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Radiology Positioning
9-10-02
The written report, signed by the interpreting physician should be considered an integral part of a radiologic procedure or
interpretation.
CPT codes – we use modifiers to get paid for the written report.
-22 - This is used when the services provided are greater than what is usually required for the listed
procedure – e.g. 72052 is the code for 7 xrays, 72052-22 would be for the 7 xrays and an additional
position i.e. open mouth and lateral flexion at the same time.
-52 - Under certain circumstances a service or procedure is partially reduced or eliminated at the Dr.
discretion – less xrays than the code calls for – 72120-52.
-26 - Certain procedures are a combination of a Dr. component and a technical component. When the
physician component is reported separately use –26. 72100-26.
CPT Codes – technical component = taking; professional component = reading (write and sign the report)
Supertech Terms
TCF – Total Correction Factor
FFD – Focal Film Distance
Measurement goes in the window – the red window is for kids
Radiology Positioning Lecture
9-17-02
CPT codes
Cervical codes
day
72040 Spine, cervical; anteroposterior (2 pictures – 1 is open mouth and one is for C3-C7) and lateral (3) – first
72050 minimum four views (olbiques or lateral – 2 each) – this will = 5 if done with 72040 the first day you bill
it this way – if service is done another day it has to be 4 more x-rays
72052 complete, including oblique and flexion and/or extension studies – a Davis 7 series or a Davis series
AP Open mouth – C1 & C2
AP lower Cervical – C3 – C7
Lateral
R & L Posterior Obliques
Flexion
Extension
Thoracic codes
72070 Spine, thoracic; anteroposterior and lateral (2)
72072 Spine, thoracic; anteroposterior and lateral, including swimmer’s view of the cervicothoracic junction (3
total – only take if you can’t see the cervicothoracic junction on the first lateral view)
72074 Spine, thoracic; complete, including obliques, minimum four views
Thoracolumbar codes
72069 Spine, thoracolumbar, standing (scoliosis) – can be used for the Full spine anteroposterior
72080 Spine, thoracolumbar, anteroposterior and lateral (T10-L2/3)
72010 Spine, entire, survey study anteroposterior and lateral – 14 x 36 FSAP, 3 laterals – 1 cervical, 1 thoracic,
1 lumbar (lots of projectional distortion)
72090 Scoliosis study, including supine and erect studies – can’t use it unless you have a table they can lay on
supine (L & R bending and full erect spine)
Lumbar codes
72100 Spine, lumbosacral; anteroposterior and lateral (if you include the pelvis in a single shot, use this code)
72110 complete, with oblique views – for spondylolysis (pars defect)
72114 complete, including bending views – AP, lateral, 2 obliques and L&R bending and/or flexion/extension
(can be as much as 8 films – usually the bending x-rays are done on a later date)
72120 Spine, lumbosacral; bending views only, minimum four views
“Linda’s Notes” by Linda Hite – These notes are not guaranteed to be complete or without errors – they are meant to be a supplement
to help you study.
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Chest Codes
71010
71020
71021
71022
71030
Chest, single view, frontal (screening device)
Chest, two views, frontal and lateral
with apical lordotic procedure (really don’t need to know)
with oblique projections (really don’t need to know)
Chest, complete, minimum four views (really don’t need to know)
Rib codes
71100 Ribs, unilateral, two views (2 views)
71101 including posteroanterior chest, minimum three views ( suspect a fractured rib causing lung to deflate)
71110 Ribs, bilateral; three views
Should I lose money using a radiologist?
Technology part and professional part – global codes. If you send it out to be read and then have to interpret
it to the patient
99211 – 5 minutes or less to explain an outside report (can be reported by a CA – but you can’t charge as
much as you can for your time)
99212 – less than 15 minutes (6-15) to explain an outside report
Xray Positioning
9-24-02
Davis Seven series – includes lateral, extension lateral, flexion lateral, (beam should be high enough to include C1 and
low enough to include C7, light in front and behind the neck, then the spine should be in the middle), LOP cervical
(patient faces front, tube angle is a little different), RPO – right posterior oblique right shoulder is against the buckey
(demonstrates the left foramina – Dr. G prefers that we rotate the head slightly – not to lateral but to move the mandible
out of the way) Cervical, all these are done at 72”. AP lower cervical (tube tilt is the same as for the obliques but the
tube is at 40”), AP open mouth. (Use the foam support if the head doesn’t rest against the buckey – this all depends on
the thoracic curve of the patient). For the open mouth the central ray should be at the uvula – top of the beam is just
under the nose and just under the bottom lip when the mouth is open – this is only for viewing the C1 and C2 vertebra.
Know the topographical anatomy – T6 at the sternum, T10 at the umbilicus, etc. Patients that come in with osteoporosis,
you will need to increase the tilt of the tube cephalically to get through the mass. Take the lateral first, and possibly
measure the angle so you have a better idea as to how much of a tilt you need to have.
