THYROID UPTAKE (Codes 800 and A800)
ICD-9 CODE: __________
EXAMINATION: THYROID UPTAKE
DATE STARTED: __________
DATE COMPLETED: __________
RADIOPHARMACEUTICAL: __________µCi I-131 sodium iodide p.o.
HISTORY: __________
FINDINGS: The
24-hour thyroidal radioactive iodine uptake is __________% (normal range 10‑30%).
OPINION:
******************************************************************************
ICD-9 Codes
242.00 Toxic diffuse goiter (Graves’ disease)
242.10 Toxic uninodular goiter
242.20 Toxic multinodular goiter
242.80 Thyrotoxicosis of other specified origin
(e.g., factitia)
242.90 Thyrotoxicosis, NOS
245.1 Subacute thyroiditis
242.2 Chronic lymphocytic thyroiditis
246.1 Dyshormogenic goiter
THYROID SCINTIGRAPHY AND UPTAKE (Codes 801 and A801)
ICD-9 CODE: __________
EXAMINATION: THYROID SCINTIGRAPHY AND UPTAKE
DATE STARTED:
__________
DATE COMPLETED:
__________
RADIOPHARMACEUTICAL: __________ mCi Tc-99m pertechnetate i.v. and
____ uCi I-131 (sodium iodide) p.o.
HISTORY:
__________________
FINDINGS: The thyroid images demonstrate uniform activity in a gland of normal size
and configuration. The 24-hour
radioactive iodine uptake is ___% (normal range 10-30%).
OPINION:
******************************************************************************
ICD-9 Codes
193 Malignant neoplasm of thyroid gland
226 Benign neoplasm of thyroid gland
240.0 Simple goiter
241.0 Nontoxic uninodular goiter
241.1 Nontoxic multinodular goiter
242.00 Toxic diffuse goiter (Graves’ disease)
242.10 Toxic uninodular goiter
242.20 Toxic multinodular goiter
242.80 Thyrotoxicosis of other specified origin
(e.g., factitia)
242.90 Thyrotoxicosis, not otherwise specified
245.1 Subacute thyroiditis
242.2 Chronic lymphocytic thyroiditis
245.3 Chronic fibrous thyroiditis
246.1 Dyshormonogenic goiter
759.2 Thyroglossal duct cyst
784.2 Swelling, mass, or lump in neck
786.6 Swelling, mass, or lump in chest
THYROID SCINTIGRAPHY (Codes 802 and A802)
ICD-9 CODE:
__________
EXAMINATION:
THYROID SCINTIGRAPHY
DATE OF STUDY:
__________
RADIOPHARMACEUTICAL:
__________ mCi Tc-99m pertechnetate i.v.
HISTORY: __________
FINDINGS: The thyroid images demonstrate uniform activity in a gland of normal size and configuration.
OPINION:
******************************************************************************
ICD-9 Codes
193 Malignant neoplasm of thyroid gland
226 Benign neoplasm of thyroid gland
240.0 Simple goiter
241.0 Nontoxic uninodular goiter
241.1 Nontoxic multinodular goiter
242.00 Toxic diffuse goiter (Graves’ disease)
242.10 Toxic uninodular goiter
242.20 Toxic multinodular goiter
242.80 Thyrotoxicosis of other specified origin
(e.g., factitia)
242.90 Thyrotoxicosis, not otherwise specified
245.1 Subacute thyroiditis
242.2 Chronic lymphocytic thyroiditis
245.3 Chronic fibrous thyroiditis
246.1 Dyshormonogenic goiter
759.2 Thyroglossal duct cyst
784.2 Swelling, mass, or lump in neck
786.6 Swelling, mass, or lump in chest
WHOLE-BODY I-131 RETENTION (Codes 813)
[I-131 Administration by Nuclear Medicine]
ICD-9 CODE:
193
EXAMINATION:
WHOLE-BODY I-131 RETENTION
DATE STARTED: __________
DATE COMPLETED: __________
RADIOPHARMACEUTICAL: __________ mCi I-131 sodium iodide p.o.
HISTORY: __________
FINDINGS: I-131 sodium iodide was administered orally
on ________ (after confirmation that the patient was not pregnant or
breast-feeding).ΠThe patient was given both written and oral
instructions regarding radiation safety precautions intended to maintain
exposure to other individuals as low as reasonably achievable. A whole-body count was obtained with a probe
detector immediately following administration of I-131. A repeat whole-body count was obtained _____
hours later.
The calculated whole-body
retention of I-131 is _____ % of the administered dose.
OPINION: Whole-body retention of I-131 at _____ hours
is _____ %.
******************************************************************************
ICD-9 Codes
193 Malignant
neoplasm of thyroid gland
WHOLE-BODY I-131 IMAGING AND RETENTION (Codes 814 and A814)
[I-131 Administration by Nuclear Medicine]
ICD-9 CODE:
193
EXAMINATION:
WHOLE-BODY I-131 IMAGING AND RETENTION
DATE STARTED: __________
DATE COMPLETED: __________
RADIOPHARMACEUTICAL: __________ mCi I-131 sodium iodide p.o.
HISTORY: __________
FINDINGS: I-131 sodium iodide was administered orally
on ________ (after confirmation that the patient was not pregnant or
breast-feeding).ΠThe patient was given both
written and oral instructions regarding radiation safety precautions intended
to maintain exposure to other individuals as low as reasonably achievable. A whole-body count was obtained with a probe
detector immediately following administration of I-131. A repeat whole-body count , as well as images
of the head, neck, trunk, and proximal extremities, were obtained _____ hours
later.
The calculated whole-body
retention of I-131 is _____ % of the administered dose.
There is expected I-131 activity in the salivary glands, stomach,
colon, and urinary bladder. No increased
activity consistent with functioning thyroid tissue is seen.
OPINION:
1. Whole-body retention of I-131 at _____ hours
is _____ %.
2. No functioning thyroid
tissue.
******************************************************************************
ICD-9 Codes
193 Malignant
neoplasm of thyroid gland
WHOLE-BODY I-131 IMAGING (Codes 816 and A816)
[I-131 Administration by Nuclear Medicine]
ICD-9 CODE:
193
EXAMINATION:
WHOLE-BODY I-131 IMAGING
DATE STARTED: __________
DATE COMPLETED: __________
RADIOPHARMACEUTICAL: __________ mCi I-131 sodium iodide p.o.
HISTORY: __________
FINDINGS: I-131 sodium iodide was administered orally
on ________ (after confirmation that the patient was not pregnant or
breast-feeding).ΠThe patient was given both
written and oral instructions regarding radiation safety precautions intended
to maintain exposure to other individuals as low as reasonably achievable. Images of the head, neck, trunk, and proximal
extremities were obtained _____ hours later.
There is expected I-131 activity in the salivary glands, stomach,
colon, and urinary bladder. No increased
activity consistent with functioning thyroid tissue is seen.
OPINION: No
functioning thyroid tissue.
******************************************************************************
ICD-9 Codes
193 Malignant
neoplasm of thyroid gland
WHOLE-BODY I-131 IMAGING (Codes
815 and A815)
[I-131 Administration by Radiation Oncology]
ICD-9 CODE:
193
EXAMINATION:
WHOLE-BODY I-131 IMAGING
DATE OF STUDY: __________
HISTORY:
__________
FINDINGS: A ______-mCi therapeutic dose of I-131 sodium
iodide was administered orally on
__________ by the staff of the Division of Radiation Oncology. Images of the head, neck, trunk, and proximal
extremities were obtained _____ hours later.
There is expected I-131 activity in the salivary glands, stomach,
colon, and urinary bladder. No increased
activity consistent with functioning thyroid tissue is seen.
OPINION: No
functioning thyroid tissue.
******************************************************************************
ICD-9 Codes
193 Malignant
neoplasm of thyroid gland
THYROID UPTAKE AND THERAPY (Code 805)
ICD-9 CODE:
________
EXAMINATION:
THYROID UPTAKE
DATE STARTED: ________
DATE COMPLETED: ________
RADIOPHARMACEUTICAL: _____ uCi I-131 sodium iodide p.o.
FINDINGS: The 24 hour radioactive iodine uptake is ___%
of the administered dose (normal range 10-30%).
CONSULTATION AND RADIOACTIVE
IODINE THERAPY
DATE: ________
HISTORY: ________
PHYSICAL FINDINGS: ________
LABORATORY FINDINGS: ________
OPINION: ________
TREATMENT: The risks and benefits of I-131 therapy and
of alternate modes of therapy with antithyroid drugs and surgery were explained
to the patient. The patient’s written
informed consent for treatment was obtained.
The patient was given both written and oral instructions regarding
radiation safety precautions intended to maintain exposure to other individuals
as low as reasonably achievable. The
patient received ____ mCi of I-131 sodium iodide p.o. at ______ on ______. The patient will continue treatment with ____________________
and will be followed by Dr. __________.
The patient was informed of the need for lifetime medical follow-up to
monitor thyroid function, because of the high risk of eventual hypothyroidism.
Thank you for the referral
of this patient.
******************************************************************************
ICD-9 Codes
242.00 Toxic diffuse goiter (Graves’ disease)
242.10 Toxic uninodular goiter
242.20 Toxic multinodular goiter
242.80 Thyrotoxicosis of other specified origin
(e.g., factitia)
242.90 Thyrotoxicosis, NOS
245.1 Subacute thyroiditis
242.2 Chronic lymphocytic thyroiditis
246.1 Dyshormogenic goiter
414.9 Chronic
ischemic heart disease, NOS
I-131 THERAPY: MODEL REPORT
ICD-9
CODE: 242.0
EXAMINATION: THYROID UPTAKE
DATE
STARTED:
DATE
FINISHED:
RADIOPHARMACEUTICAL: 3.6 µCi I-131 sodium iodide p.o.
FINDINGS: The 24 hour radioactive iodine uptake is 74%
of the administered dose (normal range 10-30%).
CONSULTATION
AND RADIOACTIVE IODINE THERAPY
DATE:
HISTORY: Mrs. Gilmore is a 28 year old woman referred
by Dr. Brown for treatment of hyperthyroidism.
