A Guide for Referring Healthcare Providers

INSIDE IMAGING
A G u ide For R efe rr i n g H e a l th c a re P rov i d e r s
w ww.di n w.co m
Scheduling Phone: 253-841-4353 | Fax: 253-446-3973
5/2014
INSIDE IMAGING
A G u i d e For R eferr i ng Heal t hcare P rovi d er s
The following pages have been provided to help you with the most up-to-date information to help you guide
your patients and have handy tips and resources at your fingertips. Please keep this reference binder handy.
It is our goal to add resources and update this binder regularly. We hope you find it helpful.
If you have questions, or would like additional referral coordinator binders or sheets,
please contact: [email protected] or call 253-583-8613.
For scheduling or referral questions contact: [email protected] or call 253-841-4353
Table of Content:
5/2014
IVR – Phone Tree
Location Hours and Contacts
Handy Contacts
Procedures Definitions
List of Procedures Walk-In Services Insurance/Cash Policy/Financial Assistance
Insurance Guide
General Study Preparations
Abdomen Ultrasound Prep
List of NSAIDs
List of Diuretics Water Pills
IV Hydration for low GFR Patients MRI General Guidelines
MRI CPT Coding Guide
CT General Guidelines
CT CPT Coding Guide
Ultrasound General Guidelines
Ultrasound CPT Coding Guide
Breast Imaging Guide
Bone Density (DEXA)
Minor Child Policy
Caregiver’s Declaration Form
Computer Generated Orders Referral Forms: Specialty
Common
Breast Imaging & Bone Density
Sample Marketing Flyers
3
4
5
6
7
10
11
12
16
17
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
PHONE TREE 253-841-4353
Press 1 – Physician or Healthcare Provider
Press 2 – Appointments or Pre-registration
Press 1 – Pre-Registration
Press 2 – Healthcare Provider
Press 3 – Patient
Press # – To repeat message
Note: You may Press 4 if you wish to leave a message in our voice mail system.
The prompt does not verbally say this.
Press 3 – Fax/Mailing Address/Hours/Directions
Press 1 – Fax/Mailing Address
Press 2 – Hours
Press 3 – Directions to Puyallup
Press 4 – Directions to Sunrise
Press 5 – Directions to Bonney Lake
Press 6 – Directions to Bonney Lake Prairie Ridge
Press 7 – Directions to Good Samaritan Medical Office Building
Press # – To repeat message
Press 4 – File Room for Copy of Films
Press 1 – Bonney Lake
Press 2 – Puyallup
Press 3 – Sunrise
Press 0 – If unsure of location
Press # – To repeat message
Press 5 – Reports Faxed
Press 6 – Billing Press 1 - Provider
Press 2 - Patient
Press 0 – All Other Calls
Press * – To retun to return the main menu for options
Puyallup | Bonney Lake | Sunrise
5/2014
Phone: 253-841-4353 | Fax: 253-446-3973
-3-
LOCATIONS AND HOURS*
BONNEY LAKE
IMAGING CENTER
21110 SR 410 East, Suite 110
Bonney Lake, WA 98391-8457
SERVICES:
MRI,CT, Ultrasound, DEXA,
Digital Mammography,
Creatinine Lab Services (Note: No X-ray at this location)
Appointment Hours
Monday – Friday: 8:00 am – 4:00 pm
Walk-in Non-Contrast CT and
Monday – Friday: 8:00 am – 4:00
Walk-in Creatinine Lab Services
Monday – Friday: 9:00 am – 4:00 pm
BONNEY LAKE
MEDICAL BUILDING
10004 204th Avenue E, Suite 2600
Bonney Lake, WA 98391-6539
SERVICES:
X-ray (walk-in)
Ultrasound (by appt.)
Appointment Hours
Monday – Friday: 8:00 am - 12:00 pm / 1:00 pm – 4:00 pm
Walk-in X-ray
Monday – Friday: 8:30 am - 12:00 pm / 1:00 pm – 5:00 pm
PUYALLUP
IMAGING CENTER
222 15th Avenue SE
Puyallup, WA 98372-3754
SERVICES:
MRI, CT, Ultrasound, X-ray,
DEXA, Digital Mammography,
Stereotactic Breast Biopsy, Breast MRI, Guided Biopsy (MRI or
Ultrasound), Fluoroscopy, Creatinine Lab Services,
IV Hydration for low GFR (CT) patients
Appointment Hours
Monday – Friday: 7:00 am – 7:00 pm
Walk-in X-ray
Monday – Friday: 8:30 am – 5:00 pm
Walk-in Non-Contrast CT
Monday – Friday: 9:00 am – 4:00 pm
Walk-in Creatinine Lab Services
Monday – Friday: 9:00 am – 4:00 pm
5/2014
GOOD SAMARITAN
MEDICAL OFFICE
BUILDING
1450 5th St. SE, Suite 4600
Puyallup, WA 98372-4655
SERVICES:
X-ray services for providers
at this location.
Walk in X-ray - Monday – Friday: 8:30 am – 4:30 pm
SUNRISE IMAGING
CENTER
11212 Sunrise Blvd. E, Suite 200
Puyallup, WA 98374-8847
SERVICES: MRI, CT,
Ultrasound, X-ray, Digital
Mammography, DEXA,
Creatinine Lab Services
Appointment Hours
Monday – Friday: 7:30 am – 5:00 pm (ALL MODALTIES)
Saturday Hour Appts Available:
• MRI (non contrast)
• Screening Mammogram
Saturday: 800 am – 11:45 am / 12:45 pm – 4:15 pm
Walk-in X-ray
Monday – Friday: 8:00 am – 5:00 pm
Saturday: 8:00 am – 11:45 am / 12:45 pm – 4:15 pm
Walk-in Non-Contrast CT
Monday – Friday: 9:00 am – 4:00 pm
Walk-in Creatinine Lab Services
Monday – Friday: 9:00 am – 4:00 pm
Hours are subject to change. We occasionally offer later
appointments and / or Saturday hours based on availability.
*
Note: Some walk-in CT exams require insurance pre-authorization –
check with your insurance.
Central Phone: 253-841-4353 | Central Fax: 253-446-3973
Scheduling Hours: Monday – Friday: 7:00 am – 6:00 pm
Pre-Registration Phone: 253-446-3971
Monday – Friday: 7:00 am – 6:00 pm | Saturday: 8:00 am – 4:30 pm
-4-
HANDY CONTACTS
Why do patients pre-register? By calling our pre-registration department as soon as a patient knows when their
appointment is, we are able to verify additional health information that is key for a quick and easy visit. Ensuring that
the patient is aware of any exam preparations is also extremely important. Patients must contact the pre-registration
department at least 24 hours PRIOR to appointment. If there is a chance that we cannot make personal contact at least
24 hours in advance – the appointment may need to be cancelled or rescheduled.
Plain Film (X-ray) and many of our non-contrast CTs can be done on a walk-in basis with a doctor’s referral.
HELPFUL CONTACTS:
General Questions
All Locations
253-841-4353
Central Scheduling
All Locations
253-841-4353 Administrative Fax
All Locations
253-583-8630
Scheduling Manager
Cindy Peterson
253-583-8645
[email protected]
Epic#18525
[email protected]
[email protected] Epic#45881
Scheduling Fax
All Locations
253-446-3973
Creatinine Labs
All Locations
253-841-4353 x 6006
Pre-Auth Group
All Locations
253-841-4353 x 6005
Operations Manager
Angie Eckroth
253-583-8650
Billing Department
All Locations
253-581-2550 / 800-229-4333
Billing Manager
Kirsten Maxwell
253-583-8620 / 253-583-8621
[email protected]
Puyallup Imaging Site Manager Salli Lohrengel
253-841-4353 x 3970
[email protected]
Bonney Lake & Sunrise
Imaging Sites Manager
Dave Hulse
253-841-4353 x 3990 [email protected]
Practice Liaison
Cal Mosher II
253-583-8614
[email protected]
Marketing Manager
Rachael Costner 253-583-8613
[email protected]
Marketing Fax
All Locations
253-583-8633
Musculoskeletal (MSK) Team
Provider to Radiologist
Direct Line
253-446-3978
Neuroradiological Team
Provider to Radiologist
Direct Line
253-446-3974
5/2014
[email protected]
-5-
PROCEDURE DEFINITIONS
BONE DENSITOMETRY (DEXA) - Bone Densitometry
RADIOGRAPHY & FLUOROSCOPY - Radiography uses
uses low-dose x-rays to record measurements of the strength
x-rays to help diagnosis a variety of health conditions. X-rays
or “denseness” of the bones in specific areas in the body. The
allow a Radiologist to view internal structures such as bones,
measurements are then used to help your physician/healthcare
joints, the lungs and heart. Sometimes radiography is ordered
provider determine whether you may be at increased risk of
with fluoroscopy. During fluoroscopy the Radiologist often uses
fracture or in need of medical or dietary supplements and/or a
a contrast agent to help visualize a particular area of the body
specific exercise regimen to help strengthen your bones.
as it functions.
COMPUTED TOMOGRAPHY (CT) - CT or CAT scans
STEREOTACTIC BREAST BIOPSY - Stereotactic
use x-rays to view body tissues and organs from a series of
breast biopsy uses x-rays taken from multiple angles along
different cross-sections and angles. CT is ordered to look for
with a special needle to sample breast tissue for closer analysis
possible fractures, damage from bleeding/trauma, tumors, or to
and observation. This procedure helps determine the nature
help guide needles for tissue biopsy.
of breast lumps or lesions, and assists in planning follow-up
medical care.
CREATININE LAB SERVICES - Labs are required if
patients are at risk of CIN (contrast induced neuropathy).
ULTRASOUND - Ultrasound uses high-frequency sound
(see page 21 for more details on high risk patients)
waves to record and view real-time movement and images
of internal body organs. (Ultrasound does not use radiation.)
IV HYDRATION - Hydration for low GFR patients requiring
Ultrasound may be ordered to evaluate the possible cause of
CT IV contrast imaging prior to CT Imaging procedure
pain, swelling, or problems with internal tissues. Ultrasound
(Puyallup location only).
is commonly used to provide a parent’s first moving image of
their unborn child. These images may be captured in incredible
MAGNETIC RESONANCE IMAGING (MRI) - MRI
detail with our 4-D ultrasound capabilities.
uses a combination of radio waves and magnetic fields to
create images of internal organs and tissues. (MRI does not
VASCULAR ULTRASOUND - Vascular ultrasound
use radiation.) MRI is ordered for conditions where problems
involves the scanning of arteries and veins in the body, either by
may be suspected in body organs (like the brain, liver or other
traditional sonography or with Doppler ultrasound. It is used to
organs), soft-tissues (like blood vessels and muscles) and/or
assess whether blood vessels are open, narrowed or occluded
bony tissues (like joints, bones, and spine).
such as with a blood clot.
MAMMOGRAPHY (DIGITAL) – State of the art, digital
Mammography produces high-resolution images of breast tissue
using low-dose x-rays. Screening mammography can help detect
potential problems even before they are detectable by touch or
by symptomatic complaint.
