Ordering Protocols

CT and MRI Ordering Guide

BODY PARTSIGNS / SYMPTOMSEXAM TO ORDER (CPT)
BRAINTrauma, CVA, Bleeding, Headache, Shunt Check, Alzheimer's, Memory Loss, TIA, Mental Status Change, ConfusionCT Head W/O Dye (70450) OR MRI Brain W/O Dye (70551) -MRI for more severe symptoms or persistent symptoms after a CT Head W/O Dye was performed-
BRAINHearing Loss, Tumor, Elevated Prolactin Levels, Cranial Nerve Lesions, Dizziness, Vertigo, Multiple Sclerosis, AVM, Pituitary Lesions, Seizures, InfectionMRI Brain W/O & W Dye (70553)
BRAINStroke, CVA, TIA, AneurysmMRI Brain W/O Dye (70551)
SINUSESPain, Congestion, SinusitisCT Sinuses W/O Dye (70486)
ORBITSTrauma, Fracture, Foreign BodyCT Orbits W/O Dye (70480)
ORBITSInfection, MassCT Orbits W Dye (70481)
ORBITSGrave's Disease, Exophthalmos, Proptosis, Pseudotumor, Vascular Lesions, MassMRI Orbits W/O & W Dye (70543)
FACIAL BONESTrauma, PainCT Maxillofacial W/O Dye (70486)
TEMPORAL BONESTinnitus, Cholesteatoma, Pain, TraumaCT Temporal Bones W/O Dye (70480)
NECKMass, AdenopathyCT Soft Tissue Neck W Dye (70491)
NECKInfection, Pain, Vocal Cord ParalysisMRI Soft Tissue Neck W/O & W Dye (70543) OR CT Soft Tissue Neck W Dye (70491)
CHESTHilar or Mediastinal Mass, Lung Cancer, Lymphoma, Sarcoid, Staging, Mesothelioma Metastatic Work-upCT Chest W Dye (71260)
CHESTNodule, Cough, PainCT Chest W/O Dye (71250)
CHESTInterstitial Lung Disease, IPF, UIP, SarcoidHigh Resolution CT Chest W/O Dye (71250)
CHESTNeural Tumor, Brachial Plexus PathologyMRI Chest W/O Dye (71550)
ABDOMEN & PELVISPain, Colitis, IBD, Crohns, Appendicitis, Abscess, Tumor, CancerCT Abdomen/Pelvis W Oral & IV Dye (74177)
ABDOMEN & PELVISHematuria With Pain, Stone SurveyCT Abdomen/Pelvis W/O Dye (74176)
ABDOMEN & PELVISHemangioma, Hepatoma, Hepatitis, Cirrhosis, Pancreatitis, PseudocystCT Abdomen W/O & W Dye (74170)
ABDOMEN & PELVISBiliary Obstruction, GB Stones, Jaundice, Abnormal Enzymes, Adrenal MassMRI Abdomen W/O Dye MRCP (74181)
ABDOMEN & PELVISIBD, Occult GI Bleeding, Diffuse SBD, (Gluten Enteropathy)CT Abdomen/Pelvis W Dye Enterography (74177)
ABDOMEN & PELVISFibroid, Ovarian Mass, EndometriomaMRI Pelvis W/O & W Dye (72197) OR CT Abdomen/Pelvis W Dye (74177)
ABDOMEN & PELVISIncomplete Colonoscopy or ScreeningCT Colonography (74261,74262,74263) OR Barium Enema (74280,74270)
CERVICAL, THORACIC & LUMBAR SPINEPain, Trauma, Fracture, FusionCT Cervical Spine W/O Dye (72125), CT Thoracic Spine W/O Dye (72128), CT Lumbar Spine W/O Dye (72131)
CERVICAL, THORACIC & LUMBAR SPINERadiculopathy, Disc Herniation, Degenerative DiseaseMRI Cervical Spine W/O Dye (72141), MRI Thoracic Spine W/O Dye (72146), MRI Lumbar Spine W/O Dye (72148)
CERVICAL, THORACIC & LUMBAR SPINESyrinx, MS, Tumor, Cancer, Mets, Osteomyelitis, Myelopathy, Discitis, Compression Fracture w/Hx of Malignancy, Epidural AbscessMRI Cervical Spine W/O & W Dye (72156), MRI Thoracic Spine W/O & W Dye (72157), MRI Lumbar Spine W/O & W Dye (72158)
UPPER & LOWER EXTREMITIES - NON JOINTSFracture, Fusion, MalunionCT Upper Extremity W/O Dye (73200), CT Lower Extremity W/O Dye (73700)
