Outpatient Radiology Order Form DEPARTMENT OF RADIOLOGY
Outpatient Radiology Order Form DEPARTMENT OF RADIOLOGY
Outpatient Radiology Order Form DEPARTMENT OF RADIOLOGY
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<strong>Outpatient</strong> <strong>Radiology</strong> <strong>Order</strong> <strong>Form</strong><br />
<strong>DEPARTMENT</strong> <strong>OF</strong> <strong>RADIOLOGY</strong><br />
A joint service of The Chester County Hospital<br />
and PENN <strong>Radiology</strong><br />
IMPORTANT: You are required to bring this form,<br />
insurance cards and referral forms with you or your<br />
test may be delayed or need to be rescheduled.<br />
Name _______________________________________________________________________________________________________<br />
Date of Birth _______________________________________ Home Phone _______________________________________________<br />
INDICATION FOR STUDY<br />
ICD-9 CODE REQUIRED FOR EACH DIAGNOSIS<br />
* If you have ordered an exam with contrast, please indicate if BUN and Creatinine lab work also was ordered.<br />
Yes<br />
No<br />
Special Instructions:<br />
PHYSICIAN NAME (please print) ______________________________________________________ DATE __________________________________<br />
PHYSICIAN’S SIGNATURE REQUIRED _______________________________________________ _<br />
PHONE _______________________________ _<br />
R<br />
R<br />
R<br />
Head and Neck Imaging Service Code CPT Code<br />
Facial Bones<br />
Nasal Bones<br />
724 - 1004<br />
724 - 1013<br />
70150<br />
70160<br />
Orbits for Foreign Body 724 - 1018 70030<br />
Sinuses<br />
Neck Soft Tissue<br />
Chest Imaging<br />
Chest - One View<br />
724 - 1019<br />
724 - 1016<br />
724 - 1033<br />
70220<br />
70360<br />
71010<br />
Chest Two Views - PA & Lateral 724 - 1034 71020<br />
Ribs Unilateral With PA Chest R L 724 - 1561 71101<br />
Ribs Bilateral With PA Chest 724 - 5052 71111<br />
Sternum<br />
Digital Mammography / Ultrasound<br />
L<br />
L<br />
L<br />
724 - 1039<br />
71120<br />
Mammo. Unilat. W/Clinical Indicator (Dx) 724 - 1161 77055<br />
Mammo. Bilat. Clinical Indicator (Dx) 724 - 1160 77056<br />
Screening Mammogram Bilateral 724 - 1691 77057<br />
Screening Mammogram Unilateral<br />
77052<br />
Breast Ultrasound Unilateral 724 - 5004 76645<br />
If Indicated<br />
Spine and Pelvis<br />
R L<br />
Cervical Spine<br />
724 - 1042<br />
72050<br />
Cervical Spine with Flex/ ext. 724 - 1043 72052<br />
Thoracic Spine<br />
Lumbar Spine<br />
Lumbar w/Flex and Extension<br />
724 - 1059<br />
724 - 1055<br />
72070<br />
72110<br />
Pelvis 1 View AP Only 724 - 1049 72170<br />
Pelvis / Hip Infant 2 View 724 - 1336 73540<br />
Scoliosis Series *CCH Only 724 - 5010 72069<br />
Sacrum & Coccyx<br />
724 - 1050<br />
72220<br />
DEXA Bone Density 724 - 2393 77080<br />
Upper Extremities<br />
Clavicle<br />
Scapula<br />
724 - 1075<br />
724 - 1084<br />
72120<br />
73000<br />
73010<br />
R L Upper Extremities Service Code CPT Code<br />
R L<br />
Shoulder<br />
Humerus<br />
Elbow<br />
Forearm<br />
Wrist<br />
Hand<br />
724 - 1568<br />
724 - 1083<br />
724 - 1077<br />
724 - 1079<br />
724 - 1087<br />
724 - 1081<br />
73030<br />
73060<br />
73080<br />
73090<br />
73110<br />
73130<br />
Finger or Fingers / Thumb 724 - 1078 73140<br />
Hand (2 Views) (Arthritis) 724 - 1082 73120<br />
Wrist (2 Views) (Arthritis) 724 - 1089 73100<br />
AC Joints<br />
SC Joints<br />
Lower Extremities<br />
724 - 1074<br />
724 - 1038<br />
73050<br />
71130<br />
Hip Unilateral Complete 724 - 1099 73510<br />
