X-RAY REQUISITION
101 N 3RD STREET
BROOKLYN, NY 11211
Tel: 1888.594.5910
Fax: 718-594-1006
Accession Number
PT Account#
Date of Service _________/_________/_________
STAT
Facility Name_____________________________ Room #____________
Routine hours are Monday-Friday from 8am-5pm
If Patient is home bound, please put home address:
PATIENT NAME
LAST
SOCIAL SECURITY#
male
female
MEDICARE#
INSURANCE CO.
#
Arrival Time-Military:
PATIENT IS: q SNF
q HOMEBOUND
ORDERING PHYSICIAN:
NPI#
q OTHER
# of patients seen on this visit:
Last Name
First Name
X-RAY EXAMS
# of Views
200
Abdomen
210
Chest
220
Ribs
SYMPTOMS/DIAGNOSIS/REASON
CLINICAL SYMPTOMS: DIAGNOSIS/SYMPTOM/REASON REQUIRED
Rt
Clavicle
Rt
Lt
240
Elbow
Rt
Lt
250
Fingers
Rt
Lt
3
4
Forearm
Rt
Lt
270
Hand
Rt
Lt
280
Humerus
Rt
Lt
290
Scapula
Rt
Lt
300
Shoulder
Rt
Lt
310
Wrist
Rt
Lt
LOWER EXTREMITY EXAMS
787.3
OVER FOR ADDITONAL DIAGNOSIS CODES
- Please circle Diag. Code SYMPTOMS/DIAGNOSIS/REASON
Chest/Ribs
Abnormal Chest Sounds
Chest/Pulmonary Congestion
CHF
Collapsed Lung
COPD
Cough
Rt
Lt
330
Femur
Rt
Lt
340
Foot
Rt
Lt
350
Heel
Rt
Lt
360
Hip
Rt
Lt
370
Knee
Rt
Lt
380
Pelvis
Rt
Lt
390
Tibia-Fibula
Rt
Lt
400
Toes
Rt
Lt
Respiratory Distress
PICC - Line Placement
5
410
Other Exam
Rt
Lt
420
Stump
Rt
Lt
430
Other Exam
Rt
Lt
SPINE EXAMS
440
Cervical
450
Lumbosacral
460
Sacrum/Coccyx
520
Thoracic
470
Facial Bones
480
Mandible
490
Nasal Bone
500
Sinuses
510
Skull
HEAD/FACIAL EXAMS
787.5
564.00
787.91
Ileus
Ankle
4
789.4
Diarrhea
320
3
Abnormal Distention
Constipation
5
260
2
DIAG. CODE
Abnormal Bowel sounds
Lt
230
2
Abdomen
Abnormal Rigidity
UPPER EXTREMITY EXAMS
FR (Rev. 1008)
necessary with reason documented in residents chart.
Technologist Name:
AUTH. #
1
x-ray requests must be medically
A doctor's order must be obtained prior to submitting
the requisition.
MEDICAID#
1
excluding holidays. An additional charge applies for tests performed
after regular hours, weekends and holidays. All regular and stat
FIRST
DATE OF BIRTH _________/_________/_________
Additional Charge Applies
Pain-Chest/Rib
Pleural Effusion
Pneumonia
Positive PPD
DIAG. CODE
786.7
428.0
518
496
786.2
786.50
511.9
486
795.5
786.05
Discomfort, Pressure, Tightness in chest
786.59
Emphysema
Wheezin
780.6
492.8
786.09
786.07
V58.81
ATTN: NURSE-IMPORTANT
Medicare regulations require the
physician to provide the diagnosis
code for each test ordered. It is the
Nurse's responsibility to document
Diagnosis code on the requisition.
Thank you.
