disc height:
Paraspinal tissues: Cervical disc levels: C2-C3: C3-C4: C4-C5: C5-C6: C7-T1:
IMPRESSION:
Name: CT CS P/ MYL AR [Edit] [Delete]
CPT: 72126
CT CERVICAL SPINE POST MYELOGRAM:
COMPARISON: Cervical myelogram same date. INDICATION: TECHNIQUE: Volumetric
scans were performed on a 16 channel CT scanner with intrathecal contrast instilled at the time
of myelography. Additional isotropic multiplanar reconstructions were obtained in the
sagittal,coronal and oblique planes. CONTRAST: FINDINGS: Subarachnoid space: Vertebrae:
Alignment: Disc height: Paraspinal tissues: Cervical disc levels: C2-C3: The cord is normal in
morphology. The neural foramina are patent bilaterally and the facet joints are normal. C3-C4:
C4-C5: C5-C6: C6-C7: C7-T1:
IMPRESSION:
Name: CT T&LS WO AR [Edit] [Delete]
CPT: 72128
CT THORACIC AND LUMBAR SPINES WITHOUT CONTRAST:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16
channel CT scanner without intravenous contrast. Additional isotropic multiplanar
reconstructions were obtained in the sagittal and coronal planes. THORACIC: FINDINGS:
Vertebrae: Alignment: Disc height: Canal dimensions: Neural foramina: Facets: Paraspinal
tissues: LUMBAR: FINDINGS: Vertebrae: Alignment: Disc height: Paraspinal tissues: Lumbar
disc levels: T12-L1: L1-L2: L2-L3: L3-L4: L4-L5: L5-S1:
IMPRESSION: THORACIC SPINE CONCLUSION: LUMBAR SPINE CONCLUSION:
Name: CT TS WO AR [Edit] [Delete]
CPT: 72128
CT THORACIC SPINE WITHOUT CONTRAST:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16
channel CT scanner without intravenous contrast. Additional isotropic multiplanar
reconstructions were obtained in the sagittal and coronal planes. FINDINGS: Vertebrae:
Alignment: Disc height: Canal dimensions: Neural foramina: Facets: Paraspinal tissues:
IMPRESSION:
Name: CT T&LS p/MY AR [Edit] [Delete]
CPT: 72129
CT THORACIC AND LUMBAR SPINES POST MYELOGRAM:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16
channel CT scanner with intrathecal contrast instilled at the time of myelography. Additional
isotropic multiplanar reconstructions were obtained in the sagittal,coronal and oblique planes.
CONTRAST: 10 cc Isovue-300 M. THORACIC: FINDINGS: Vertebrae: Alignment: Disc
height: Canal dimensions: Subarachnoid space: Neural foramina: Facets: Paraspinal tissues:
LUMBAR: FINDINGS: Subarachnoid space: Vertebrae: Alignment: Disc height: Paraspinal
tissues: Lumbar disc levels: T12-L1: L1-L2: L2-L3: L3-L4: L4-L5: L5-S1:
IMPRESSION: THORACIC SPINE CONCLUSION: LUMBAR SPINE CONCLUSION:
Name: CT LS WO AR [Edit] [Delete]
CPT: 72131
CT LUMBAR SPINE WITHOUT CONTRAST:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16
channel CT scanner without intravenous contrast. Additional isotropic multiplanar
reconstructions were obtained in the sagittal and coronal planes. FINDINGS: Vertebrae:
Alignment: Disc height: Paraspinal tissues: Lumbar disc levels: T12-L1: L1-L2: L2-L3: L3-L4:
L4-L5: L5-S1:
IMPRESSION:
Name: CT T&LS WO AR [Edit] [Delete]
CPT: 72131
CT THORACIC AND LUMBAR SPINES WITHOUT CONTRAST:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16
channel CT scanner without intravenous contrast. Additional isotropic multiplanar
reconstructions were obtained in the sagittal and coronal planes. THORACIC: FINDINGS:
Vertebrae: Alignment: Disc height: Canal dimensions: Neural foramina: Facets: Paraspinal
tissues: LUMBAR: FINDINGS: Vertebrae: Alignment: Disc height: Paraspinal tissues: Lumbar
disc levels: T12-L1: L1-L2: L2-L3: L3-L4: L4-L5: L5-S1:
IMPRESSION: THORACIC SPINE CONCLUSION: LUMBAR SPINE CONCLUSION:
Name: CT LS P/MYL AR [Edit] [Delete]
CPT: 72132
CT LUMBAR SPINE POST MYELOGRAM:
COMPARISON: Lumbar myelogram same date. INDICATION: TECHNIQUE: Volumetric
scans were performed on a 16 channel CT scanner with intrathecal contrast instilled at the time
of myelography. Additional isotropic multiplanar reconstructions were obtained in the
sagittal,coronal and oblique planes. CONTRAST: 15 cc Isovue-200 M. FINDINGS:
Subarachnoid space: Vertebrae: Alignment: Disc height: Paraspinal tissues: Lumbar disc levels:
T12-L1: L1-L2: L2-L3: L3-L4: L4-L5: L5-S1:
IMPRESSION:
Name: CT T&LS p/MY AR [Edit] [Delete]
CPT: 72132
CT THORACIC AND LUMBAR SPINES POST MYELOGRAM:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16
channel CT scanner with intrathecal contrast instilled at the time of myelography. Additional
isotropic multiplanar reconstructions were obtained in the sagittal,coronal and oblique planes.
