COMPUTED TOMOGRAPHY (CT) SCANS Exam Reference / …

1 AREA OF INTEREST HEADBODY PART EXAMREASON FOR EXAMORAL CONTRASTIV CONTRASTPROCEDURES TO PRE-CERTCODESBRAINB leed, trauma, headachesNONOCT Brain without70450 Mass, tumor, infection, melanoma, HIV, meningioma, mets stagingNOYESCT Brain with and without70470 CTA HEADA neurysmNOYESCTA Head70496 CTA NECKC arotid OcclusionNOYESCTA Neck70498 ORBITST rauma, fracture, foreign bodyNONOCT Orbits without70480 Mass, abcess, pain, swelling, Graves disease, cellulitisNOYESCT Orbits with70481 SINUSS inusitus, mass, pain, polyps, deviated septum, congestion, foreign bodyNONOCT Sinus without70486 FACET rauma, fractureNONOCT Maxillofacial70486 TEMPORAL BONESC holestatoma, tinnitis, congenital hearing lossNONOCT Temporal Bones without70480 SOFT TISSUE NECKP alpable neck mass, stone, neoplasmNOYESCT Neck with and without70492 Lymphoma, lymphadenopathyNOYESCT Neck with and without70492 Parotid swelling, vocal chord paralysisNONOCT Neck (9729) 2016 advanced Radiology ConsultantsCOMPUTED TOMOGRAPHY (CT) SCANSExam Reference / Protocol GuidelinesFor additional information on CT and other radiologic exams, please consult the American College of Radiology s ACR Appropriateness Criteria document found at PART EXAMREASON FOR EXAMORAL CONTRASTIV CONTRASTPROCEDURES TO PRE-CERTCODESABDOMEN: from lung base to illiac crestPainYESNOCT AbdomenPelvis without74176 PELVIS:from iliac crest to pubisPain, fracture, arthritis, mets, bone lesionNONOCT Pelvis without72192 Soft tissue mass, tumor, abcess, infection, cellulitisYESYESCT Pelvis with72193 ABDOMEN AND PELVIS GENERAL: from lung base to pubisMass, hernia, diverticulitis, appendicitis, restaging CA, nausea, vomitingYESYESCT Pelvis with and without74178 ABDOMEN/ PELVIS: EnterographyCrohn s disease, small bowel obstructionYES Arrive 1 hour prior to appt.

2 Time, patient must drink oral contrast in the officeYES35 years of age or older: CT Abdomen with and withoutPelvis with7417835 years of age or younger: CT Abdomen and Pelvis with only74176 LIVERI ncrease LFTs, RUQ pain, jaundice, liver cancer, cirrhosis, hepatoma, hemangioma, hepatitisYESYESCT Abdomen with and withoutCT Pelvis with74178 AREA OF INTEREST ABDOMEN 2016 advanced Radiology (9729) COMPUTED TOMOGRAPHY (CT) SCANSExam Reference / Protocol GuidelinesFor additional information on CT and other radiologic exams, please consult the American College of Radiology s ACR Appropriateness Criteria document found at PART EXAMREASON FOR EXAMORAL CONTRASTIV CONTRASTPROCEDURES TO PRE-CERTCODESRENALR enal stoneNONOCT Abdomen withoutPelvis without74176 MassNOYESCT Abdomen with and withoutCT Pelvis with74178 URINARY SYSTEMH ematuriaNOYESCT Abdomen with and withoutCT Pelvis with and without74178 WITH 3D76377 CTA ABDOMENAAA, renal artery stenosis, dissection, hypertensionNOYESCTA Abdomen74175 CTA ABDOMEN AND PELVISAAA, renal artery stenosis, dissection, hypertensionNOYESCTA Abdomen and Pelvis74174 CTA RUNOFF(PAD)

3 Peripheral Artery DiseaseNOYESCTA Abdomen Aorta Runoff75635 CHESTN odule, opacities seenNONOCT Chest without71250 Hilar adenopathy, lung cancerNOYESCT Chest with71260 CTA CHESTP ulmonary embolism AneurysmNOYESCTA Chest71275 HIGH RESOLUTIONI nterstitial lung diseaseNONOCT Chest high resolution without70490 AREA OF INTEREST RENAL 2016 advanced Radiology (9729) COMPUTED TOMOGRAPHY (CT) SCANSExam Reference / Protocol GuidelinesFor additional information on CT and other radiologic exams, please consult the American College of Radiology s ACR Appropriateness Criteria document found at PART EXAMREASON FOR EXAMORAL CONTRASTIV CONTRASTPROCEDURES TO PRE-CERTCODESUPPER EXTREMITIES: hand, wrist, elbow, forearm, humerus, shoulderPain, arthritis, fracture, fusion, malunionNONOCT Upper Extremity without contrast73200 Infection, tumor, mass, cancer, mets (MRI is more sensitive)NOYESCT Upper Extremity with contrast73201 LOWER EXTREMITIES: foot, ankle, knee, hip, tibia, fibula, femurPain, arthritis, fracture, fusion, malunionNONOCT Lower Extremity without contrast73700 Infection, tumor, mass, cancer, mets (MRI is more sensitive)NOYESCT Lower Extremity with contrast73701 CERVICAL SPINEI mmediate Post-opNOYESCT Cervical Spine with72126 Neck pain, fracture, eval hardwareNONOCT Cervical Spine without72125 THORACIC SPINEI mmediate Post-opNOYESCT Thoracic Spine with72129 Pain, fracture, eval hardwareNONOCT Thoracic Spine without72128 LUMBAR SPINEI mmediate Post-opNOYESCT Lumbar Spine with72132 Pain, fracture, eval hardwareNONOCT Lumbar Spine without72131 AREA OF INTEREST EXTREMITIES 2016 advanced Radiology (9729) COMPUTED TOMOGRAPHY (CT)

4 SCANSExam Reference / Protocol GuidelinesFor additional information on CT and other radiologic exams, please consult the American College of Radiology s ACR Appropriateness Criteria document found at the Risk of Contrast Induced NephrotoxicitySome patients receiving intravenous contrast require bloodwork prior to contrast injectionTHE FOLLOWING PATIENTS SHOULD HAVE A RECENT EGFR (Estimated Glomular Filtration Rate): Age 70 or older History of renal disease - (*note - kidney stones/renal cysts do not require eGFR)- Dialysis - Kidney surgery - Kidney transplant - Kidney cancer- Single kidney History of hypertension requiring medical therapy (patients on high blood pressure medication) History of diabetes mellitus (including patients on metformin)ACCEPTABLE BLOOD WORK GUIDELINES: eGFR should be within 90 days of imaging eGFR should be within 30 days if the patient had a recent hospitalizationDOSING GUIDELINES: eGFR > 45 - Technologists can proceed with the contrast injection eGFR is between 30-44 - Radiologist approval is needed prior to injection.

5 Clinical judgement required and oral and/or IV hydration should be considered if patient can tolerate it. eGFR < 30 - Radiologist should speak with the ordering clinician for clearance before proceeding with contrast injection or if alternative tests may be useful for diagnosisDIALYSIS GUIDELINES:Defer to Nephrologist for course of treatment 2016 advanced Radiology (9729) COMPUTED TOMOGRAPHY (CT) SCANSExam Reference / Protocol GuidelinesFor additional information on CT and other radiologic exams, please consult the American College of Radiology s ACR Appropriateness Criteria document found at