She was well until approximately 4 months ago, when she developed
nervousness, heat intolerance, palpitations, and increased frequency of bowel
movements. The patients reports that she
has lost approximately 12 pounds over the last 4 months despite a good
appetite. She has noted some enlargement
of her thyroid gland, but has had no pain or tenderness of her neck. Her husband told her that her eyes appear
prominent, but she has not experienced blurring of vision, diplopia, or pain or
burning of her eyes. She denies changes
in her skin or hair. She tires easily,
particularly when walking up stairs. She
was first seen by Dr. Brown 7 weeks ago and was found to have elevated thyroid
function tests. Treatment with
propanolol, 10 mg t.i.d., and propylthiouracil, 100 mg t.i.d., was begun, and
the patient noted improvement in her symptoms.
However, after 4 weeks of treatment the patient developed a rash and the
propylthiouracil was discontinued. She
remains on propanolol, but the dose was increased one week ago to 20 mg
t.i.d. She is now referred for
definitive treatment with I-131. The
patient lives with her husband and 2 children (ages 11 months and 4
years). She takes oral contraceptives,
is currently in the 4th day of her menses, and has a recently negative
pregnancy test (see below). She is not
breast-feeding. Her past medical history
is unremarkable except for an appendectomy at age 9. There is no family history of thyroid
disease.
PHYSICAL
FINDINGS: The patient is thin, appears
agitated, and has a readily noticeable stare.
Her pulse is 85/minute (on the current dose of propanolol). Respiratory rate is 15/min. Blood pressure is 130/80 mm/Hg. Her skin is smooth, warm and moist. There is no evidence of pretibial myxedema. Her hair is fine. There is mild exophthalmos and lid lag, but
the conjunctivae and ocular motions are normal. The thyroid gland is moderately enlarged
(approximately 60 gm), smooth and soft.
There are no palpable nodules. On
auscultation, a bruit is heard over the thyroid gland. Hear heart and lungs are normal. There is a fine tremor and generalized hyperreflexia
of moderate degree, but muscular strength is well maintained.
LABORATORY
FINDINGS: On
OPINION: The history, physical findings and laboratory
studies in this patient are most consistent with hyperthyroidism due to
diffuse toxic goiter (Graves’ disease).
There are no complicating medical problems. This patient was discussed with Dr. Brown and
it was agreed to proceed with I-131 therapy.
In this young patient with typical diffuse toxic goiter and only mild to
moderate symptoms of hyperthyroidism, the usual dose of 100 uCi/gm of thyroid
tissue was selected. The calculated dose
was 8.1 mCi, based on the thyroid weight of 60 gm and 24 hour radioactive
iodine uptake of 74%.
TREATMENT: The risks and benefits of I-131 therapy and
of alternate modes of therapy with antithyroid drugs and surgery were explained
to the patient. The patient’s written
informed consent for treatment was obtained.
The patient was given both written and oral instructions regarding
radiation safety precautions intended to maintain exposure to other individuals
as low as reasonably achievable. The
patient received 8.3 mCi of I-131 sodium iodide p.o. at
Thank you for
the referral of this patient.
PARATHYROID SCINTIGRAPHY Code 803 and A803
[With SPECT Code 803S and
A803S]
ICD-9 CODE:
__________
EXAMINATION:
PARATHYROID SCINTIGRAPHY (WITH TOMOGRAPHIC IMAGING)
DATE OF STUDY:
__________
RADIOPHARMACEUTICAL: __________ mCi Tc-99m sestamibi i.v.
HISTORY: __________
FINDINGS: After the intravenous administration of
Tc-99m sestamibi, planar images of the neck and mediastinum were obtained at
approximately 10 minutes and 2 hours. Tomographic
(SPECT) images of the neck and mediastinum were obtained immediately following
the initial planar images.
There is physiologic distribution of the radiopharmaceutical. No focus of persistent activity consistent
with an enlarged parathyroid gland is seen.
OPINION: No
scintigraphic evidence for enlarged parathyroid glands.
******************************************************************************
ICD-9 Codes
252.0 Primary hypepararthyroidism
588.8 Renal failure with secondary hyperparathyroidism
MIBG SCINTIGRAPHY (Codes MIBG and AMIBG)
ICD-9 CODE: __________
EXAMINATION: MIBG SCINTIGRAPHY
DATE STARTED: __________
DATE COMPLETED: __________
RADIOPHARMACEUTICAL: mCi I-123 metaiodobenzylguanidine (MIBG)
i.v. and drops SSKI solution p.o. three times daily for
days beginning on .
HISTORY: __________
FINDINGS: Images of the head, neck, trunk, and proximal
extremities were obtained _____ hours after administration of I-123 MIBG. There
is expected I-123 MIBG activity in the salivary glands, myocardium, liver, and
urinary bladder. No foci of abnormal
I-123 MIBG accumulation are seen.
OPINION:
******************************************************************************
ICD-9 Codes
194.0 Malignant neoplasm of adrenal gland
227.0 Benign neoplasm of adrenal gland
255.6 Medulloadrenal hyperfunction
SOMATOSTATIN-RECEPTOR SCINTIGRAPHY (Codes Octreo and AOctreo)
ICD-9 CODE: __________
EXAMINATION: SOMATOSTATIN-RECEPTOR SCINTIGRAPHY (WITH
TOMOGRAPHIC IMAGING) Œ
DATE STARTED: __________
DATE COMPLETED: __________
RADIOPHARMACEUTICAL: __________ mCi In-111 pentetreotide i.v.
HISTORY: __________
FINDINGS: Whole-body images were obtained ______ hours
and ______ hours after injection of In‑111 pentetreotide. Tomographic (SPECT) images of the ¨ were obtained at __________ hours. There
is expected In-111 pentetreotide activity in the spleen, kidneys, and
liver. No foci of abnormal In-111
pentetreotide accumulation are seen.
OPINION: No
evidence for somatostatin-receptor-positive tumor.
ΠIf SPECT not performed, instruct transcriptionist to
delete.
¨ Insert region of body (chest, abdomen, pelvis)
imaged.
******************************************************************************
ICD-9 Codes
152.9 Malignant
neoplasm of small intesting, NOS
153.9 Malignant
neoplasm of colon, NOS
157.4 Malignant
pancreatic Islet cell neoplasm
162.9 Malignant
neoplasm of bronchus or lung, NOS
193 Malignant
tumor of thyroid gland
194.0 Malignant
neoplasm of adrenal gland
194.6 Paraganglioma
211.7 Benign
pancreatic islet cell neoplasm
212.3 Benign
neoplasm of bronchus or lung
227.0 Benign
neoplasm of adrenal gland
258.0 Multiple
endocrine neoplasia
259.2 Carcinoid
syndrome
BLOOD VOLUME (Codes 818 and A818)
ICD-9 CODE:
__________
EXAMINATION:
BLOOD VOLUME
DATE OF STUDY:
__________
RADIOPHARMACEUTICAL: __________ µCi Cr-51 labeled autologous red
blood cells i.v.;
__________ µCi I-125 human serum albumin
i.v.; and _____ drops SSKI solution p.o.
HISTORY: ___________
FINDINGS: At the time of this study, the patient's body
weight was ___ kg and the peripheral venous hematocrit was ___%. The measured
red cell volume was ___ ml/kg (predicted normal range for this patient ___ to
___ ml/kg). The measured plasma volume
was ___ ml/kg (predicted normal ___ to ___ ml/kg). The whole-body hematocrit was ___% and the
ratio of whole-body hematocrit to peripheral venous hematocrit was ___.
OPINION:
******************************************************************************
ICD-9 Codes
238.4 Polycythemia vera
289.0 Secondary erythrocytosis (includes “stress
polycythemia”)
SPLEEN IMAGING (Codes 806 and A806)
ICD-9 CODE: __________
EXAMINATION: SPLEEN IMAGING
DATE STARTED: __________
DATE COMPLETED: __________
RADIOPHARMACEUTICAL: __________ mCi Tc-99m heat-damaged
in-vitro-labeled autologous red blood cells i.v.
HISTORY: __________
FINDINGS: Images of the abdomen obtained __________ minutes after administration of
Tc-99m heat-damaged red cells show normal
uptake of tracer in the spleen, which is normal in size, shape, and location.
OPINION:
******************************************************************************
ICD-9 Codes
287.3 Thromobcytopenia,
primary
289.5 Disease
of spleen, unspecified
759.0 Anomalies
of spleen (includes aberrant, absent, and accessory spleen, asplenia, polysplenia)
759.3 Situs
inversus
789.2 Splenomegaly
865.00 Injury
to spleen (use for splenosis)
LYMPHOSCINTIGRAPHY (Code 807)
ICD-9 CODE: __________
EXAMINATION: LYMPHOSCINTIGRAPHY
DATE OF STUDY: __________
RADIOPHARMACEUTICAL: ______
mCi millipore-filtered Tc-99m
sulfur colloid injected
____(describe)______.
HISTORY: __________
FINDINGS: __________
OPINION: __________
******************************************************************************
ICD-9 Codes
172.X Malignant
melanoma of: (2=ear; 3=other face; 4=scalp and neck; 5=trunk; 6=upper extremity; 7=lower
extremity; 9=NOS)
174.9 Malignant
neoplasm of female breast, NOS
196.X Lymph
node metastasis of (0=head and neck; 3=axilla; 4=inguinal; 6=intrapelvic)
457.1 Lymphedema
757.0 Congenital
lymphedema
LIVER SPLEEN SCINTIGRAPHY (Codes 836 and A836)
ICD-9 CODE:
__________
EXAMINATION:
LIVER-SPLEEN SCINTIGRAPHY
DATE OF STUDY:
__________
RADIOPHARMACEUTICAL: __________ mCi Tc-99m sulfur colloid i.v.
HISTORY: __________
FINDINGS: The
liver and spleen are of normal size and configuration. There is uniform colloid
uptake in both organs.
OPINION:
******************************************************************************
ICD-9 Codes
197.7 Hepatic
metastases
211.5 Benign
neoplasm of liver (adenoma, FNH)
228.04 Hemangioma,
intraabdominal
289.4 Hypersplenism
289.5 Disease
of spleen, unspecified
571.2 Alcoholic
cirrhosis of liver
571.40 Chronic
hepatitis, unspecified
571.5 Nonalcoholic
cirrhosis
571.8 Other
chronic nonalcoholic liver disease
759.0 Anomalies
of spleen (includes aberrant, absent, and accessory spleen, asplenia, polysplenia)
789.1 Hepatomegaly
789.2 Splenomegaly
865.00 Injury
to spleen (use for splenosis)
HEPATOBILIARY SCINTIGRAPHY (Codes 840 and A840)
ICD-9 CODE:
__________
EXAMINATION:
HEPATOBILIARY SCINTIGRAPHY
DATE OF STUDY:
__________
RADIOPHARMACEUTICAL: __________ mCi Tc-99m _______Œ_______ i.v. ¨
HISTORY: __________
FINDINGS: Following intravenous administration of
Tc-99m ______Œ_____, sequential abdominal images were obtained through ____ minutes. There is prompt, uniform accumulation of the
tracer by the liver. There is normal filling of the intrahepatic ducts, common
bile duct and gallbladder and normal excretion of the tracer into the duodenum.