Hips Bilateral<br />
Femur<br />
724 - 1101<br />
724 - 1093<br />
73520<br />
73550<br />
Knee - 3V (Non Trauma/Pain) 724 - 1102 73562<br />
Knee Complete/4V Trauma/Pathology<br />
Tibia & Fibula<br />
724 - 1105<br />
73590<br />
Ankle Complete 724 - 1090 73610<br />
Foot Complete<br />
Heel / Calcaneus<br />
Toe / Toes<br />
Abdomen<br />
724 - 1094<br />
724 - 1097<br />
724 - 1106<br />
73630<br />
73650<br />
73660<br />
Abdomen Survey / KUB 724 - 1073 74000<br />
Obstruction Series (Abdomen & Chest) 724 - 1345 74022<br />
Gastrointestinal Tract<br />
Barium Swallow / Esophagus 724 - 1350 74220<br />
Upper GI w /Air Contrast 724 - 1352 74247<br />
Small Bowel Study<br />
724 - 1144<br />
74250<br />
Barium Enema w /Air Contrast 724 - 1122 74280<br />
Urinary Tract<br />
Voiding Cystourethrogram 724 - 1063 74455<br />
(REV 11/11, 6/12, 4/13)<br />
# 7724-P247
CT Bone Lengths (Scanogram) (No IV)<br />
Ultrasound (US) Service Code CPT Code<br />
R<br />
R<br />
CT Scan Service Code CPT Code<br />
L<br />
L<br />
CT Brain without (Trauma)<br />
CT Brain with / without (Mass)<br />
CT Facial Bones (Fracture) No IV<br />
CT Orbits (FX) 0016<br />
70480<br />
CT Sinus without Contrast<br />
CT Sinus VTI (without Contrast)<br />
CT Temporal Bones (iac) (Mastoid Air Cells) without Contrast<br />
CT Dental Scan (without Contrast)<br />
US Soft Tissue Neck / Thyroid 726 - 6042 76536<br />
US Chest<br />
US Breast<br />
US Abdomen<br />
US Aorta<br />
US Kidney<br />
726 - 6024<br />
724 - 5004<br />
726 - 6011<br />
726 - 6038<br />
726 - 6037<br />
76604<br />
76645<br />
76700<br />
76770<br />
76770<br />
US Pregnant Uterus 1st Tri 726 - 6032 76805<br />
US Pregnant Uterus 2nd. 3rd Tri 726 - 6031 76810<br />
Fetal Biophysical Profile 726 - 6028 76818<br />
US Transvaginal Pelvis 726 - 6064 76830<br />
US Pelvis Non OB<br />
US Scrotum<br />
726 - 6033<br />
726 - 6039<br />
76856<br />
76870<br />
US Superficial Structure (location requested) 726 - 6104 76882<br />
US Infant Hip<br />
US Neonatal Head<br />
726 - 6082<br />
726 - 6041<br />
76885<br />
76506<br />
Infant Pylorus (Pyloric Stenosis) 726 - 6012 76705<br />
Infant Spine<br />
US Carotid Arteries<br />
726 - 6043<br />
726 - 6026<br />
76800<br />
93880<br />
US Extremity Veins Bilateral Arm or Leg 726 - 6006 93970<br />
US Extremity Veins Unilateral (DVT) 726 - 6005 93971<br />
ABI/PVR Arm/Leg<br />
Mandible<br />
Maxilla<br />
CT Angio Neck (Occlusion, Stenosis) with Contrast<br />
CT Soft Tissue Neck with Contrast (Mass, Abscess)<br />
CT Chest / abd / Pelvis with Contrast (Met Eval)<br />
CT Chest / abd with Contrast (Dissection) (Yes IV) (No Oral)<br />
CT Chest (Pulmonary Embolism) with Contrast<br />
CT Chest Routine with Contrast (Nodule, Mass)<br />
CT Chest Hi Resolution (without Contrast) R/O ILD<br />
CT Chest (Non Contrast)<br />
CT Cervical Spine without Contrast<br />
CT Thoracic Spine without Contrast<br />
CT Lumbar Spine without Contrast<br />
CT Upper Extremity without Contrast R L<br />
CT Lower Extremity without Contrast R L<br />
CT abd / Pelvis (AAA) (Yes IV) (No Oral)<br />
726 - 6048<br />
93922<br />
Aterial-Duplex Arm/Leg 726 - 6007 93926<br />
0013<br />
0015<br />
0018<br />
0032<br />
0032<br />
0068<br />
0018 / 0104<br />
0081<br />
0022<br />
0025 / 0010 / 0040<br />
0083 / 0010<br />
0025<br />
0025<br />
0024<br />
0024<br />
0042<br />
0001<br />
0038<br />
0003<br />
0006<br />
0010 / 0040<br />
CT Abdomen and Pelvis with Contrast (Diverticulitis, Appy, Pain, Met Eval) (Yes IV) (Yes Oral) 0010 / 0040 74177<br />