CONTRAST: 10 cc Isovue-300 M. THORACIC: FINDINGS: Vertebrae: Alignment: Disc
height: Canal dimensions: Subarachnoid space: Neural foramina: Facets: Paraspinal tissues:
LUMBAR: FINDINGS: Subarachnoid space: Vertebrae: Alignment: Disc height: Paraspinal
tissues: Lumbar disc levels: T12-L1: L1-L2: L2-L3: L3-L4: L4-L5: L5-S1:
IMPRESSION: THORACIC SPINE CONCLUSION: LUMBAR SPINE CONCLUSION:
Name: MRI CS WO AR [Edit] [Delete]
CPT: 72141
MRI OF THE CERVICAL SPINE WITHOUT CONTRAST:
Comparison: Indications: Technique: Multiplanar images were obtained on a 3 Tesla Siemens
ultrahigh field MRI scanner without intravenous contrast utilizing a series of customized pulse
sequences. Findings: Craniocervical junction: Cervical cord: Vertebrae: Vertebral arteries:
Alignment: Disc heights and hydration: Paraspinal region: Other: prn Cervical disc levels: C2-3:
C3-4: C4-5: C5-6: C6-7: C7-T1:
IMPRESSION:
Name: MRICSPN WO AR [Edit] [Delete]
CPT: 72141
MRI CERVICAL SPINE WITHOUT CONTRAST :
COMPARISON: INDICATIONS: TECHNIQUE: Multiplanar images were obtained on a 3
Tesla Siemens ultrahigh field MRI scanner without intravenous contrast, utilizing a series of
customized pulse sequences. FINDINGS: Craniocervical junction: Cervical cord: Vertebrae:
Vertebral arteries: Alignment: Disc height and hydration: Paraspinous tissues: Cervical disc
levels: C2-C3: C3-C4: C4-C5: C5-C6: C6-C7: C7-T1:
IMPRESSION:
Name: MRITSPN WO AR [Edit] [Delete]
CPT: 72146
MRI THORACIC SPINE WITHOUT CONTRAST:
COMPARISON: INDICATIONS: TECHNIQUE: Multiplanar images were obtained on a 3
Tesla Siemens ultrahigh field MRI scanner without intravenous contrast, utilizing a series of
customized pulse sequences. FINDINGS: Vertebrae: Discs: Alignment: Neural foramina: Spinal
cord/conus: Paraspinous tissues:
IMPRESSION:
Name: MRI LSPN WO AR [Edit] [Delete]
CPT: 72148
MRI LUMBAR SPINE WITHOUT CONTRAST:
COMPARISON: INDICATION: TECHNIQUE: Multiplanar images were obtained on a 3 Tesla
Siemens ultrahigh field MRI scanner without intravenous contrast, utilizing a series of
customized pulse sequences. FINDINGS: Lumbar count: Conus medullaris: Vertebrae:
Alignment: Disc height and hydration: Paraspinal region: Lumbar disc levels: T12-L1: L1-L2:
L2-L3: L3-L4: L4-L5: L5-S1:
IMPRESSION:
Name: MRI CS W/WO AR [Edit] [Delete]
CPT: 72156
MRI OF THE CERVICAL SPINE WITH AND WITHOUT CONTRAST :
Comparison: Indications: Technique: Multiplanar images were obtained on a 3 Tesla Siemens
ultrahigh field MRI scanner with and without intravenous contrast utilizing a series of
customized pulse sequences. CONTRAST: Oral contrast Findings: Craniocervical junction:
Cervical cord: Vertebrae: Vertebral arteries: Alignment: Disc heights and hydration: Paraspinal
region: Other: prn Cervical disc levels: C2-3: C3-4: C4-5: C5-6: C6-7: C7-T1:
IMPRESSION:
Name: MRICSPN W/WO AR [Edit] [Delete]
CPT: 72156
MRI CERVICAL SPINE WITH AND WITHOUT CONTRAST:
COMPARISON: INDICATIONS: TECHNIQUE: Multiplanar images were obtained on a 3
Tesla Siemens ultrahigh field MRI scanner both before and after intravenous contrast
administration, utilizing a series of customized pulse sequences. Contrast: FINDINGS:
Craniocervical junction: Cervical cord: Vertebrae Vertebral arteries: Alignment: Disc height and
hydration: Paraspinous tissues: Cervical disc levels: C2-C3: C3-C4: C4-C5: C5-C6: C6-C7: C7T1:
IMPRESSION:
Name: MRITSPN W/WO AR [Edit] [Delete]
CPT: 72157
MRI THORACIC SPINE WITH AND WITHOUT CONTRAST:
COMPARISON: INDICATIONS: TECHNIQUE: Multiplanar images were obtained on a 3
Tesla Siemens ultrahigh field MRI scanner both before and after intravenous contrast
administration, utilizing a series of customized pulse sequences. Contrast: FINDINGS:
Vertebrae: Discs: Alignment: Neural foramina: Spinal cord/conus: Paraspinous tissues:
IMPRESSION:
Name: MRILSPN W/WO AR [Edit] [Delete]
CPT: 72158
MRI LUMBAR SPINE WITH AND WITHOUT :
COMPARISON: INDICATION: TECHNIQUE: Multiplanar images were obtained on a 3 Tesla
Siemens ultrahigh field MRI scanner both before and after intravenous contrast administration,
utilizing a series of customized pulse sequences. Contrast: FINDINGS: Lumbar count: Conus
medullaris: Vertebrae: Alignment: Disc height and hydration: Paraspinal region: Lumbar disc
levels: T12-L1: L1-L2: L2-L3: L3-L4: L4-L5: L5-S1:
IMPRESSION:
Name: 1V PELVIS (Default) [Edit] [Delete]
CPT: 72170
AP PELVIS:
There is no evidence of fracture or focal lesion. No degenerative change noted at SI joints or
hips.
IMPRESSION: Negative pelvis examination.
Name: PELVIS (Default) [Edit] [Delete]
CPT: 72190
PELVIS:
There is no evidence of fracture or focal lesion. No degenerative change noted at SI joints or
hips.
IMPRESSION: Negative pelvis examination.
Name: CTA V/A/P RO AR [Edit] [Delete]
CPT: 72191
CTA VASCULAR, ABDOMEN AND PELVIS; RUNOFF:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16
channel spiral CT scanner with dynamic bolus intravenous injection of nonionic contrast and
acquisition of images. Additional maximum intensity projection 2D and volume rendered 3D
reconstructions were obtained and performed on a separate Vitrea workstation. Contrast: A 20
ga. angiocath was placed in the right antecubital fossa for contrast infusion. 100 cc Optiray 350
were utilized. __ cc were administered intravenously via power injector. No reaction.
FINDINGS: VASCULAR: Aortic arch: Thoracic aorta: Abdominal aorta: Celiac axis: Superior
mesenteric artery: Renal arteries: Inferior mesenteric artery: Aortic bifurcation: RIGHT SIDE:
Common iliac artery: Internal iliac artery: External iliac artery: Common femoral artery: Deep
femoral artery: Superficial femoral artery: Popliteal artery: Anterior tibial artery: Tibioperoneal
trunk: Posterior tibial artery : Peroneal artery: LEFT SIDE: Common iliac artery: Internal iliac
artery: External iliac artery: Common femoral artery: Deep femoral artery: Superficial femoral
artery: Popliteal artery: Anterior tibial artery: Tibioperoneal trunk: Posterior tibial artery :
Peroneal artery: CONCLUSIONS: ABDOMEN: FINDINGS: Lung bases: Liver: Bile ducts:
Gallbladder: Pancreas: Spleen: Adrenals: Kidneys: Retroperitoneum: Bowel/Mesentery:
Abdominal wall: Bones: CONCLUSIONS: PELVIS: FINDINGS: Bladder: Reproductive organs:
Pelvic lymph nodes: Bowel:
IMPRESSION:
Name: CTA V/AB/PEL AR [Edit] [Delete]
CPT: 72191
CTA VASCULAR, ABDOMEN AND PELVIS:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16
channel spiral CT scanner with dynamic bolus intravenous injection of nonionic contrast and
acquisition of images. Additional maximum intensity projection 2D and volume rendered 3D
reconstructions were obtained and performed on a separate Vitrea workstation. Contrast: A 20
ga. angiocath was placed in the right antecubital fossa for contrast infusion. 100 cc Optiray 350
were utilized. ___ cc were administered intravenously via power injector. No reaction.
VASCULAR: FINDINGS: Aortic arch: Thoracic aorta: Abdominal aorta: Celiac axis: Superior
mesenteric artery: Renal arteries: Inferior mesenteric artery: Aortic bifurcation: Iliac arteries:
CONCLUSIONS: ABDOMEN: FINDINGS: Lung bases: Liver: Bile ducts: Gallbladder:
Pancreas: Spleen: Adrenals: Kidneys: Retroperitoneum: Bowel/Mesentery: Abdominal wall:
Bones: CONCLUSIONS: PELVIS: FINDINGS: Bladder: Reproductive organs: Pelvic lymph
nodes: Bowel:
IMPRESSION:
Name: CT PEL WO AR [Edit] [Delete]
CPT: 72192
CT PELVIS WITHOUT CONTRAST:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16
channel spiral CT scanner. Additional isotropic multiplanar reconstructions were obtained in the
sagittal and coronal planes. FINDINGS: REPRODUCTIVE ORGANS: BLADDER: PELVIC
LYMPH NODES: BOWEL: BONES:
IMPRESSION:
Name: CT PEL W AR [Edit] [Delete]
CPT: 72193
CT PELVIS WITH CONTRAST:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16
channel spiral CT scanner after intravenous administration of nonionic contrast. Additional
isotropic multiplanar reconstructions were obtained in the sagittal and coronal planes.
