Radiology Ordering Guide

This guide is to help you order the correct imaging study.

HOW TO USE THIS GUIDE:

1. Choose modality
o CT
o Fluoroscopy
o MRI
o Ultrasound
o MG Decision Tree

2. Find indication (Use ctrl+F on keyboard to search for keywords)

3. Choose study and appropriate CPT code or codes

4. Use the prior authorization guide to determine whether or not

authorization is needed

Appendix:
Page 18 – Prior Authorization Guide
Page 19 – Screening Questions
Page 20 – Exam Prep
Page 21 – Services and Locations
Page 22 – CT Coding Body
Page 23 – MRI Coding Body
Page 24 – US Coding Body
Page 25 – Cash Pay Fee Schedule (Non-Insured Patients Only)

Radiology Diagnostic Center Five Cities Medical Imaging Digital Medical Imaging
1310 Las Tablas Road, Ste. 103 921 Oak Park Blvd, Ste. 102 522 East Plaza Drive
Templeton Pismo Beach Santa Maria
P: (805) 434-0829 P: (805) 779-7900 P: (805) 928-3673
F: (805) 434-0826 F: (805) 779-7910 F: (805) 928-9588

Interventional Radiology Services – P: (805) 792-0115 * F: (805) 461-5570

CT - Head
CPT

CT - Computed Tomography
BODY PART REASON FOR EXAM EXAM TO PRE-CERT CODE
Head / Brain Trauma CT Head / Brain 70450
Headaches Without Contrast
CVA, Stroke
Bleed, Hemorrhage
Alzheimer’s
Memory Loss, Confusion
Vertigo, Dizziness
Shunt Check
Hydrocephalus
Metastatic Staging CT Head / Brain 70460
Mass/Tumor With Contrast
Infection
Headache w/ associated
neurologic signs
Melanoma CT Head / Brain 70470
HIV Without and With Contrast
Toxoplasmosis
Orbits Trauma CT Orbit 70480
Fracture Without Contrast
Foreign Body
Graves Disease
Pseudo Tumor CT Orbit 70481
Pain With Contrast
Exopthalmus
Abscess
Mass CT Orbit 70482
Retinoblastoma Without and With Contrast
Facial Bones Trauma CT Facial Bones 70486

Fracture Without Contrast

Cellulitis CT Facial Bones With Contrast 70487
Sinuses Sinusitis CT Sinus Limited 76380
Osteomeatal Complex CT Sinus Complete 70486
Sinusitis Polyps
Temporal Hearing Loss, Conductive* CT Inner Ears, Temporal Bones 70480
Bone Without Contrast
Cholesteotoma
Trauma
*Sensory neuro hearing loss,
order MRI with and without contrast.
CT - Head (Continued)
CPT

CT - Computed Tomography
BODY PART REASON FOR EXAM EXAM TO PRE-CERT CODE
Neck Mass CT Neck 70491
Infection With Contrast
Cancer Workups *If elevated creatinine order
Parotid Mass without contrast
Hoarseness CT Neck 70490
Vocal Chord Paralysis Without Contrast
Voice Changes
Submandibular Stone CT Soft Tissue Neck 70492
Infection of Submandibular Gland Without and With Contrast
Infection of Parotid Gland
Parotid Stone

CT - Spine
CPT
BODY PART REASON FOR EXAM EXAM TO PRE-CERT
CODE
Cervical Trauma, Fracture, Fusion CT Cervical Spine 72125
Spine Assess Bone Degenerative Changes Without Contrast
*MRI recommended for disc
herniation, mets, infection

Thoracic Trauma, Fracture, Fusion CT Thoracic Spine 72128

Spine Assess Bony Degenerative Changes Without Contrast
*MRI recommended for disc
herniation, mets, infection

Lumbar Trauma, Fracture, Fusion CT Lumbar Spine 72131

Spine Assess Bony Degenerative Changes Without Contrast
*MRI recommended for disc
herniation, mets, infection

Chest F/U nodules CT Chest 71250

Renal Failure Patients Without Contrast

Cough CT Chest 71260
Pneumonia With Contrast
Lung CA
Esophageal CA
Lymphoma
Lung Nodule
Mass
Tracheal Stenosis
Chest Wall Mass
CT - Chest
CPT

CT - Computed Tomography
BODY PART REASON FOR EXAM EXAM TO PRE-CERT CODE
Chest, High Interstitial Disease CT Chest 71250
Resolution Fibrosis Without Contrast
COPD
Hemoptysis
Bronchiectasis
Sarcoidosis
Pleural Plaques
Asbestosis

CT - Abdomen & Pelvis

CPT
BODY PART REASON FOR EXAM EXAM TO PRE-CERT CODE
Abdomen F/U for pts with renal cell carcinoma CT Abdomen Without Contrast 74150
in renal failure (recommend MRI)
Abdominal Pain (generalized) CT Abdomen 74160
Mass With Contrast
RUQ Pain
LUQ Pain
Epigastric Pain
Pseudocyst
Pancreatitis
Abdomen & Hematuria with Pain CT Abdomen and Pelvis 74176
Pelvis Stone (Stone Study) Without Contrast
Abdominal Pain CT Abdomen and Pelvis 74177
Crohns/Ulcerative Colitis/IBD With Contrast
Diverticulitis
Abscess
Mass
Hernia (i.e., umbilical, inguinal)
Kidney Cyst vs. Mass CT Abdomen Without and 74178
Cancer Staging With Contrast
CT Pelvis With Contrast
Abdomen Adrenal Mass - No Oral Prep CT Abdomen 74170
(Renal/ Adrenal) Abnormal Ultrasound Without and With Contrast
Renal Mass - No Oral Prep
Liver Hemangioma - No Oral Prep
(recommend MRI)