5/2014
-6-
LIST OF PROCEDURES
CT – Walk-in Non-contrast
Weight Limit: 440 LB
All locations - Monday - Friday 9:00 am to 4:00 pm Please make sure insurance does NOT require authorization.
Brain Neck, Soft Tissue Spine
• Cervical
Extremities; Upper / Lower
Petrous Bone
• Thoracic
KUB
Sinuses
• Lumbar
Lung CT Low Dose Scan* (*Lung Ct Low Dose Scan not covered by insurance and is paid at time of service.)
CT – Scheduled
Abdomen
Ankle
Appendix
Bone Length
Brain
Chest
• High Resolution
Clavicle
Extremities; Upper / Lower
Facial Bones
Fistulogram
Weight Limit: 440 LB
Foot
Head
Hip
Internal Auditory Canal / Temporal
Kidney / Bladder (KUB)
Knee
Leg
Maxillo-Facial
Neck, Soft Tissue
Orbits
Pelvic
Petrous Bone
Sacro-Iliac Joint
Sinuses
Spine
TMJ Triple Phase
Upper Extremity
Urogram (IVP)
CT Specials
Abdomen Angiogram
Aorta Angiogram
Chest Angiogram
Endograft Angiogram
Enterography
• Cervical
• Thoracic
• Lumbar
Weight Limit: 440 LB
Head / Brain Angiogram
Hip Arthrogram
Lower Extremity Angiogram
Neck Angiogram
Pelvis Angiogram
Renal Angiogram
Upper Extremity Angiogram
Upper Extremity Arthrogram
DEXA Scan (Bone Density)
Weight Limit: 350 LB
Fluoroscopy
Weight Limit: 400 LB
Arthrocentesis
• Small Joint
• Intermediate Joint
• Major Joint
Arthrogram - Fluoroscopy only • Elbow
• Hip
• Shoulder
• Wrist
Arthrogram with MRI / CT
• Ankle
• Hip
• Knee
• Shoulder
• Wrist
5/2014
Barium Enema (ACBE)
• Colostomy
Pain Injection (Marcaine)
Barium Swallow (Esophogram)
Chest (Sniff test)
Sialography
Small Bowel Follow Through (SBFT)
Spine
T-Tube Cholangiogram
Upper GI • 2 or 4 Views
Duodenography
Enteroclysis (Small Bowel Tube)
Esophogram with UGI
• Double contrast (Air & Barium)
• Single contrast (Barium)
Fistulogram / Abscessogram
Hysterosalpingogram (HSG)
IVP (Excretory Urogram)
Lumbar Puncture
• Hip
• Sacro-iliac joint
• Double contrast (Air & Barium)
• Single contrast (Barium)
-7-
Fluoroscopy at Good Samaritan Hospital
Barium Swallow (Modified) Fallopian Catheter
Pharyngeal Speech Evaluation
Biliary Gastro Tube Pharyngogram
Biopsy, Needle
Laryngography Renal / Pelvis Catheter
Bronchography Myelography
Tomography (Allenmore)
Cavernosography Nephrosotomy Urography / Venography
Cystourography (VCUG)
Pancreatic Voiding Cystourogram (VCUG)
Enema, Therapeutic
Perineogram
Esophogram (Modified)
Peritoneogram
Interventional Procedures at Allenmore & Good Samaritan Hospital
Abscess / Biliary Drainage
Angiograms / Venograms
Arterial Embolization
Biopsies*
Central Venous Access
Dialysis Catheter
Gastrostomy
Fluoroscopy Procedures
IVC Filter / Greenfield
Joint Aspiration
Kyphoplasty / Vertebroplasty
Lumbar Puncture* / Spinal Taps
Nephrostomy / Ureteral Stent
Paracentesis
Port Injections
Thoracentesis
Tube Injections
*Also at Puyallup Imaging Center (15th Ave SE)
Mammography
Galactogram
Mammogram
• Screening
• Diagnostic
Weight Limit: 450 LB
Needle Localization
• by Mammo • by Galactogram
Stereotactic Breast Biopsy
MRI
Weight Limit: 550 LB
No MRI
MRI – OK
Brain or Aneurysm clips
Breast Expanders Implanted TENS Neuro Stimulators
Pacemaker
Cardiac & Vascular Stent (conditional)
Insulin Pump (only if removable)
Joint replacements (6 wks post-op)
Mechanical Heart valve (6 wks post-op)
Med-Tronic Pump (ask RAD)
Medication Indwelling Pump (ask RAD)
Metal Rods (6 wks post-op)
Oral Braces
Penile Implant
Surgical Screws / Pins (non-exam area)
Sternal Wires from Bypass
(6 wks post-op)
Abdomen
Ankle
Arm
Biliary Tree
Bone Marrow
Brachial Plexus
Brain
Brain + IAC
Brain & MRA Head
Breast with Limited Chest
Breast Core Biopsy
Breast Localization & Biopsy
Cervical
Chest
Elbow
Foot
Forearm
Hand
Hip
Knee
Leg
Lumbar
Lumbar Plexus
MRCP
MR Enterography
Orbits / Face
Neck, Soft Tissue
Pelvic
Pituitary
Shoulder
Thoracic
TMJ
Wrist
Cholangiopancreatography
Extremity; Upper / Lower
Head
Neck
Pelvis
MRA - Angiogram
Abdomen
Brain
• Venous Circulation 5/2014
-8-
MRA - Arthrogram
Ankle
Elbow
Hip
Knee
Shoulder
Wrist
MRA - Arthrogram at Good Samaritan Hospital
Cardiac
Myocardium
Nuclear Medicine at Good Samaritan Hospital
Bone Scans
HIDA / Biliary Scans
GI Bleed Scans
Lymph Node Injection / Scan
Meckel’s Scan
MUGA / Gated Blood Scan
Myocardial Perfusion Scan
Renal Scan
Thyroid Uptake / Scan
Thyroid Ablation / Treatment
Treadmill Stress Test
VQ Lung Scan
Ultrasound
Abdominal
• Complete
• Limited
• Limited w/Kidneys
Abdominal Aorta
• Medicare Screen
Axilla / Breast
Breast
• Core Biopsy
• Clip Placement
• Cyst Aspiration
• Wire Localization of Nodule
Chest
Extremity; Upper / Lower Fetal Doppler Head
Weight Limit: 500 LB
Hysterosonogram (Saline Color
Flow)
Lymph Node Biopsy
Neck, soft tissue
Parotid Biopsy
Pelvic • Complete
• Limited
• Trans-Vaginal & Trans Abdominal
Pyloric Stenosis (Infants)
Renal Soft Tissue
• Aspiration of Limb
Spinal Canal (Newborns)
Pregnant Uterus
• Under 14 wks
• 14-17 wks
• Over 18 wks
• Limited
• Follow-Up
• Multiple Fetuses
• Biophysical Profile
• Trans-Vaginal
Tendon Sheath Injection
Testicular / Scrotal Thyroid • Cyst Aspiration
• Core Biopsy
• Needle Aspiration with Biopsy
Ultrasound at Good Samaritan Hospital
Cranial
G.I. Endoscopic
Infant Hips (Mary Bridge)
IV Placement
Vascular Scans
Abdominal Aorto-iliac Duplex
Carotid Artery Duplex
Lower Extremity Arterial Duplex
Lower Extremity Segmental Eval/
ABI’s (PPG’s)
Trans-Rectal
Weight Limit: 350 LB
Lower Extremity Venous Thrombosis
Evaluation
Lower Extremity Venous Insufficiency
Evaluation
Mesenteric-Splanchic Artery Duplex
Renal Artery Duplex
Upper Extremity Arterial Duplex
Upper Extremity Venous Duplex
Vascular Scans at MultiCare Vascular
Hemodialysis Access Dopplers
Intra-Cranial Duplex
5/2014
Lower Extremity Arterial with
Exercise
Penile Vessels Duplex
-9-
FOR WALK-IN SERVICES, ONLY SITES AND HOURS
WHERE SERVICES ARE OFFERED ARE LISTED
Patients must understand that they may have to wait for the next available appointment.
Due to some insurance restrictions, we may have to schedule the appointment on a different date.
WALK-IN NON CONTRAST CT HOURS:
Bonney Lake (SR410)
9:00 am to 4:00 pm (Monday – Friday)
Puyallup (222 - 15th Ave SE) 9:00 am to 4:00 pm (Monday – Friday)
Sunrise
9:00 am to 4:00 pm (Monday – Friday)
CT Non Contrast Brain (cerebral / head)
CT Non Contrast Kidney (KUB)
CT Non Contrast Lower Extremity (bone evaluation)
CT Non Contrast Sinuses (complete / limited)
CT Non Contrast Cervical Spine
CT Non Contrast Thoracic Spine
CT Non Contrast Lumbar Spine
CT Non Contrast Upper Extremity (bone evaluation)
CT Non Contrast Low Dose Lung Screening
(*Lung Ct Low Dose Scan not covered by insurance and is paid at time of service.)
Patients may elect to schedule any CT exam at any of our centers during
normal business hours instead of using the walk-in method. Scheduling the
exam guarantees a time slot for a quicker in and out process.
WALK-IN PLAIN FILM HOURS (X-RAY):
Puyallup
Sunrise
Bonney Lake
Medical Building
8:30 am to 5:00 pm (Monday – Friday)
8:00 am to 5:00 pm (Monday – Friday)
8:00 am to 11:45 pm / 12:45 to 4:00 pm (Saturday)
8:30 am to Noon / 1:00 pm to 5:00 pm (Monday – Friday)
WALK-IN CREATININE HOURS:
Puyallup
Sunrise 5/2014
8:30 am to 7:00 pm (Monday – Friday)
8:00 am to 4:00 pm (Monday – Friday)
8:00 am to 11:45 pm / 12:45 to 4:00 pm (Saturday)
- 10 -
INSURANCE COVERAGE
While this list is not all-inclusive, it reflects the majority of the insurance plans we work with. If you have questions,
or do not see your insurance plan listed, please feel free to contact us.