CONTRAST: Oral contrast FINDINGS: REPRODUCTIVE ORGANS: BLADDER: PELVIC
LYMPH NODES: BOWEL: BONES:
IMPRESSION:
Name: CT PEL W/WO AR [Edit] [Delete]
CPT: 72194
CT PELVIS WITH AND WITHOUT CONTRAST:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16
channel spiral CT scanner both before and after intravenous administration of nonionic contrast.
Additional isotropic multiplanar reconstructions were obtained in the sagittal and coronal planes.
CONTRAST: Oral contrast FINDINGS: REPRODUCTIVE ORGANS: BLADDER: PELVIC
LYMPH NODES: BOWEL: BONES:
IMPRESSION:
Name: MRI PEL W/WO AR [Edit] [Delete]
CPT: 72197
MRI PELVIS WITH AND WITHOUT CONTRAST:
COMPARISON: INDICATION: TECHNIQUE: Multiplanar images were obtained on a 3 Tesla
Siemens ultrahigh field MRI scanner both before and after intravenous contrast administration,
utilizing a series of customized pulse sequences. Contrast: FINDINGS: Bladder: Reproductive
organs: Pelvic lymph nodes: Bowel:
IMPRESSION:
Name: BILAT SI JOINTS (Default) [Edit] [Delete]
CPT: 72202
SACROILIAC JOINTS:
The SI joints show no widening, focal lesion or sclerosis. No fracture.
IMPRESSION: Negative SI joint examination.
Name: SACRUM/COCCYX (Default) [Edit] [Delete]
CPT: 72220
SACRUM/COCCYX:
The sacrum and coccyx shows no evidence of fracture or abnormal alignment. No focal lesion.
IMPRESSION: Negative sacrum/coccyx examination.
Name: CLAVICLE (Default) [Edit] [Delete]
CPT: 73000
& RL& CLAVICLE:
AP views of the &rl& clavicle, with and without cephalic angulations, show no evidence for
fracture or other significant bone, joint or soft tissue abnormality.
IMPRESSION: Negative &rl& clavicle.
Name: SCAPULA (Default) [Edit] [Delete]
CPT: 73010
& RL& SCAPULA:
Multiple views of the &rl& scapula show no evidence for fracture or other significant bone, joint
or soft tissue abnormality.
IMPRESSION: Negative &rl& scapula.
Name: 2-view Shoulder (Default) [Edit] [Delete]
CPT: 73020
& RL& SHOULDER:
There is no evidence of fracture, focal lesion or degenerative change. Adjacent ribs appear
normal.
IMPRESSION: Negative shoulder examination.
Name: SHOULDER (Default) [Edit] [Delete]
CPT: 73030
& RL& SHOULDER:
There is no evidence of fracture, focal lesion or degenerative change. Adjacent ribs appear
normal.
IMPRESSION: Negative shoulder examination.
Name: AC Joints (Default) [Edit] [Delete]
CPT: 73050
AC JOINTS WITH AND WITHOUT WEIGHTBEARING:
Views of the AC joints, with and without weightbearing, reveal no fracture or other significant
bone, joint or soft tissue abnormality.
IMPRESSION: Negative AC joints.
Name: HUMERUS (Default) [Edit] [Delete]
CPT: 73060
& RL& HUMERUS:
There is no evidence of fracture, focal lesion or cortical irregularity. Visualized soft tissues
unremarkable.
IMPRESSION: Negative humerus examination.
Name: ELBOW (Default) [Edit] [Delete]
CPT: 73080
& RL& ELBOW:
No fracture or cortical irregularity is evident. There is normal alignment. No degenerative
change or posterior fat pad displacement.
IMPRESSION: Negative elbow examination.
Name: FOREARM (Default) [Edit] [Delete]
CPT: 73090
& RL& FOREARM:
There is no evidence of fracture or focal lesion and no cortical irregularity. No posterior fat pad
displacement.
IMPRESSION: Negative forearm examination.
Name: 2-view Wrist (Default) [Edit] [Delete]
CPT: 73100
& RL& WRIST:
Two views. No fracture line or cortical irregularity is evident. There is normal alignment. Joint
spaces are well maintained with no degenerative change.
IMPRESSION: Normal wrist.
Name: WRIST (Default) [Edit] [Delete]
CPT: 73110
& RL& WRIST:
There is no evidence of fracture or cortical irregularity. Alignment is normal. Joint space is well
maintained with no degenerative change.
IMPRESSION: Negative wrist examination.
Name: HAND (Default) [Edit] [Delete]
CPT: 73120
& RL& HAND:
No fracture or focal lesion is evident. There is normal alignment without degenerative change.
IMPRESSION: Negative hand examination.
Name: HAND (Default) [Edit] [Delete]
CPT: 73130
& RL& HAND:
No fracture or focal lesion is evident. There is normal alignment without degenerative change.
IMPRESSION: Negative hand examination.
Name: FINGERS (Default) [Edit] [Delete]
CPT: 73140
& RL& FINGERS:
No fracture line or cortical irregularity evident. Normal alignment without degenerative change.
IMPRESSION: Negative finger examination.
Name: CTA UP EXT AR [Edit] [Delete]
CPT: 73206
CTA UPPER EXTREMITY:
COMPARISON: INDICATIONS: TECHNIQUE: Volumetric scans were performed on a 16
channel spiral CT scanner with dynamic bolus intravenous injection of nonionic contrast and
acquisition of images. Additional maximum intensity projection 2D and volume rendered 3D
reconstructions were obtained and performed on a separate Vitrea workstation. Contrast: 1 A 20
ga. angiocath was placed in the right antecubital fossa for contrast infusion. 00 cc Optiray 350
were utilized. ¬¬__ cc were administered intravenously via power injector. No reaction. CT
ANGIOGRAM OF THE &RL& ARM: FINDINGS:& RL& Subclavian Artery: The &rl&
subclavian artery is normal in calibers and contours. There is no evidence of aneurysm or
stenosis. & RL& Subscapular Artery: The &rl& subscapular artery and its branches are widely
patent, without irregularity or stenosis. & RL& Circumflex Humeral Artery: The &rl&
circumflex humeral artery is widely patent, without irregularity or stenosis. & RL& Axillary
Artery: The &rl& axillary artery is widely patent, without irregularity or stenosis. & RL&
Brachial Artery: The &rl& brachial artery is widely patent, without irregularity or stenosis.
IMPRESSION:
Name: R/L HIP 1 VIEW (Default) [Edit] [Delete]
CPT: 73500
& RL& HIP:
The proximal femur shows no fracture or focal lesion. Acetabulum intact. Hip joint space well
maintained with no degenerative change.
IMPRESSION: Negative hip examination.
Name: HIP (Default) [Edit] [Delete]
CPT: 73510
& RL& HIP SERIES:
The proximal femur shows no fracture or focal lesion. Acetabulum intact. Hip joint space well
maintained with no degenerative change.
IMPRESSION: Negative hip examination.
Name: B HIPS/PELVIS (Default) [Edit] [Delete]
CPT: 73520
BILATERAL HIPS INCL AP PELVIS:
Bilateral AP and lateral hips including an AP pelvis projection shows the visualized skeletal
structures to be unremarkable and the joint spaces preserved. There are no fractures, dislocations
or other signficant abnormality.
IMPRESSION: Negative bilateral hips.