OPINION:
ΠSpecify whether radiopharmaceutical is disofenin
or mebrofenin.
¨ Give dose of sincalide, if patient was pretreated. Give dose of morphine sulfate if
administered. Also describe these interventions in findings.
******************************************************************************
ICD-9 Codes
See code list for liver-spleen scintigraphy for
codes relating to hepatic parenchymal diseases.
573.3 Hepatitis, unspecified 790.4 Abnormal transaminase or LDH
574.00 Acute calculous cholecystitis 790.5 Abnormal alkaline phosphatase
574.10 Chronic calculous cholecystitis 996.82 Complication of liver transplant
574.20 Cholelithiasis (without obstruction) 997.4 Complication of digestive system surgery
574.51 Choledocholithiasis
575.0 Acute acalculous cholecystitis
575.1 Chronic acalculous cholecystitis
576.1 Cholangitis
576.2 Non-calculous bile duct obstruction
576.3 Perforation of bile duct
751.61 Biliary atresia
751.69 Biliary anomalies (e.g., choledochal cyst)
782.4 Jaundice
787.01 Nausea and vomiting
789.01 RUQ abdominal pain
HEPATOBILIARY SCINTIGRAPHY + GB EJECTION FRACTION/Sincalide (Codes 841
and A841)
ICD-9 CODE:
__________
EXAMINATION:
HEPATOBILIARY SCINTIGRAPHY (WITH SINCALIDE ADMINISTRATION)
DATE OF STUDY:
__________
RADIOPHARMACEUTICAL: ____ mCi Tc-99m _______Œ_______i.v. and ____ µg
sincalide i.v.
HISTORY: __________
FINDINGS: Following intravenous administration of
Tc-99m ______Œ_____, sequential abdominal images were obtained. There is prompt, uniform accumulation of the tracer by the liver. There
is normal filling of the intrahepatic ducts, common bile duct and gallbladder
and normal excretion of the tracer into the duodenum.
In order to evaluate the
contractile response of the gallbladder in response to cholecystokinin, _____
µg sincalide (0.02 µg/kg) was administered by slow intravenous infusion approximately
_____ minutes after the administration of the radiopharmaceutical. Sequential imaging was continued for _____
minutes after the start of the sincalide infusion. These
images demonstrate prompt contraction of the gallbladder. The calculated gallbladder ejection fraction
is _____% (normal greater than 35%).
OPINION:
1. Normal biliary imaging study.
2. Normal contractile response of gallbladder to
sincalide infusion.
ΠSpecify whether radiopharmaceutical is disofenin
or mebrofenin.
******************************************************************************
ICD-9 Codes
574.10 Chronic
calculous cholecystitis
574.20 Cholelithiasis
(without obstruction)
575.0 Acute
acalculous cholecystitis
575.1 Chronic
acalculous cholecystitis
576.2 Non-calculous
bile duct obstruction
576.2 Non-calculous
bile duct obstruction
575.8 Other
disorders of cystic duct or gallbladder (includes biliary dyskinesia)
576.5 Spasm
of sphincter of Oddi
787.01 Nausea
and vomiting
789.01 RUQ
abdominal pain
787.1 Heartburn
787.3 Flatulence,
eructation, gas pain
HEPATOBILIARY SCINTIGRAPHY + GB EJECTION FRACTION/Fatty Meal (Codes
841F and A841F)
ICD-9 CODE:
__________
EXAMINATION:
HEPATOBILIARY SCINTIGRAPHY (WITH FATTY MEAL ADMINISTRATION)
DATE OF STUDY:
__________
RADIOPHARMACEUTICAL: ____ mCi Tc-99m ______Œ_____ i.v. and ____ oz.
______¨_____ p.o.
HISTORY: __________
FINDINGS: Following intravenous administration of
Tc-99m ______Œ_____, sequential abdominal images were obtained. There is prompt, uniform accumulation of the tracer by the liver. There
is normal filling of the intrahepatic ducts, common bile duct and gallbladder
and normal excretion of the tracer into the duodenum.
In order to evaluate the
contractile response of the gallbladder in response to cholecystokinin, _____
ounces of _____¨_______ was administered orally approximately
_____ minutes after the administration of the radiopharmaceutical. Sequential imaging was continued for _____
minutes after administation of the fatty meal.
These images demonstrate prompt
contraction of the gallbladder. The
calculated gallbladder ejection fraction is _____% (normal greater than 50%).
OPINION:
1. Normal biliary imaging study.
2. Normal contractile response of gallbladder to
fatty meal administration.
ΠSpecify whether radiopharmaceutical is disofenin
or mebrofenin.
¨ Specify whether fatty
meal is milk or Ensure Plus
******************************************************************************
ICD-9 Codes
574.10 Chronic
calculous cholecystitis
574.20 Cholelithiasis
(without obstruction)
575.0 Acute
acalculous cholecystitis
575.1 Chronic
acalculous cholecystitis
576.2 Non-calculous
bile duct obstruction
576.2 Non-calculous
bile duct obstruction
575.8 Other
disorders of cystic duct or gallbladder (includes biliary dyskinesia)
576.5 Spasm
of sphincter of Oddi
787.01 Nausea
and vomiting
789.01 RUQ
abdominal pain
787.1 Heartburn
787.3 Flatulence,
eructation, gas pain
NORMAL DUAL-ISOTOPE SCHILLING TEST (Code 809)
ICD-9 Code:
__________
EXAMINATION:
SCHILLING TEST
DATE STARTED:
__________
DATE COMPLETED:
__________
RADIOPHARMACEUTICAL: __________ uCi Co-58 cyanocobalamin p.o.;
____ uCi Co-57 cyanocobalamin-intrinsic factor complex p.o.; and separate 1 mg
intramuscular injections of cyanocobalamin on ______ and _____.
HISTORY: __________
FINDINGS: The 48-hour urinary excretion of Co-58
cyanocobalamin without intrinsic factor is ___% of the administered dose. The 48-hour excretion of the Co-57
cyanocobalamin-intrinsic factor complex is ___% of the administered dose. Normally over 10% of the orally administered
dose should be excreted in the first 48 hours.
The normal ratio of excretion of cyanocobalamin with the intrinsic
factor to that without intrinsic factor is about 1.0 (range 0.7-1.2). The ratio in this patient is ____. This is a normal study.
OPINION:
1. Normal
dual-isotope Schilling test.
2. The
findings indicate that there is no evidence of intrinsic factor deficiency and
that there is normal absorption of cyanocobalamin in capsule form. If the patient has a low serum vitamin B12
level, it is possible that this may reflect difficulty absorbing vitamin B12
bound to food (e.g., as a result of atrophic gastritis). The results of this test indicate that
vitamin B12 replacement in such a patient could be accomplished by oral supplementation,
and that parenteral administration of vitamin B12 is not necessary.
******************************************************************************
ICD-9 Codes
266.2 Vitamin
deficiency (includes folic acid and vitamin B12)
281.0 Pernicious
anemia
281.1 Other
vitamin B12 deficiency anemia
281.2 Folate
deficiency anemia
281.3 Megaloblastic
anemia, NOS
535.1 Atrophic
gastritis
579.2 Bacterial
overgrowth syndrome
579.3 Postsurgical
malabsorption
579.9 Malabsorption,
NOS
DUAL-ISOTOPE SCHILLING TEST (Code 811)
[PERNICIOUS ANEMIA]
ICD-9 CODE:
__________
EXAMINATION:
SCHILLING TEST
DATE STARTED:
__________
DATE COMPLETED:
__________
RADIOPHARMACEUTICAL: _____ uCi Co-58 cyanocobalamin p.o.; ____ uCi
Co-57 cyanocobalamin-intrinsic factor complex p.o.; and separate 1 mg
intramuscular injections of cyanocobalamin on ______ and _____.
HISTORY: __________
FINDINGS: The 48-hour urinary excretion of Co-58
cyanocobalamin without intrinsic factor is __% of the administered dose. The 48-hour excretion of the Co-57
cyanocobalamin-intrinsic factor complex is ___% of the administered dose. Normally over 10% of the orally administered
dose should be excreted in the first 48 hours.
The normal ratio of excretion of cyanocobalamin with intrinsic factor to
that without intrinsic factor is about 1.0 (range 0.7-1.2). The ratio in this patient is ___. These results are abnormal. Since intrinsic factor greatly increased the
absorption of cyanocobalamin, the results suggest primary deficiency of
intrinsic factor (e.g., pernicious anemia).
OPINION: Abnormal Schilling test. The findings most likely represent intrinsic
factor deficiency.
******************************************************************************
ICD-9 Codes
266.2 Vitamin
deficiency (includes folic acid and vitamin B12)
281.0 Pernicious
anemia
281.1 Other
vitamin B12 deficiency anemia
281.2 Folate
deficiency anemia
281.3 Megaloblastic
anemia, NOS
535.1 Atrophic
gastritis
579.2 Bacterial
overgrowth syndrome
579.3 Postsurgical
malabsorption
579.9 Malabsorption, NOS
DUAL-ISOTOPE SCHILLING TEST (Code 810)
[MALABSORPTION]
ICD-9 CODE:
__________
EXAMINATION:
SCHILLING TEST
DATE STARTED:
__________
DATE COMPLETED:
__________
RADIOPHARMACEUTICAL: _____ uCi Co-58 cyanocobalamin p.o.; ____ uCi
Co-57 cyanocobalamin-intrinsic factor complex p.o.; and separate 1 mg
intramuscular injections of cyanocobalamin on ______ and _____.