Hepatitis, Cirrhosis - No Oral Prep

CT - Abdomen & Pelvis (Continued)
CPT

CT - Computed Tomography
BODY PART REASON FOR EXAM EXAM TO PRE-CERT CODE
Pelvis Fracture CT Pelvis 72192
Non-Union Without Contrast
Prostate Treatment Planning
Arthritis CT Pelvis 72193
Cancer Staging With Contrast
Mass
Cysts
Pain
Infection
Abscess
Bone Infection CT Pelvis 72194
(recommend MRI)
Without and With Contrast
CT Urogram Transitional Cell Carcinoma of CT Abdomen and Pelvis 74178
(Kidneys/ Bladder) Kidney and/or Bladder With and Without Contrast
Defects/Bladder Leakage

CT Enteropgraphy Crohns Disease/ CT Abdomen and Pelvis 74177

Inflammatory Bowel Disease With Contrast
Suspected Partial SBO
(Small Bowel Obstruction)
Small Bowel Masses
Celiac Disease
CT Cystogram Leakage CT Abdomen and Pelvis 74176
Colovesical Fistula With and Without Contrast
Virtual Colon Survey CT Abdomen and Pelvis
Colonoscopy Failed Colonoscopy Without Contrast
DIAGNOSTIC 74261
SCREENING 74263

CT - Extremities
CPT
BODY PART REASON FOR EXAM EXAM TO PRE-CERT CODE

Upper Extremities Fracture CT Upper Extremity 73200

Finger Fusion Without Contrast

Hand Non-Union/Malunion
Wrist Infection CT Upper Extremity 73201
Forearm Tumor/Mass/Cancer/Mets With Contrast
(recommend MRI)
Elbow
Humerus
Shoulder
Clavicle
Scapula
CT - Extremities (Continued)
CPT

CT - Computed Tomography
BODY PART REASON FOR EXAM EXAM TO PRE-CERT CODE
Sternoclavicular Fracture CT Chest 71250
Joint Non Union/Malunion Without Contrast
Lower Extremities Fracture CT Lower Extremity 73700
Foot Fusion Without Contrast
Ankle Non-Union/Malunion
Calf (Tibia/ Fibula) Arthritis
Knee Patello Femoral Malalignment
Thigh (Femur) Anteversion/Malrotation (Bilateral)
Infection CT Lower Extremity 73701
Tumor/Mass/Cancer/Mets With Contrast
(recommend MRI)

Leg Lengths Abnormality Leg Length CT Limited 76380

Malrotation XR Bone Length 77073
FAI Protocol Femoral Anteversion for CT Hip Without Contrast AND 72192

FAI Cam Lesion CT Knee Without Contrast 73700

CT - Arthrography (Joints with Intraarticular Contrast)

CPT
BODY PART REASON FOR EXAM EXAM TO PRE-CERT CODE

CT Arthrogram Cartilage Abnormality Requires 3 codes:

Hip Meniscus Abnormality 1 - Choose upper or lower ext:

Knee Labrum Abnormality Lower Extremity With Contrast 73701

Ankle Loose Bodies OR
Shoulder Upper Extremity With Contrast 73201
Elbow 2 - Fluoro Guided Arthrogram 77002
Wrist 3 - Choose body part:
Hip 27093
Knee 27370
Ankle 27648
Shoulder 23350
Elbow 24220
Wrist 25246
CT - Angiograpghy (CTA)
CPT

CT - Computed Tomography
BODY PART REASON FOR EXAM EXAM TO PRE-CERT CODE
CTA Brain/ Head TIA, CVA CTA Brain 70496
Vascular Malformation
Aneurysm
AVM (Arterio/ Venous Malformation)
CTA Carotid/ Neck Carotid Stenosis CTA Carotid 70498
Bruit
TIA, CVA
Carotid Dissection
CTA Chest Thoracic Aortic Dissection CTA Chest 71275
Thoracic Aortic Aneurysm
Coarctation
Aortic Root Dilation
CTA Chest Chest Pain / Dyspnea CTA Chest 71275
PE Study Tachypnea
Shortness of Breath
Pulmonary Hypertension (PA HTN)

CTA Chest and Thoracic and Abdominal CTA Chest 71275

CTA Abdomen Aortic Dissection CTA Abdomen 72191

* Dissection going past renals

Calcium Scoring Calcium Scoring of Coronary Arteries Calcium Score 75571

Family History of CAD
Aorta, Renal, Stent Aneurysm (AAA) CTA Abdomen and 74175
Stent Obstruction/Leak/Malfunction CTA Pelvis 72191
Crossing Vessels
Anatomic Marking for Partial/
Complete Nephrectomy
Renal Artery Stenosis
CTA Upper Trauma CTA Upper Extremity 73206
Extremities Arterial Stenosis
CTA Upper Peripheral Artery Disease CT Lower Extremity 73706
Extremities Ischemia to Lower Extremity
Arterial Stenosis
CTA Run-Off Peripheral Artery Disease (PAD) CTA Abdomen, Pelvis, Bilateral 75635
Ischemia to Lower Extremity Lower Extremities
Arterial Stenosis
Fluoroscopy

