MRI Ordering Algorithm
MRI Lab Requirements for exams with contrast                                                                                                                                                                           .  
Serum Creatinine & Sodium Bicarbonate values required, GFR if available    
Ÿ Lab values must be drawn with results given to MRI prior to exam date    
Ÿ Lab values must be within 30 days of exam date                                                               
Ÿ All patients age 60 and OVER are required to have the above labs drawn     
Ÿ All patients UNDER the age of 60 are required to have the above labs drawn for any of the following:  
Ÿ 1)  Diabetes                                                                                                                                                                          
Ÿ 2) Liver or Kidney Disease                                                                                                                                                
Ÿ 3) Hypertension                                                                                                                                                           
       
MRI Screening Form      
       
The MRI screening form is VERY important, and must be filled out PRIOR to the MRI exam.    
1) This is a legal document.  The patient, legal guardian or pt's Power of Attorney needs to fill out the form   
2) The patient's weight can not exceed 350 lbs. ( Some pt's weighing less than that may still not fit in the opening but we will attempt it)  
3) If the patient does welding/grinding of metal, they need to have an Orbits xray done prior to the MRI  
4) Claustrophobic patients may need an order for meds.  We do not dispense them in MRI.    
5) Severely claustrophobic patients or Bethesda patients MAY REQUIRE general anesthesia.  This needs to be scheduled ahead of time.  
       
Possible Contra-indications for MRI     
       
Pacemaker: Not able to have MRI exam    
Interstim ( Bladder Control Device): Not able to have MRI exam    
Aneurysm Clips: Implant card or Operative notes with record of device needs to be obtained and cleared with MRI dept.  
Prosthetic Heart Valves: Implant card or Operative notes with record of device needs to be obtained and cleared with MRI dept.  
Ventricular or Spinal Shunts: Implant card or Operative notes with record of device needs to be obtained and cleared with MRI dept.  
Neuro Stimulators / Electrode implants: Implant card or Operative notes with record of device needs to be obtained and cleared with MRI dept.  
Inner Ear Prosthesis: Implant card or Operative notes with record of device needs to be obtained and cleared with MRI dept.  
Ortho hardware / Surgical clips: OK after 6 weeks post surgery (or sooner in life-threatening indications)  
Vascular stents: OK after 6 weeks post surgery (or sooner in life-threatening indications)  
Pregnancy: Consult radiologist prior to scheduling    
       
