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Warning Text %XTableStyleMedium2PivotStyleLight16`ۀ Front (2) Generic Front aFrontQBack (2) EBack   ;F  ;F  ;M   ;N   ;: `i 0MIM#:________________, Clinic Code:_____________LDate of service: ________________________Time of service:___________________*Please provide the most revelant signs and/or symptoms (see back for detailed description required for Notification/Authorization Request) ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________LUniversity of North Carolina Health Care System Radiology Imaging Order FormMRI accompanying an ArthrogramOccult Hip fractureLegg-Calve Perthes Disease!slipped Capital Femoral Epiphysis Lateral TearMeniscal Tear/InjuryCruciate Liagment TearCollatral Ligamentous TearPasterolateral Complex InjuryChondromalacia PatellaOsteochondritis Dissecans*Ligament and tendon injuries ankle or footTarsal Coalition Tarse; tunnelMorton's NeuromaNeuropathic Osteodystrophy Diabetic foot diseaseCTCTAMRAContrast Body PartMRI"Notification/Authorization Number:65. Does pt have recent(within 6 mos) serum creatinine?+MR lower extremity; any joint w/wo contrast1MR lower extremity; other than joint w/o contrast/MR lower extremity; other than joint w contrast2MR lower extremity; other than joint w/wo contrast"MRA lower extremity; w/wo contrastUpper and Lower ExtremityUpper and Lower extremityAbscessSeptic Arthritis Palpable massHTumor eval suspected or known involving soft tisue or osseous structuresSignificant Trauma Fracture eval to corfim fracture'Fracture eval to define extent fracture(Fracture eval to assess fracture healingNeuropathic OsteodystrophyPre/post op eval fm specialistBone scintigraphy abnormalityPesistent extremity pain OsteonecrosisIntra_Articular loose body+CTA, MRA Supporting Diagnostic Information:'Atherosclerotic steno-occlusive disease(Thromboembolic disease_arterial & venousIntramural Hematoma%Aarterio-Venous/Fistula Malformation Arterial FibrodysplasiaRaynaud's syndrome!Dialysis Graft eval, post doppler VasculitisArterial Entrapment SyndromeMusculosketal Neoplasm0Ligament and tendon injuries, known or suspectedJoint locking or InstabilityOsteochondral Lesion)Hemarthrosis documented by arthrocentesisRotor Cuff Tear knowm/suspected#Glenoid Labral Tear known/suspectedBankart LesionBankart Variation LesionPerthes ALPSA Lesion HAGL Lesion"Suspected Occult Shoulder FractureAdhesive Capsulitis EpicondylitisBiceps Tendon ruptureTriceps Tendon ruptureMedial Collateral Ligament TearCapitellar OsteochondritisSuspected Occult Elbow FractureTriangular Fibrocartilage TearUlnar Collateral Ligament tearCarpal tunnel syndroneMR joint Supporting diagnostic #MR non joint Supporting diagnostic Inflammatory MyophathyBrachial PlexopathyBrachial Plexus Mass)MR joint/non joint Supporting diagnostic Inflammatory Myopathy1. List all previous diagnostic studies completed related to this symptom/event:____________________________________________________2. List all previous treatments completed related to this sympton/event:__________________________________________________________3. List all risk factors associated with this symptom/event:__________________________________________________________________________(e.g. ultrasound, x-ray)(e.g. NSAIDS, antibiotics)(e.g. age, chemotherapy)4. List all complicating factors associated with this symptom/event________________________________________________________________________ (e.g. Cancer, Immunocompromised)The following diagnostic indications for CT and MR are accompanied by pre-test considerations as well as clinical supporting data and prerequisite information.?3. History of Diabetes, mulitple myeloma, lubpus or sclerodermaMRI CodeCT Code wOrdering Physician Signature: I certify that these diagnosis codes support the test ordered and are medically necessaryOElective: a reasonable delay in treatment will not adversely affect the outcome5. Most revelant signs and/or symptoms (see back for details)________________________________________________________________________CT upper extremity w/o contrastCT upper extremity w contrast CT upper extremity w/wo contrast!CTA upper extremity w/wo contrastCT lower extremity w/o contrastCT lower extremity w contrast CT lower extremity w/wo contrast!CTA lower extremity w/wo contrast*MR upper extremity; any joint w/o contrast(MR upper extremity; any joint w contrast+MR upper extremity; any joint w/wo contrast1MR upper extremity; other than joint w/o contrast/MR upper extremity; other than joint w contrast2MR upper extremity; other than joint w/wo contrast"MRA upper extremity; w/wo contrast*MR lower extremity; any joint w/o contrast(MR lower extremity; any joint w contrast/University of North Carolina Health Care SystemRadiology Imaging Order Form"MIM#:_______, Clinic Code:________Code Description AdressograhCode;1. Has the patient had an allergic reaction to IV contrast?!