Name: FEMUR (Default) [Edit] [Delete]
CPT: 73550
& RL& FEMUR:
There is no evidence of fracture or focal lesion. No significant degenerative change at the hip or
knee. No radiopaque foreign body.
IMPRESSION: Negative femur examination.
Name: R/L KNEES (Default) [Edit] [Delete]
CPT: 73560
& RL& KNEE:
The knee joint space and femoropatellar joint space are well maintained. There is no fracture or
effusion.
IMPRESSION: Negative knee examination.
Name: &RL& Knee (Default) [Edit] [Delete]
CPT: 73562
& RL& KNEE:
The knee joint space and femoropatellar joint space are well maintained. There is no fracture or
effusion.
IMPRESSION: Negative knee examination.
Name: KNEE (Default) [Edit] [Delete]
CPT: 73564
& RL& KNEE:
The knee joint space and femoropatellar joint space are well maintained. There is no fracture or
effusion.
IMPRESSION: Negative knee examination.
Name: T/F (Default) [Edit] [Delete]
CPT: 73590
& RL& TIBIA-FIBULA:
The tibia and fibula show no fracture, cortical irregularity or focal lesion. Soft tissues
unremarkable.
IMPRESSION: Negative tibia/fibula examination.
Name: R/L ANKLE (Default) [Edit] [Delete]
CPT: 73600
& RL& ANKLE:
Ankle mortise intact. The distal tibia and fibula show no fracture or focal lesion. Visualized
tarsal bone is unremarkable without degenerative change.
IMPRESSION: Negative ankle examination.
Name: ANKLE (Default) [Edit] [Delete]
CPT: 73610
& RL& ANKLE:
Ankle mortise intact. The distal tibia and fibula show no fracture or focal lesion. Visualized
tarsal bone is unremarkable without degenerative change.
IMPRESSION: Negative ankle examination.
Name: R/L FOOT (Default) [Edit] [Delete]
CPT: 73620
& RL& FOOT:
The bony structures of the foot show no fracture or cortical irregularity. There is no
malalignment or degenerative change and no focal lesion.
IMPRESSION: Negative foot examination.
Name: FEET W/WT (Default) [Edit] [Delete]
CPT: 73630
& RL& FOOT WITH NONWEIGHTBEARING VIEWS:
The bony structures of the foot show no fracture or cortical irregularity. There is no
malalignment or degenerative change and no focal lesion.
IMPRESSION: Negative foot examination.
Name: FEET WITH WT (Default) [Edit] [Delete]
CPT: 73630.1
& RL& FOOT WITH WEIGHTBEARING AND NONWEIGHTBEARING VIEWS:
The bony structures of the foot show no fracture or cortical irregularity. There is no
malalignment or degenerative change and no focal lesion. In weightbearing lateral view, the
calcaneal angle is ___.
IMPRESSION: Normal foot examination including weightbearing view.
Name: HEEL (Default) [Edit] [Delete]
CPT: 73650
& RL& HEEL:
Lateral and tangential views of the &rl& heel reveal no spur formation or other significant bony
abnormality.
IMPRESSION: Negative &rl& heel.
Name: KNEE ARTH CHG [Edit] [Delete]
CPT: 73654
& RL& KNEE:
Mild to moderate degenerative arthritic change is observed in the &rl& knee and patella. There is
no evidence for fracture or other significant abnormality.
IMPRESSION: Mild to moderate degenerative arthritic change is observed in the &rl& knee
and patella.
Name: TOE (Default) [Edit] [Delete]
CPT: 73660
& RL& TOES:
AP and lateral views of the &rl& toes with attention to the toe, show no evidence for fracture or
other significant bone, joint or soft tissue abnormality.
IMPRESSION: Negative &rl& toes.
Name: CT &RL& KN AR [Edit] [Delete]
CPT: 73700
CT &RL& KNEE:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16
channel CT scanner without intravenous contrast. Additional isotropic multiplanar
reconstructions were obtained in the sagittal and coronal planes. FINDINGS:
IMPRESSION:
Name: CT KN REPL AR [Edit] [Delete]
CPT: 73700
CT KNEE REPLACEMENT:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16
channel CT scanner without IV contrast. The standard DePuy Trumatch knee imaging protocol
was followed precisely. FINDINGS: Imaging of the knee was performed according to the
standard protocol. Image data was sent in CT format to the DePuy company for assistance in
fabrication of a knee prosthesis.
IMPRESSION: Successful DePuy Trumatch protocol of the knee for fabrication of knee
replacement prosthesis.
Name: US T/A/V P AR [Edit] [Delete]
CPT: 73856
TRANSABDOMINAL AND TRANSVAGINAL PELVIC ULTRASOUND:
COMPARISON: INDICATION: TECHNIQUE: Real-time sonography and multiplanar
sonographic images were obtained on a Siemens Antares ultrasound unit. Both transabdominal
and transvaginal scans were obtained. Transvaginal images were obtained to clarify and provide
high resolution. Color-flow Doppler was utilized. FINDINGS: Uterus: Right ovary: Left ovary:
Cervix: Free fluid:
IMPRESSION:
Name: AP ABDOMEN (Default) [Edit] [Delete]
CPT: 74000
AP ABDOMEN:
The bowel gas pattern is normal with no ileus or obstruction. No abnormal calcification present.
No free air. No calcification noted of the kidneys or ureters.
IMPRESSION: Negative AP abdomen examination.
Name: KUB [Edit] [Delete]
CPT: 74000
KUB:
The bowel gas pattern is normal with no ileus or obstruction. No abnormal calcification present.
No free air. No calcification noted of the kidneys or ureters.
IMPRESSION: Negative abdomen examination.
Name: SUPINE ABDOMEN [Edit] [Delete]
CPT: 74000
SUPINE ABDOMEN:
The bowel gas pattern is normal with no ileus or obstruction. No abnormal calcification present.
No free air. No calcification noted of the kidneys or ureters.
IMPRESSION: Negative abdomen examination.
Name: 2 View Abd (Default) [Edit] [Delete]
CPT: 74010
ABDOMEN; TWO VIEWS:
The bowel gas pattern is normal with no ileus or obstruction. No abnormal calcification present.
No free air. No calcification noted of the kidneys or ureters.
IMPRESSION: Negative two view abdomen examination.
Name: FLAT & UP ABD (Default) [Edit] [Delete]
CPT: 74020
FLAT & UPRIGHT ABDOMEN:
The bowel gas pattern is normal with no ileus or obstruction. No abnormal calcification present.
No free air. No calcification noted of the kidneys or ureters.
IMPRESSION: Negative two view abdomen examination.
Name: ABD (Default) [Edit] [Delete]
CPT: 74022
ACUTE ABDOMINAL SERIES :
The bowel gas pattern is normal with no ileus or obstruction. No abnormal calcification present.
No free air. No calcification noted of the kidneys or ureters. Single view of the chest shows no
focal infiltrate, consolidation or effusion. Heart and mediastinum normal.
IMPRESSION: Negative acute abdominal series.
Name: CT ABD WO AR [Edit] [Delete]
CPT: 74150
CT ABDOMEN WITHOUT CONTRAST:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16
channel spiral CT scanner. Additional isotropic multiplanar reconstructions were obtained in the
sagittal and coronal planes. CONTRAST: Oral contrast FINDINGS: LUNG BASES: LIVER:
BILE DUCTS: GALLBLADDER: PANCREAS: SPLEEN: ADRENALS: KIDNEYS: AORTA:
RETROPERITONEUM: BOWEL/MESENTERY: ABDOMINAL WALL: BONES:
IMPRESSION:
Name: CT ABD W AR [Edit] [Delete]
CPT: 74160
CT ABDOMEN WITH CONTRAST:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16
channel spiral CT scanner after intravenous administration of nonionic contrast. Additional
isotropic multiplanar reconstructions were obtained in the sagittal and coronal planes.