Flouroscopy
EXAM PREP CPT CODE
IR Lumbar Epidural Injection - 62311
FL Guidance - 77003
Myelogram Thoracic - 72255
OR
Lumbar - 72265
AND
Intrathecal Inection - 62284

Esophogram - Contrast XR w/ Barium NPO 8 hrs prior to exam 74220

NPO 4 hrs prior to exam. These exams are scheduled
Swallowing Function - Contrast XR w/ Barium in coordination with a speech pathologist. 74230

UGI (Upper Gastrointestinal) NPO 8 hrs prior to exam 74240

UGI with KUB NPO 8 hrs prior to exam 74241

UGI with SBFT NPO 8 hrs prior to exam 74245

UGI with Air NPO 8 hrs prior to exam 74246

UGI with Air and KUB NPO 8 hrs prior to exam 74247

UGI with Air and SBFT NPO 8 hrs prior to exam 74249

SBFT (Small Bowel Follow Thru) NPO 8 hrs prior to exam 74250

Hypotonic Duodenography 74260

Pick up BE prep kit from center within 24 hours of
BE (Barium Enema) with or without KUB scheduling. 74270
Pick up BE prep kit from center within 24 hours of
BE with Air scheduling. 74280

IVP No food 2 hrs prior to exam. Patient can drink. 74400

Indications for this exam: UTI, Hematuria, Incontinence,
Cystourethrogram - Retrograde Urinary Frequency 74450
Patient needs to arrive pre-cathed.
Indications for this exam: UTI, Hematuria, Incontinence,
Cystourethrogram - Voiding (VCUG) Urinary Frequency 74455
Must be done between the 7th - 10th day following the
Hysterosalpinogram (HSG) (Includes cpt 58340) start of the patient's menstrual cycle. 4740 AND 58340
No sexual contact once period has started until after
procedure.
Venogram - Extremity Unilateral Venogram Unilateral - 75820
Injection - 36005
Venogram - Extremity Bilateral Venogram Bilateral - 75822
Injection - 36005

FL Guided Lumbar Puncture Hydrate well day before exam.

FL Guided Needle Placement

FL Guided Picc Placement

FL Guided Port Study Tunneled ports need to come pre-accessed

SNIFF Test
MRI - Head & Neck
CPT

MRI - Magnetic Resonance Imaging

BODY PART REASON FOR EXAM PROCEDURE TO PRE-CERT CODE
Brain Alzheimer’s, Dementia, Memory Loss MRI Brain 70551
Mental Status Changes, Confusion Without Contrast
Headache Without Focal Symptoms
Seizures (children)
Stroke, CVA, TIA
Trauma
Cranial Nerve Lesions MRI Brain 70553
Dizziness, Vertigo Without and With Contrast
Headache With Focal Symptoms
HIV
IAC/Hearing Loss
Infection
Multiple Sclerosis
Neurofibromatosis
Pituitary Lesion, Elevated Prolactin
Seizures (adult new onset)
Tumor / Mass / Cancer / Mets
Vascular Lesions
Vision Changes
Trigeminal Neuralgia Order 2 exams:
MRI Brain Without and With Contrast 70553
MRI Orbits / Face / Neck 70543
Without and With Contrast
Orbits Grave’s Disease MRI Orbits / Face / Neck 70540
Trauma Without Contrast
Exopthalmos, Proptosis MRI Orbits / Face / Neck 70543
Pseudotumor Without and With Contrast
Tumor / Mass / Cancer / Mets
Vascular Lesions
Optic Neuritis
Neck Infection MRI Orbits/Face/Neck 70543
Pain Without and With Contrast
Tumor / Mass / Cancer / Mets
Vocal Cord Paralysis
Parotid Gland
MRI - Spine
CPT

MRI - Magnetic Resonance Imaging

BODY PART REASON FOR EXAM PROCEDURE TO PRE-CERT CODE
Cervical Arm / Shoulder Pain or Weakness MRI Cervical Spine 72141
Degenerative Disease Without Contrast
Neck Pain
Disc Herniation
Cervical Fusion
Radiculopathy
Discitis MRI Cervical Spine 72156
Osteomylitis Without and With Contrast
Multiple Sclerosis
Myelopathy
Syrinx
Tumor / Mass / Cancer / Mets
Vascular Lesions, AVM
Thoracic Back Pain MRI Thoracic Spine 72146
Compression Fx (no hx of cancer) Without Contrast
Degenerative Disease
Disc Herniation
Radiculopathy
Trauma
Compression Fx (with hx of cancer) MRI Thoracic Spine 72157
Discitis Without and With Contrast
Osteomylitis
Multiple Sclerosis
Myelopathy
Syrinx
Tumor / Mass / Cancer / Mets
Vascular Lesions
AVM
Lumbar Back Pain MRI Lumbar Spine 72148
Compression Fx (no hx malig / mets) Without Contrast
Degenerative Disease
Disc Herniation
Radiculopathy
Sciatica
Spondylolithesis
Stenosis
Trauma
Compression Fx (no hx malig / mets) MRI Lumbar Spine 72158
Discitis Without and With Contrast
Osteomylitis
Tumor / Mass / Cancer / Mets
MRI - Chest / Abdomen / Pelvis
CPT

