WAKE FOREST UNIVERSITY
BAPTIST MEDICAL CENTER
CARDIOVASCULAR MRI
IMAGING REQUEST FORM
CALL to schedule at (336) 716-8663 then
FAX form & SCRIPT to (336) 716-8683
X
Patient Name:
MRN:
Date:
Referring MD:
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This form is not for medical records, for internal use only.
STUDY REQUESTED: Place an “X” in each appropriate box
STUDY
ORDER CODES
(WFUBMC use only)
Cardiac MRI Valve Disease and/or cardiac output – Aortic, mitral, tricuspid and/or pulmonic valves.
9701
Cardiac MRI for Morphology & Function (Lt Heart) –Masses, cardiomyopathy, pericardium, myocarditis and toxicity. 9702
Cardiac MRI for Morphology & Function (Right Heart) – ARVD, RVOT disease, masses, etc.
9703
Cardiac MRI for Morphology & Function Without Contrast-LV Regional Wall Motion and EF Only
9720
Cardiac MRI Iron Overload Assessment – Hemachromatosis, transfusions, thalassemia
9704
Cardiac MRI Iron Overload + Flow Velocity-Iron Overload plus flow velocities
9717
Cardiovascular MRA Pulmonary Vein Evaluation + 3D – Orientation of pulmonary veins pre/post ablation.
9705
Cardiovascular MRA Chest w/wo Infusion + 3D – Dissection, aneurysm, coarctation.
9706
Cardiac MRI of Coronary Arteries – Anomalies, proximal course of coronary arteries.
9707
Cardiac MRI Congenital Work-up – Requires phone call to physician.
Call MRI physician
Cardiac MRI Adenosine Stress (Perfusion) – Myocardial ischemia and viability.
9708
Cardiac MRI Dobutamine Stress (Wall Motion) – Myocardial ischemia and viability.
9709
Cardiac MRI Dobutamine Stress Without Contrast-Wall Motion Only
9711
Cardiac MRI Exercise Stress Without Contrast-Wall motion only, Myocardial Ischemia
9712
Cardiac MRI Exercise Stress (Wall Motion) – Myocardial ischemia.
9710, Routine Stress EKG
Cardiac MRI Stress & Flow Velocities Without Contrast-CMRI Stress plus Flow Velocities
9718
Cardiac MRI Stress, Flow Velocities, With & Without Contrast-CMRI Stress plus Flow Velocities
9719
PATIENT INSTRUCTIONS FOR STRESS PROCEDURES:
1. NPO for 6 hours, except for medications.
2. No caffeine for 24 hours, including tea, soft drinks, chocolate, and decaffeinated products.
3. No theophyline containing products for 24 hours.
RELEVANT SIGNS/SYMPTOMS DIAGNOSIS: (Mandatory – Must be in ICD-9 Numeric Code) **Circle below or enter code in this space
Code
786.50
786.51
786.59
412.
410.12
414.9
413.1
411.1
411.89
Sign/Symptom
Chest pain, unspecified
Precordial chest pain
Pressure, tightness in chest
Old myocardial infarction
AMI, anterior wall
Chronic ischemic heart disease
Prinzmetal angina
Unstable angina
Coronary artery disease
746.4
424.0
424.1
424.2
785.2
424.90
Congenital insufficiency of aortic valve
Mitral valve disorders
Aortic valve disorders
Tricuspid valve disorders
Undiagnosed cardiac murmur
Endocarditis, valve Unspecified, cause unspecified
786.05
416.0
425.4
428.1
429.3
402.10
782.3
402.91
786.09
428.0
425.1
674.84
429.0
277.3
963.1
250.0
276.6
Shortness of breath
Primary pulmonaryhypertension
Other primary cardiomyopathies
Left heart failure
Cardiomegaly
Hypertensive heart disease, benign, without CHF
Edema, localized NOS
Hypertensive heart disease, with congestive heart failure
Other respiratory distress
Congestive heart failure
Hypertrophic obstructive cardiomyopathy
Postpartum cardiomyopathy
Myocarditis
Amyloidosis
Exposure to antineoplastic drugs and immunosuppressive drugs
Diabetes
Fluid overload disorder
164.1
212.7
423.2
423.9
999.9
Malignant neoplasm, heart
Benign neoplasm, heart
Constrictive pericarditis
Unspecified disease of pericardium
Other
Code
Sign/Symptom
746.89
745.2
745.4
745.5
746.2
746.9
745.10
745.12
746.89
746.85
Other congenital anomaly, heart
Tetralogy of Fallot
VSD
Ostium Secundum, ASD
Other endocardial defects
Unspecified congenital anomaly of the heart
Complete transposition, great vessels
Corrected transposition, great vessels
Other congenital anomaly, heart
Coronary artery anomaly, congenital
427.0
427.1
780.2
427.31
427.1
426.3
427.9
426.7
785.1
780.4
Paroxysmal supraventricular tachycardia
Paroxysmal ventricular tachycardia
Syncope and collapse, vasovagal attack
Atrial fibrillation
Paroxysmal ventricular tachycardia
Left bundle branch block
Arrhythmia
Wolfe-Parkinson White syndrome
Palpitations
Dizziness
441.4
747.3
747.29
759.82
441.2
417.0
747.1
Abdominal aneurysm w/o mention of rupture
Anomalies of pulmonary artery
Other anomalies of aorta
Marfan’s syndrome
Thoracic aneurysmw/o tention of rupture
Arteriovenous fistula of pulmonary vessels
Coarctation of aorta
861.01
997.1
Cardiac contusion
Cardiac complications
{revised 05-06-08}
Physician (or Designee) Signature:
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