MRI Exam Clinical Indication Examples Recommended exam to order CPT CODE
Head and Neck        
Brain Headache, Stroke, trauma, pain MRI Brain w/o contrast 70551  
  MS,  Hx of cancer, Seizure, Neurologic symptoms MRI Brain with & w/o contrast 70553  
Orbits r/o Optic Neuroma, visual disturbance MRI Brain AND MRI Orbits both with & w/o contrast 70553 & 70543  
IAC's r/o Acoustic Neuroma, tinnitus, hearing loss MRI Brain with & w/o contrast 70553  
Pituitary Pituitary tumor,  Elevated labs (prolactin) MRI Brain with & w/o contrast 70553  
Cranial Nerves Bells Palsy MRI Brain with & w/o contrast 70553  
Brachial Plexus Brachial neuritis / impingement MRI Orbits/ Face/ Neck with & w/o contrast 70543  
Soft Tissue Neck soft tissue lumps/ mass, lymphadenopathy MRI Orbits/ Face/ Neck with & w/o contrast 70543  
  *** CT Neck often a better study ***      
Spine      
Cspine pain, radiculopathy, herniated disc MRI Cervical spine w/o contrast 72141
  MS MRI Cervical spine with & w/o contrast 72156
Tspine pain, pre-kyphoplasty, herniated disc MRI Thoracic spine w/o contrast 72146
  Bone mets to T-spine MRI Thoracic spine with & w/o contrast 72157
Lspine back pain, sciatica, pre-kyphoplasty, herniated disc MRI Lumbar spine w/o contrast 72148
  **if patient has any hx of prev L-spine surgery MRI Lumbar spine with & w/o contrast 72158
  Hx of cancer to r/o bone mets MRI Lumbar spine with & w/o contrast 72158
Chest and Abdomen      
Breast Always bilateral even for pts with hx of mastectomy MRI Breast with & w/o contrast 77059
Abdomen      
to assess: Liver MRI Abdomen with & w/o contrast 74183
  Pancreas MRI Abdomen with & w/o contrast 74183
  Kidneys MRI Abdomen with & w/o contrast 74183
  Adrenals MRI Abdomen w/o contrast 74181
  MRCP - Gallbladder / Biliary Tree MRCP   (MRI Abdomen) w/o contrast 74181
  Appendix **CT often a better option** MRI Abdomen w/o contrast 74181
Vascular      
Circle of Willis (MRA Brain) Abnormal CT, Aneurysm MRA Head (MRA Brain) w/o contrast 70544
Carotids ( MRA Neck ) Carotid Bruit, Abnormal U/S MRA Neck with & w/o contrast 70549
Renals ( MRA Abd ) Renal Arteries for stenosis MRA & MRI Abdomen both with & w/o contrast 74183 & 74185
Run-Off ( Arteriogram of legs ) Abd aorta to ankles included MRA Runoff with contrast 73725 & 72198 & 74185
Aortagram dissection  **CT often a better study** MRA Chest with & w/o contrast 71555
Iliacs Pelvis arteries only **CT often a better study** MRA Pelvis with & w/o contrast 72198
Upper Ext Arteriogram Arteries of that region only**CT often a better study** MRA Upper Ext with & w/o contrast 73225
Lower Ext Arteriogram Arteries of that region only**CT often a better study** MRA Lower Ext with & w/o contrast 73725
MRI Exam Clinical Indication Examples Recommended exam to order CPT CODE
Lower Extremities     Exam to Prior Auth  
Bony Pelvis fracture of sacrum, insufficiency fractures MRI Pelvis w/o contrast MRI Pelvis 72195
  Osteomyelitis MRI Pelvis with & w/o contrast MRI Pelvis w/o & with 72197
Soft Tissue Pelvis uterine fibroids, CA, abnormal ultrasound MRI Pelvis with & w/o contrast MRI Pelvis w/o & with 72197
Hip Pain, arthritis, AVN, post-arthrogram MRI Hip w/o contrast MRI Lower Ext Joint 73721
  Osteomyelitis MRI Hip with & w/o contrast MRI Lower Ext Joint w/o & with 73723
Knee Pain, Meniscus or ligament injury, fracture MRI Knee w/o contrast MRI Lower Ext Joint 73721
  Osteomyelitis, Bone cyst, Tumor, Mass, ST lump MRI Knee with & w/o contrast MRI Lower Ext Joint w/o & with 73723
Ankle Pain, Achilles tendon, ligaments, fracture MRI Ankle w/o contrast MRI Lower Ext Joint 73721
  Osteomyelitis, Bone cyst, Tumor, Mass, ST lump MRI Ankle with & w/o contrast MRI Lower Ext Joint w/o & with 73723
Femur / Upper Leg Muscle tear, trauma, fracture MRI Femur / Thigh w/o contrast MRI Lower Ext Non Joint 73718
  Osteomyelitis, Bone cyst, Tumor, Mass, ST lump MRI Femur / Thigh with & w/o contrast MRI Lower Ext Non Joint w/o & with 73720
Tib/ Fib  - Lower Leg Muscle tear, trauma, fracture MRI Tib-Fib w/o contrast MRI Lower Ext Non Joint 73718
  Osteomyelitis, Bone cyst, Tumor, Mass, ST lump MRI Tib-Fib  with & w/o contrast MRI Lower Ext Non Joint w/o & with 73720
Foot or Toes pain, fracture MRI Foot w/o contrast MRI Lower Ext Non Joint 73718
  Osteomyelitis, Mass, Tumor, ST lump MRI Foot with & w/o contrast MRI Lower Ext Non Joint w/o & with 73720
         
Upper Extremities        
Shoulder pain, rotator cuff tear, labrum tear, post-arthrogram MRI Shoulder w/o contrast MRI Upper Ext Joint 73221
  Osteomyelitis, mass, tumor, cyst, ST lump MRI Shoulder with & w/o contrast MRI Upper Ext Joint w/o & with 73223
Elbow pain, post-arthrogram MRI Elbow w/o contrast MRI Upper Ext Joint 73221
  Osteomyelitis, mass, tumor, cyst, ST lump MRI Elbow with & w/o contrast MRI Upper Ext Joint w/o & with 73223
Wrist pain, trauma, fracture, post-arthrogram MRI Wrist w/o contrast MRI Upper Ext Joint 73221
  Osteomyelitis, mass, tumor, cyst, ST lump MRI Wrist with & w/o contrast MRI Upper Ext Joint w/o & with 73223
Hand / Finger / Thumb pain, trauma, fracture MRI Hand w/o contrast MRI Upper Ext Non Joint 73218
  Osteomyelitis, mass, tumor, cyst, ST lump MRI Hand  with & w/o contrast MRI Upper Ext Non Joint w/o & with 73220
Humerus / Upper Arm pain, muscle tear, trauma, fracture MRI Humerus w/o contrast MRI Upper Ext Non Joint 73218
  Osteomyelitis, mass, tumor, cyst, ST lump MRI Humerus with & w/o contrast MRI Upper Ext Non Joint w/o & with 73220
Forearm / Lower Arm pain, muscle tear, trauma, fracture MRI Forearm w/o contrast MRI Upper Ext Non Joint 73218
  Osteomyelitis, mass, tumor, cyst, ST lump MRI Forearm with & w/o contrast MRI Upper Ext Non Joint w/o & with 73220
Scapula pain, muscle tear, trauma, fracture MRI Scapula w/o contrast MRI Upper Ext Non Joint 73218
  Osteomyelitis, mass, tumor, cyst, ST lump MRI Scapula with & w/o contrast MRI Upper Ext Non Joint w/o & with 73220
Any Questions??? -- Feel free to contact the MRI technologist at  (920) 262-4397.  A radiologist is also available at (920) 262-4244