MRI - Magnetic Resonance Imaging

BODY PART REASON FOR EXAM PROCEDURE TO PRE-CERT CODE
Brachial Brachial Plexus Injury MRI Chest Without and With Contrast 71552
Plexus Nerve Avulsion MRI Neck Without and With Contrast 70543
Tumor / Mass / Cancer / Mets (Please authorize BOTH codes.)
Chest- Tumor / Mass / Cancer / Mets MRI Chest / Mediastinum 71552
Mediastinum Without and With Contrast
Breast Implant Rupture MRI Bilateral Breast Without Contrast 77059
Abnormal Mammogram MRI Bilateral Breast 77059
Abnormal Ultrasound Without and With Contrast
Dense Breast/High Risk
Mass / Lesion / Cancer
Palpable Mass
Abdomen MRCP (Biliary / Pancreatic Ducts) MRI Abdomen Without Contrast 74181
Adrenal Adenoma MRI Abdomen 74183
Adrenal Mass (not adenoma) Without and With Contrast
Hemangioma
Liver, Kidney, or Pancreas Mass
Tumor / Mass / Cancer / Mets
Pelvis Adenomyosis MRI Pelvis Without Contrast 72195
Fracture
Muscle / Tendon Tear
Urethral Diverticulum
Sports Hernia
Fibroids MRI Pelvis Without and With Contrast 72197
Osteomylitis
Septic Arthritis
Tumor / Mass / Cancer / Mets
Abcess
Ulcer

MRI - Enterography Abdomen & Pelvis

CPT
BODY PART REASON FOR EXAM PROCEDURE TO PRE-CERT CODE
Abdomen Crohns Disease/Inflammatory Order 2 Exams:
Pelvis Bowel Disease MRI Abdomen 74183
GI Bleed Without and With Contrast
Suspected Partial SBO MRI Pelvis Without and With Contrast 72197
(Small Bowel Obstruction)

Small Bowel Masses

Celiac Disease
MRI - Extremities
CPT

MRI - Magnetic Resonance Imaging

BODY PART REASON FOR EXAM PROCEDURE TO PRE-CERT CODE
Non-Joint: Fracture MRI — Non Joint Without Contrast
Arm Stress Fracture Lower Extremity 73718
Hand Muscle / Tendon Tear Upper Extremity 73218
Finger Abcess MRI — Non Joint Without and With
Leg Ulcer I.V. Contrast
Foot Bone Tumor / Mass / Cancer / Mets Lower Extremity 73720
Toe Cellulitis Upper Extremity 73220
Fasciitis
Myositis
Morton‘s Neuroma
Osteomylitis
Soft Tissue Tumor / Mass / Cancer
Joint: Arthritis MRI — Joint Without Contrast
Shoulder Avascular Necrosis (AVN) Lower Extremity 73721
Elbow Fracture Upper Extremity 73221
Wrist Stress Fracture
Hip Internal Derangement
Knee Joint Pain (specify joint)
Ankle Labral Tear
Meniscal Tear
Muscle Tear
Tendon Tear
Ligament Tear
Cartilage Tear
Osteochondritis Dessicans (OCD)
Abcess MRI — Joint Without and With
Ulcer I.V. Contrast
Cellulitis Lower Extremity 73723
Fasciitis Upper Extremity 73223
Myositis
Inflammatory Arthritis (pannus eval)
Osteomylitis
Septic Arthritis
Tumor / Mass / Cancer / Mets
MRI - Arthrography (Joint with Intraarticular Contrast)
CPT

MRI - Magnetic Resonance Imaging

BODY PART REASON FOR EXAM PROCEDURE TO PRE-CERT CODE
Shoulder Labral Tear MRI Joint With Intra-articular Contrast
Elbow Loose Bodies
Wrist OCD Stability Requires 3 codes:
Hip Post-op Meniscus Evaluation 1 — Lower Extremity With Contrast OR 73722
Knee Upper Extremity With Contrast 73222
Ankle 2 — Fluoro Guided Arthrogram 77002
3 — Choose one code for body part:
Shoulder 23350
Elbow 24220
Wrist 25246
Hip 27093
Knee 27370
Ankle 27648

MRA / MRV - MR Angiography / MR Venography

CPT
BODY PART REASON FOR EXAM PROCEDURE TO PRE-CERT CODE
Head (MRA) Stroke, CVA, TIA MRA Head Without Contrast 70544
Aneurysm
Head (MRV) Venous Thrombosis MRV Head Without Contrast 70544
Neck Stroke, CVA, TIA MRA Neck Without Contrast 70547
Dissection MRA Neck Without and With Contrast 70549

Chest Thoracic Aorta MRA Chest Without and With Contrast 71555
(other than dissection)