___________Yes, __________No'2. Is he pt on Glucophage (melformin)? ___________Yes, _________No___________Yes, _________No44. Is pt on IV antibiotics or taking daily doses of )NSAIDs (Advil, Aleve, Celebrex, Lodine)? __________Yes, ___________No75. Does pt have recent(within 6 mons) serum creatinine?__________Yes, _________ No,If yes, VALUE____________, DATE, ___________56. Does the pt have previous studies NOT done at UNC?___________Yes, _________No0If yes remind pt to bring studies for comparison2If, NO the test needs to be drawn BEFORE the study7The result can be called in or the pt can bring resultson the date of the study. __________Yes, ________No*2. Does the patient have an aneurysm clip?-1. Does the patient have a cardiac pacemaker?__________Yes, _________No/3. Does the patient have a cardiac heart valve?;4. Does the patient have any mechanical devises or implants&(neruostimulators, cochlear implants)?5. Is the pt claustrophobic?Is sedation needed?Date: Non-elective1_________________________________________________Aneurysm%CT Supporting diagnostic information: Description 0Check off ICD 9 code with Diagnostic Description Dissection OsteomyelitisZDate of service: ________________________Time of service:_________________________________KOrdering Provider Name:________________Ordering Provider#:_________________PProvider Pager:________________Clinic Contact:____________________Pager/tel no.:/Commercial Insurance Carrier required Questions.Department of Radiology required CT questions:/Department of Radiology required MRI questions ROrdering Provider Name:_________________________Ordering Provider#:_______________UProvider Pager:__________Clinic Contact:____________________Pager/tel no.:___________u1. List all previous diagnostic studies completed related to this symptom/event:_____________________________________t2. List all previous treatments completed related to this sympton/event:____________________________________________t3. List all risk factors associated with this symptom/event:________________________________________________________s4. List all complicating factors associated with this symptom/event________________________________________________CPT CodeWithWithoutWith and Without ProcedurePETNuclear Cardiology4REQUIRED Questions for Commercial Insurance Carriers&If yes, a serum creatinine is requiredcMedicare will only pay for services that it determines to be reasonable and necessary under section 1862 (a)(1) of the Medicare Law. When ordering tests for which Medicare reimbursement will be sought, physicians should order only those individual tests that are necessary for the diagnosis and treatment of a patient, rather than for screening purposes.Nuclear Medicine Addressograph)101 Manning Drive, Chapel Hill, NC 27514UNC Health Care S< ystemEDate of Service____________________Time of Service___________________ Ultrasound Fluoroscopy CPT Code(s) ICD-9 Code(s)BOrdering Provider Code:________________Provider Pager:____________BClinic Name/Clinic Code: _________________________________________CClinic Contact:_______________________Pager/tel no.:_______________@Ordering Provider Name:_________________________________________Body Part/Procedure-Attending (if different)_____________________fax:(919)843-0924$Date:______________ Time:___________#Signature:_________________________fax:(919)966-8046fax:(919)843-2900Diagnostic X-RAY/QDRY_________________________________________________________________________________________:1. Please provide the most relevant signs and/or symptoms:{2. What is suspected or being ruled out?___________________________________________________________________________________y3. Diagnosis: _____________________________________________________Suspected?_____________or Confirmed?__________________KYES NO 1. Has the patient had an allergic reaction to IV contrast? uYES NO 3. Does the patient have a history of diabetes, renal disease, multiple myeloma, lupus or scleroderma?2YES NO 4. Is the patient on IV antibiotics?dYES NO 5. Is the patient taking daily doses of NSAIDs (Advil, Aleve, Celebrex, Lodine, etc)?LYES NO 7. Pregnancy? Date of LMP: EYES NO 1. Does this patient have a cardiac pacemaker? FYES NO 2. Does this patient have an aneurysm clip? nYES NO 4. Does the patient have any mechanical devices or implants (neurostimulators, cochlear, etc.)?Outpatient Radiology Order Form^CT Scan Scheduling Questions: If yes to any of the answers please inform Radiology scheduler.UYES NO 2. Is the patient on any medication containing metformin? (Glucophage)YES NO 8. Is patient currently on any blood thinners (e.g. Coumadin, Aspirin, Plavix,Effient)? If YES, most recent INR (1 week) ___ZMRI Scheduling Questions: If yes to any of the answers please inform Radiology scheduler.TYES NO 3. Does the patient have a artificial cardiac heart valve? !Chart Location: Provider Orders Ordering Provider Signature: I certify that these diagnosis codes support the test ordered and the test(s)are medically necessary.iYES NO 6. Does the patient have a recent (within 3 months) serum creatinine value? If yes, when? 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