HISTORY: ___________
FINDINGS: The 48-hour urinary excretion of
cyanocobalamin without intrinsic factor is ____% of the administered dose. The 48-hour excretion of the Co-57
cyanocobalamin-intrinsic factor complex is ____% of the administered dose. Normally over 10% of the orally administered
dose should be excreted in the first 48 hours.
The normal ratio of excretion of cyanocobalamin with the intrinsic
factor to that without intrinsic factor is about 1.0 (range 0.7-1.2). The ratio in this patient is ___. The values for cyanocobalamin excretion are
low and intrinsic factor did not improve excretion significantly. The results suggest primary intestinal
malabsorption rather than pernicious anemia.
OPINION: Abnormal Schilling test. The findings most likely represent primary
intestinal malabsorption of cyanocobalamin.
******************************************************************************
ICD-9 Codes
266.2 Vitamin
deficiency (includes folic acid and vitamin B12)
281.0 Pernicious
anemia
281.1 Other
vitamin B12 deficiency anemia
281.2 Folate
deficiency anemia
281.3 Megaloblastic
anemia, NOS
535.1 Atrophic
gastritis
579.2 Bacterial
overgrowth syndrome
579.3 Postsurgical
malabsorption
579.9 Malabsorption, NOS
NORMAL SINGLE-ISOTOPE SCHILLING TEST (Code 808)
ICD-9 CODE:
__________
EXAMINATION:
SCHILLING TEST
DATE STARTED:
__________
DATE COMPLETED: __________
RADIOPHARMACEUTICAL: _____ uCi Co-57 cyanocobalamin p.o. and
separate 1 mg intramuscular injections of cyanocobalamin on ______ and _____.
HISTORY: ___________
FINDINGS: The 48-hour urinary excretion of Co-57
cyanocobalamin is _____% of the administered dose. Normally over 9% of the orally administered
dose should be excreted in the first 48 hours.
This is a normal study.
OPINION:
1.
Normal Schilling test.
2. The
findings indicate that there is no evidence of intrinsic factor deficiency and
that there is normal absorption of cyanocobalamin in capsule form. If the patient has a low serum vitamin B12
level, it is possible that this may reflect difficulty absorbing vitamin B12
bound to food (e.g., as a result of atrophic gastritis). The results of this test indicate that
vitamin B12 replacement in such a patient could be accomplished by oral
supplementation, and that parenteral administration of vitamin B12 is not
necessary.
******************************************************************************
ICD-9 Codes
266.2 Vitamin
deficiency (includes folic acid and vitamin B12)
281.0 Pernicious
anemia
281.1 Other
vitamin B12 deficiency anemia
281.2 Folate
deficiency anemia
281.3 Megaloblastic
anemia, NOS
535.1 Atrophic
gastritis
579.2 Bacterial overgrowth syndrome
579.3 Postsurgical
malabsorption
579.9 Malabsorption,
NOS
ABNORMAL SINGLE-ISOTOPE SCHILLING TEST (Code 812)
ICD-9 CODE:
__________
EXAMINATION:
SCHILLING TEST
DATE STARTED:
__________
DATE COMPLETED:
__________
RADIOPHARMACEUTICAL: _____ µCi Co-57 cyanocobalamin p.o. and
separate 1 mg intramuscular injections of cyanocobalamin on ______ and _____.
HISTORY: __________
FINDINGS: The 48-hour urinary excretion of Co-57
cyanocobalamin is ____% of the administered dose. Normally over 9% of the orally administered
dose should be excreted in the first 48 hours.
This is an abnormal study indicative of inadequate intestinal absorption
of vitamin B12. If clinically indicated,
a repeat examination with simultaneous administration of Co-57 cyanocobalamin
and intrinsic factor would be useful to distinguish intrinsic factor deficiency
(e.g., pernicious anemia) from primary intestinal malabsorption of vitamin B12.
OPINION: Abnormal Schilling test. See above.
******************************************************************************
ICD-9 Codes
266.2 Vitamin
deficiency (includes folic acid and vitamin B12)
281.0 Pernicious
anemia
281.1 Other
vitamin B12 deficiency anemia
281.2 Folate
deficiency anemia
281.3 Megaloblastic
anemia, NOS
535.1 Atrophic
gastritis
579.2 Bacterial
overgrowth syndrome
579.3 Postsurgical
malabsorption
579.9 Malabsorption, NOS
NORMAL SINGLE-ISOTOPE SCHILLING TEST WITH INTRINSIC FACTOR
(Code 808F)
ICD-9 CODE:
__________
EXAMINATION:
SCHILLING TEST WITH INTRINSIC FACTOR
DATE STARTED:
__________
DATE COMPLETED:
__________
RADIOPHARMACEUTICAL: _____ uCi Co-57 cyanocobalamin p.o., I NF XI
unit intrinsic factor p.o., and separate 1 mg intramuscular injections of
cyanocobalamin on ______ and _____.
HISTORY: ___________
FINDINGS: The 48-hour urinary excretion of Co-57
cyanocobalamin is _____% of the administered dose. Normally over 9% of the orally administered
dose should be excreted in the first 48 hours.
This is a normal study.
OPINION:
******************************************************************************
ICD-9 Codes
266.2 Vitamin
deficiency (includes folic acid and vitamin B12)
281.0 Pernicious
anemia
281.1 Other
vitamin B12 deficiency anemia
281.2 Folate
deficiency anemia
281.3 Megaloblastic
anemia, NOS
535.1 Atrophic
gastritis
579.2 Bacterial
overgrowth syndrome
579.3 Postsurgical
malabsorption
579.9 Malabsorption,
NOS
ABNORMAL SINGLE-ISOTOPE SCHILLING TEST WITH INTRINSIC FACTOR
(Code 812F)
ICD-9 CODE:
__________
EXAMINATION:
SCHILLING TEST WITH INTRINSIC FACTOR
DATE STARTED:
__________
DATE COMPLETED:
__________
RADIOPHARMACEUTICAL: _____ µCi Co-57 cyanocobalamin p.o. , I NF XI
unit intrinsic factor p.o., and separate 1 mg intramuscular injections of
cyanocobalamin on ______ and _____.
HISTORY: __________
FINDINGS: The 48-hour urinary excretion of Co-57
cyanocobalamin is ____% of the administered dose. Normally over 9% of the orally administered
dose should be excreted in the first 48 hours.
OPINION: Abnormal Schilling test with intrinsic
factor. Given the abnormal result of the Schilling test without intrinsic
factor performed on _______, the failure of normalization of vitamin B12
absorption in this patient by intrinsic factor indicates that primary
intestinal malabsorption (rather than intrinsic factor deficiency) is the most
likely cause for this patient’s vitamin B12 malabsorption.
******************************************************************************
ICD-9 Codes
266.2 Vitamin
deficiency (includes folic acid and vitamin B12)
281.0 Pernicious
anemia
281.1 Other
vitamin B12 deficiency anemia
281.2 Folate
deficiency anemia
281.3 Megaloblastic
anemia, NOS
535.1 Atrophic
gastritis
579.2 Bacterial
overgrowth syndrome
579.3 Postsurgical
malabsorption
579.9 Malabsorption, NOS
GASTRO-INTESTINAL BLEEDING STUDY (Codes 863 and A863)
ICD-9 CODE:
__________
EXAMINATION:
GASTRO-INTESTINAL BLEEDING STUDY
DATE OF STUDY:
__________
RADIOPHARMACEUTICAL: __ mCi Tc-99m in vitro labeled red cells i.v.
HISTORY: __________
FINDINGS: Following intravenous administration of
Tc-99m labeled red cells, sequential abdominal images were obtained through
____ minutes. No abnormal foci of labeled
red cell extravasation are seen.
OPINION: No evidence for active gastro-intestinal
bleeding.
******************************************************************************
ICD-9 Codes
531.00 Acute
gastric ulcer with hemorrhage
532.00 Acute
duodenal ulcer with hemorrhage
535.00 Acute
gastritis
557.0 Acute ischemic enterocolitis
562.12 Diverticulosis
of colon with hemorrhage
569.85 Angiodysplasia
of intestine with hemorrhage
578.0 Hematemesis
578.1 Melena
578.9 GI
bleeding, NOS
BOWEL SCINTIGRAPHY (Codes 838 and A838)
ICD-9 CODE:
__________
EXAMINATION:
BOWEL SCINTIGRAPHY
DATE OF STUDY:
__________
RADIOPHARMACEUTICAL: ____ mCi Tc-99m pertechnetate i.v.
HISTORY: __________
FINDINGS: Sequential abdominal images demonstrate no
abnormal foci of Tc-99m pertechnetate uptake.
OPINION: No evidence for ectopic gastric mucosa.
******************************************************************************
ICD-9 Codes
560.0 Intussusception
578.1 Melena
578.9 GI
bleeding, NOS
751.0 Meckel’s
diverticulum
751.5 Other
anomalies of intestine (includes duplication)
GASTRIC EMPTYING STUDY (Codes 859 and A859)
[SOLID]
ICD-9 CODE:
__________
EXAMINATION:
GASTRIC EMPTYING STUDY
DATE OF STUDY:
__________
RADIOPHARMACEUTICAL: ____ mCi Tc-99m sulfur colloid incorporated
into 120 g egg substitute, along with 2 slices toast, 30 g strawberry jam, and
120 mL water p.o.
HISTORY: __________
FINDINGS:
After oral ingestion of the radiolabeled meal, sequential anterior and
posterior Πabdominal images were obtained through __________
hours. There is normal emptying of gastric contents in to the intestine. The residual gastric activity is __________%
of peak activity at 30 minutes, __________% at 1 hour, __________% at 2 hours,
and __________% at 4 hours.
The corresponding upper limit values in normal
subjects are 100% at 30 minutes, 90% at 1 hour, 60% at 2 hours, and 10% at 4
hours.
OPINION:
Œ
Indicate if
only anterior or posterior views obtained.
******************************************************************************
ICD-9 Codes
250.6 Diabetic gastroparesis
306.40 Psychogenic GI tract disorder
307.54 Psychogenic vomiting
536.10 Acute
dilatation of stomach
536.20 Persistent
vomiting
536.3 Gastroparesis
787.01 Nausea
with vomiting
787.02 Nausea
alone
787.03 Vomiting
alone
GASTRIC EMPTYING STUDY - DELAYED EMPTYING: MODEL REPORT
ICD-9
CODE: 250.6
EXAMINATION: GASTRIC EMPTYING STUDY
DATE OF
STUDY:
RADIOPHARMACEUTICAL: 1.05 mCi Tc-99m sulfur colloid incorporated
into 2 scrambled eggs, along with 2 slices dry toast and 250 mL water p.o.