Vascular Anomalies
Subclavian Vessels
Aortic Dissection Order 2 Exams:
MRA Chest Without and With Contrast 71555
MRA Abdomen 74185
Without and With Contrast
Arch & Great Stroke, CVA, TIA MRA Neck Without and With Contrast 70549
Vessels
Abdomen AAA (abdominal aortic aneurysm) MRA Abdomen 74185
(MRA) Abdominal Aortic Dissection Without and With Contrast
Mesenteric Ischemia
Pre Kidney Transplant
Renal Mass Order 2 Exams:
Uncontrolled Blood Pressure MRA Abdomen 74185
Without and With Contrast
MRI Abdomen 74183
Without and With Contrast
MRA / MRV - MR Angiography / MR Venography
CPT

MRI - Magnetic Resonance Imaging

BODY PART REASON FOR EXAM PROCEDURE TO PRE-CERT CODE
Abdomen Venous Thrombosis MRV Abdomen 74185
(MRV) Venous Pathology Without and With Contrast
Pelvis AVM (arteriovenous malformation) MRA Pelvis 72198
Without and With Contrast
Pelvic Congestion Order 2 Exams:
MRA Pelvis 72198
Without and With Contrast
MRI Pelvis 72197
Without and With Contrast
Peripheral Claudication Requires 3 codes:
Run-Off Cold Foot MRA Abdomen 74185
Pain Without and With Contrast
MRA Lower Extremity 73725
Without and With Contrast (Left)
MRA Lower Extremity 73725
Without and With Contrast (Right)
Ultrasound - Neck
CPT

Ultrasound
BODY PART REASON FOR EXAM PREP CODE
Soft Tissues Mass None 76536
Neck (Thyroid), Abnormalities detected on other imaging
Head / Face (CT / MRI / PET / NM)

Enlarged thyroid gland

Multinodular goiter (MNG)
Abnormal lab tests
(elevated calcium levels / abnormal thyroid level)

Parathyroid adenomas
Hyperthyroidism / Hypothyroidism

Carotid Artery Weakness None 93880

Headache
Syncope
Hemiplegia
Difference in arm blood pressure
Aphasia
Ataxia
Reversible ischemic neurological deficit (RIND)
Bruit
Vertigo / dizziness (non medicare)
Memory loss (non medicare)
Dementia (non medicare)
Transient ischemic attack (TIA)
Confusion
Stroke
Visual disturbance
Cerebrovascular accident (CVA)
Amaurosis fugax

Ultrasound - Chest
CPT
BODY PART REASON FOR EXAM PREP CODE
Chest Diaphragm paralysis None 76604
Pleural effusion
Superficial mass
Aorta Aortic aneurysm (follow up to AAA) NPO 6 hours prior 76775
(Limited Pulsatile aorta to exam
Retroperitoneal) Bruit
Family history AAA (non medicare)
Ultrasound - Abdomen
CPT

Ultrasound
BODY PART REASON FOR EXAM PREP CODE
Abdomen Cirrhosis or hepatic disease Complete 76700
(Hepatitis / Portal Hypertension) Limited 76705
(Complete US includes ALL of
Abdominal distention (fluid collection) ascites NPO 6 hours prior
the following organs: Liver,
Gallbladder, Pancreas, Bilateral Pain (Abdominal / Epigastric / Periumbilical) to exam
Kidneys, Spleen, Aorta, IVC,
CBD)
Nausea / Vomiting
Gallstones
(Limited US includes RUQ, RLQ,
Obstructive symptoms of the biliary system
1 organ, or hernia)
(Jaundice)

Abnormal diagnostic tests (CT / MR)

Gastroesophageal reflux (GERD)
Splenomegaly
Abnormal liver functions
(Elevated LFT‘s / Fatty liver)

Hepatomegaly
Cirrhosis or hepatic disease (hepatitis/
portal hypertension)

Ascites
Varices
Portal vein thrombosis
Budd-Chiari Syndrome NPO 6 hours prior 76705
Intrahepatic Portosystemic Venous Shunts — TIPS to exam
Hepatomegaly
Splenomegaly

Ultrasound - Pelvis
CPT
BODY PART REASON FOR EXAM PREP CODE
Pelvis Pain (pelvic or adnexal tenderness) Pelvis Complete 76856
(Complete includes the Ovarian cyst AND
Uterus, Ovaries, Uterine fibroids Transvaginal 76830
Bilateral Adnexa) Enlarged uterus or ovary (mass) *Please note: An Us Pelvis
Complete is a Transabdominal
Adnexal abnormalities
exam.Transvaginal Us is needed
Dysfunctional uterine bleeding and both exams MUST be
ordered.
Post menopausal bleeding
Precocious puberty Fill bladder with 32 oz
Polycystic ovary Disease (PCOD) of water 1 hour prior
Ovarian follicle monitoring to exam. Do not void.
Ovarian torsion/Pelvic pain
Follow up fibroid embolization
Ovarian vein embolization
Evaluation of pelvic congestion syndrome (PCS)
Ultrasound - Scrotum
CPT

Ultrasound
BODY PART REASON FOR EXAM PREP CODE
Scrotum Pain 76870
Trauma
Torsion
Mass
Varicocele
Epididymitis
Hydrocele (swelling)
Undescended testes