• A&I Benefits (First Choice)
• AARP/Medicare Complete-Secure Horizons
• Aetna
• Ameriben
• AmeriGroup
• Anthem BCBS of CA
• APWU
• BCBS
• Benefit Planners (First Choice)
• Blue Card Plans
• Breast & Cervical Program
• Carpenter's Trust (First Choice)
• Cement Masons & Plasterers Trust (First Choice)
• ChampVA
• Community Health Plan of Washington (CHPW)
• Cigna
• Coordinated Care*
• Definity
• Evercare HMO & PPO
• First Choice Health Admin (Multicare)
• FISERVE Health
• GEHA (First Choice)
• Group Health-Options/Alliant Plus*
• H.E.R.E. Health Trust (First Choice)
• Health Comp (First Choice)
• Health Net Pearl-MedAdvantage
• Her Peace of Mind
• HMA - Healthcare Management
• Humana / GoldChoice MedAdvantage
• ILWU International Longshore & Warehouse
Union (First Choice)
• KPS (First Choice)
• L&I (Worker's Comp)
• LEOFF Health & Welfare Trust (First Choice)
• Loomis Benefits West (First Choice)
• Mail Handlers Benefit Plan (First Choice)
• Medicare
• Meritain Health (First Choice)
• Midwest National Life Insurance
• Molina Healthcare*
• Mountain States Administrative Services
• National Rural Electric Coop (First Choice)
• NPN (Northwest Physician's Network)
• NW Administrators (Cigna)
• NW Iron Workers (First Choice)
• NW Laborer's
• NW Plumbers & Pipe Fitters (First Choice)
• NW Roofers Trust (First Choice)
• NW Sheet Metal Workers (First Choice)
• ODS (First Choice)
• Operating Engineers (First Choice)
• OWCP - Federal Workers Compensation
• Pacific Source (First Health)
• Pacificare - Secure Horizons
• Painter's Trust (First Choice)
• PHCS
• Premera Blue Card - Out of State
• Premera*
• Principal Financial Group (First Choice)
• Providence Health (First Choice)
• Provider One
• Puget Sound Electrical Workers PSEW (First Choice)
• Puget Sound Health Partners (PSHP)
• Puget Sound Health Partners/Columbia United Providers
• Railroad Medicare
• RBMS
• Regence
• Regence MedAdvantage
• Retail Clerks (First Choice)
• Seattle Plumbers & Pipe Fitters (First Choice)
• Secure Horizon's
• Sound Health & Wellness (Retail Clerks) (First Choice)
• Sound PATH
• Sterling Medicare
• Teamsters
• Triwest
• Trusteed Plan TPSC (First Choice)
• UHC Community Plan
• Unicare (First Choice)
• United Employee's Benefit Plan UEBT (First Choice)
• United Healthcare
• US Family Health
• WA Firefighter Commissioner Association (First Choice)
• WA Teamster's / NW Administrators
• Western Benefits (First Choice)
• Worker's Comp - Self Insured
• Zenith Administrators WA County Ins Pool
(First Choice)
*Not all plans - please call for details.
SELF-PAY DISCOUNT POLICY
(No Insurance Coverage for DINW Services)
Pay in full at the time of service or within 30 days and receive a 40% discount.
Call our Billing Department at 253-581-2550 for complete details.
FINANCIAL ASSISTANCE PROGRAM
Diagnostic Imaging Northwest provides financial assistance for balances $200 or more.
If you believe that you might qualify for financial assistance, please contact our billing office for information by calling:
253-581-2550 ext. 6122
For your convenience there are business cards available at the front desk with this number on them.
5/2014
- 11 -
Can Patient Sign a
WAIVER?
No
INSURANCE COMPANY
AARP/MEDICARE Complete
UHC West
Aetna
800.547.4457
ALLIANT PLUS (First Choice-Group Health)
888.767.4670
AMERIBEN
Schedule Out
2 weeks
cpt specific
Must check each plan for details
Medsolutions
888.693.3211
A&I Benefits (First Choice)
EXAM
CT's and MRI's
No
CT's and MRI's
1 week
cpt specific
Yes
Yes
Pd @ level 2 benefits
CT's and MRI's
1 week
CT's and MRI's
1 week
Must have out of network benefits
800.786.7930
Yes
CT's and MRI's
1 week
Amerigroup (Healthy Options)
MedSolutions
800.454.3730
No
CT's and MRI's
1 week
ANTHEM BCBS of CA (AIM) 800.274.7767
Yes
cpt specific
CT's and MRI's
1 week
grouper specific
ANTHEM BCBS of NEVADA (AIM)
Prefix LQP
877.291.0366
Yes
APWU
Yes
CT's and MRI's
1 week
Benefit Planners (First Choice)
866.868.7409
Yes
CT's and MRI's
1 week
BCBS of Georgia- CKL (AIM) 866.714.1103
Yes
CT's and MRI's
(American Postal Worker's Union)
888.693.3211
CT's and MRI's
1 week
grouper specific
1 week
grouper specific
BCBS Kroeger - KROAN (AIM-some plans)
800.737.9261
Yes
MRI Spine/Brain/ST Neck
No Auth for all other MRI/CT's
1 week
BCBS of N.Carolina (AIM)
BCBS of S.Carolina (NIA)
BCBS of Pennsylvania - CDQ
Comcast
BCBS of N.Carolina (AIM)
Yes
Yes
Yes
CT's and MRI's
CT's and MRI's
CT's and MRI's
1 week
1 week
1 week
Yes
CT's and MRI's
866.455.8414
866.500.7664
(AIM)
866.745.1791
866.455.8414
1 week
grouper specific
Bridgespan - Regence
[AIM]
[BHealth]
Yes
CHPW (Community Health Plan)
No
MedAdvantage / H.Options
800.440.1561
Essentials Gold / Silver [BHealth]
5/2014
CT's and MRI's
1 week
grouper specific
All MRI's
No auth for CT's
2 weeks
grouper specific
5/7/2014
- 12 -
INSURANCE COMPANY
Cigna
Must check each plan for details
MedSolutions
Can Patient Sign a
WAIVER?
No
COLUMBIA UNITED PROVIDERS (NPN)
253.573.1880
No
All MRI's
No auth for CT's
Coordinated Care
All Plans
No
CT's and MRI's
(NIA) 800.727.8627
cpt specific
1 week
1 week
grouper specific
Definity
DSHS
Schedule Out
1 week
EXAM
CT's and MRI's
[For Retro-up to 10 days]
888.444.4314
800.562.3022
(Qualis)
Yes
CT's and MRI's
1 week
No
CT Head, Abdomen, Pelvis
MRI Brain, C-Spine, L-Spine, Extremity, Breast
FISERVE HEALTH
2 weeks
Yes
CT's and MRI's
1 week
1 week
GEHA (First Choice)
MedSolutions
888.693.3211
Yes
CT's and MRI's
$100 penalty for pt if no auth
Great West [CIGNA]
MedSolutions
888.693.3211
No
CT's and MRI's
Group Health-Options/Alliant Plus
Must have out of network benefits
Health Comp (First Choice)
800.960.7247
Health Net of Oregon
MedSolutions
Humana
Pd @ level 2
1 week
CT - grouper specific
MRI - cpt specific
Yes
ANY EXAM OVER $500.00
Yes
CT's and MRI's
866.825.1550 [RADConsult]
Yes
Gold Choice / MedAdvantage / Gold Plus
(Aim)
CT's and MRI's
PPO plan - No Auths
No Auth - MRI Breast
1 week
1 week
cpt specific
KPS (First Choice)
LEOFF
1 week
cpt specific
800.552.7114
grouper specific
CT's and MRI's
1 week
Yes
MRI Breast / All MRA's
No auth for CT's
1 week
Yes
CT's and MRI's
1 week
MRI Head/spine/extremities
1 week
L&I (Worker's Comp)
Processed thru Qualis
No
800.848.0811 Qualis 800.541.2849 Diane Walker 360.902.5182
CT Head
Lifewise (AIM)
866.666.0776
Essential Gold, Silver, Bronze [BHealth]
Yes
Mail Handlers Benefit Plan (First Choice)
800.410.7778
Yes
CT's and MRI's
1 week
Meritain Health (First Choice)
Yes
CT's and MRI's
Must check each plan for details
1 week
Yes
CT's and MRI's
1 week
800.925.2272
Moda Health (First Choice) (AIM)
CT's and MRI's
1 week
grouper specific
grouper specific
Molina
800.665.1029
Healthy Options / Medicare Options Plus
No
CT's and MRI's
2 weeks
CT=all con MRI=cpt
5/7/2014
5/2014
- 13 -
INSURANCE COMPANY
Mountain States Administrative Services
520.722.0811
Can Patient Sign a
WAIVER?
Yes
EXAM
CT's and MRI's
No
CT's and MRI's
NALC (CIGNA) [MedSolutions] 888.693.3211
Schedule Out
1 week
1 week
CPT specific
National Rural Electric Coop (First Choice)
800.231.6935
Yes
CT's and MRI's
1 week
NW Iron Workers (NXW Prefix)
ICM 800-862-3338
Yes
CT's and MRI's
1 week
NW Sheet Metal Workers (CIGNA)
No
CT's and MRI's
1 week
CPT specific
OWCP - Federal W.Comp
ACS #614402800
850.558.1818
Yes
MRI Head/spine/extremities
1 week
Pacific Source (First Health)
877.291.0510
Yes
CT's and MRI's
1 week
CT Head only
PREMERA (AIM)
866.666.0776
Yes
CT's and MRI's
1 week
Heritage / Dimensions / Lifewise / Preferred Gold, Silver, Bronze / Multi-State
No auth or RQI for ALK or MSJ
PREMERA BLUE CARD - OUT of STATE
Must check each plan for details
Yes
CT's and MRI's
Project Access
Yes
CT's and MRI's
1 week
Providence Health (First Choice) (AIM)
Yes
CT's and MRI's
1 week
Puyallup Tribal Health
Yes
CT's and MRI's
1 week
REGENCE (AIM)
877.291.0509
Med Advantage / Classic / Basic
No
CT's and MRI's
1 week
Sound Path
253.779.8830
Sound / Peak Plus / Alpine / Charter / Apex
No
ALL MRI'S / MRA's / CTA's
No Auth for CT's
Steelworkers
(NIA)
Yes
CT's and MRI's
UHC West AARP/MEDICARE Complete
No
CT's and MRI's
1 week
UHC Community Plan (H.Options)
No
CT's and MRI's
1 week
UHC MedAdvantage (Medicare)
No
CT's and MRI's
1 week
UHC Military West (Tricare)
No
Ordered from Madigan=
No Auth needed
1 week
US Family Health
800.585.5883
No
CT's and MRI's
1 week
1 week
grouper specific
grouper specific
1 week
1 week
CPT specific
5/7/2014
5/2014
- 14 -
INSURANCE COMPANY
Veterans Administration
Can Patient Sign a
WAIVER?