HISTORY: 26 year old woman with insulin-dependent
diabetes mellitus. The patient has a
several-month history of early satiety, nausea, and vomiting. Evaluate for gastroparesis.
FINDINGS: After administration of the radiolabeled test
meal, sequential anterior and posterior abdominal images were obtained at
15-minute intervals through 105 minutes.
The images demonstrate no emptying of gastric contents through 45
minutes, indicative of prolongation of the lag phase. Thereafter, there is emptying of a small
amount of the radiolabeled test meal into the small intestine. The fraction of ingested activity remaining
in the stomach was 95% at 60 minutes, 85% at 90 minutes, and 80% at 105
minutes. The corresponding mean values
in normal subjects are approximately 70% at 60 minutes, 60% at 90 minutes and
40% at 105 minutes.
OPINION: Moderately prolonged gastric emptying. In a patient with insulin-dependent diabetes
mellitus, the findings are consistent with gastroparesis.
GASTRIC EMPTYING STUDY (Code 858 and A858)
[LIQUID]
ICD-9 CODE:
__________
EXAMINATION:
GASTRIC EMPTYING STUDY Œ
DATE OF STUDY:
__________
RADIOPHARMACEUTICAL:
__________ µCi Tc-99m sulfur colloid mixed with mL ___¨____
____Ž____ .
HISTORY:
__________
FINDINGS:
Sequential _____¸_____ images of the abdomen were
obtained for minutes after administration of the
radiopharmaceutical. There is normal emptying of the gastric contents into
the intestine. The residual activity at
60 minutes is __________% of peak activity.
The mean normal value in children under age 2 is __________% and in
older children is __________%. No gastroesophageal reflux is noted. ‘
OPINION:
Œ
If study
specifically performed to assess reflux and/or aspiration, modify examination
description as appropriate; e.g., “GASTRIC EMPTYING/GASTROESOPHAGEAL
REFLUX/PULMONARY ASPIRATION STUDY.”
¨
INSERT: Water or
milk or formula or orange juice.
Ž
INSERT: p.o. or
via nasogastric tube or via
gastrostomy tube
¸
INSERT: anterior or
posterior
If appropriate,
indicate whether delayed views were obtained to assess for aspiration.
‘
If appropriate,
indicate whether images of the chest show evidence for pulmonary aspiration.
******************************************************************************
ICD-9 Codes
507.0 Aspiration pneumonia
530.81 Esophageal
reflux
536.20 Persistent
vomiting
536.3 Gastroparesis
536.9 Functional
disorder of stomach, NOS
770.8 Other
respiratory problems of newborn (e.g., apneic spells)
779.3 Feeding
problems in newborn
783.3 Feeding
difficulties
783.4 Failure
to thrive
HEPATIC BLOOD-POOL IMAGING (Code HBP)
ICD-9 CODE:
__________
EXAMINATION:
HEPATIC BLOOD-POOL IMAGING (TOMOGRAPHIC)
DATE OF STUDY:
__________
RADOPHARMACEUTICAL: ____mCi Tc-99m modified in vivo labeled red
cells i.v. Œ
HISTORY: ________
FINDINGS: Delayed SPECT images of the upper abdomen
were obtained after injection of Tc-99m red cells. ______(describe)____________________
OPINION: ________
Œ
If appropriate,
change to Tc-99m in vitro labeled red cells.
******************************************************************************
ICD-9 Codes
155.0 Malignant neoplasm of liver
197.7 Hepatic metastases
211.5 Benign neoplasm of liver (adenoma, FNH)
228.04 Hemangioma, intra-abdominal
789.1 Hepatomegaly
793.6 Nonspecific findings on abdominal radiologic study
ICD-9 CODES FOR SKELETAL SCINTIGRAPHY
Primary Malignant Neoplasm of:
141.9 Tongue, NOS
142.9 Salivary Gland, NOS
143.9 Gum, NOS
144.9 Floor of mouth, NOS
145.9 Mouth, NOS
146.9 Oropharynx, NOS
147.9 Nasopharynx, NOS
148.9 Hypopharynx, NOS
150.9 Esophagus, NOS
151.9 Stomach, NOS
152.9 Small intestine, NOS
153.9
154.1 Rectum
155.0 Liver, primary
156.9 Biliary tract, NOS
157.4 Islets of Langerhans
157.9 Pancreas, NOS
158.0 Retroperitoneum
160.9 Sinuses, NOS
161.9 Larynx, NOS
162.9 Bronchus and lung, NOS
163.9 Pleura, NOS
164.9 Mediastinum, NOS
170.9 Bone and cartilage, NOS
171.9 Soft tissues, NOS
172.9 Melanoma, NOS
174.9 Female breast, NOS
175.9 Male breast, NOS
179 Uterus
180.9 Cervix, NOS
183.0 Ovary
184.9 Female GU tract, NOS
185 Prostate
186.9 Testis
187.9 Male GU tract, NOS
188.9 Bladder, NOS
189.0 Kidney (except pelvis)
189.9 Urinary organ, NOS
191.9 Brain, NOS
193 Thyroid
194.0 Adrenal
195.0 Head, face, and neck, NOS
195.1 Thorax, NOS
195.2 Abdomen, NOS
195.3 Pelvis
Metastatic Neoplasms of:
196.9 Lymph nodes, NOS
197.0 Lung
197.7 Liver
198.3 Brain and spinal cord
198.5 Bone and bone marrow
199.0 Disseminated carcinomas
Other Tumors
200.00 Non-Hodgkin’s lymphoma, NOS
201.90 Hodgkin’s disease, NOS
203.00 Multiple myeloma
204.90 Lymphoid leukemia
205.90 Myeloid leukemia
213.X Benign Neoplasm of bone and cartilage (0=skull and face;
1=mandible; 2=vertebral column; 3=ribs, sternum, clavicle; 4=scapula and UE
long bones; 5=UE short bones; 6=pelvic bones, sacrum, coccyx; 7=LE long bones,
8=LE short bones; 9=site unspecified)
Infection
380.14 Malignant otitis
externa
440.2X Atherosclerosis of extremeties (0=NOS;
3=ulceration; 4=gangrene)
681.10 Cellulitis of toe
682.6 Cellulitis of leg
682.7 Cellulitis of foot
682.9 Cellulitis, site
unspecified
711.0X Pyogenic arthritis
730.0X Acute osteomyelitis
730.1X Chronic osteomyelitis
790.7 Bacteremia
Metabolic Disease
252.0 Hyperparathyroidism
268.2 Osteomalacia, NOS
274.9 Gout, NOS
282.60 Sickle cell anemia, NOS
588.0 Renal osteodystrophy
731.0 Paget’s disease
733.00 Osteoporosis, NOS
Joint Disease
714.0 Rheumatoid arthritis
715.9X Osteoarthritis
(degenerative disease)
716.9X Arthropathy, NOS
719.0X Joint effusion
722.6 Degenerative disc
disease
726.90 Enthesopathy, NOS
727.00 Synovitis and
tenosynovitis, NOS
Trauma
732.7 Osteochondritis
dissecans
733.10 Pathologic fracture,
NOS
756.11 Spondylolysis
Injury To:
959.0 Face and neck
959.1 Trunk
959.2 Shoulder, arm
959.3 Elbow, forearm, wrist
959.4 Hand
959.5 Finger
959.6 Hip, thigh
959.7 Knee, leg, ankle, foot
959.8 Other sites (includng
multiple sites)
959.9 Unspecified site
Miscellaneous Disorders
728.10 Muscular calcification and ossification,
NOS
731.2 Hypertrophic
osteoarthropathy
732.10 Legg-Calve-Perthe
disease
733.0 Bone and cartilage
disorder, NOS
733.40 Aseptic necrosis, NOS
733.42 Aseptic necrosis,
femoral head
737.30 Scoliosis, idiopathic
Symptoms/Signs
719.4X Joint pain
723.1 Neck pain
724.1 Thoracic spine pain
724.2 Low back pain
724.3 Sciatica
729.5 Limb pain
790.5 Abnormal serum enzyme (alkaline phosphatase)
793.7 Nonspecific radiological abnormality, musculoskeletal system
Follow-up Evaluation
V67.0 After surgery
V67.1 After radiotherapy
V67.2 After chemotherapy
V67.4 After treatment of
fracture
Musculoskeletal
System Diseases
Where
5th digit required as indicated by X:
0=site NOS; 1=shoulder; 2=arm; 3=forearm; 4=hand and wrist;
5=pelvis/thigh; 6=leg; 7=ankle and foot; 8=other site (including ribs,
vertebrae, skull); 9=multiple sites.
BONE SCINTIGRAPHY (Code 837 and A837)
ICD-9 CODE:
__________
EXAMINATION:
BONE SCINTIGRAPHY (WHOLE-BODY)
DATE OF STUDY:
___________
RADIOPHARMACEUTICAL: ____ mCi Tc-99m MDP i.v.
HISTORY: ___________
FINDINGS: Delayed whole-body scintigrams were
obtained. There is normal distribution of activity throughout the skeleton.
OPINION:
LIMITED BONE SCINTIGRAPHYOF THE HANDS/WRISTS (Code 839 and A839)
ICD-9 CODE:
__________
EXAMINATION:
BONE SCINTIGRAPHY (LIMITED)
DATE OF STUDY:
___________
RADIOPHARMACEUTICAL: ____ mCi Tc-99m MDP i.v.
HISTORY: ___________
FINDINGS: A limited examination of the hands and wrists
was performed consisting of radionuclide angiography, immediate post-injection
images, and delayed images. No
abnormalities are demonstrated.
OPINION:
LIMITED BONE SCINTIGRAPHYOF THE LUMBAR SPINE WITH SPECT (Code 851 and
A851)
ICD-9 CODE:
__________
EXAMINATION:
BONE SCINTIGRAPHY (LIMITED/SPECT)
DATE OF STUDY:
___________
RADIOPHARMACEUTICAL: ____ mCi Tc-99m MDP i.v.
HISTORY: ___________
FINDINGS: A limited examination of the lumbar spine and
pelvis Πwas performed consisting of delayed planar images, as well as
tomographic (SPECT) images of the lumbosacral spine. ΠNo
abnormalities are demonstrated.