Dr. G prefers different geometric positioning of the patient for certain views (i.e. the lumber) – we’ll learn these as we go
through the course. He is looking for the central pay to be more parallel to the discs of the vertebra. Lists and curves
are dealt with differently
X-ray Positioning
10-01-02
George’s line – alignment of vertebral bodies posteriorly
Swimmers View – move shoulder out of the wat to see C7-T1 area; use lateral lumbar line on Supertech; critical to assess
fracture of C5, C6, C7 (most commonly fractured)
Articular processes of C5, C6, C7 are the most commonly missed fractures of the cervical spine. Use Pillar Views (always
take bilaterally) – used to view articular pillars (processes); patientrotates head 45 degrees to side away from side
wanting to x-ray to move mandible out of the way
Thoracic Spine A-P – normally straight and skinny; if scoliosis expected then widen beam; can be done at 40 or 72
inches; filter top 1/3 of x-ray beam because upper thoracic vertebra are smaller; patient takes deep breath and holds it;
on females lower border of breasts is at about the diaphragm level
Thoracic Spine Latera –
Widen beam horizontally to accomadate kyphosis; measure under patient arms while they hold them out; filter
bottom because upper portion needs more x-ray to penetrate shoulder thickness; do NOT expose breasts in x-ray beam;
beam should align with mid-axillary line and posterior surface of back skin; need to have patient roll shoulder forward to
move them out of the way either
“Linda’s Notes” by Linda Hite – These notes are not guaranteed to be complete or without errors – they are meant to be a supplement
to help you study.
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Thoracic Spine – in a lateral thoracic film, the anterior margin of the beam should be at the mid-axillary line and the
posterior margin of the beam should be at the posterior edge of the skin – that’s it!!! No need to expose the breast
tissue to the rays.
Manipulate shoulders out of the way – (this only works with people with good shoulders) – put hands together crossed
over palms together in front of them and drop them down OR hands on head and elbows together.
CHANGE ON SUPERTECH – Lateral thoracic – change from 80 to 90
X-ray Positioning
10-15-02
This information is for the Diag. Imaging test in the a.m.
Dr.G – off-focus radiation; adds about 25% to patient’s dose
Scatter – smaller area, uncorrected makes the image lighter, less tissue irradiated.
Increase mAs 15% to make up the density difference – do this if you are doing a spot view – makes the series about the
same.
Room fog – even though it wasn’t in the primary beam – scatter got on the film – if you use the film after it has been
fogged you will get a layer over the image – it won’t be as good.
AP thoracic done and film was set on the floor, a piece of lead was leaned against it and another film was shot (like a
normal one), the AP thoracic was fogged and it was much darker than a film (like above) that hadn’t been exposed yet –
the thoracic film was sensitized.
If you expose one side and protect the other half, and then protect ½ of the exposed side while you expose it again you
can see a definite line of demarcation (fog).
TEST – why is the bottom half of this x-ray is darker than the to half? Due to scatter or fog.
XRAY POSITIONING
Thoracic – 5-6” for the beam width, height depends on the patient. Central ray at the middle of the sternum in the
midline. DO NOT expose the female breast tissue. Filter the top because the top is skinnier at the top than at the
bottom.
The bigger difference between the lower and the upper part may need to use more of a filter – this is determined by trial
and error.
Measure the big part – over the shoulder from spine to sternum, phase of respiration that film will be taken in.
For Lateral – is will be wider due to the thoracic kyphosis – height doesn’t change – the anterior of the beam hits the midaxillary line, the posterior beam is at the posterior edge of the scapula - whole beam should only be 7-8 inches – depends
on the patient size.
Shine the light where the part is!!!
We are skinnier in the thoracic spine than at the shoulder so the filter will go on the bottom half of the beam. Have
patient roll shoulders to circumduct the scapula out of the way as much as possible – bring their elbows together. Dr. G
has them cross their hands and hold them in front of them – the pecs pull the scapulas out of the way.
Breathing instructions are – take a deep breath and hold it – above the diaphragm – keeps the diaphragm out of the way.
Most can be done at 72” – some instances require 40” (didn’t catch what they were) – be sure to include the correction
factor for the 40/72 distance.
LUMBAR SPINE – lumbopelvic x-ray
Pelivc unleveling due to a short leg. 14 x17
Iliac crest – central ray should be 1 inch below the crest – this only works for normal lordotic lumbar spine.
Hypolordotic (pelvis compensates) the central ray will go to the top of the crest – lumbar spine gets longer, pelvis gets
shorter in the picture. Vertical central ray should be at the belly button – have them point to the belly button and the
crest. Helps you line up the ray.
“Linda’s Notes” by Linda Hite – These notes are not guaranteed to be complete or without errors – they are meant to be a supplement
to help you study.
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Gonad protection – velcro belt at greater trochanters, shield for males is a triangle (females is a heart) – don’t hide the
pubic symphysis – shield should only be 1” max in the light – everything else below it. For females you need to protect
higher – tip of the heart goes on the pubic symphysis, the rest of the heart goes above. This will fill most of the pelvic
bowl.