CONTRAST: Oral contrast FINDINGS: LUNG BASES: LIVER: BILE DUCTS:
GALLBLADDER: PANCREAS: SPLEEN: ADRENALS: KIDNEYS: AORTA:
RETROPERITONEUM: BOWEL/MESENTERY: ABDOMINAL WALL: BONES:
IMPRESSION:
Name: CT ABD W/WO AR [Edit] [Delete]
CPT: 74170
CT ABDOMEN WITH AND WITHOUT CONTRAST:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16
channel spiral CT scanner both before and after intravenous administration of nonionic contrast.
Additional isotropic multiplanar reconstructions were obtained in the sagittal and coronal planes.
CONTRAST: Oral contrast FINDINGS: LUNG BASES: LIVER: BILE DUCTS:
GALLBLADDER: PANCREAS: SPLEEN: ADRENALS: KIDNEYS: AORTA:
RETROPERITONEUM: BOWEL/MESENTERY: ABDOMINAL WALL: BONES:
IMPRESSION:
Name: CTA V/A/P RO AR [Edit] [Delete]
CPT: 74175
CTA VASCULAR, ABDOMEN AND PELVIS; RUNOFF:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16
channel spiral CT scanner with dynamic bolus intravenous injection of nonionic contrast and
acquisition of images. Additional maximum intensity projection 2D and volume rendered 3D
reconstructions were obtained and performed on a separate Vitrea workstation. Contrast: A 20
ga. angiocath was placed in the right antecubital fossa for contrast infusion. 100 cc Optiray 350
were utilized. __ cc were administered intravenously via power injector. No reaction.
FINDINGS: VASCULAR: Aortic arch: Thoracic aorta: Abdominal aorta: Celiac axis: Superior
mesenteric artery: Renal arteries: Inferior mesenteric artery: Aortic bifurcation: RIGHT SIDE:
Common iliac artery: Internal iliac artery: External iliac artery: Common femoral artery: Deep
femoral artery: Superficial femoral artery: Popliteal artery: Anterior tibial artery: Tibioperoneal
trunk: Posterior tibial artery : Peroneal artery: LEFT SIDE: Common iliac artery: Internal iliac
artery: External iliac artery: Common femoral artery: Deep femoral artery: Superficial femoral
artery: Popliteal artery: Anterior tibial artery: Tibioperoneal trunk: Posterior tibial artery :
Peroneal artery: CONCLUSIONS: ABDOMEN: FINDINGS: Lung bases: Liver: Bile ducts:
Gallbladder: Pancreas: Spleen: Adrenals: Kidneys: Retroperitoneum: Bowel/Mesentery:
Abdominal wall: Bones: CONCLUSIONS: PELVIS: FINDINGS: Bladder: Reproductive organs:
Pelvic lymph nodes: Bowel:
IMPRESSION:
Name: CTA V/AB/PEL AR [Edit] [Delete]
CPT: 74175
CTA VASCULAR, ABDOMEN AND PELVIS:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16
channel spiral CT scanner with dynamic bolus intravenous injection of nonionic contrast and
acquisition of images. Additional maximum intensity projection 2D and volume rendered 3D
reconstructions were obtained and performed on a separate Vitrea workstation. Contrast: A 20
ga. angiocath was placed in the right antecubital fossa for contrast infusion. 100 cc Optiray 350
were utilized. ___ cc were administered intravenously via power injector. No reaction.
VASCULAR: FINDINGS: Aortic arch: Thoracic aorta: Abdominal aorta: Celiac axis: Superior
mesenteric artery: Renal arteries: Inferior mesenteric artery: Aortic bifurcation: Iliac arteries:
CONCLUSIONS: ABDOMEN: FINDINGS: Lung bases: Liver: Bile ducts: Gallbladder:
Pancreas: Spleen: Adrenals: Kidneys: Retroperitoneum: Bowel/Mesentery: Abdominal wall:
Bones: CONCLUSIONS: PELVIS: FINDINGS: Bladder: Reproductive organs: Pelvic lymph
nodes: Bowel:
IMPRESSION:
Name: CT AB PEL WO AR [Edit] [Delete]
CPT: 74176
CT ABDOMEN AND PELVIS WITHOUT CONTRAST:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16
channel spiral CT scanner without intravenous contrast. Additional isotropic multiplanar
reconstructions were obtained in the sagittal and coronal planes. ABDOMEN: FINDINGS: Lung
bases: Liver: Bile ducts: Gallbladder: Pancreas: Spleen: Adrenals: Kidneys: Aorta:
Retroperitoneum: Bowel/Mesentery: Abdominal wall: Bones: CONCLUSIONS: 1. PELVIS:
FINDINGS: Bladder: Reproductive organs: Pelvic lymph nodes: Bowel: CONCLUSIONS:
IMPRESSION:
Name: CTABPELW/WO AR [Edit] [Delete]
CPT: 74177
CT ABDOMEN AND PELVIS WITH AND WITHOUT CONTRAST:
COMPARISON: INDICATION: TECHNIQUE: Multiphasic volumetric scans were performed
on a 16 channel spiral CT scanner both before and after intravenous administration of nonionic
contrast. Additional isotropic multiplanar reconstructions were obtained in the sagittal and
coronal planes. Contrast: A 20 ga. angiocath was placed in the right antecubital fossa for contrast
infusion. 100 cc Optiray 300 were utilized. ___ cc were administered intravenously via power
injector. No reaction. ABDOMEN: FINDINGS: Lung bases: Liver: Bile ducts: Gallbladder:
Pancreas: Spleen: Adrenals: Kidneys: Aorta: Retroperitoneum: Bowel/Mesentery: Abdominal
wall: Bones: CONCLUSIONS: 1. Normal examination. PELVIS: FINDINGS: Bladder:
Reproductive organs: Pelvic lymph nodes: Bowel: CONCLUSIONS:
IMPRESSION:
Name: MRCP [Edit] [Delete]
CPT: 74181
MRCP:
COMPARISON: INDICATIONS: TECHNIQUE: Multiplanar images were obtained on a 3
Tesla Siemens ultrahigh field MRI scanner without intravenous contrast, utilizing a series of
customized pulse sequences. MRCP: FINDINGS: BILIARY TREE: GALLBLADDER:
PANCREATIC DUCT: ABDOMEN: FINDINGS: Liver: Pancreas: Spleen: Adrenals: Kidneys:
Aorta: Retroperitoneum: Bowel/Mesentery: Abdominal wall: Bones:
IMPRESSION:
Name: MRI ABD W/WO AR [Edit] [Delete]
CPT: 74183
MRI ABDOMEN WITH AND WITHOUT CONTRAST:
COMPARISON: INDICATIONS: TECHNIQUE: Multiplanar images were obtained on a 3
Tesla Siemens ultrahigh field MRI scanner both before and after intravenous contrast
administration, utilizing a series of customized pulse sequences. Contrast: ABDOMEN:
FINDINGS: Liver: Bile ducts: Gallbladder: Pancreas: Spleen: Adrenals: Kidneys: Aorta:
Retroperitoneum: Bowel/Mesentery: Abdominal wall: Bones:
IMPRESSION:
Name: MRA ABD AOR AR [Edit] [Delete]
CPT: 74185
MRA ABDOMINAL AORTA:
COMPARISON: INDICATIONS: TECHNIQUE: Multiplanar magnetic resonance arteriograms
were obtained on 3 Tesla Siemens ultrahigh field MRI scanner with intravenous contrast,
utilizing a series of customized pulse sequences. Image processing performed on an independent
workstation included maximum intensity projections and 3-D volume rendering of the imaged
vasculature. Contrast: FINDINGS: Abdominal aorta: Celiac axis: Superior mesenteric artery:
Renal arteries: Inferior mesenteric artery: Aortic bifurcation: Iliac arteries:
IMPRESSION:
Name: MRA ABD RO AR [Edit] [Delete]
CPT: 74185
MRA ABDOMEN; RUNOFF:
COMPARISON: INDICATIONS: TECHNIQUE: Multiplanar magnetic resonance arteriograms
were obtained on 3 Tesla Siemens ultrahigh field MRI scanner with intravenous contrast,
utilizing a series of customized pulse sequences. Image processing performed on an independent
workstation included maximum intensity projections and 3-D volume rendering of the imaged
vasculature. Contrast: FINDINGS: Thoracic aorta: Abdominal aorta: Celiac axis: Superior
mesenteric artery: Renal arteries: Inferior mesenteric artery: Aortic bifurcation: RIGHT SIDE:
Common iliac artery: Internal iliac artery: External iliac artery: Common femoral artery: Deep
femoral artery: Superficial femoral artery: Poplital artery: Anterior tibial artery: Tibioperoneal
trunk: Posterior tibial artery: Peroneal artery: LEFT SIDE: Common iliac artery: Internal iliac
artery: External iliac artery: Common femoral artery: Deep femoral artery: Superficial femoral
artery: Poplital artery: Anterior tibial artery: Tibioperoneal trunk: Posterior tibial artery: Peroneal
artery:
IMPRESSION:
Name: CTA V/A/P RO AR [Edit] [Delete]
CPT: 75635
CTA VASCULAR, ABDOMEN AND PELVIS; RUNOFF:
COMPARISON: INDICATION: TECHNIQUE: Volumetric scans were performed on a 16
channel spiral CT scanner with dynamic bolus intravenous injection of nonionic contrast and
acquisition of images. Additional maximum intensity projection 2D and volume rendered 3D
reconstructions were obtained and performed on a separate Vitrea workstation. Contrast: A 20
ga. angiocath was placed in the right antecubital fossa for contrast infusion. 100 cc Optiray 350
were utilized. __ cc were administered intravenously via power injector. No reaction.
FINDINGS: VASCULAR: Aortic arch: Thoracic aorta: Abdominal aorta: Celiac axis: Superior
mesenteric artery: Renal arteries: Inferior mesenteric artery: Aortic bifurcation: RIGHT SIDE:
Common iliac artery: Internal iliac artery: External iliac artery: Common femoral artery: Deep
femoral artery: Superficial femoral artery: Popliteal artery: Anterior tibial artery: Tibioperoneal
trunk: Posterior tibial artery : Peroneal artery: LEFT SIDE: Common iliac artery: Internal iliac
artery: External iliac artery: Common femoral artery: Deep femoral artery: Superficial femoral
artery: Popliteal artery: Anterior tibial artery: Tibioperoneal trunk: Posterior tibial artery :
Peroneal artery: CONCLUSIONS: ABDOMEN: FINDINGS: Lung bases: Liver: Bile ducts:
Gallbladder: Pancreas: Spleen: Adrenals: Kidneys: Retroperitoneum: Bowel/Mesentery:
Abdominal wall: Bones: CONCLUSIONS: PELVIS: FINDINGS: Bladder: Reproductive organs:
Pelvic lymph nodes: Bowel:
IMPRESSION:
Name: Breast US State [Edit] [Delete]
CPT: 76445
:
IMPRESSION: NOTE: Ultrasound is not the preferred modality for the evaluation of
microcalcifications which is an important diagnostic factor for breast malignancy.
Mammography or MRI of the breast is recommended for a more reliable evaluation for breast
carcinoma.
Name: US THY AR [Edit] [Delete]
CPT: 76536
THYROID ULTRASOUND:
COMPARISON: INDICATION: TECHNIQUE: Real-time sonography and multiplanar
sonographic images were obtained on a Siemens Antares ultrasound unit. Color-flow Doppler
was utilized. FINDINGS: Right lobe: Left lobe: Isthmus:
IMPRESSION:
Name: US ABD AR [Edit] [Delete]
CPT: 76700
ULTRASOUND ABDOMEN:
COMPARISON: INDICATION: TECHNIQUE: Real-time sonography and multiplanar
sonographic images were obtained on a Siemens Antares ultrasound unit. FINDINGS: Liver:
Intrahepatic biliary ducts: Gallbladder: Common bile duct: Pancreas: Spleen: Right kidney: Left
kidney: Bladder: Aorta:
IMPRESSION:
Name: US ABD AOR AR [Edit] [Delete]
CPT: 76770
ULTRASOUND ABDOMINAL AORTA:
COMPARISON: INDICATION: TECHNIQUE: Real-time sonography and multiplanar
sonographic images were obtained on a Siemens Antares ultrasound unit. FINDINGS:
CONCLUSIONS: Proximal: The waveform is [] with a velocity of [<>] cm/s. Mid: The
waveform is [] with a velocity of [<>] cm/s. Distal: The waveform is [] with a velocity of [<>]
cm/s. Popliteal artery: The waveform is [] with a velocity of [<>] cm/s. Anterior tibial artery:
The waveform is [] with a velocity of [<>] cm/s. Posterior tibial artery: The waveform is [] with
a velocity of [<>] cm/s.
IMPRESSION:
Name: US DOP RA/K AR [Edit] [Delete]
CPT: 76770
DOPPLER ULTRASOUND OF THE RENAL ARTERIES AND KIDNEYS:
Arterial Velocities cm/sec Aorta - Right Renal - proximal - , mid - , distal - , hilar - Left Renal proximal - , mid - , distal - , hilar - Renal Aortic Ratios: Right - , Left - (1-59% <3.5, 60-99%
>3.5) Renal resistive indices: Right segmental - Left segmental - Right interlobar - Left
interlobar - Right arcuate - Left arcuate - Normal renal resistive index is less than or equal to
0.70. A resistive index greater than 0.70 suggests increased renovascular resistance, which
correlates with renal insufficiency.
IMPRESSION:
Name: US REN ART AR [Edit] [Delete]
CPT: 76770
RENAL ARTERY ULTRASOUND:
COMPARISON: INDICATION: TECHNIQUE: Real-time sonography and multiplanar
sonographic images were obtained on a Siemens Antares ultrasound unit. Duplex Doppler
interrogation was performed of the pertinent arterial structures. FINDINGS: DIAGNOSTIC
RENAL SONOGRAM: Right kidney: Left kidney: Bladder:
IMPRESSION:
Name: US RENAL AR [Edit] [Delete]
CPT: 76770
RENAL ULTRASOUND:
COMPARISON: INDICATION: TECHNIQUE: Real-time sonography and multiplanar
sonographic images were obtained on a Siemens Antares ultrasound unit. FINDINGS: Right
kidney: Left kidney: Renal resistive indices: Right segmental - [<>] Left segmental - [<>] Right
interlobar - [<>] Left interlobar - [<>] Right arcuate - [<>] Left arcuate - [<>] Normal renal
resistive index is less than or equal to 0.70. A resistive index greater than 0.70 suggests increased
renovascular resistance, which correlates with renal insufficiency. Bladder: Aorta: The proximal
abdominal aorta measures []. The mid abdominal aorta measures []. The distal abdominal aorta
measures []. The right iliac artery measures []. The left iliac artery measures [].