EXAM
866.458.6630
No
All Studies
Will be scheduled by VA Rep with Auth given at time of scheduling
Worker's Comp - Self Insured
Yes
(Sedgwick, Eberle Vivan, Broadspire, Puget Sound, etc)
Verbal Auth from Claims Manager
MRI Head/spine/extremities
CT Head
Schedule Out
n/a
1 week
NO PRIOR AUTHORIZATIONS REQUIRED
Blue Card Plans for -- Check Insurance Card carefully
Anthem
(MCZAN)
Kansas
Minnesota
Illinois - Non Boeing Plans
Michigan
Texas
Tennessee
Massachusetts Idaho
Carpenter's Trust (First Choice)
Must not be Chiropractor ordering exam
Cement Masons & Plasterers Trust (First Choice)
ChampVA
Cigna - Medicare Plan only
Employee Benefit Management (EBMS--First Choice)
First Choice Health Admin (Multicare)
Plans begin with: 870
Group Health - PPO plans only
Health Net Pearl - MedAdvantage
H.E.R.E. Health Trust (First Choice)
HMA - Healthcare Management
Plans begin with: 9HP
ILWU International Longshore & Warehouse Union (First Choice)
Loomis Benefits West (First Choice)
Medicare
Midwest National Life Insurance
MVA accounts
Patient will be asked to sign a waiver - we will bill once as a courtesy
NW Laborer's (Premera TSTP)
NW Plumbers & Pipe Fitters (First Choice)
NW Roofers Trust (First Choice)
Operating Engineers (First Choice)
Painters Trust (First Choce)
Premera = BYR, BCU
Principal Financial Group (First Choice)
Puget Sound Electrical Workers PSEW (First Choice)
Railroad Medicare
Regence - Boeing / FEP / Kent Fire / KingCare / Pierce County / City of Tacoma / Uniform Medical
Regence Group Administrators / Health Management Administrators
Seattle Plumbers & Pipe Fitters (First Choice)
Sterling Medicare
Trusteed Plan TPSC (First Choice)
UMR (First Choice)
Unicare (First Choice)
Western Benefits (First Choice)
Zenith Administrators WA County Ins Pool (First Choice)
PLANS THAT WE DO NOT TAKE at this time
Group Health - Core or non-First Choice plans
Molina - Marketplace [Gold / Silver] WAIVER REQUIRED = patient will be billed
Premera - MedAdvantage
5/2014
5/7/2014
- 15 -
GENERAL STUDY PREPARATIONS
CT Scan without any Contrast
No prep.
Fistulogram – No solid foods 4 hours prior to exam, clear liquids 2 hours prior.
CT Scan with IV Contrast
No solid foods 4 hours prior to exam. Clear liquids only 2 hours prior to exam.
Creatinine level may be required
CT Scan with IV and Oral Contrast (Abdomen, Appendix &/or Pelvic)
Pick up Oral contrast the day prior to exam at any imaging center
No solid foods after ingesting 1st bottle of contrast. Clear liquids only 2 hour prior to exam.
Creatinine level may be required
CT Enterography
Clear liquids 12 hours prior. NPO 4 hours prior.
Arrive 1 hour 30 minutes prior to appt time to drink oral contrast (Volumen)
Creatinine level may be required
CTA – Angiograms
No solid foods 4 hours prior to exam. Clear liquids only 2 hours prior to exam.
Creatinine level may be required
CT Lab Protocol
Any “Yes” – requires creatinine level within the last 4 weeks
Diabetic
Current Anemia Tx
Prior MI or Hx of CHF
Kidney/Renal Dx
Significant Cardiovascular Dx
Over Age 59 (60+)
Significant Liver Dx Cirrhosis with Hypoalbuminemia
Chemo Tx within 30 days
Taking Diuretics
Daily NSAIDs/Motrin/Ibuprofen
GFR = 60+ Ok for contrast study
GFR = 30 – 49 IV Hydration required
GFR = 50 – 59 Possible Hydration
GFR = Below 30 – schedule without contrast
Arthrograms using Fluoroscopy followed by CT or MRI
By MRI: Scout Films may be required.
If on blood thinners – need to stop 4 days prior with PT/INR day/morning of exam.
Comfortable clothing without metal, no jewelry.
DEXA Scan
No calcium day of exam. No metal on clothing. Must wait 1 week after contrast exam.
Fluoroscopy Arthrocentesis
• If on blood thinners – need to stop 4 days prior with PT/INR day/morning of exam.
5/2014
- 16 -
Fluoroscopy Continued
Barium Enema
• Two (2) day prep. Call for instructions: 253-841-4353.
Hysterosalpingogram - HSG
• Bathe & douche morning of exam - No unprotected intercourse from start of period until after exam.
We don’t want to risk a viable pregnancy with radiation.
• Skip meal prior to exam
IVP by Fluoro
• Clear liquids 24 hours prior to exam, then NPO 2 hours prior.
• If on blood thinners – need to stop 4 days prior with PT/INR day/morning of exam.
Lumbar Puncture – LP
• NPO 4 hours prior to exam.
• Morning meds may be taken with a sip of water only.
• If on blood thinners – need to stop 4 days prior with PT/INR day/morning of exam
Pain Injection – Marcaine Injection
• If on blood thinners – need to stop 4 days prior with PT/INR day/morning of exam
Sialography
• Clear liquids 2 hours prior to exam
Barium Swallow
Duodenography
EnteroclysisEsophogram
Fistulogram Spine
Upper GI
SBFT- Small Bowel Follow Thru
• NPO 8 hours prior
• Morning meds may be taken with a sip of water only.
• No gum, mints or cigarettes
Mammograms (Screening & Diagnostic) No deodorant, perfume or powder. Wear two piece outfits.
Galactogram
No deodorant, perfume or powder. Wear two piece outfits.
Needle Loc by Mammogram
Skip meal just prior to exam
No deodorant, perfume or powder. Wear two piece outfits.
Stereotactic Breast Biopsy (Must have all prior scans available at time of biopsy)
Skip meal just prior to exam
No deodorant, perfume or powder. Wear two piece outfits.
If on blood thinners – need to stop 4 days prior with PT/INR day/morning of exam
Wear old bra or sports bra – will be leaving with ice packs
MRI Scan with or without Gadolinium
Scout films required if patient had previous eye injury from working with metal, grinding or welding equipment and sought
medical attention. Performed day before MRI (no Saturdays).
No pacemakers, Surgical clips in head or Neuro-stimulators.
No metal or jewelry, remove piercings.
Creatinine level may be required (see below).
MRI Lab Protocol
Any “Yes” – requires creatinine level within the last 6 months
Diabetic
Kidney/Renal Dx
Prior MI or Hx of CHF Significant Cardiovascular Dx
GFR = 30+ Ok for contrast study
Chemo Tx within 6 mo
Over Age 59 (60+)
GFR = Below 30 schedule without contrast
MRI Scan – Biliary Tree
No solid foods for 4 hours prior.
Scout films & no metal or jewelry, remove piercings.
Creatinine level, scout films may be required
5/2014
- 17 -
MR Angiogram (Abdomen and MRCP)
Nothing by mouth for 4 hours prior.
Creatinine level may be required
Scout films & no metal or jewelry, remove piercings.
MR Angiogram (Except Abdomen or MRCP)
Scout films may be required.
MRI Scan – Breast Biopsy
Skip meal prior to appointment.
If on blood thinners – need to stop 4 days prior with PT/INR day/morning of exam.
Wear old Bra. Scout films & no metal or jewelry, remove piercings.
Ultrasound Abdomen
• Fat free diet day prior to exam List of Fat Free Diets - see attached list.
• NPO after midnight (or 6 hours minimum)
Breast
• No deodorant, powder or perfume
Breast Biopsy, Breast Needle Locs
• If on blood thinners – stop 4 days prior and PT/INR morning of exam
• No deodorant, powder or perfume
• Wear loose fitting bra
Hysterosonogram
• Bathe and douche morning of exam
• Skip meal prior to exam
• No unprotected intercourse from start of period until after exam.
We don’t want to risk a viable pregnancy with radiation.
Pelvic
• If over age 18 – we will do abdominal & transvaginal exam (if medically indicated)
• 32 oz of water – 1 hour prior to exam and hold bladder
• Patient will be able to empty bladder prior to transvaginal portion
Pregnancy (complete, follow-up or limited)
• 1st Trimester – 32 oz of water - 1 hour prior to exam and hold bladder
• 2nd Trimester - 16 oz of water - 1 hour prior to exam and hold bladder
• 3rd Trimester – No Water
• Must be minimum of 18 weeks for fetal survey
• LMP & EDC on all patients
• HCG level required if ruling out ectopic pregnancy
Renal
• 16 oz of water – 30 to 45 minutes prior to exam and hold bladder
Vascular Ultrasound Carotid, Upper & Lower Extremity Arterial & Venous Scans
• No prep required
Renal, Mesenteric-Splanchnic, Abdominal Aorto-iliac Arterial Scans
• No solid foods after midnight. No gum or smoking after midnight.
If your exam is not listed, please call 253-841-4353 to confirm.
Many other routine exams require no prep.
To order additional General Study Prep sheets,
schedule an appointment or any referral questions,
Call: 253-841-4353
5/2014
- 18 -
ABDOMEN ULTRASOUND PREP
Fat-free diet day prior to appointment
Nothing to eat or drink after midnight | No gum, mints or cigarettes
FAT FREE FOODS
Vegetables: Most vegetables contain little fat. The types with only trace amounts include alfalfa sprouts,
artichokes, asparagus, beets, cabbage, eggplant, mushrooms, potatoes, pumpkin and tomatoes. Other essentially
fat-free vegetables include cauliflower with just .3 g of fat per ½-cup serving, carrots with .5 g of fat per 3.5-oz.
serving and broccoli with .3 g per ½-cup serving. NO BUTTER; try lemon for seasoning.
Fruits: Oranges, prunes, peaches and grapefruit are essentially fat-free. Most fruit juices and applesauce
are also fat-free. Other fruits, such as bananas, melon, grapes, strawberries, pineapple and pears contain just
minuscule amounts of fat.
Protein: Egg whites are fat-free as all the fat in the egg is contained in the yolk. Whey protein powder is
another fat-free protein, but check containers to make sure you choose a brand with no additives that may
raise the fat content. Beans, specifically black, lima and lentils, contain essentially no fat per serving.
Dairy: Non-fat dairy products contain no fat. Skim milk, non-fat yogurt, non-fat cottage cheese and non-fat
kefir offer satiating protein and bone-building calcium.
Shellfish: Clams, lobster, scallops, shrimp are low in fat. (use lemon - no butter)
Grains: Puffed wheat and rice cereals with no additional ingredients contain no fat. Rice noodles are another
fat-free option that may be added to Asian soups and salads. Enjoy air-popped popcorn as a fat-free snack.
Liquids: Water, coffee and tea contain no fat. Sodas and fruit drinks are also free of fat, but still provide
considerable calories while offering little in the way of nutrients.
Condiments & Spices: Fat-free labeled dressings (salad, mayonaise, sour cream), catsup, salsa, honey,
mustard, garlic, bouillons, steak and hot sauces (read label), most spices.