787.02
Pain-Abdominal (cramps)
789.00
Pain-Stomach
536.8
Tube Placement
V55.4
Vomiting
SYMPTOMS/DIAGNOSIS/REASON
Skeletal/Bone
Bruise/Contusion Lower Limb
Bruise/Contusion Upper Limb
Edema
Pain-Ankle
Pain-Cervical
Pain-In Limb
Pain-Head (skull, facial area)
Pain-Hip
Pain-Joint
Pain-Knee
Pain-Low Back
Pain-Shoulder
Pain-Thoracic
Pain-Wrist
Sprain/Strain, Unspecified Site
Swelling Limbs
787.03
DIAG. CODE
924.5
923.9
782.3
719.47
723.1
729.5
784.0
719.45
719.40
719.46
724.2
719.41
724.1
719.48
848.9
729.81
ALL HARD COPY REQUESTS
MUST BE CALLED IN.
DELIVERY REQUESTS ALLOW 48 HOURS
Person signing below verifies the medical necessity of the test being performed.
The signature also verifies the presence of physicians' order the test being performed.
Signature Required:
560.9
Nausea
514
Shortness of Breath
Fever/Elev Temp
560.1
Intestinal Obstruction
PAYABLE EKG DIAGNOSIS..................................................................ICD-9
ABNORMAL EKG-ECG......................................................................... 794.31
ACUTE ENDOCARDITIS UNSPEC........................................................ 421.9
ACUTE MYOCARDIAL INFARCTION UNSPEC................................... 410.90
ANEURYSM OF HEART....................................................................... 414.19
ATRIAL FIBRILLATION......................................................................... 427.31
ATRIAL FLUTTER................................................................................. 427.31
BRADYCARDIA..................................................................................... 427.89
CARDIAC ARREST................................................................................. 427.5
CARDIAC DYSRHYTHMIA UNSPEC (Arrhythmia NOS)........................ 427.9
CARDIOGENIC SHOCK....................................................................... 785.51
CARDIOMEGALY.................................................................................... 429.3
CARDIOMYOPATHY............................................................................... 425.4
CARDIOVASCULAR DISEASE UNSPEC (ASCVD)............................... 429.2
CHEST PAIN UNSPEC......................................................................... 786.50
CHEST PAIN, TIGHTNESS, PRESSURE............................................. 786.59
CHRONIC ISCHEMIC HEART DISEASE UNSPEC............................... 414.9
CHRONIC PULMONARY HEART DISEASE UNSEC............................. 416.9
CONGESTION HEART DISEASE (CHF)................................................ 428.0
CORONARY ATHEROSCLEROSIS (ASHD)........................................ 414.00
CYANOSIS.............................................................................................. 782.5
DIZZINESS AND GIDDINESS................................................................ 780.4
EDEMA.................................................................................................... 782.3
HEART FAILURE UNSPEC.................................................................... 428.9
HEARTBURN.......................................................................................... 787.1
HYPOPATASSIUM.................................................................................. 276.7
HYPERTENSION ESSENTIAL............................................................... 401.1
MECHANICAL COMPLICATIONS CARDIAC DEVICE......................... 996.01
MYOCARDITIS UNSPEC........................................................................ 429.0
OTHER ABNORMAL HEART SOUNDS.................................................. 785.3
PAINFUL RESPIRATION....................................................................... 786.52
PALPITATIONS....................................................................................... 785.1
PRECORDIAL PAIN.............................................................................. 786.51
PREMATURE BEATS UNSPEC.............................................................. 427.6
STROKE (CVA).......................................................................................... 436
SYNCOPE AND COLLAPSE.................................................................. 780.2
TACHYCARDIA UNSPEC....................................................................... 785.0
UNDIAGNOSED CARDIAC MURMURS................................................. 785.2
UNSPEC ANGINA PECTORIS................................................................ 413.9
UNSPEC TRANSIENT CEREBRAL ISCHEMIA (TIA)............................. 435.9
Since a preoperative EKG is considered as screening, it is usually not payable.
However, there may be existing medical conditions that can preclude the patient
from having surgery. In such instances, the performance of the EKG is for that
specific condition and not for screening purposes, and my be covered.
PAYABLE CHEST CONDITIONS......................................................