IMPRESSION:
Name: OB US 1ST AR [Edit] [Delete]
CPT: 76801
OB ULTRASOUND FIRST TRIMESTER:
COMPARISON: INDICATION: TECHNIQUE: Real-time sonography and multiplanar
sonographic images were obtained on a Siemens Antares ultrasound unit FINDINGS: The mean
crown-rump length is [] mm ([] weeks, [] days). The gestational sac volume is [] cc ([] weeks, []
days). The yolk sac is identified. The amnion is identified. The fetal heart rate is [] bpm.
IMPRESSION:
Name: OB US NUCH AR [Edit] [Delete]
CPT: 76801
OB ULTRASOUND (NUCHAL TRANSLUCENCY):
COMPARISON: [] INDICATION: []. TECHNIQUE: Real-time sonography and multiplanar
sonographic images were obtained on a Siemens Antares ultrasound unit FINDINGS: The
maximum crown-rump length is []mm ( [] weeks, [] days). The maximum nuchal translucency
measures [] mm. The yolk sac is identified. The amnion is identified. The fetal heart rate is []
bpm.
IMPRESSION: 1. Early live intrauterine pregnancy. 2. A heart beat is identified. 3. The
gestational age by ultrasound is [] weeks, [] days. 4. Maximum crown-rump length is [] mm. 5.
Maximum nuchal translucency is [] mm.
Name: Stephenson OBUS [Edit] [Delete]
CPT: 76801
OB ULTRASOUND:
LMP- 00/00/00 Clinical Age by LMP-00/00/00 Comparison made with prior study dated
00/00/00. Single viable intrauterine gestation: Fetal heart rate: bpm. Placenta Location: Previa:
No __ Yes __ Fetal Presentation: Cervix Length: AFI: Fetal Measurements: BPD: cm weeks,
days gestational age. Head circumference: cm weeks, days gestational age. Abd circumference:
cm weeks, days gestational age. Femur length: cm weeks, days gestational age. Average
gestational age by ultrasound: Estimated date of delivery by ultrasound: Estimated fetal weight:
gms or lb oz. % Ratios: HC/AC: % Normal= FL/BPD: % Normal= FL/AC: % Normal= Fetal
Anatomy: 4 Chamber heart: Seen Normal 3 Vessel Cord: Seen Cord Insertion: Seen Kidneys:
Seen Spine: Seen Stomach: Present: Bladder: Present: Maternal uterus and ovaries:
IMPRESSION: 1. Single viable intrauterine gestation with gestational age of and a due date of
2. Fetal anatomy appears 3.
Name: OB US AR [Edit] [Delete]
CPT: 76805
OB ULTRASOUND:
COMPARISON: INDICATION: TECHNIQUE: Real-time sonography and multiplanar
sonographic images were obtained on a Siemens Antares ultrasound unit FINDINGS: There is a
single living fetus in the [] position. The placenta is Grade [] and [] in position []. There is a
normal amount of amniotic fluid. [Comments on fetal anatomy] The mean biparietal diameter is
[] cm ([] weeks, [] days). The mean head circumference is [] cm ([] weeks, [] days). The mean
abdominal circumference is [] cm ([] weeks, [] days). The mean femur length is [] cm ([] weeks,
[] days). Fetal indices are in the normal range, with the HC/AC ratio measured at []. Estimated
fetal weight is [] grams +/- [] grams.
IMPRESSION: 1. Single living fetus in [] position with a [] placenta []. 2. Fetal age by dates is
[] weeks, [] days. Fetal age by ultrasound criteria is [] weeks, [] days. EDC by ultrasound criteria
is []. 3. Estimated fetal weight is [] grams +
Name: Shared OB US [Edit] [Delete]
CPT: 76805
OB ULTRASOUND:
FINDINGS: Real-time, high-resolution ultrasound of the pelvis demonstrates The fetal anatomy
is (normal) (abnormal). Portions of the appear normal. MEASUREMENTS: Biparietal diameter:
weeks, days. Head circumference: weeks, days. Abdominal circumference: weeks, day. Femur
length: weeks, days. Femur length/Abdominal circumference: The estimated fetal age by
sonogram is weeks and days. The estimated date of delivery by sonogram is //20. The estimated
fetal weight is . The cervix measures cm.
IMPRESSION: 1. There is a live intrauterine pregnancy in presentation. 2. The estimated fetal
age is weeks, days. 3. The estimated date of delivery is //20. 4. The estimated fetal weight is . 5.
The placenta is located. There is no previa. The am
Name: Stephenson OBUS [Edit] [Delete]
CPT: 76805
OB ULTRASOUND:
LMP- 00/00/00 Clinical Age by LMP-00/00/00 Comparison made with prior study dated
00/00/00. Single viable intrauterine gestation: Fetal heart rate: bpm. Placenta Location: Previa:
Fetal Presentation: Cervix Length: AFI: Fetal Measurements: BPD: cm weeks, days gestational
age. Head circumference: cm weeks, days gestational age. Abd circumference: cm weeks, days
gestational age. Femur length: cm weeks, days gestational age. Average gestational age by
ultrasound: Estimated date of delivery by ultrasound: Estimated fetal weight: gms or lb oz. %
Ratios: HC/AC: % Normal= FL/BPD: % Normal= FL/AC: % Normal= Fetal Anatomy: 4
Chamber heart: 3 Vessel Cord: Cord Insertion: Kidneys: Spine: Stomach: Bladder: Maternal
uterus and ovaries:
IMPRESSION: 1. Single viable intrauterine gestation with gestational age of and a due date of
2. Fetal anatomy appears
Name: US PEL T/V AR [Edit] [Delete]
CPT: 76830
TRANSVAGINAL PELVIC ULTRASOUND:
COMPARISON: INDICATION: TECHNIQUE: Real-time sonography and multiplanar
sonographic images were obtained on a Siemens Antares ultrasound unit. Transvaginal images
were obtained at the healthcare provider's request to clarify and provide high resolution. Colorflow Doppler was utilized. FINDINGS: Uterus: Right ovary: Left ovary: Cervix: Free fluid:
IMPRESSION:
Name: US T/A/V P AR [Edit] [Delete]
CPT: 76830
TRANSABDOMINAL AND TRANSVAGINAL PELVIC ULTRASOUND:
COMPARISON: INDICATION: TECHNIQUE: Real-time sonography and multiplanar
sonographic images were obtained on a Siemens Antares ultrasound unit. Both transabdominal
and transvaginal scans were obtained. Transvaginal images were obtained to clarify and provide
high resolution. Color-flow Doppler was utilized. FINDINGS: Uterus: Right ovary: Left ovary:
Cervix: Free fluid:
IMPRESSION:
Name: US PEL T/A AR [Edit] [Delete]
CPT: 76856
TRANSABDOMINAL PELVIC ULTRASOUND:
COMPARISON: INDICATION: TECHNIQUE: Real-time sonography and multiplanar
sonographic images were obtained on a Siemens Antares ultrasound unit. Transabdominal scans
were obtained. Color-flow Doppler was utilized. FINDINGS: Uterus: Right ovary: Left ovary:
Cervix: Free fluid:
IMPRESSION:
Name: US TEST AR [Edit] [Delete]
CPT: 76870
TESTICULAR ULTRASOUND:
COMPARISON: INDICATION: TECHNIQUE: Real-time sonography and multiplanar
sonographic images were obtained on a Siemens Antares ultrasound unit. Color-flow Doppler