Ultrasound - Retroperitoneal
CPT
BODY PART REASON FOR EXAM PREP CODE
Kidney (renal) Pain (CVA tenderness/flank pain) Only for bladder: 76770
and Bladder Obstruction (hydronephrosis) Fill bladder with 32 oz
(Organs include: Hypertension of water 1 hour prior
Bilateral Kidneys, Follow up to other diagnostic imaging test to exam.
Bladder Pre & Post Void. (CT or MRI) Do not void.
Male also includes limited Abnormal lab values (BUN or Creatinine)
Prostate) Stones (renal)
Chronic renal medical disease (renal function/
renal failure)
Polycystic kidney disease (PCKD)
Urinary tract infection/cystitis/pyelonephritis
Renal cancer
Trauma
Hematuria (microscopic or gross)
Neurogenic bladder
Urinary retention - Evaluate post void residual
(PVR)

Bladder diverticula
Renal Transplant Post renal transplant No Prep 76776
Urinoma
Lymphocele
Pain
Elevated lab values (creatinine)
Poor renal function
Renal Doppler Renal artery stenosis Complete 93975
Renal artery aneurysm Limited 93976
Renal vein thrombosis
Hypertension
Abnormal laboratory values NPO 6 hours prior
Elevated creatinine/BUN to exam
Ultrasound- Extremities/ Musculoskeletal
CPT

Ultrasound
BODY PART REASON FOR EXAM PREP CODE
Upper or Lower Pain Complete 76881
Extremity Fluid collection (Bakers Cyst) – Limited Limited 76882
(non Doppler) Mass – Limited No Prep
Biceps tendon/rotator cuff exams (MSK radiologist
needs to perform - Book w/JRIS) – Complete
Musculoskeletal Biceps tendon scan with injection
Bakers cyst aspiration with injection
Joints/shoulder/elbow/ankle/knee ultrasound
Upper or Lower Edema/swelling Complete Bilateral 93970
Extremity Venous Calf pain (non medicare) Limited or Unilateral 93971
Doppler Post surgical (non medicare)
Redness No Prep
Follow up DVT
Positive Homan sign (shooting pain with foot
dorsiflexion)
History long plane/car trip
Upper or Lower Claudication/pain with walking Lower Extremity Bilateral 93925
Extremity Arterial Decreased or absent pulses Lower Extremity Unilateral 93926
Duplex Arthrosclerosis Upper Extremity Bilateral 93930
Bruit Upper Extremity Unilateral 93931
High risk family history (non medicare)
Numbness (non medicare) No Prep
S/P graft or stenting
Ulcer on foot or toe (non medicare)
Discoloration of feet or legs (non medicare)
Thoracic outlet syndrome
Decrease arm pressure
Cold fingers or toes (poor circulation)
Venous Reflux Edema/swelling No Prep 93965
Leg ulcer (non medicare)
Pain (non medicare)
Venous insufficiency
Varicose veins
Burning or tingling (non medicare)
Phlebitis/Thrombophlebitis
 Breast Ordering Decision Tree
Does the patient have a problem (pain, lump, etc..)

YES No

Order: "SCREENING MG WITH 
How old is the patient? DIAGNOSTIC MG & BREAST US IF 
REQUIRED"

<30 >30

Order: "BREAST  Order: 
ULTRASOUND  "DIAGNOSTIC 
WITH  MAMMOGRAM 
DIAGNOSTIC  AND BREAST 
MG IF  ULTRASOUND" 
INDICATED BY  (MUST INDICATE 
RAD" (MUST  LOCATION OF 
INDICATE  PROBLEM)
LOCATION OF 
PROBLEM)
 Radiology Guide for Prior Authorization
1. Determine Insurance      2. Choose Modality      3. Call for auth if needed    

US XR FL MG DX CT MRI PET
Medicare
RAF ‐ Venous & 
Cencal Arterial Only
Care to Care Care to Care Care to Care

Blue Cross (Incl. Covered CA) AIM or BC UM AIM or BC UM AIM or BC UM

Blue Cross‐UFCW BC UM BC UM BC UM

Blue Shield (Incl. Covered CA) NIA NIA NIA

Aetna Medsolutions Medsolutions Medsolutions

Cigna Medsolutions Medsolutions Medsolutions

United Healthcare UHC UHC UHC

United Ag
Humana HealthHelp HealthHelp HealthHelp

GEHA US Imaging US Imaging US Imaging

Care to Care 888‐318‐0276
AIM 877‐291‐0360 *Tax ID: 95‐2862709 (Pueblo Radiology)
BC UM 800‐274‐7767 Option 1,5,2 *NPI: 1871549899
NIA 888‐642‐2583
Medsolutions 888‐693‐3211
UHC 877‐842‐3210
Health Help 866‐826‐1550
US Imaging 877‐874‐6385

*Phone numbers above are a reference to use if you do not have online access to obtain auth.
*If insurance company states "No Auth Required" we must have a reference number for the call.
*Contrast ONLY needs to be changed on Medsolutions auths.  All others can be left as‐is even if contrast on exam changes.
  