UPPER & LOWER EXTREMITIES - NON JOINTSPain, Muscle/Tendon TearMRI Upper Extremity W/O Dye (73218), MRI Lower Extremity W/O Dye (73718)
UPPER & LOWER EXTREMITIES - NON JOINTSAbscess, Cellulitis, Fasciitis, Osteomyelitis, Neuroma, Soft Tissue TumorMRI Upper Extremity W/O & W Dye (73220), MRI Lower Extremity W/O & W Dye (73720)
UPPER & LOWER EXTREMITIES - JOINTSAVN, Internal Derangement, Labral, Meniscal Ligament & Cartilage Tears, OCDMRI Upper Extremity Joint W/O Dye (73221), MRI Lower Extremity Joint W/O Dye (73721) -Studies can be done with intra-articular dye if indeterminate-
UPPER & LOWER EXTREMITIES - JOINTSAbscess, Cellulitis, Fasciitis, Osteomyelitis, Myositis, Tumor, MassMRI Upper Extremity Joint W/O & W Dye (73223), MRI Lower Extremity Joint W/O & W Dye (73723)
PELVIS (BONY)Pain, FractureCT Pelvis W/O Dye (72192)
PELVIS (BONY)Muscle/Tendon Tear, AVNMRI Pelvis W/O Dye (72195)
PELVIS (BONY)Tumor, Mass, Osteomyelitis, Septic ArthritisMRI Pelvis W/O & W Dye (72197)
ABDOMINAL AORTAAneurysm, Dissection, Post Stent Grafting, Renal Artery Stenosis, Mesenteric StenosisCTA Abdomen W IV Dye (74175)
PULMONARY ARTERIESAneurysm, Dissection, Chest Pain, Dyspnea, PECTA Chest W IV Dye (71275)
THORACIC AORTATachypnea, Hemoptysis, SOB, Pulmonary Hypertension, Pulmonary Venous MappingCTA Chest W IV Dye (71275)
THORACIC AORTAAneurysm, Dissection, Post Stent Grafting, StenosisCTA Chest W Dye (71275)
THORACIC AORTAScreening Cardiac Calcium ScoringCT Heart W/O Dye Coronary Calcium Score (75571)
LOWER EXTREMITIESPeripheral Artery DiseaseCTA Abdominal Aorta and Lower Extremity Runoff W Dye (75635)
CAROTIDStenosis, Bruit, TIA, CVA, Vascular TumorCTA Neck W Dye (70498)
BRAINAneurysm, Stenosis, ObstructionCTA Head W Dye (70496)
BRAINAneurysm, Stenosis, ObstructionMRA Head W/O Dye (70544)

Additional Ordering Notes
1. To schedule an exam call: (928) 537-6554.
2. CT Abdomen will only include from the top of the diaphragm to the top of the iliac crest. If the patient is experiencing any diffuse or lower quadrant pain, if appendicitis is suspected or if you have concerns about the colon, small bowel, urinary tract or any pelvic organs then you must order a CT Pelvis as well.
3. Patients over 59 years of age, patients with renal disease and diabetics need to have a DOCUMENTED normal BUN and creatinine within the last 3 months.
4. Premedication is required for some patients receiving intravenous contrast, including patients with a known contrast allergy, patients with a history of severe allergic reaction and patients with asthma who use inhalers daily.
5. Pacemakers, ocular metallic foreign bodies, mechanical ear implants, non-removable TENS units, any wire loop devices are all examples of devices that are incompatible with MRI.
6. This form is only a guide to ordering CT & MRI exams. If you have any questions regarding which exam may be appropriate for your needs, please call the Radiologist. You may call the Radiology Department at the hospital (928) 537-6338, or a Radiologist may be reached at (928) 537-6569 from 7 A.M. - 9 P.M.
7. Comparison studies and x-rays are very helpful, please make sure outside exams are made available prior to exam.