was utilized. FINDINGS: Right testicle: Left testicle: Right epididymis: Left epididymis:
IMPRESSION:
Name: MRI BREAST [Edit] [Delete]
CPT: 77059
MRI BREAST :
COMPARISON: INDICATION: TECHNIQUE: Multiplanar images were obtained on a 3 Tesla
Siemens ultrahigh field MRI scanner both before and after intravenous contrast administration,
utilizing a series of customized pulse sequences, including a T1 3-D dynamic acquisition
obtained pre- and postinjection of intravenous contrast at 0, 1, 2, 3, 4 and 5 minutes. Coronal
images were obtained utilizing the body coil to fully evaluate the axillary lymph nodes. Contrast:
FINDINGS: Right Breast: Left Breast: DYNACAD POSTPROCESSING: On an independent
workstation the study was postprocessed using a DynaCAD computer detection system to
optimize interpretation by generating multiplanar and 3-D reconstructions, creating subtraction
images from the dynamic contrast data and computing tumor volumes and dimensions. 20 cc
Optimark was injected intravenously. Map images were obtained with uptake curves
automatically generated on demand. FINDINGS: Right Breast: Left Breast:
IMPRESSION:
Name: US CAR AR [Edit] [Delete]
CPT: 93880
ULTRASOUND CAROTIDS:
COMPARISON: INDICATION: TECHNIQUE: Multiple longitudinal and transverse real-time
ultrasonographic images of the extracranial carotid circulation were performed. Duplex Doppler
interrogation was performed. FINDINGS: RIGHT SIDE: Internal carotid artery peak velocity:
Systolic: [<>]cm/s Diastolic: [<>]cm/s Common carotid artery peak velocity: Systolic: [<>]cm/s
Diastolic: [<>]cm/s Internal carotid/common carotid ratio: Systolic: [<>] Diastolic: [<>]
Comments: LEFT SIDE: Internal carotid artery peak velocity: Systolic: [<>]cm/s Diastolic:
[<>]cm/s Common carotid artery peak velocity: Systolic: [<>]cm/s Diastolic: [<>]cm/s Internal
carotid/common carotid ratio: Systolic: [<>] Diastolic: [<>] Comments: VERTEBRAL
ARTERY FLOW: Right side: Systolic: [<>] cm/s Diastolic: [<>] cm/s Left side: Systolic: [<>]
cm/s Diastolic: [<>] cm/s Comments:
IMPRESSION:
Name: US ABI AR [Edit] [Delete]
CPT: 93923
ULTRASOUND ABI:
COMPARISON: INDICATION: TECHNIQUE: Bilateral brachial systolic pressures were
measured by upper arm cuff. Bilateral ankle systolic pressures were measured utilizing Doppler
ultrasound. Ankle/brachial indices were calculated bilaterally. FINDINGS: The right
ankle/brachial index is []. The left ankle/brachial index is [].
IMPRESSION:
Name: USABIPRE/PT AR [Edit] [Delete]
CPT: 93923
ULTRASOUND ABI PRE AND POST EXERCISE:
COMPARISON: INDICATION: TECHNIQUE: Bilateral brachial systolic pressures were
measured by upper arm cuff. Bilateral ankle systolic pressures were measured utilizing Doppler
ultrasound. Ankle/brachial indices were calculated bilaterally both before and after a five-minute
exercise period. FINDINGS: The right ankle/brachial index is [] before exercise and [] after
exercise. The left ankle/brachial index is [] before exercise and [] after exercise.
IMPRESSION:
Name: US BLE ART AR [Edit] [Delete]
CPT: 93925
BILATERAL LOWER EXTREMITY ARTERIAL ULTRASOUND:
COMPARISON: INDICATION: TECHNIQUE: Multiple longitudinal and transverse real-time
ultrasonographic images and duplex Doppler interrogation was performed of the arterial system
of both lower extremities. FINDINGS: RIGHT SIDE: External iliac artery: The waveform is []
with a velocity of [<>] cm/s. Common femoral artery: The waveform is [] with a velocity of [<>]
cm/s. Deep femoral artery: The waveform is [] with a velocity of [<>] cm/s. Superficial femoral
artery: Proximal: The waveform is [] with a velocity of [<>] cm/s. Mid: The waveform is [] with
a velocity of [<>] cm/s. Distal: The waveform is [] with a velocity of [<>] cm/s. Popliteal artery:
The waveform is [] with a velocity of [<>] cm/s. Anterior tibial artery: The waveform is [] with a
velocity of [<>] cm/s. Posterior tibial artery: The waveform is [] with a velocity of [<>] cm/s.
LEFT SIDE: External iliac artery: The waveform is [] with a velocity of [<>] cm/s. Common
femoral artery: The waveform is [] with a velocity of [<>] cm/s. Deep femoral artery: The
waveform is [] with a velocity of [<>] cm/s. Superficial femoral artery:
IMPRESSION:
Name: US BLE VEN AR [Edit] [Delete]
CPT: 93970
BILATERAL LOWER EXTREMITIES VENOUS ULTRASOUND :
COMPARISON: INDICATION: TECHNIQUE: Multiple longitudinal and transverse real-time
ultrasonographic images of the right and left lower extremities were performed. Duplex Doppler
interrogation was performed. Compression and augmentation maneuvers were performed.
FINDINGS:
IMPRESSION:
Name: US BUE VEN AR [Edit] [Delete]
CPT: 93970
BILATERAL UPPER EXTREMITIES VENOUS ULTRASOUND :
COMPARISON: INDICATION: TECHNIQUE: Multiple longitudinal and transverse real-time
ultrasonographic images of the right and left upper extremities were performed. Duplex Doppler
interrogation was performed. Compression and augmentation maneuvers were performed.
FINDINGS:
IMPRESSION:
Name: US VEN LE AR [Edit] [Delete]
CPT: 93971
&RL& LOWER EXTREMITY VENOUS ULTRASOUND:
COMPARISON: INDICATION: TECHNIQUE: Multiple longitudinal and transverse real-time
ultrasonographic images of the &rl& lower extremity were performed. Duplex Doppler
interrogation was performed. Compression and augmentation maneuvers were performed.
FINDINGS:
IMPRESSION:
Name: US VEN UE AR [Edit] [Delete]
CPT: 93971
&RL& UPPER EXTREMITY VENOUS ULTRASOUND:
COMPARISON: INDICATION: TECHNIQUE: Multiple longitudinal and transverse real-time
ultrasonographic images of the &rl& upper extremity were performed. Duplex Doppler
interrogation was performed. Compression and augmentation maneuvers were performed.
FINDINGS:
IMPRESSION:
Name: US ABD AOR AR [Edit] [Delete]
CPT: 93978
ULTRASOUND ABDOMINAL AORTA:
COMPARISON: INDICATION: TECHNIQUE: Real-time sonography and multiplanar
sonographic images were obtained on a Siemens Antares ultrasound unit. FINDINGS:
CONCLUSIONS: Proximal: The waveform is [] with a velocity of [<>] cm/s. Mid: The
waveform is [] with a velocity of [<>] cm/s. Distal: The waveform is [] with a velocity of [<>]
cm/s. Popliteal artery: The waveform is [] with a velocity of [<>] cm/s. Anterior tibial artery:
The waveform is [] with a velocity of [<>] cm/s. Posterior tibial artery: The waveform is [] with
a velocity of [<>] cm/s.
IMPRESSION:
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