 
Radiology Screening Questions 
 
MRI (Magnetic Resonance Imaging) 
 Height & Weight   Any prior surgery on the area(s) being 
 Do you have a pacemaker?  scanned? 
 Do you wear any medication patches?   Have you ever been diagnosed with cancer? 
 Do you have any implanted metal or   Do you have any prior related imaging studies
electronic devices (stents, hardware, pumps,   History of kidney disease requiring dialysis 
etc.)?  or surgery? (ex: kidney transplant or 
 Are you claustrophobic?  cancer)* 
 Have you ever had metal in your eyes for   History of hypertension requiring 
which you sought medical attention? (If yes,  medication?* 
please also send an order for an XR Orbits)   History of diabetes* 
 Are you pregnant? 
 
CT (Computed Tomography) 
 Height & Weight   History of kidney disease requiring dialysis 
 Are you pregnant?  or surgery? (ex: kidney transplant or 
 Any prior surgery on the area(s) being  cancer)* 
scanned?   History of hypertension requiring 
 Have you ever been diagnosed with cancer?  medication?* 
 Are you allergic to iodine?   History of diabetes?* 
 Do you have any mobility restrictions   Taking Metformin or a drug containing 
  Metformin? (ex: Glucophage)* 
 
MG (Mammography) 
If yes for either question below the patient must   Do you have breast implants? 
have a diagnostic MG (not a screening) and Breast US   Do you have any mobility restrictions 
(please include order for both): 
 Personal history of breast cancer within the 
 Where are prior 
last 5 years?  mammograms? (Will NOT 
 Any current breast problems (pain, lump, 
etc.)? 
perform MG without priors) 
 
*Please note: The questions in BOLD with an asterisk* above only need to be asked if the exam is going to 
include contrast. If the patient answers “Yes” to any of these questions we will need to have a Creatinine level 
within the previous 60 days. If the patient has not had this done we will need to order these labs and have 
them drawn within 24 hours of scheduling the patient’s appointment. 
 
 
Page 19
  

 
RADIOLOGY ASSOCIATES EXAM PREP 
 
Fluoroscopy 
 UGI Series/Small Bowel    
 Nothing to eat or drink eight (8) hours prior to the study.    
 Small Bowel exam could take up to 3‐4 hours.  
 
 Barium Enema    
 Pick up a Barium Enema kit at our office at least two (2) days before your study and follow the enclosed 
  instructions. 
 
 IVP    
 Do not eat or drink anything for two (2) hours prior to your scheduled exam.  
 
Ultrasound 
 Abdomen   
   Nothing to eat or drink eight (8) hours prior to study.  
 
 Renal, Pelvis, or OB/GYN 
 Drink 4‐5 8oz. glasses of water (24‐36 oz) 1 hour prior to exam.  
 DO NOT urinate. A full bladder is essential.  (Note: The slower the bladder fills, the less discomforting) 
 
CT Scan 
 Abdomen/Pelvis (No IVP)
 Pick up oral contrast preparation at our office within 24 hours of scheduling your examination and follow the 
  enclosed instructions (if exam requires contrast). 
 
 Abdomen/Pelvis with IVP 
   Nothing to eat or drink two (2) hours prior to exam.  
  
 Chest 
 Nothing to eat or drink two (2) hours prior to exam.  
 
 CT Colonography 
    Pick up a prep kit at our office within 24 hours of scheduling your examination and follow the enclosed 
  instructions.  
 
Magnetic Resonance Imaging (MRI) 
 MRI of the Abdomen/Pelvis  
   Nothing to eat or drink four (4) hours prior to your examination.  

Page 20
 www.rasloimaging.com

Services and Locations

DMI FCMI RDC

Imaging Center Locations QCT QCT DX &
Bone Density only only QCT
CHC Designated Fax Line CT Scan   
(805) 286-4624 Digital Mammography  
Fluoroscopy   
Digital Medical Imaging (DMI)
522 East Plaza Drive, Santa Maria, CA. 93454
MRI – High Field   
PH: (805) 928-3673 FAX: (805) 928-9588 MRI – High Field Open 
PET / CT Imaging  
Five Cities Medical Imaging (FCMI) Ultrasound  
921 Oak Park Blvd., Ste. 102, Pismo Beach, CA 93449 X-Ray   
PH: (805) 779-7900 FAX: (805) 779-7910

Radiology Diagnostic Center (RDC)

1310 Las Tablas Road, Ste# 103, Templeton, CA 93465
PH: (805) 434-0829 FAX: (805) 434-0826

Diagnostic Services

 Bone Density Screening  PET / CT Imaging

 CT Scan (multi-slice)  Ultrasound
 Digital Mammography  Vascular Imaging
 Fluoroscopy  X-Ray (General Diagnostic)
 MRI – High Field and High Field Open

Interventional Radiology (IR) Services – Most procedures performed at SVH or FH. Call IR to coordinate.