CT Abdomen and Pelvis without Contrast (Renal Stone) (No Oral)<br />
CT Abdomen and Pelvis (Endograft Stent Protocol) (Yes IV) (No Oral)<br />
CT Urogram with and without Contrast (Yes IV) (No Oral)<br />
CT Pelvis without Contrast (Fracture Only) (No IV) (No Oral)<br />
CT Angiogram Femoral Runoff with IV Contrast (No Oral)<br />
CT Angiogram Circle of Willis with Contrast (Aneurysm, Vasculitis)<br />
CT Calcium Scoring (No IV)<br />
0009 / 0027<br />
0082 / 0040<br />
0011 / 0039 / 0104<br />
0027<br />
0100<br />
0080<br />
0102<br />
0076<br />
73700<br />
Nuclear Medicine / Endocrine System Service Code CPT Code<br />
Brain Imaging Spect<br />
727 - 7022<br />
78607<br />
Thyroid Imaging / Uptake with scan 727 - 7051 78007<br />
Kidney Imaging Vascular Flow & Funct. 727 - 7032 78707<br />
Kidney Imaging Vascular Flow & Funct. w/Lasix 727 - 7145 78708<br />
Kidney Imaging Vascular Flow & Funct. w/Captopril 727 - 7145 78708<br />
Liver & Spleen Imaging / Static Only 727 - 7036 78215<br />
Hepatobiliary System Imaging With CCK 727 - 72163 78227<br />
Gastric Emptying Study<br />
Without CCK 727 - 70282 78226<br />
727 - 7025<br />
78264<br />
Bone and / or Joint Imaging Ltd. Area 727 - 7014 78300<br />
Bone and / or Joint Imaging Whole Body 727 - 7013 78306<br />
Bone and / or Joint Imaging - 3 Phase 727 - 7018 78315<br />
Bone and / or Joint Tomography Spect 727 - 7017 78320<br />
Cardiac Blood Pool Imaging Multi (MUGA) 727 - 7024 78472<br />
Myocardial Perfusion Imaging (Gated SPECT) 727 - 72049 78452<br />
V/Q Scan (Perfusion/Ventilation) 727 - 72171 78582<br />
Pulmonary Quantification 727 - 71728 78598<br />
White Blood Cell<br />
Indium<br />
Ceretec<br />
Parathyroid<br />
<strong>RADIOLOGY</strong> SCHEDULING<br />
70450<br />
70470<br />
70486<br />
70486<br />
70486<br />
70480<br />
70486 / 76376<br />
70498<br />
70491<br />
71260 / 74160 / 72193<br />
71275 / 74160<br />
71260<br />
71260<br />
71250<br />
71250<br />
72125<br />
72128<br />
72131<br />
73200<br />
73700<br />
74177<br />
74176<br />
74177<br />
74178<br />
72192<br />
75635<br />
70496<br />
727 - 7120<br />
727 - 7177<br />
727 - 7116<br />
78805<br />
78805<br />
78070<br />
THE CHESTER COUNTY HOSPITAL .... . . . . 610-431-5131<br />
701 East Marshall Street, West Chester, PA<br />
General <strong>Radiology</strong>, GI Fluoroscopy, Ultrasound, CT Scanning, MRI, Nuclear Medicine,<br />
and Radiation Therapy.<br />
THE CHESTER COUNTY HOSPITAL<br />
FERN HILL MEDICAL CAMPUS . . . . . . . . . . . ..... . . . . 610-431-5131<br />
Fern Hill Medical Building<br />
915 Old Fern Hill Road, Bldg D, Suite 400, West Chester, PA<br />
General <strong>Radiology</strong>, Digital Mammography, Ultrasound, Dexa Scan, CT Scanning, MRI.<br />
THE CHESTER COUNTY HOSPITAL<br />
<strong>RADIOLOGY</strong> AT KENNETT SQUARE .... . . . . 610-431-5131<br />
Kennett Medical Campus<br />
402 McFarlan Road, Suite 204, Kennett Square, PA<br />
General <strong>Radiology</strong>, Digital Mammography, Ultrasound, Dexa Scan, CT Scanning, MRI.<br />
THE CHESTER COUNTY HOSPITAL<br />
<strong>RADIOLOGY</strong> AT EXTON .............. . . . . . . 610-431-5131<br />
The Commons at Oaklands<br />
700 West Lincoln Highway, Exton, PA<br />
General <strong>Radiology</strong>, Ultrasound, Digital Mammography, CT Scanning, Dexa Scan.<br />
PENN PET/CT<br />
AT THE CHESTER COUNTY HOSPITAL .... . . . . 610-495-0060<br />
701 East Marshall, West Chester, PA<br />
For directions visit: www.chestercountyhospital.org<br />
*To order an MRI Study, use the MRI specific order form.
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