Dark hole is the absence of lamina – this is normal. He reviewed the anatomy of the spine on x-ray. ASIS is usually
cutoff. AIIS is a rounded protuburence, the acetabulum is more pointed and angulur.
Kohler’s tear drop – in the book – it is the projection of the normal pelvis. If it’s white all the way to the middle this could
be Paget’s or cancer – from the tear drop to the medial portion of the femur head should be the same measurement.
Bladder – distented will show on the film. Dark spots represent gas in the lower intestines. Small intestine doesn’t
usually have air in it – it would be pathological.
Lateral lumbar – ischial tuberosities don’t have to be on it – raise tube 3 inches from the central ray on the AP. We x-ray
the back ½ of the abdomen. Don’t expose the belly button. Normal lordosis, a little bit of light will pass behind the
lordosis. The vertical central ray is usually in line with the greater trochanter.
Can’t take a normal x-ray of an abnormal spine with normal x-ray technique. (Antalgic, obese)
Filter on top of the diaphragm – strange looking filter – READ BOOK for information on how to place it. Spinous filter
should compliment the skin surface for the lordosis – a tear-drop shaped filter. Rotate it so it is in the lordosis. Then we
put in another filter to protect L1-L3 because we have extra bones (the ilium) at L4-L5 so we need more punch down
there – L1-L3 has to be protected (#1 or #2 grade filter). Gonad shield needs to be added.
X-ray Positioning
Fill in the blank – What’s wrong with this film? No collimation, fog, no side marker, improper flashed, underpenetrated,
over-exposed. (1 or 2 questions). SLIDES – Positioning – Name the view (R lateral cervical; L anterior oblique lumbar)
and Identify anatomy – 3rd cervical vertebra body, spinous, etc.
Multiple choice, true/false, matching – 25-30
Tube tilt for lumbosacral spot film (L5/S1 AP Spot Film or Ferguson’s view) – abdomen pressure can reduce the lordosis,
25 degree cephalic tube tilt is the best guess for normal. If they have a weird posture, you may want to take a lateral
first to see what you are dealing with. Drop the tube stand to 35 above the table, 40 from film plane to focal spot.
Central ray hits at the ASIS – increased lordosis will increase the angle and the central ray will be below the ASIS –
decreased lordosis will decrease the angle and central ray will be above the ASIS.
Degree of tilt will determine the location of the central ray in relation to the ASIS.
35% is a normal lordosis in standing, 25% is probably more a “best guess” for supine.
On the x-ray – if a tube tilt is involved, the top edge will be narrower than the bottom edge.
Oblique lumbars – R posterior oblique lumbar – posterior side of body is closest to the film – pars intra-articularis is what
we are trying to see with this view.
Partes interarticularis is the “proper” plural or “pars”
You can have pars defects with or without slippage.
Get the plane through the pelvis at 45 degrees, shoulders need to be tilted 45 degrees also. Central ray is ½ way
between belly button and ASIS – patient can stabilize with arm and leg, Dr. can use foam supports.
X-ray coming in from the front, the divergence is backwards to be able to see L1 and L5 discs. If the x-ray is coming in
from the back, it is easier for the patient to support themselves at a 4 degree angle and the divergence of the rays are
appropriate for the lordosis.
Coming from the front, finding the landmarks can be hard to find. From the back the SPs define the edge, iliac crest
(central ray goes about 2 inches above)
Make sure marker is on the proper side – anatomically correct. Get a dry spine to help figure this out.
Anterior oblique the Scottie Dog is right handed (LAO) – from the front. Posterior oblique the Scottie Dog is left handed
(LPO).
“Linda’s Notes” by Linda Hite – These notes are not guaranteed to be complete or without errors – they are meant to be a supplement
to help you study.
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TP is the nose, pedicle is the eye, superior articular facet is the ear, the neck is the pars, inferior articular facet is the
front paw of the dog, body of the dog is the R lamina – all R side. The pedicles should be in the middle of the vertebral
body. (Opposite lamina is on the left of the x-ray in an elliptical shape)
For the test – know the location of each of the parts and what level.
Front leg from dog below and ear from dog above should come together.
Sacrum and coccyx – AP - HAVE to have a fleet enema to clear out the area so you can see the sacrum and coccyx in the
x-ray (the bowel is right over the area you want to see).
Top of sacrum is anterior and we need to use a cephalic tube tile 10-25 degrees to get a good view. A 45 degree tilt will
put the pubic symphysis on top of the sacrum. Coccyx view needs a caudal tube tilt of 10-20 degrees.
Lateral sacrum doesn’t need the enema prep. Dark line is the sacral spinal canal where the cauda equina lives.
“Linda’s Notes” by Linda Hite – These notes are not guaranteed to be complete or without errors – they are meant to be a supplement
to help you study.