Resources: http://whatscookingamerica.net/NutritionalChart.htm; fatfree.com; livestrong.com
5/2014
- 19 -
NSAIDS: NON-STEROIDAL
ANTI-INFLAMMATORY DRUGS
Aspirin (Anacin, Ascriptin, Bayer, Bufferin, Ecotrin, Excedrin)
Meclofenamate sodium (Meclomen)
Choline and magnesium salicylates (CMT, Tricosal, Trilisate)
Mefenamic acid (Ponstel)
Choline salicylate (Arthropan)
Meloxicam (Mobic)
Celecoxib (Celebrex)
Nabumetone (Relafen)
Diclofenac potassium (Cataflam)
Naproxen (Naprosyn, Naprelan*)
Diclofenac sodium (Voltaren,Voltaren XR)
Naproxen sodium (Aleve, Anaprox)
Diclofenac sodium with misoprostol (Arthrotec)
Oxaprozin (Daypro)
Diflunisal (Dolobid)
Piroxicam (Feldene)
Etodolac (Lodine, Lodine XL)
Rofecoxib (Vioxx)
Fenoprofen calcium (Nalfon)
Salsalate (Amigesic, Anaflex 750, Disalcid, Marthritic,
Mono-Gesic, Salflex, Salsitab)
Flurbiprofen (Ansaid)
Ibuprofen (Advil, Motrin, Motrin IB, Nuprin)
Indomethacin (Indocin, Indocin SR)
Ketoprofen (Actron, Orudis, Orudis KT, Oruvail)
Magnesium salicylate (Arthritab, Bayer Select, Doan’s Pills,
Magan, Mobidin, Mobogesic)
Sodium salicylate (various generics)
Sulindac (Clinoril)
Tolmetin sodium (Tolectin)
Valdecoxib (Bextra)
Note: Some products, such as Excedrin, are combination drugs (Excedrin is acetaminophen, aspirin, and caffeine).
Note: Acetaminophen (Paracetamol; Tylenol) is not on this list. Acetaminophen belongs to a class of drugs called analgesics (pain
relievers) and antipyretics (fever reducers). The exact mechanism of action of acetaminophen is not known. Acetaminophen relieves
pain by elevating the pain threshold, that is, by requiring a greater amount of pain to develop before it is felt by a person. It reduces
fever through its action on the heat-regulating center of the brain. Specifically, it tells the center to lower the body’s temperature
when the temperature is elevated. Acetaminophen relieves pain in mild arthritis but has no effect on the underlying inflammation,
redness and swelling of the joint.
Paracetamol, unlike other common analgesics such as aspirin and ibuprofen, has no anti-inflammatory properties, and so it is not a
member of the class of drugs known as non-steroidal anti-inflammatory drugs or NSAIDs.
* Naproxen Sodium
“ Naprelan contains naproxen sodium, a member of the arylacetic acid group of nonsteroidal anti-inflammatory drugs (NSAIDs)”
“The chemical name for naproxen sodium is 2-naphthaleneacetic acid, 6-methoxy-a-methyl-sodium salt, (S).”
5/2014
- 20 -
LIST OF WATER PILLS / DIURETICS
-AAbbolactone®
Acelat®
Acetamox®
Aldace®
Aldactide®
Aldactone®
Aldactone A
Aldactazide®
Alderon®
Aldopur®
Aldoril®
Aldospirone®
Almatol®
Altex®
Anicar®
Apo-Hydro®
Aquareduct®
®
-BBumetanide
Bumex
-CCanephron
Capozide®
Crinuryl®
-DDehydratin®
Demadex
Deverol®
Diacarb
Diamox®
Diatensec®
Dichlotride®
Dilamox®
Diluran®
5/2014
Dira®
Diuramid®
Duraspiron®
Dyazide®
-GGlaucomide®
Glauconox®
Glaupax®
-EEdecril®
Edecrin®
Edecrina®
Ederen®
Elodrine®
Endecril®
Endural®
Errolon®
Esidrix
Eumicton®
Euteberol®
Eutensin®
Еxtur®
-HHidromedin®
-FFarsix®
Finuret®
Fludeх®
Fluidrol®
Fluss®
Fonurit®
Franyl®
Froop®
Frumex®
Frumide®
Frusedan®
Frusehexal (Hexal)®
Frusema®
Frusol®
Furosemide
hydrochlorothiazide
HydroDIURIL®
Hydromedin®
HydroSaluric®
Hypothiazid
-IIndaflех®
Indap
ndapamide Аrifоn®
Inderide®
Ipamix®
-LLacalmin®
Lacdene®
Laractone®
Lasix
Lediamox®
Lo-Aqua®
Lopressor HCT®
Lоrvаs®
Lozol®
-MMaxzide®
Melarcon®
Меtindamide®
metolazone
Microzide®
Mingit®
Moduretic®
-NNаtriliх®
Natrionex®
Nefurofan®
Nephramid®
-OOretic®
Otacril®
-RRenamid®
Reomax®
-SServier®
spironolactone
Sulfadiurine®
-TTaladren®
Таndiх®
Timolide®
Triampur
Torsemide
-UUregit®
Uregyt
-VVaseretic®
-ZZaroxolyn
- 21 -
IV HYDRATION FOR LOW GFR PATIENTS
REQUIRING CT IMAGING WITH IV CONTRAST
As an added convenience to the medical community and for patient ease, Diagnostic Imaging Northwest (an
alliance of Medical Imaging Northwest and MultiCare Good Samaritan Hospital) is proud to offer IV hydration
for low GFR patients requiring CT IV contrast imaging at the Puyallup office near Good Samaritan Hospital.
Risk factors for Contrast-Induced Nephropathy (CIN) include:
• Age > 60 yrs.
• History of contrast-induced nephropathy
• Renal transplant
• Diabetes • Chronic kidney disease
• Acute myocardial infarction
• Congestive heart failure
• Hypertension or hypotension
• Anemia
• History or multiple myeloma
• IV contrast in past 72 hours
• High volume of intravenous contrast
(greater than 2mL/kg)
• Conditions associated with dehydration/
intravascular volume depletion
(e.g. sepsis, cirrhosis, pancreatitis)
• Long term use of non-steroidal antiinflammatory drugs (NSAIDS), Celebrex
(celecoxib), aminoglycosides, amphotericin B,
cisplatin, cyclosporine, diuretics, lithium,
metformin, methotrexate
• Calculated glomerular filtration rate (GFR)
<60mL/min.
If age is the only factor, IV hydration is unnecessary unless GFR is less than 50mL/min.
• All CT patients can be accommodated at our imaging facility except in the case of:
• Known difficult venous access (tough sticks)
• Contrast reaction patients
Appointments may be scheduled through our Central Phone: 253-841-4353
Scheduling Hours: 7:00 am to 6:00 pm (M-F)
Pre-Registration Phone: 253-446-3971 | Central Fax: 253-446-3973
IV Hydration Services offered at: Puyallup Imaging Center
5/2014
222 15th Avenue SE, Puyallup,WA 98372-3754
- 22 -
5/2014
- 23 -
w+w/o**
w+w/o**
w+w/o
w+w/o**
w+w/o**
w+w/o
without
without
without
without
w+w/o
without
without
without
without
Abdomen
Brain
Breast w/ Limited Chest
Cervical
Thoracic
Lumbar
Shoulders
Elbows
Wrists
Hands
Pelvis/SI Joint
Hips
Knees
Ankles
Feet
w+w/o
w+w/o
w+w/o
without
w+w/o(<8 yrs)
w+w/o(<8 yrs)
without
without
without
without
without
without
without
without
without
Hx Surgery to
Exam Site
w+w/o
w+w/o
w+w/o
w+w/o
w+w/o
w+w/o
w+w/o
w+w/o
w+w/o
w+w/o
w+w/o
w+w/o
w+w/o
w+w/o
w+w/o
w+w/o
w+w/o
w+w/o
w+w/o
w+w/o
w+w/o
without
w+w/o
without
without
without
without
without
without
without
without
without
without
without
without
No specified
exceptions
** MS Protocol (Multiple Sclerosis)
Only schedule MRI’s with & without or without contrast.
Only on a rare occasion will you schedule with contrast only.
Hx Sx Exam Site = History of surgery to exam site
Hx Cancer = all cancer except Basal Cell Skin Cancer
Enterography = MRI abdomen + pelvis without contrast
w+w/o
Lab Protocol on Contrast Exams if:
Over 60 - or Diabetic - or Renal / Kidney Disease - or Significant Heart Disease - or Chemotherapy in last 6 months
> If yes to above - need Creatinine level within last 6 months
Estimated GFR = 30+ Contrast is given | Estimated GFR = -30 No contrast given
* Osteomyelitis = XR within 2 weeks of MRI
Boney/Soft Tissue Mass = XR within 4 weeks of MRI
Exceptions: No XR Required for Soft Tissue Neck, Baker or Ganglion Cyst
or Prior CT scan of area
Hx Cancer
If patient has >>
*Soft Tissue
Mass, Nodules,
Neoplasms
Infection,
*Osteomyelitis,
*Bone tumor,
Inflammatory
Arthritis
w+w/o
Guideline only -- exceptions always exist
MRI GENERAL GUIDELINES
MRI CPT CODING GUIDE
FOR PRIOR INSURANCE AUTHORIZATION ONLY
• 70553 Brain w/ & w/o contrast
• 72156 Cervical w/ & w/o contrast
• 70336 TMJ (UNI or BILAT)
• 70543 Orbit, Face & Neck,
Carotids (pituitary, IAC’s)
• 70546 Angio, Head
• 70549 Angio, Neck
• 71552 Chest
• 71555 Angio, Chest
• 72157 Thoracic Spine w/ & w/o contrast
• 73223 Upper Extremity, joint (shoulder, elbow, wrist, hand) w/ & w/o contrast
• 73220 Upper Extremity, other than joint
(humerus, forearm) w/ & w/o contrast
• 77021, 19103 & 19295 Breast Biopsy
• 77059 & 71550-52 Bilateral Breast
*ABDOMEN
STUDY
includes upper quadrants only
• 72158 Lumbar w/ & w/o contrast
ABDOMEN STUDY*
PELVIS STUDY*
• 74183 Abdomen w/ & w/o contrast
• 74181 Cholangiopancreatography
• 74185 Angio, Abdomen w/ & w/o contrast
• 74181 Entrography
• 72197 Pelvis w/ & w/o contrast
• 72198 Angio, Pelvis w/ & w/o contrast
ANGIOGRAPHY
• 70546 MRA Head
• 70549 MRA Neck
• 71555 MRA Chest
• 73225 MRA Upper Extermity
• 74185 MRA Abdomen
• 74181 Cholangiopancreatography
• 73725 MRA Lower Extermity
*PELVIS
STUDY
includes lower quadrants only
• 73720 Lower Extremity, other than joint
(thigh, lower leg, foot) w/ & w/o contrast
• 73725 Angio, Lower Extremities
• 73723 Lower Extremity, joint (hip, knee,
ankle, foot) w/ & w/o contrast
ARTHROGRAMS
(Fluoroscopy Injection & MRI)
• 21116 & 70336 TMJ
• 23350 & 73222 Shoulder
• 24220 & 73222 Elbow
• 25246 & 73222 Wrist
• 27096 & 73722 SI Joint
• 27093 & 73722 Hip
• 27370 & 73722 Knee
• 27648 & 73722 Ankle
Diagnostic Imaging Northwest
Puyallup | Bonney Lake | Sunrise
Imaging Centers
Phone: 253-841-4353 | Fax: 253-446-3973
5/2014
- 24 -
5/2014
- 25 -
Mass / Tumor
Pituitary