 Abdominal Aortic Aneurysm  Internal Bleeding

 Abscess / Fluid Drainage  Pelvic Congestion Syndrome
 Angiography / Angioplasty / Stenting  Peripheral Arterial Disease
 Arterial Disease / Plaque Excision  Spine Interventions / Pain Management
 Biliary Interventions  Thromobolysis
 Biopsies  TIPS (Transjugular Intrahepatic Portosystemic
 Dialysis Access Shunt)
 DVT Thrombolysis  Varicose Vein / Spider Vein Treatment
 Fibroid Embolization  Vascular Access
 Gastrostomy Tubes  Vertebroplasty
 Inferior Vena Cava (IVC) Filters
 Infertility

Page 21
 CT CPT CODING
CT Head / Brain ‐   CT Maxillofacial, 
W/O – 70450  Face, Sinus ‐  
W – 70460  W/O – 70486 
W/O&W – 70470  W – 70487 
W/O&W – 70488 
CT Orbit, Sella, 
P.Foss, or Ear ‐  
CT ST Neck ‐  
W/O – 70480 
W/O – 70490 
W – 70481 
W – 70491 
W/O&W – 70482 
W/O&W – 70492

CT Chest (Thorax) ‐   CT Cervical Spine ‐  
W/O – 71250  W/O – 72125 
W – 71260  W – 72126 
W/O&W – 71270  W/O&W – 72127

CT Thoracic Spine ‐  
CT Abdomen ‐  
W/O – 72128 
W/O – 74150 
W – 72129 
W – 74160 
W/O&W – 72130
W/O&W – 74170 

CT Lumbar Spine ‐  
CT Pelvis ‐   W/O – 72131 
W/O – 72192  W – 72132 
W – 72193  W/O&W – 72133
W/O&W – 72194 

CT Abdomen & Pelvis ‐  
W/O – 74176 
CT Upper Ext. ‐  
W – 74177 
W/O – 73200 
W/O&W – 74178
W – 73201 
W/O&W – 73202 
(Arthrogram has add. 
Coding) 
CTA‐  
CTA Head W+W/O – 70496 
CTA Neck W+W/O – 70498 
CT Lower Ext. ‐   CTA Chest W+W/O –71275 
W/O – 73700  CTA Pelvis W+W/O –72191 
W – 73701  CTA Upper Extremity W+W/O –73206 
W/O&W – 73702  CTA Lower Extremity W+W/O –73706 
(Arthrogram has add.  CTA Abdomen & Pelvis W+W/O – 74174 
Coding)  CTA Abdomen W+W/O – 74175 
CTA Aorta & Bilateral Iliofemoral Runoff W+W/O – 75635 

Page 22
  

Page 23
 US CPT CODING

US Head & Neck 
Soft Tissues ‐  
76536  

US Breast (Unilateral 
US Chest ‐  
/ Bilateral) ‐  
76604 
Complete – 76641 
Limited ‐ 76642

US Ext. Non 
Vascular  
(Axilla)  US Abdomen 
Complete – 76881  Complete – 76700 
Limited – 76882  Limited (RUQ, LUQ, Liver, 
Gallbladder, etc…) ‐ 
76705
US Retroperitoneal  
(Renal, Aorta) 
Complete – 76770 
Limited – 76775 
US Pelvis – non OB 
 (TA Male or Female) 
Complete – 76856 
Limited (Bladder) – 76857 

US Testicular / Scrotal –   US Transvaginal (non OB) – 
US Vascular 
76870  76830 

US Duplex Carotid Arteries – Bilateral – 93880 
US Duplex Carotid Arteries – Unilateral – 
93882 

US Duplex Lower Extremity – Bilateral – 93925 
US Duplex Lower Extremity Arterial –  OB US 
Unilateral – 93926 
US OB (Single Gestation) ‐ Less than 14 wks – 76801 
US Duplex Upper Extremity Arterial – Bilateral  US OB (Add. Gestations) ‐ Less than 14 wks  – 76802 
– 93930  US OB (Single Gestation) ‐ Equal to or Greater than 14 wks – 
US Duplex Upper Extremity Arterial –  76805 
Unilateral – 93931  US OB (Add. Gestations) ‐ Equal to or Greater than 14 wks – 
76810 
US Duplex Upper or Lower Extremity Venous ‐ 
US OB (Single Gestation) ‐ Fetal Evaluation – 76811 
Limited or Unilateral – 93971 
US OB (Add. Gestations) ‐ Fetal Evaluation – 76812 
US Duplex Upper or Lower Extremity Venous ‐ 
US OB (1 or More Gestations) – Limited – 76815 
Complete Bilateral – 93970 
US OB (Each Gestation) ‐ Follow Up or Repeat – 76816 
 
US Transvaginal – 76817 
 
Digital Medical Imaging Radiology Diagnostic Center Five Cities Medical Imaging
(DMI) (RDC) (FCMI)
522 East Plaza Drive 1310 Las Tablas Road, Ste# 103, 921 Oak Park Blvd., Ste. 102,
Santa Maria, CA. 93454 Templeton, CA 93465 Pismo Beach, CA 93449
PH: (805) 928-3673 PH: (805) 434-0829 PH: (805) 779-7900

DIAGNOSTIC XRAY CASH RATES

 1 View XR - $25
 2-3 View XR - $30
 4 View XR - $40
 5+ View XR - $50

Below are ballpark averages per modality:

US / FL: $60 - $200
CT: $200 - $350
MR: $500 - $950

For exact pricing on all modalities other than XRAYS

please refer the patient to a Radiology Associates
facility.

Page 25