OPINION:
ΠModify as appropriate if different areas scanned.
REPORTING
GUIDELINES FOR BONE DENSITOMETRY
For
examinations of the Hip and the Spine,
there are three standard reports: Spine,
Hip, and a combined Spine/Hip. Note that
in the combined report, the spine comes first.
Fill in the blanks as indicated.
If the study
is not a follow-up examination, when
you reach the end of the Findings (for that portion of the study), instruct the
transcriptionist to delete the last paragraph of the Findings.
If the study is a follow-up examination, fill in the
blanks using the percent change since the baseline exam. Note this is now a simple comparison of the
current and initial data points, and not a rate (% change/year) as we had been
reporting previously.
The characters after the % change can be used to
determine the statistical significance.
Example: 1.2% = not statistically significant
2.3%* = statistically significant (denoted by the *)
2.3%# = manual calculation of
significance required due to change in scan mode (denoted by the #).
In the last case, the following standards can be used
to assess significance.
Lumbar spine: change
of ³ 0.022 gms/cm2
Total hip: change of ³ 0.027 gms/cm2
Forearm
R+U 1/3 change of ³ 0.015 gms/cm2
In such cases, we should state that the change is statistically significant, but a
different scan mode was used for the two examinations, and this may minimally
affect comparison of the results.)
OPINIONS in
adults are based on the T-score
of: Total (L1-4) for the spine and the
Total hip region for the hip. For the forearm, we use a Distal 1/3 forearm evaluation.
OPINIONS in
children are based on the Z-score
(and the separate pediatric dictation report code(s) should be used). Discuss the reporting of pediatric cases
with attending staff before dictating.
|
If the
bone mineral density is: |
OPINION: |
|
above +2 SD |
increased |
|
+2 SD to –1.0 SD |
normal |
|
–1.0 SD to –2.5 SD |
indicative of osteopenia by WHO criteria |
|
–2.5 SD to –3.5 |
moderately decreased and indicative of osteoporosis
by WHO criteria |
|
–3.5 SD or lower |
markedly decreased and indicative of osteoporosis by
WHO criteria |
In patients with decreased bone mineral density who
have a history of malabsorption, hepatobiliary disease, chronic renal failure,
renal tubular acidosis, or other possible causes of osteomalacia, the study
should be discussed with attending staff before reporting and it may be
appropriate to add the following to the Opinion.
“However, given this patient’s history,
osteomalacia is a more likely diagnosis than osteoporosis.”
If there has been a statistically significant change
in bone density, add:
“There
has been an [increase/decrease] in bone mineral density since the baseline
examination.”
If there is a noticeable upward trend (since the start
of therapy, add:
“Recent measurements suggest improvement
in bone mineral density since initiation of therapy, as evidenced by a change
of xx% since the most recent prior scan of yy”.
Caution: The spine data
(Total L1-4) are on the last line of
the printout, while the hip data (Total hip) are on the next to last line.
ICD-9 CODES FOR BONE DENSITOMETRY
733.00 Osteoporosis,
unspecified
733.01 Senile
osteoporosis (postmenopausal osteoporosis)
733.02 Idiopathic
osteoporosis
733.03 Disuse
osteoporosis
733.09 Osteoporosis,
other (including drug-induced osteoporosis; if steroids, add E932.0 as a
second code)
V58.69 Monitoring
of FDA-approved drug therapy for osteoporosis
V67.51 Follow-up
after completion of drug treatment for osteoporosis
733.13 Pathologic fracture of vertebra 805.4 Lumbar spine fracture
733.90 Osteopenia 805.6 Sacrum or coccyx fracture
805.00 Cervical spine fracture (unspecified level) 806.8 Closed spinal cord injury (with fracture)
805.2 Thoracic spine fracture 806.9 Open spinal cord injury (with fracture)
242.90
Hyperthyroidism, unspecified
252.0 Hyperparathyroidism
255.0 Cushing’s
syndrome (includes iatrogenic cortisol excess)
259.3 Other
ectopic hormone secretion
268.2 Osteomalacia,
unspecified
275.3 Disorders
of phosphorus metabolism
V58.69 Long-term
current (or expected) use of high-risk medications (e.g., ≥ 7.5 mg
prednisone for ≥ 3 mo; if steroids, add E932.0 as a second code)
588.0 Renal
osteodystrophy
256.2 Postablative
ovarian failure (e.g., oophorectomy or post-radiation)
256.31 Premature
menopause
256.3 Other
ovarian failure
627.2 Menopausal
symptoms (flushing, sleeplessness, headache, lack of concentration, etc.)
627.4 States
associated with artificial menopause
758.6
Gonadal dysgenesis (includes ovarian dysgenesis and
Turner’s syndrome)
V49.81 Postmenopausal
status (age-related) (natural); always add V82.81 as secondary code
V82.81 Screening
for osteoporosis for fracture risk ( use
as secondary code with V49.81, but otherwise avoid unless no other code
appropriate – consult with attending before using this code)
ADULT SPINE BONE DENSITOMETRY (Code DXAS)
DATE OF STUDY:
___________
HISTORY:
_________
EXAMINATION:
BONE DENSITOMETRY OF THE SPINE
FINDINGS: The bone mineral density of L1-L4Πwas assessed by dual-energy
x-ray absorptiometry. The average bone
mineral density within this region is ____(A)____
gm/sq-cm. This is ___(B)____ standard deviations ____(C)____ the mean of the average bone mineral density for age-
and gender-matched subjects (the “Z-score”).
It is ____(D)____ standard
deviations ____(E)____ the
mean peak bone mineral density in young adults (the “T-score”).¨
ŽSince the baseline examination of ____(F)____ , the bone mineral
density has ____(G)___ ____(H)_ %; this change ____(I)____ statistically
significant.
OPINION: The bone mineral density of the lumbar spine
is ____(J)____ .
General comments regarding
interpretation of bone mineral density measurements: In adults, comparison of the measured bone
mineral density with the average value in young normal subjects (the
"T-score") has been found to be useful in assessing fracture
risk. Fracture risk approximately
doubles for each 1.0 standard deviation (SD) an individual's bone mineral
density is below the average value of young normal subjects. The World Health
Organization (WHO) has defined T-scores of –1.0 to –2.5 as indicative of low
bone mass (osteopenia), and T-scores of –2.5 or lower to be indicative of
osteoporosis.
The National
Osteoporosis Foundation (www.nof.org) recommends adequate intake of calcium and
vitamin D and regular weight-bearing exercise in all patients. In Caucasian postmenopausal women, the NOF
recommends treatment with pharmacologic therapy if the T score is below
–2.0. Treatment might also be considered
if the T-score is between –1.5 and –2.0 in patients who are at higher risk
(e.g., personal history of fracture as an adult, history of fragility fracture
in a first-degree relative, low body weight (< about 127 lbs), current
smoking, or use of oral corticosteroid therapy for more than 3 months). Guidelines for treatment of osteopenia alone
in other racial groups, men, and premenopausal women are not available, but
treatment should definitely be considered if the bone density reaches the level
of osteoporosis (T-score below –2.5).
ΠChange as appropriate if
some vertebral bodies are excluded from the analysis, and state why they were
omitted.
¨ Add descriptive changes, as
appropriate, regarding radiographically apparent findings that may be altering
the measured bone mineral density.
Ž
Delete
this paragraph, if this is not a follow-up examination.
|
(A) |
BMD value |
(F) |
date of first study |
|
(B) |
“Z-score” |
(G) |
increased, decreased |
|
(C) |
above, below |
(H) |
% change |
|
(D) |
“T-score” |
(I) |
is, is not |
|
(E) |
above, below |
(J) |
increased normal indicative of osteopenia
by WHO criteria moderately decreased and
indicative of osteoporosis by WHO criteria markedly decreased and
indicative of osteoporosis by WHO criteria [Comment on effect of therapy and statistically significant changes
if appropriate.] |
ADULT HIP BONE DENSITOMETRY (Code DXAH)
DATE OF STUDY:
___________
HISTORY:
_________
EXAMINATION:
BONE DENSITOMETRY OF THE HIP
FINDINGS: The bone mineral density of the leftΠhip was assessed by
dual-energy x-ray absorptiometry. The
average bone mineral density within the total hip region is ____(A)____ gm/sq-cm. This is ___(B)____
standard deviations ____(C)____
the mean of the average bone mineral density for age- and gender-matched
subjects (the “Z-score”). It is ____(D)____ standard deviations ____(E)____ the mean peak bone mineral
density in young adults (the “T-score”).¨
ŽSince the baseline examination of ____(F)____ , the bone mineral
density has ____(G)___ ____(H)_ %; this change ____(I)____ statistically
significant.
OPINION: The bone mineral density of the hip is ____(J)____ .
General comments regarding
interpretation of bone mineral density measurements: In adults, comparison of the measured bone
mineral density with the average value in young normal subjects (the
"T-score") has been found to be useful in assessing fracture
risk. Fracture risk approximately
doubles for each 1.0 standard deviation (SD) an individual's bone mineral
density is below the average value of young normal subjects. The World Health
Organization (WHO) has defined T-scores of –1.0 to –2.5 as indicative of low
bone mass (osteopenia), and T-scores of –2.5 or lower to be indicative of
osteoporosis.
The National
Osteoporosis Foundation (www.nof.org) recommends adequate intake of calcium and
vitamin D and regular weight-bearing exercise in all patients. In Caucasian postmenopausal women, the NOF
recommends treatment with pharmacologic therapy if the T score is below
–2.0. Treatment might also be
considered if the T-score is between –1.5 and –2.0 in patients who are at
higher risk (e.g., personal history of fracture as an adult, history of
fragility fracture in a first-degree relative, low body weight (< about 127
lbs), current smoking, or use of oral corticosteroid therapy for more than 3
months). Guidelines for treatment of
osteopenia alone in other racial groups, men, and premenopausal women are not
available, but treatment should definitely be considered if the bone density
reaches the level of osteoporosis (T-score below –2.5).
ΠChange to RIGHT as
appropriate.
¨ Add descriptive changes, as
appropriate, regarding radiographically apparent findings that may be altering
the measured bone mineral density.