Sinus
Spine (C, T, L)
Pain / Fracture / Trauma
Hematuria / Flank pain / r/o Stones
Bone Pain / Fracture / Trauma
Infection / Mass
Mass / Tumor
Mass / Tumor
Mass / Tumor (Rare)
Facial Bones
Foot
Hip
IAC w/Temporal
IVP
Knee
KUB (Abdomen/Pelvis)
Leg
Neck Soft Tissue
Orbits
*Pelvic
CTAs:
Abdomen/Pelvis
Chest
#Enterography
Sinusitis
Pain / Fracture
Pain / Mass / Tumor (MRI Better Exam)
Hematuria (Urologist)
(MRI Better Exam for Hematoma/Cellulitis
Osteomylitis/Soft Tissue Mass/ Stress Fx/
Muscle or Tendon Injury)
MRI is Exam of choice for TMJ
RbMets (MRI Better Exam)
Triple Phase - Pancreactic Protocol + Oral Contrast
r/o Epigastric Hernia + Oral Contrast
w+w/o (Lab Protocol May Apply)
NOTES:
# Volumen contrast only
*Oral contrast with these studies
Fracture / Pain
Pain / Trauma + Oral Contrast / r/o Hernia
+Oral Contrast Fracture (No Oral Contrast)
Pain / Fracture / Trauma
Abd Aortic Aneurysm (AAA) / Dissection
Aortic Dissection / Pulmonary Embolism
Small bowel disorder (GI doctor)
Mass / Infection (MRI Better Exam)
Mass / Tumor
Mass / Swelling
Graves Dx / Optic Nerve (MRI Better Exam)
Mass / Infection / Non-Bone Pain + Oral
Contrast
MRI Better Exam
Trauma / Fracture
Pain / Fracture / Trauma
Fracture / Pain
Inner Ear / Mastoids
Mass / Infection
Extremities
CVA / Trauma / Headache / Seizures
Pulmonary Nodule Follow-Up
Interstitial Lung (ILD) / Fibrosis
r/o Hernia + Oral Contrast
r/o Hernia + Oral Contrast
Pain / Fracture / Trauma
Pain / Hx CA / Elevated LFT’s + Oral Contrast
Pain / Hx CA / Diverticulitis + Oral Contrast
Mass / Tumor
RLQ Pain / Fever + Fast Prep Oral Contrast
r/o Mets (MRI Better Exam)
Mass / Hx CA / Abn CXR / Cough
*Abdomen
*Abdomen/Pelvis
Ankle
Appendix
Brain
Chest
Chest-High Res
Without IV
With IV % (Lab Protocol May Apply)
CTs
Guideline only -- exceptions always exist
CT GUIDELINES
CT CPT CODING GUIDE
FOR PRIOR INSURANCE AUTHORIZATION ONLY
• 70470 Brain (Head) w/ & w/o contrast
• 70486 Sinus, Limited Maxillofacial
• 70488 Face/Maxilla/Mand. w/ & w/o contrast
• 70492 Neck, Soft Tissue w/ & w/o contrast
• 70496 Angio, Head
• 70498 Angio, Neck
• 70482 Orbits, IAC’s and Temporal Bones
w/ & w/o contrast
• 72127 Cervical Spine w/ & w/o contrast
• 71270 Chest w/ & w/o contrast
• 71275 Angio, Chest
• 72130 Thoracic Spine w/ & w/o contrast
• 73202 Upper Extremity w/ & w/o contrast
• 73206 Angio, Upper Extremity
ABDOMEN STUDY
includes upper quadrants only
• 74170 Abdomen w/ & w/o contrast
• 74175 Angio, Abdomen (Rental)
• 72133 Lumbar Spine w/ & w/o contrast
• 74178 Abdomen Pelvis w/ & w/o contrast
DEXA Scan
• 76070 Bone Density Study
ANGIOGRAPHY
• 70496 CTA Head
• 70489 CTA Neck
• 71275 CTA Chest
• 73206 CTA Upper Extermity
• 74175 CTA Abdomen
• 72191 CTA Pelvis
• 73706 CTA Lower Extermity
ABDOMEN STUDY
PELVIS STUDY
PELVIS STUDY
includes lower quadrants only
• 72194 Pelvis w/ & w/o contrast
• 72191 Angio, Pelvis
• 74150 & 72192 KUB
(Kidney, ureter, bladder)
• 74178 Abdomen Pelvis w/
& w/o contrast
• 73702 Lower Extremity w/ & w/o contrast
• 73706 Angio, Lower Extremities
ARTHROGRAMS
(Fluoroscopy Injection & CT)
• 21116 & 70487 TMJ
• 23350 & 73201 Shoulder
• 24220 & 73201 Elbow
• 25246 & 73201 Wrist
• 27096 & 73701 SI Joint
• 27093 & 73701 Hip
• 27370 & 73701 Knee
• 27648 & 73701 Ankle
Diagnostic Imaging Northwest
Puyallup | Bonney Lake | Sunrise
Imaging Centers
Phone: 253-841-4353 | Fax: 253-446-3973
5/2014
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5/2014
6/28/2013
- 27 -
Anatomic survey and dating +
Core images – see above +
Maternal adnexae +
Estimated Gestational Age +
Estimated Fetal Weight +
NOTE: DINW does NOT perform OB Ultrasounds solely for the
purpose of obtaining fetal face picture (Keepsake Ultrasound). There
must be a medical indication for the exam. This would violate federal
regulations and could jeopardize our accreditation.
Fetal anatomic survey (if less than 18 weeks a complete OB US does not usually
include a fetal anatomic survey but is still a complete if it’s the patients first
examination).
Includes:
COMPLETE INITIAL OB US
OB US >/=14 weeks =
Number of fetuses, gestational age (size & dates), intracranial/spinal/abdominal anatomy,
heart, umbilical cord, placental structure, amniotic fluid, maternal adnexa.
OB US <14 weeks =
Number of fetuses, gestational age (size & dates), threatened AB, placental structure,
maternal uterus.
Diagnostic Imaging Northwest
Puyallup | Bonney Lake | Sunrise
Scheduling: 253-841-4353 | Pre-Reg: 253-446-3971 | Fax: 253-446-3973
Rare exam
OB US – TRANSVAGINAL
Quick “look” exam to assess one area only (pt will have had a complete exam prior to
this exam).
Only obtained for a requested single item.
Includes:
Core images + one
Specific item requested ie: cervix, placenta,
AFI, fetal position.
OB US, LIMITED
Used to re-assess interval growth (small for dates, large for dates, high risk) or if the
original fetal anatomic survey was incomplete.
Includes:
Core images – see above +
Estimated Gestational Age +
Estimated Fetal Weight +
Missing items from fetal anatomic survey
Fetal position
Fetal movement
Fetal Cardiac activity
Amniotic Fluid – subjective
Placenta position
Maternal cervix
OB US, FOLLOW-UP
CORE REQUIREMENTS FOR ALL OB ULTRASOUNDS:
OB ULTRASOUND
PROTOCOLS
ULTRASOUND CPT CODING GUIDE
• 76536 Head & Neck, Soft Tissue
ARTERIAL DUPLEX
• 93880 Carotid Artery, Bilateral
• 93882 Carotid Artery, Unilateral
• 93930 Upper Extremity Arterial, Bilateral
• 93931 Upper Extremity Arterial, Unilateral
• 93975 Mesenteric-Renal-Splanchnic Artery
• 93978 Abdominal Aorto-Iliac
• 93925 Lower Extremity Artery, Bilateral
• 93926 Lower Extremity Artery, Unilateral
• 93923 Lower Extremity Segmental (ABI)
• 76604 Chest
• 76645 Breast
• 76880 Upper Extremity
ABDOMEN STUDY
PELVIS STUDY
OB ULTRASOUND
• 76801 Under 14 Weeks
• 76802 Under 14 Weeks, Twins
• 76805 Over 14 Weeks
• 76810 Over 14 Weeks, Twins
• 76811 20 Week Detailed Fetal Anatomy
• 76812 20 Week Detailed Fetal Anatomy, Twins
• 76815 Limited
• 76816 Follow-Up
• 76818 Biophysical Profile
• 76700 Abdominal
• 76705 Abdominal, Limited
• 76770 Retroperitoneal (Renal)
• 76856 Pelvic
• 76830 Pelvic, Transvaginal
• 76870 Testicular/Scrotal
VENOUS DUPLEX
• 93970 Extremity Venous, Bilateral
• 93971 Extremity Venous, Unilateral
• 93970 + 93965 Lower Extremity Venous
Insufficiency Evaluation, Bilateral
• 93971 + 93965 Lower Extremity Venous
Insufficiency Evaluation, Unilateral
Diagnostic Imaging Northwest
Puyallup | Bonney Lake | Sunrise
Imaging Centers
Phone: 253-841-4353 | Fax: 253-446-3973
5/2014
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5/2014
- 29 -
n/a
n/a
Galactogram in affected Breast
Breast MRI
U/S
U/S in affected Breast
CALL RADIOLOGIST
For Recommendation
Breast MRI
U/S
Pain
Drainage
(Clear/bloody)
3 / 6 month
Follow-up
Leaking Implants
Patients with
Pain / Lump and
Breast Feeding within
the last 6 months?
U/S
Breast MRI
Per Rad Recommendation
Bilateral Dx + Galactogram in
affected Breast
Bilateral Dx only
Breast MRI + Dx Mammo
Mammogram is okay - need
to pump breast immediately
prior to exam
Mammogram is okay - need
to pump breast immediately
prior to exam
Bilateral Dx + Galactogram in
affected Breast
Bilateral Dx only
Breast MRI
Bilateral Dx + Galactogram in
affected Breast
Bilateral Dx only
Bilateral Dx + U/S in
affected Breast
Bilateral Dx + U/S in
affected Breast
Bilateral Dx + U/S in
affected Breast
Bilateral Dx or Screening @
PCP discretion
Bilateral Dx or Screening @
PCP discretion
n/a
40+ years old and
last Mammogram
more that 365 days
Screening
25+ years old and
last Mammogram
more that 365 days
n/a***
n/a
25+ years old and
last Mammogram
6-12 months ago
Puyallup | Bonney Lake | Sunrise
Scheduling: 253-841-4353 | Pre-Reg: 253-446-3971 | Fax: 253-446-3973
Diagnostic Imaging Northwest
We encourage patients to check with their insurance carriers for benefits on all screening exams.
*** If patient’s Mother has a history of Breast Cancer – Routine screening should begin at
Mother’s age of Diagnosis minus 10 years or Age 40 (whichever is earlier).
U/S in affected Breast
U/S in affected Breast
U/S in affected Breast
n/a
n/a***
25+ years old and
last Mammogram
within 6 months ago
Mastitis, Mass or Lump
(No active dx)
No Symptoms
Personal Hx of
Breast CA
IF
Under 25
years old
Guideline only -- exceptions always exist
BREAST IMAGING GUIDE
DEXA SCAN DIAGNOSIS GUIDE
The following are insurance guidelines for DEXA coverage. Medicare (and most other insurances) have very specific
guidelines for coverage. If a patient’s referral does not indicate a potentially covered diagnosis we will be asking your
patient to sign a payment waiver for this study. For your convenience, below is a general list of covered diagnoses.
