Pacific Cardiovascular Associates Pediatric Cardiology Testing and Referral Form
Patient Name_____________________________________________________ DOB: ______________
 Electrocardiogram (93000,93010)
 Chest x-ray (71020)
 Echocardiogram (93303, 93320,93325)
 Treadmill stress test (93015)
 24 hour holter monitor (93324)
 30 day event monitor (93271,93272)
 CT angiogram chest w & w/o contrast (71275)
 MRA chest <exc myocardium> w & w/o contrast (71555)
 MRI chest w & w/out contrast (71552)
 Cardiac MRI (75554)
 Tilt table (93360)
 Diagnostic heart catheterization (93531)
 Interventional heart catheterization
 ASD closure (93580, 93312-TEE or 93662-ICE)
 PDA or other vessel closure (37204)
 Balloon pulmonary valvuloplasty (92990)
 Balloon aortic valvuloplasty (92986)
 Balloon angioplasty coarctation (35472)
 Stent angioplasty coarctation (35472, 37205)
 Balloon angioplasty pulmonary artery (92997)
 Stent angioplasty pulmonary artery (92997, 37205)
 Other: ___________________________________
 Cardiac surgery: _________________________________________________________________
 Other: _________________________________________________________________________
Location of Study/Procedure
 Long Beach
 Other: _________________________________________________________
MD to Perform
 Blurton  Morchi
 Swensson
 Tan
 Other: ________________________
Urgency
 Routine  ASAP
Patient Diagnosis with ICD-9: ___________________________________________________________
____________________________________________________________________________________
Office Use Only:
 Authorization:_______________________________________________________________________
 Scheduled date and time: ______________________________________________________________
 Notify Parents: ______________________________________________________________________
 Mail instructions/directions: ____________________________________________________________
 Reminder Call: ______________________________________________________________________