Ž
Delete
this paragraph, if this is not a follow-up examination.
|
(A) |
BMD value |
(F) |
date of first study |
|
(B) |
“Z-score” |
(G) |
increased, decreased |
|
(C) |
above, below |
(H) |
% change |
|
(D) |
“T-score” |
(I) |
is, is not |
|
(E) |
above, below |
(J) |
increased normal indicative of osteopenia
by WHO criteria moderately decreased and
indicative of osteoporosis by WHO criteria markedly decreased and
indicative of osteoporosis by WHO criteria [Comment on effect of therapy and statistically significant changes
if appropriate.] |
ADULT SPINE AND HIP BONE DENSITOMETRY (Code DXAC)
DATE OF STUDY:
___________
HISTORY:
_________
EXAMINATION:
BONE DENSITOMETRY OF THE SPINE
FINDINGS: The bone mineral density of L1-L4Πwas assessed by dual-energy
x-ray absorptiometry. The average bone
mineral density within this region is ____(A)____
gm/sq-cm. This is ___(B)____ standard deviations ____(C)____ the mean of the average bone mineral density for age-
and gender-matched subjects (the “Z-score”).
It is ____(D)____ standard
deviations ____(E)____ the
mean peak bone mineral density in young adults (the “T-score”).¨
ŽSince the baseline examination of ____(F)____ , the bone mineral
density has ____(G)___ ____(H)_ %; this change ____(I)____ statistically
significant.
OPINION: The bone mineral density of the lumbar spine
is ____(J)____ .
ΠChange as appropriate if some
vertebral bodies are excluded from the analysis, and state why they were
omitted.
¨ Add descriptive changes, as
appropriate, regarding radiographically apparent findings that may be altering
the measured bone mineral density.
Ž
Delete
this paragraph, if this is not a follow-up examination.
EXAMINATION:
BONE DENSITOMETRY OF THE HIP
FINDINGS: The bone mineral density of the leftΠhip was assessed by
dual-energy x-ray absorptiometry. The
average bone mineral density within the total hip region is ____(A)____ gm/sq-cm. This is ___(B)____
standard deviations ____(C)____
the mean of the average bone mineral density for age- and gender-matched
subjects (the “Z-score”). It is ____(D)____ standard deviations ____(E)____ the mean peak bone mineral
density in young adults (the “T-score”).¨
ŽSince the baseline examination of ____(F)____ , the bone mineral
density has ____(G)___ ____(H)_ %; this change ____(I)____ statistically
significant.
OPINION: The bone mineral density of the hip is ____(J)____ .
General comments regarding
interpretation of bone mineral density measurements: In adults, comparison of the measured bone
mineral density with the average value in young normal subjects (the
"T-score") has been found to be useful in assessing fracture
risk. Fracture risk approximately doubles
for each 1.0 standard deviation (SD) an individual's bone mineral density is
below the average value of young normal subjects. The World Health Organization
(WHO) has defined T-scores of –1.0 to –2.5 as indicative of low bone mass
(osteopenia), and T-scores of –2.5 or lower to be indicative of osteoporosis.
The National
Osteoporosis Foundation (www.nof.org) recommends adequate intake of calcium and
vitamin D and regular weight-bearing exercise in all patients. In Caucasian postmenopausal women, the NOF recommends
treatment with pharmacologic therapy if the T score is below –2.0. Treatment might also be considered if the
T-score is between –1.5 and –2.0 in patients who are at higher risk (e.g.,
personal history of fracture as an adult, history of fragility fracture in a
first-degree relative, low body weight (< about 127 lbs), current smoking,
or use of oral corticosteroid therapy for more than 3 months). Guidelines for treatment of osteopenia alone
in other racial groups, men, and premenopausal women are not available, but
treatment should definitely be considered if the bone density reaches the level
of osteoporosis (T-score below –2.5).
ΠChange to RIGHT as
appropriate.
¨ Add descriptive changes, as
appropriate, regarding radiographically apparent findings that may be altering
the measured bone mineral density.
Ž
Delete
this paragraph, if this is not a follow-up examination.
|
(A) (B) (C) (D) (E) |
BMD value “Z-score” above, below “T-score” above, below |
(F) (G) (H) (I) |
date of first study increased, decreased % change is, is not |
(J) |
increased normal indicative of osteopenia
by WHO criteria moderately decreased and
indicative of osteoporosis by WHO criteria markedly decreased and
indicative of osteoporosis by WHO criteria [Comment on effect of therapy and statistically significant changes
if appropriate.] |
ADULT FOREARM BONE DENSITOMETRY (Code DXAF)
DATE OF STUDY:
___________
HISTORY:
_________
EXAMINATION:
BONE DENSITOMETRY OF THE FOREARM
FINDINGS: The bone mineral density of the leftΠforearm was assessed by
dual-energy x-ray absorptiometry. The
average bone mineral density within the distal third of the radius and ulna is ____(A)____ gm/sq-cm. This is ___(B)____
standard deviations ____(C)____
the mean of the average bone mineral density for age- and gender-matched
subjects (the “Z-score”). It is ____(D)____ standard deviations ____(E)____ the mean peak bone mineral
density in young adults (the “T-score”).¨
ŽSince the baseline examination of ____(F)____ , the bone mineral
density has ____(G)___ ____(H)_ %; this change ____(I)____ statistically
significant.
OPINION: The bone mineral density of the distal-third
radius and ulna is ____(J)____ .
General comments regarding
interpretation of bone mineral density measurements: In adults, comparison of the measured bone
mineral density with the average value in young normal subjects (the
"T-score") has been found to be useful in assessing fracture
risk. Fracture risk approximately
doubles for each 1.0 standard deviation (SD) an individual's bone mineral
density is below the average value of young normal subjects. The World Health
Organization (WHO) has defined T-scores of –1.0 to –2.5 as indicative of low
bone mass (osteopenia), and T-scores of –2.5 or lower to be indicative of
osteoporosis.
The National
Osteoporosis Foundation (www.nof.org) recommends adequate intake of calcium and
vitamin D and regular weight-bearing exercise in all patients. In Caucasian postmenopausal women, the NOF
recommends treatment with pharmacologic therapy if the T score is below
–2.0. Treatment might also be
considered if the T-score is between –1.5 and –2.0 in patients who are at
higher risk (e.g., personal history of fracture as an adult, history of
fragility fracture in a first-degree relative, low body weight (< about 127
lbs), current smoking, or use of oral corticosteroid therapy for more than 3
months). Guidelines for treatment of osteopenia
alone in other racial groups, men, and premenopausal women are not available,
but treatment should definitely be considered if the bone density reaches the
level of osteoporosis (T-score below –2.5).
ΠChange to RIGHT as
appropriate.
¨ Add descriptive changes, as
appropriate, regarding radiographically apparent findings that may be altering
the measured bone mineral density.
Ž
Delete
this paragraph, if this is not a follow-up examination.
|
(A) |
BMD value |
(F) |
date of first study |
|
(B) |
“Z-score” |
(G) |
increased, decreased |
|
(C) |
above, below |
(H) |
% change |
|
(D) |
“T-score” |
(I) |
is, is not |
|
(E) |
above, below |
(J) |
increased normal indicative of osteopenia
by WHO criteria moderately decreased and
indicative of osteoporosis by WHO criteria markedly decreased and
indicative of osteoporosis by WHO criteria [Comment on effect of therapy and statistically significant changes
if appropriate.] |
PEDIATRIC SPINE BONE DENSITOMETRY (Code DXAPS)
DATE OF STUDY:
___________
HISTORY:
_________
EXAMINATION:
BONE DENSITOMETRY OF THE SPINE
FINDINGS: The bone mineral density of L1-L4Πwas assessed by dual-energy
x-ray absorptiometry. The average bone
mineral density within this region is ____(A)____
gm/sq-cm. This is ___(B)____ standard deviations ____(C)____ the mean of the average bone mineral density for age-
and gender-matched subjects (the “Z-score”).¨
ŽSince the baseline examination of ____(D)____ , the bone mineral
density has ____(E)___ ____(F)_ %; this change ____(G)____ statistically
significant. ¸
OPINION: The bone mineral density of the lumbar spine
is ____(H)____ .
ΠChange as appropriate if
some vertebral bodies are excluded from the analysis.
¨ Add descriptive changes, as
appropriate, regarding radiographically apparent findings that may be altering
the measured bone mineral density.
Ž
Delete
this paragraph, if this is not a follow-up examination.
¸ Comment on whether the change in bone density is as
expected given normal bone growth, or is less than expected for normal bone
growth (by comparing the slope of the patient’s plotted points to the normal
growth line on the graph).
|
(A) |
BMD value |
(E) |
increased, decreased |
|
(B) |
“Z-score” |
(F) |
% change |
|
(C) |
above, below |
(G) |
is, is not |
|
(D) |
date of first study |
(H) |
increased normal at the low end of the
normal range reduced [Comment on effect of therapy and statistically significant changes
if appropriate.] |
PEDIATRIC HIP BONE DENSITOMETRY (Code DXAPH)
DATE OF STUDY:
___________
HISTORY:
_________
EXAMINATION:
BONE DENSITOMETRY OF THE HIP
FINDINGS:
The bone mineral density of the leftΠhip was assessed by
dual-energy x-ray absorptiometry. The
average bone mineral density within the total hip region is ____(A)____ gm/sq-cm. There are currently no available data bases of
pediatric hip values against which to compare these values.¨
ŽSince the baseline examination of ____(B)____ , the bone mineral
density has ____(C)___ ____(D)_ %; this change ____(E)____ statistically
significant.
OPINION: The measured bone mineral density of the
total hip region is (A)
gm/sq-cm..
ΠChange to RIGHT as
appropriate.
¨ Add descriptive changes, as
appropriate, regarding radiographically apparent findings that may be altering
the measured bone mineral density.