Your patient may wish to contact their insurance carrier for any coverage concerns.
Please feel free to contact our office should you have any questions at 253-841-4353.
MEDICARE COVERED DIAGNOSIS EXAMPLES:
252.0x
Hyperparathyroid
733.14
Femur Neck Fracture, Pathological
253.2
Panhypopituitarism
733.90
Unspecified disorder of Bone / Cartilage (Osteopenia)
253.7
Pituitary Disorder, Iatrogenic
737.19
Kyphosis
255.0
Cushing Syndrome
737.29
Lordosis
255.3
Corticoadrenal Over-activity
737.30
Scoliosis, Idiopathic
256.2
Post-ablative Ovarian Failure
758.6
Gonadal Dysgenesis
256.3x
Premature Menopause
805.xx
Vertebral Fractures
256.4
Polycystic Ovaries
806.xx
Vertebral Fractures
256.8/256.9 Other Ovarian dysfunction
V07.4
Postmenopausal Hormone Therapy
259.3
Ectopic Hormone Secretion
V07.5
Prophylactic Estrogen Therapy
275.5
Hungry Bone Syndrome
V13.51
Personal History Pathological Fracture
588.0
Renal Osteodystrophy
V49.81
Postmenopausal Status, asymptomatic
588.8x
Other disorders from Impaired Renal Function
V58.65
Current Long-Term Steroids
626.0
Absence of Menstruation
V58.68*
Long-term corticosteroid (+255.0, 733.00 – 733.03, or 733.90)
627.x
Premenopausal Disorders
V87.43
Personal Hx of Estrogen Therapy
720.0
Ankylosing Spondylitis
V87.45
Personal Hx of Systemic Steroid Therapy
733.00-02
Osteoporosis
733.12
Distal Radius Fracture, Pathological
733.13
Vertebral Fracture, Pathological
* Requires secondary diagnosis
NOTE: V82.81 (Screening for Osteoporosis) and CANCER are NOT covered Diagnoses under Medicare
5/2014
3/11/2014
- 30 -
MINOR CHILD POLICY
Diagnostic Imaging Northwest requires that all minors (under the legal age of 18) to be accompanied by a parent or legal guardian.
Step 1: When minors are referred to our centers or are walk-ins, we will request the presence of the parent or legal guardian
to sign the consent to treatment forms. Parent(s) must arrive with the minor in order to be seen unless the patient qualifies as a
mature minor (see Mature Minor Policy listed below).
Step 2: In the event a procedure requires written consent (procedures that require injection or other factors to radiate) we must
have the parent(s) or guardian onsite, aware and consenting for the procedure unless the patient qualifies as a mature minor.
Step 3: If the minor child is not accompanied by a parent or legal guardian, then the KINSHIP CAREGIVER’S
DECLARATION OF RESPONSIBILITY FOR A MINOR’S HEALTH CARE form must be completed by the adult (18
years of age or older) relative that is consenting for the health care. This form is valid for 1 day only.
Clarification of the Mature Minor Rule for information only:
Medical treatment that can be provided without parental consent (regardless of age):
Family Planning Services
Pregnancy Care (including Prenatal Care)
Minor who is married to someone 18 years or older
Emergency Services (if it is impractical to obtain consent first if needed)
Court Order: For legally emancipated minors (very uncommon)
Treatment requested for a suspected STD
Emancipated Minor (rare)
Mental Health issues to someone 13 years or older
If you have questions or concerns, feel free to contact our Compliance Officer at 253-583-8607.
5/2014
6/28/2013
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KINSHIP CAREGIVER’S DECLARATION OF
RESPONSIBILITY FOR A MINOR’S HEALTH CARE
(Use of this declaration is authorized by RCW 7.70.065)
----Please Print Clearly---I DECLARE THAT:
Minor’s Information:
I consent to health care for the child (print name): The child’s date of birth is: Caregiver’s Information:
3. My name is (print name): 4. My home address is: I am 18 years of age or older and I am a relative responsible for the health care of the minor.
My date of birth is: I am the of the above named minor.
(Relationship: e.g. grandparent, aunt/uncle, etc.)
I declare under penalty of perjury under the laws of the State of Washington that the above is true and correct.
Date: Signature of Caregiver: City/State: This declaration is ONLY valid for six months fromthe date listed here.
GENERAL NOTICE:
This Declaration does not affect the rights of the minor’s parents or legal guardian regarding the care, custody, and control of the minor, and does not mean that the
caregiver has legal custody of the minor. It also does not affect the rights of the minor to consent to his/her own medical care where authorized by law. A person
who relies on this Declaration has no obligation to make further investigation or inquiry beyond what is said on the Declaration form if the provider does not have
actual notice of the falsity of the statements made in the Declaration. A health care provider may, but is not required to, request additional documentation of a
person’s claimed status as being a relative responsible for the health care of the minor patient.
TO HEALTH CARE PROVIDERS and HEALTH CARE FACILITIES:
1. A healthcare provider or a health care facility where services are rendered shall be immune from suit in any action, civil or criminal, or from professional or other
disciplinary action, when a health care provider or health care facility relies upon a declaration signed under penalty of perjury pursuant to RCW 9A.72.085 stating
that the adult person is a relative responsible for the health care of the minor patient. RCW 7.70.065(2)(d).
2. A “health care facility” is defined as a hospital, clinic, nursing home, laboratory, office or similar place where a health care provider provides health care to patients.
RCW 70.02.010(5). A “health care provider” is a person who is licensed, certified, registered, or otherwise authorized by law of this state to provide health care in the
ordinary course of business or practice of a profession. RCW 70.02.010(8)
3. “Health care” means any care, service, or procedure provided by a health care provider: (a) To diagnose, treat, or maintain a patient’s physical or mental condition;
or (b) That affects the structure or any function of the human body. RCW 70.02.010(5). Health care includes mental health care. RCW 7.70.065(2).
5/2014
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CLARIFICATION ON COMPUTER
GENERATED ORDERS (EPIC and Clarity)
To provide clarification on computer generated orders, specifically EPIC and Clarity orders where an indication that
“Radiologist can change = YES” is on the order; DINW is allowed to change things like,
number of views & contrast status. We cannot change modality or body part or add additional exams unless all of the
following apply, (which is only on a rare occasion);
• DINW performs the original diagnostic test ordered by the treating physician/practitioner;
• The DINW Radiologist determines and documents that, because of the abnormal result of the diagnostic test performed, an
additional diagnostic test is medically necessary;
• Delaying the additional diagnostic test would have an adverse effect on the care of the patient;
• The result of the test is communicated to and is used by the treating physician/practitioner in the treatment of the patient;
and the DINW Radiologist documents in his/her report why additional testing was done.
Some Examples:
When the referring provider has ordered & given permission to change by checking Radiologist to Change = YES.
Q:
If we have an order for a Transabdominal Pelvic US and we need to also do a Transvaginal (TV) for
visualization – is this okay to add? Or is an additional order required?
A: New/updated order is needed, because a TV is a different CPT code, it falls in the added test category.
Q:
We have an order for OB US, <14 weeks, can we add the Transvaginal for visualization without an
additional order?
A: New/updated order is needed, because a TV is a different CPT code, it falls in the added test category.
Q:
We have an order for complete OB US, and it should really be a limited or follow-up OB US, is this
okay to change?
A: New/updated order is needed; different exam, different CPT code.
Q:
What if we have an order for abdomen/pelvis CT and only need the pelvis? Is this okay without
notifying referring office?
A: Do not need a new order.
Q:
Order received for Shoulder X-ray, 2 views and we need 3 views to complete the diagnosis. A: We can change the number of views as long as the order states it is okay for Radiologist to Change = YES.
Q:
Order received for CT Abdomen for diverticulitis. CT Pelvis is the appropriate exam for this diagnosis.
A: New/updated order is needed for the CT Pelvis. This is an added test (different CPT code).
For questions, please feel free to contact Cindy Peterson, Scheduling Manager: 253-583-8645
5/2014
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2014
This form is part of the patient’s medical record and must be completed for referral
Date of Referral _______-_______-_______ Referring Provider Name _______________________________________________________________
Patient Name (first, MI, last)__________________________________________________________________ D.O.B. ________-_________-_________
Patient Phone # (_______) __________-_________________(home)
(_______) __________-_______________(work or cell)
 Translator? _____________________________________ (Language)
Written Diagnosis/Reason/Symptom for Exam(s) REQUIRED
Medicare and other insurers require coding of specific/definitive diagnosis(es), sign(s) or symptom(s) to reflect the “medical necessity” for each test.
Rule out, Possible or Probable Conditions cannot be coded. For Medicare Policy information see the Part B Bulletin or www.noridian.com/medweb
Notes: Height________ Weight________ Allergies__________________________ PRIOR EXAMS:
Creatinine/GFR _____ / _____ (date drawn) ____ / ____ / ____ LABS REQUIRED FOR
IV CONTRAST STUDIES
Date of Service
 Creatinine blood draw at radiologist's discretion
Specialty Exams
Facility Location
Other Last Name: _________________________
Nuclear
NuclearMedicine
Medicine
 Lung Scan
 Biliary (HIDA)
 Renal Scan (Specify) _____________
 Cardiac Blood Pool (MUGA)
 Myocardial Stress Test and Rest
 Treadmill
 Lexiscan
 Gastric Emptying Study (GES)
Bone Scan:
 Multiple
 3-Phase
 SPECT
(area of concern ______________________________)
 Whole Body
Thyroid:  Uptake & Scan
 Scan Only
 Venogram
 Other (Specify) ______________________________
P
M
A
S
M
R
Exam ______________________________
M T W Th F S Sn
Date _______-_______-_______
Check In Time _______ : ______________
Appt. Time
_______ : ______________
O
F
(contrast & 3D reconstruction as clinically indicated by radiologist); or___no contrast
CT
CTScan
Scan
 Head
 Sinuses
 Chest
 CTA Head
 Neck
 Ltd. Sinus
 Abdomen
 CTA Neck
 C-spine
 Landmark
 Pelvis
 CTA Chest
 T-spine
 Abdomen & Pelvis
 CTA Coronary
 L-spine
 CT KUB
 CTA Abdomen
 CTA Abdomen & Pelvis
 Other (Specify) _____________  CT Colonography
______________________________  CT Enterography
 CTA Pelvis
 CTA Other (Specify) ________
MRIexam
Exam (contrast & 3D reconstruction as clinically indicated by radiologist); or___no contrast
MRI
Extremity
 Brain
Pacemaker: Y / N
 Orbits w/Brain
 w / joint arthrogram
 Face/Neck
 Abdomen (Specify)
It rt  Hand
_____________________
It rt  Wrist
 Thyroid/Larynx
 C-spine
 Pelvis
It rt  Elbow
 T-spine
 Enterography
It rt  Shoulder
 L-spine
 MRCP
It rt  Hip
It rt  Knee
 Cardiac
 MRA (Specify)
_____________________
It rt  Ankle
 Other (Specify) _____________
It rt  Foot
It rt  Other (Specify)
Injections & Procedures
__________________________
E
L
Appointments:
 Diagnostic & Therapeutic Injection (Specify)________________________________________
 Interventional Procedure (Specify)__________________________________________________
_____________________________________________________________________________________
Exam ______________________________
M T W Th F S Sn
Date _______-_______-_______
Check In Time _______ : ______________
Appt. Time
_______ : ______________
 Call patient to schedule
 Patient will call to schedule
 Return patient to the office with films
 Call STAT (_____)______-__________
 Fax STAT (_____)______-__________
 Fax Routine (_____)______-__________
Send:  CD ROM
 Films
Additional reports to: ________________
___________________________________
Follow-Up Appointment:
Date _______-_______-_______
Time _______ : ______________
PCP: ______________________________
Name of insurance is required:
___________________________________
Insurance authorization #
(if needed):
___________________________________
Original Signature REQUIRED by Referring Provider
(Medicare B News Bulletin #256, 8/29/09)
For Office Use Only
Diagnostic Imaging Phys Orders
Radiology Order Form
THIS REFERRAL IS CONFIDENTIAL AND IS INTENDED SOLELY FOR
THE USE OF THE MEDICAL PROVIDER NAMED ABOVE. IF YOU ARE
NOT THE INTENDED RECIPIENT OR THE INTENDED RECIPIENT’S
AGENT, AND HAVE RECEIVED THIS COMMUNICATION IN ERROR,
NOTIFY SENDER IMMEDIATELY AND DESTROY THIS DOCUMENT.