ABNORMAL ARTERIAL BLOOD GASES (LOW O2 SATS).................. 790.91
ABNORMAL CHEST SOUNDS (RALES)................................................ 786.7
ABNORMAL SPUTUM............................................................................ 786.4
ACUTE BRONCHITIS................................................................................ 466
ACUTE PULMONARY EDEMA NOS...................................................... 518.4
ACUTE RESPIRATORY FAILURE........................................................ 518.81
ACUTE URI NOS.................................................................................... 465.9
APNEA.................................................................................................. 786.03
ASPIRATION........................................................................................... 507.8
ASTHMA UNSPEC................................................................................ 493.21
BRONCHITIS NOS..................................................................................... 490
CARDIOMEGALY.................................................................................... 429.3
CHEST PAIN UNSPEC......................................................................... 786.50
ICD-9
CHEYNE-STROKES RESPIRATION.................................................... 786.04
CHRONIC AIRWAY OBSTRUCTION (COPD) NOS.................................. 496
CONGESTIVE HEART FAILURE (CHF)................................................. 428.0
CONTUSION TO CHEST........................................................................ 922.1
COUGH................................................................................................... 786.2
CYANOSIS.............................................................................................. 782.5
DISCOMFORT, PRESSURE, TIGHTNESS IN CHEST......................... 786.59
EDEMA.................................................................................................... 782.3
EMPHYSEMA.......................................................................................... 492.8
FRACTURE (RIBS)............................................................................... 807.00
HEART FAILURE UNSPEC.................................................................... 428.9
HEMOPTYSIS......................................................................................... 786.3
HICCOUGH............................................................................................. 786.8
INFILTRATES OF LUNG......................................................................... 518.3
INFLUENZA NOS.................................................................................... 487.1
LUNG SHADOW..................................................................................... 793.1
MYOCARDITIS UNSPEC........................................................................ 429.0
ORTHOPNEA........................................................................................ 782.02
PICC-LINE PLACEMENT......................................................................V58.81
PNEUMONIA,ORGANISM UNSPEC......................................................... 486
POSITIVE PPD....................................................................................... 795.5
PRECORDIAL PAIN.............................................................................. 786.51
PULMONARY COLLAPSE (ATELECTASIS)........................................... 518.0
PULMONARY CONGESTION................................................................. 514.0
RESPIRATORY ABNORM UNSPEC..................................................... 786.00
RESPIRATORY DISTRESS.................................................................. 786.09
SHORTNESS OF BREATH................................................................... 786.05
STRIDOR................................................................................................ 786.1
SWELLING MASS, OR LUMP IN CHEST............................................... 786.6
SYNCOPE AND COLLAPSE.................................................................. 780.2
TACHYPNEA......................................................................................... 786.06
UNSPEC, PLEURAL EFFUSION............................................................ 511.9
WHEEZING........................................................................................... 786.07
Since a preoperative Chest X-ray is considered as screening, it is usually not
payable However, there may be existing medical conditions that can preclude the
patient from having surgery. In such instances, the performance of the Chest X-ray
is for that specific condition and not for screening purposes, and may be covered.
PAYABLE ABDOMEN DIAGNOSIS........................................................ICD-9
ABDOMINAL PAIN................................................................................ 789.00
ABDOMINAL RIGIDITY UNSPEC SITE................................................ 789.40
ABDOMINAL SWELLING, MASS OR LUMP UNSPEC.......................... 789.3
ABNORMAL BOWEL SOUNDS.............................................................. 787.5
ABNORMAL FECES............................................................................... 787.7
CONSTIPATION......................................................................................... 564
DIARRHEA................................................................................................. 564
DISTENTION........................................................................................... 787.3
DYSPHAGIA............................................................................................ 787.2
HEARTBURN.......................................................................................... 787.1
INCONTINENCE OF FECES.................................................................. 787.6
NAUSEA ALONE................................................................................... 787.02
NAUSEA AND VOMITING..................................................................... 787.01
NG-TUBE PLACEMENT.......................................................................V58.82
VOMITING ALONE................................................................................ 787.03
ABNORMAL FECES............................................................................... 787.7
PAYABLE ORTHOPEDIC EXAMS
BRUISING/CONTUSION
FOLLOW-UP FX/DATE OF FIX
PAIN
SWELLING
ICD-9'S ON ORTHOPEDIC VARY
FASTRAD RADIOLOGY