MHS007 Rev. 1/14
To order more forms please contact 253-845-4353 or visit www.dinw.com/supplies-and-resources/
5/2014
6/28/2013
- 34 -
2014
2013
This form is part of the patient’s medical record and must be completed for referral
Date of Referral _______-_______-_______ Referring Provider Name _______________________________________________________________
Patient Name (first, MI, last)__________________________________________________________________ D.O.B. ________-_________-_________
Patient Phone # (_______) __________-_________________(home)
(_______) __________-_______________(work or cell)
 Translator? _____________________________________ (Language)
Written Diagnosis/Reason/Symptom for Exam(s) REQUIRED
Medicare and other insurers require coding of specific/definitive diagnosis(es), sign(s) or symptom(s) to reflect the “medical necessity” for each test.
Rule out, Possible or Probable Conditions cannot be coded. For Medicare Policy information see the Part B Bulletin or www.noridian.com/medweb
Notes: Height________ Weight________ Allergies__________________________
Creatinine/GFR _____ / _____ (date drawn) ____ / ____ / ____ LABS REQUIRED FOR
IV CONTRAST STUDIES
 Creatinine blood draw at radiologist's discretion
Common Exams
PRIOR EXAMS:
Date of Service
Facility Location
Other Last Name: _________________________
No appointment required.
Specify additional views:
 Chest__________________________
 Sinuses_________________________
 Cervical Spine___________________
 Thoracic Spine___________________
 Lumbar Spine____________________
 Scoliosis________________________
 Abdomen Series__________________
 KUB___________________________
 Pelvis only
It
rt
 Pelvis w/ Lateral Hip
It
rt
bilat  Hips
It
rt
bilat  Ribs
It
rt
bilat  Shoulder
It
rt
bilat  Elbow
It
rt
bilat  Forearm
It
rt
bilat  Wrist
It
rt
bilat  Hand
It
rt
bilat  Finger
It
rt
bilat  Knee
It
rt
bilat  Tib/Fib
It
rt
bilat  Ankle
It
rt
bilat  Foot or  Toe
It
rt
bilat  Other _____view(s)
X-ray
Bone Densitometry (DEXA)
 Spine & Femur
 Other (Specify) ___________________
Mammography & Breast Ultrasound
Ultrasound
 Vascular (Specify)______________________
 Arterial
 Venous
 AAA Screen (Medicare IPPE exam)
 Cardiac Echo
 Abdomen-Complete
 Abdomen-Limited (Area of interest?) ___________
 Superficial Soft Tissue (Area of interest?)
P
M
A
S
Fluoroscopy
____________________________________________
 Extremity It rt (Specify)______________
 Renal
 Pelvic (transabdominal &/or transvaginal as
needed for diagnostic visualization)
 Pelvic-Limited (Specify)___________________
 Pelvic-Transvaginal only
 OB __Multiple __High Risk __Follow-up __Limited
 < 14 weeks complete (transvaginal as needed
for visualization)
 Esophagram (Barium Swallow)
 Upper GI  IVP
 Small Bowel
 Barium Enema  with air contrast
 VCUG  VCUG Sedation:
 Oral  IV  NANO
 Arthrogram joint_______________________
 Other (Specify)_________________________
M
R
Exam ______________________________
M T W Th F S Sn
Date _______-_______-_______
Check In Time _______ : ______________
Appt. Time
_______ : ______________
O
F
Please use the
Breast Imaging Order Form
E
L
Appointments:
 > 14 weeks complete
 MCA Doppler  Umbilical cord Doppler
 Biophysical Profile
 Thyroid / Neck
 Testicular / Doppler
 Other (Specify) ________________________
Exam ______________________________
M T W Th F S Sn
Date _______-_______-_______
Check In Time _______ : ______________
Appt. Time
_______ : ______________
 Call patient to schedule
 Patient will call to schedule
 Return patient to the office with films
 Call STAT (_____)______-__________
 Fax STAT (_____)______-__________
 Fax Routine (_____)______-__________
Send:  CD ROM
 Films
Additional reports to: ________________
___________________________________
Follow-Up Appointment:
Date _______-_______-_______
Time _______ : ______________
PCP: ______________________________
Name of insurance is required:
___________________________________
Insurance authorization #
(if needed):
___________________________________
Original Signature REQUIRED by Referring Provider
(Medicare B News Bulletin #256, 8/29/09)
For Office Use Only
Diagnostic Imaging Phys Orders
Radiology Order Form
THIS REFERRAL IS CONFIDENTIAL AND IS INTENDED SOLELY FOR
THE USE OF THE MEDICAL PROVIDER NAMED ABOVE. IF YOU ARE
NOT THE INTENDED RECIPIENT OR THE INTENDED RECIPIENT’S
AGENT, AND HAVE RECEIVED THIS COMMUNICATION IN ERROR,
NOTIFY SENDER IMMEDIATELY AND DESTROY THIS DOCUMENT.
MHS005 Rev. 1/13
To order more forms please contact 253-845-4353 or visit www.dinw.com/supplies-and-resources/
5/2014
6/28/2013
- 35 -
This form is part of the patient’s medical record and must be completed for referral
Date of Referral _____-_____-_____ Referring Provider Name _______________________________________________________
Patient Name (first, MI, last)___________________________________________________________D.O.B. _______-_______-______
Patient Phone # (_______) __________-_________________(home)
(_______) __________-_______________(work or cell)
 Translator? _____________________________________ (Language)
2014
2013
Written Diagnosis/Reason/Symptom for Exam(s) REQUIRED
Medicare and other insurers require coding of specific/definitive diagnosis(es), sign(s) or symptom(s) to reflect the “medical necessity” for each test.
Rule out, Possible or Probable Conditions cannot be coded. For Medicare Policy information see the Part B Bulletin or www.noridian.com/medweb
Notes: Height_________ Weight_________ Breast cancer history Lt ____ Rt ____
Allergies _____________________________
Mastectomy history
Lt ____
Rt ____
Implants?
Y ____
N ____
PRIOR EXAMS:
Date of Service
Facility Location
 Physical Assistance Required
Other Last Name: ______________________
Breast Imaging & Bone Density
Appointments:
Bone Densitometry (DEXA)
Mammography
 Screening Mammogram (no symptoms)
bilat
lt
 Spine & Femur
 Diagnostic Mammogram
(Ultrasound if needed)
 Needle Biopsy if indicated
 Needle Loc / Placement
 Stereotactic Breast Biopsy
 Galactogram
lt
Diagnostic Services
rt bilat
Indicate area of concern
A
S
rt
rt
rt
bilat
bilat
bilat
lt
lt
lt
rt
rt
rt
bilat
bilat
bilat
Ultrasound
 Breast
 Breast Cyst Aspiration
 Guided Breast Biopsy
E
L
P
M
lt
lt
lt
RIGHT
Y / N
Appt. Time
_______ : ______________
Exam _______________________________
M T W Th F S Sn
Date _______-_______-_______
Check In Time _______ : ______________
Appt. Time
_______ : ______________
 Call patient to schedule
 Patient will call to schedule
 Return patient to the office with films
 Call STAT (_____)______-__________
 Fax STAT
(_____)______-__________
 Fax Routine (_____)______-__________
Send:  CD ROM
 Films
Additional reports to: __________________
MRI exam
Pacemaker:
LEFT
M T W Th F S Sn
Date _______-_______-_______
Check In Time _______ : ______________
O
F
 Other (Specify)__________________
rt
M
R
Exam _______________________________
Screening Services
(if YES, MRI services unavailable)
Creatinine / GFR ____ / ____
(date drawn) ____ / ____ / ____
 Creatinine blood draw at radiologist's discretion
 Breast MRI bilat with contrast
 Limited Chest MRI if indicated (radiologist's discretion)
 Breast MRI guided biopsy lt
rt bilat
_____________________________________
_____________________________________
PCP: ________________________________
Name of insurance is required:
_____________________________________
Insurance authorization #
(if needed):
_____________________________________
Original Signature REQUIRED by Referring Provider
(Medicare B News Bulletin #256, 8/29/09)
For Office Use Only
Diagnostic Imaging Phys Orders
Radiology Order Form
THIS REFERRAL IS CONFIDENTIAL AND IS INTENDED SOLELY FOR
THE USE OF THE MEDICAL PROVIDER NAMED ABOVE. IF YOU ARE
NOT THE INTENDED RECIPIENT OR THE INTENDED RECIPIENT’S
AGENT, AND HAVE RECEIVED THIS COMMUNICATION IN ERROR,
NOTIFY SENDER IMMEDIATELY AND DESTROY THIS DOCUMENT.
MHS006 Rev. 1/13
To order more forms please contact 253-845-4353 or visit www.dinw.com/supplies-and-resources/
5/2014
- 36 -
BONNEY LAKE IMAGING CENTER
(on Hwy. 410)
21110 SR 410 East, Suite 110
Bonney Lake, WA 98391-8457
BONNEY LAKE MEDICAL BUILDING
(just off of S. Prairie Rd.)
10004 204th Avenue E, Suite 2600
Bonney Lake, WA 98391-6539
PUYALLUP IMAGING CENTER
222 15th Avenue SE
Puyallup, WA 98372-3754
GOOD SAMARITAN MEDICAL
OFFICE BUILDING
1450 5th St. SE, Suite 4600
Puyallup, WA 98372-4655
SUNRISE IMAGING CENTER
11212 Sunrise Blvd. E, Suite 200
Puyallup, WA 98374-8847
ww w. d in w. co m
Scheduling Phone: 253-841-4353 | Fax: 253-446-3973
5/2014
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