Ž
Delete
this paragraph, if this is not a follow-up examination.
|
(A) |
BMD value |
|
(B) |
date of first study |
|
(C) |
increased, decreased |
|
(D) |
% change |
|
(E) |
is, is not |
ICD-9 CODES FOR CARDIAC BLOOD POOL IMAGING
Assessing
RV/LV Function in Patients with Pulmonary Disease (Need to correlate with dictated history; also code for
underlying lung disease)
428.0 Congestive heart failure
428.1 Left heart failure
V42.6 Follow-up examination after lung transplantation
V67.00 Follow-up examination after surgery (e.g., after lung reduction
surgery)
Evaluation of Ventricular Function Before, During, or After
Chemotherapy
428.0 Congestive heart failure (Before, during, or after chemotherapy)
428.1 Left heart failure (Before, during, or after chemotherapy)
V58.69 Long-term current use of other medication (During course of chemotherapy)
V67.51 Follow-up examination after completed treatment with high-risk
medication (After chemotherapy)
V81.2 Special screening for cardiovascular disease (nonischemic) (Use ONLY
before chemotherapy)
Evaluation of Cardiomyopathy (See detailed list for specific cardiomyopathies)
425.1 Hypertrophic obstructive cardiomyopathy
425.4 Other primary cardiomyopathies
414.8 Other specified forms of chronic ischemic heart disease
Evaluation
of Valvular Heart Disease (See detailed
list for specific valvular diseases)
424.0 Mitral valve disorders
424.1 Aortic valve disorders
428.0 Congestive heart failure
Evaluation of Coronary Artery Disease
410.X2 Acute myocardial infarction, subsequent episode of care (0=anterolateral; 1=other anterior; 2=autologous
vein graft; 3=nonautologrous
biological graft; 4=other inferior; 5=other lateral; 6=true posterior; 7=subendocardial;
8=other specified site)
412 Old myocardial infarction
414.0X Coronary atherosclerosis (0=unspecified
vessel; 1=native coronary artery; 2=autologous vein graft; 3=nonautologous biological graft; 4=artery bypass graft)
414.8 Other specified forms of chronic ischemic heart disease
Evaluation
of Congenital Heart Disease (See detailed
list for specific congential abnormalities)
428.0 Congestive heart failure
428.1 Left heart failure
V42.1 Evaluation after heart transplant
V47.2 Other
cardiorespiratory problems
996.72 Other
complication due to cardiac device, implant or graft
996.83 Complications of transplanted heart
V67.00 Follow-up examination after surgery
786.51 Precordial pain
786.59 Anterior chest pressure or tightness
794.30 Nonspecific abnormal cardiovascular
function study, unspecified
794.31 Nonspecific abnormal
electrocardiogram
CARDIAC BLOOD POOL IMAGING (REST) (Codes 832 and A832)
[WITH ONLY LVEF]
ICD-9 CODE:
__________
EXAMINATION:
CARDIAC BLOOD POOL IMAGING (REST)
DATE OF STUDY:
___________
RADIOPHARMACEUTICAL: ____ mCi Tc-99m in vivo labeled red cells i.v.
HISTORY: ___________
FINDINGS: The
cardiac chambers and great vessels are of normal size and configuration. Both
the right and left ventricles contract normally. The left ventricular
ejection fraction is __% (normal > 50%).
OPINION:
CARDIAC BLOOD POOL IMAGING (REST) (Codes 833 and A833)
[WITH BOTH RVEF AND LVEF]
ICD-9 CODE:
__________
EXAMINATION:
CARDIAC BLOOD POOL IMAGING (REST)
DATE OF STUDY:
___________
RADIOPHARMACEUTICAL: ____ mCi Tc-99m in vivo labeled red cells
i.v.
HISTORY: ___________
FINDINGS: The
cardiac chambers and great vessels are of normal size and configuration. Both
the right and left ventricles contract normally. The right ventricular
ejection fraction is __% (normal >
40%). The left ventricular ejection fraction is __% (normal > 50%).
OPINION:
CARDIAC BLOOD POOL IMAGING (REST/EXERCISE) (Codes 889 and A889)
[WITH ONLY LVEF]
ICD-9 CODE:
__________
EXAMINATION:
CARDIAC BLOOD POOL IMAGING (REST/EXERCISE)
DATE OF STUDY:
___________
RADIOPHARMACEUTICAL: __ mCi Tc-99m ____Œ_____ labeled red cells i.v.
HISTORY: ___________
FINDINGS: On the initial images obtained at rest, the cardiac chambers and great vessels are
of normal size and configuration. Both the right and left ventricles contract
normally. The left ventricular ejection fraction at rest is __% (normal
> 50%).
The Patient performed supine
bicycle exercise under the supervision of attending staff from the
Cardiovascular Division. The patient achieved a work-load of ____
OPINION:
ΠSpecify whether in vitro or modified in vivo
CARDIAC BLOOD POOL IMAGING (REST/EXERCISE) (Codes 888 and A888)
[WITH BOTH RVEF AND LVEF]
ICD-9 CODE:
__________
EXAMINATION:
CARDIAC BLOOD POOL IMAGING (REST/EXERCISE)
DATE OF STUDY:
___________
RADIOPHARMACEUTICAL: __ mCi Tc-99m
____Œ_____ labeled
red cells i.v.
HISTORY: ___________
FINDINGS: On the initial images obtained at rest, the cardiac chambers and great vessels are
of normal size and configuration. Both the right and left ventricles contract
normally. The right ventricular ejection fraction at rest is ___% (normal
> 40%). The left ventricular ejection fraction at rest is ____% (normal >
50%).
The patient performed supine
bicycle exercise under the supervision of attending staff from the
Cardiovascular Division. The patient achieved a work-load of ____
OPINION:
ΠSpecify whether in vitro or modified in vivo
DICTATION OF MYOCARDIAL PERFUSION STUDIES
I. HISTORY
The
history should include the chief complaint dovetailed to the ICD-9 code. It should also include only the most
pertinent contributing information (e.g., cardiac risk factors for a patient
with new‑onset chest pain or type of cardiac procedures in a patient with
known CAD). Specific resting ECG
findings should not be included unless they are part of the reason for the test
(Q waves in a patient without known past myocardial infarction) or could
influence the test result (LBBB).
Medications need not be included, unless specific comment relating to
the potential effect of the medical therapy on the test results or
interpretation is to be included elsewhere in the report. Include the results (positive, negative, or
equivocal—NOT the specific ECG findings) of the ECG portion of the stress
study.
Example 1: New
onset chest pain
50
year old woman with new onset of atypical exertional chest pain. Cardiac risk
factors include hypertension and diabetes mellitus. The ECG portion of today’s stress test was
positive for ischemia.
Example 2: Recurrent
chest pain in a patient post-CABG
63
year old woman status post coronary artery bypass grafting in 1993, who now has
recurrent chest pain (no need to include cardiac risk factors as we know she
has CAD). The ECG portion of today’s
stress test was negative for ischemia.
II. FINDINGS
The
findings should include the following:
A. The severity of a perfusion abnormality
(i.e., how abnormal is the perfusion defect).
B. The extent of the perfusion abnormality
(i.e., how much myocardium is involved).
C. The location of the perfusion
abnormality (i.e., anterior wall or lateral wall).
D. The amount of reversibility (i.e.,
fixed, partially or completely reversible).
E. The presence of attenuation artifacts
(these should not be called defects or abnormalities).
Example 1: Completely
reversible perfusion abnormality in one wall
There
is a completely reversible perfusion abnormality of moderate severity involving
the entire anterior wall.
Example 2: Fixed perfusion
abnormality in one wall and partially reversible perfusion abnormality in
another wall
There
is a fixed perfusion abnormality of marked severity involving the apex. In addition, there is a partially reversible
perfusion abnormality of marked severity involving the entire lateral wall.
Example 3: Attenuation
artifact
Changes
attributable to attenuation of myocardial activity by the diaphragm (or by
overlying breast tissue) are noted.
III. OPINION
The
opinion should succinctly convey the clinical interpretation of the findings.
Example 1: Completely
reversible perfusion abnormality in one wall
OPINION: Anterior wall ischemia.
Example 2: Fixed perfusion
abnormality in one wall and partially reversible perfusion abnormality in
another wall
OPINION:
1. Previous apical myocardial infarction.
2. Previous lateral wall myocardial infarction
with superimposed lateral wall ischemia.
3. Submaximal examination.
Example 3: Attenuation
artifact
OPINION:
[The
attenuation artifact does not need to be mentioned in the opinion.]
ICD-9 CODES FOR MYOCARDIAL IMAGING
Diagnosis
of Coronary Artery Disease, Including Preoperative Evaluation of High-Risk
Patients (Need to correlate very closely
with dictated history)
413.9 Angina pectoris
414.9 Chronic ischemic heart disease,
unspecifed (use this code when study demonstrates ischemia)
426.2 Left bundle branch hemiblock (left
anterior or left posterior fascicular block)
426.3 Left bundle branch block, complete
426.4
Right bundle branch block
V27.5 Cardiac
Arrest
440.X Atherosclerosis
(0=aorta; 1=renal artery; 20=extremities,
NOS; 9=generalized)
441.4 Abdominal aortic aneurysm
780.2 Syncope and collapse
786.50 Chest pain, unspecified (also code risk factors)
786.51 Precordial pain (also code risk factors)
786.59 Anterior
chest pressure or tightness (also code risk factors)
Risk Factors: 250.00 non-insulin dependent diabetes mellitus; 250.01 insulin-dependent diabetes mellitus; 272.0 hypercholesterolemia; 278.00 obesity; 305.10 smoking; 401.9 hypertension, NOS; V49.81 postmenopausal status
794.30 Abnormal function study,
unspecified (also code risk factors)
794.31
Nonspecific abnormal electrocardiogram (ECG) (also
code risk factors)
V58.69 Long-term
use of current medications (include medications in dictation)
V72.81 Preoperative
cardiovascular examination (also code risk factors)
Evaluation After
Acute Myocardial Infarction (Within First 8 Weeks)
410.X2 Acute
myocardial infarction, subsequent episode of care (initial admission is excluded)
0=anterolateral; 1=other anterior; 2=inferolateral; 3=inferoposterior;
4=other inferior; 5=other lateral; 6=true posterior; 7=subendocardial;
8=other specified site (avoid if
possible)
Evaluation of
Old Myocardial Infarction (> 8 Weeks Post Infarction)
412 Old myocardial infarction
414.01 Coronary atherosclerosis, native
coronary artery (use this code when study is negative)
414.9 Chronic ischemic heart disease,
unspecifed (use this code when study demonstrates ischemia)
Evaluation after
Revascularization
414.0X Coronary atherosclerosis (0=unspecified
vessel; 1=native coronary artery [use
post-PTCA]; 2=autologous
vein graft; 3=nonautologous
biological graft; 4=artery bypass
graft)[use post-CABG]
Evaluation of
Cardiomyopathy (For valvular heart
disease—see detailed list)
425.1 Hypertrophic obstructive cardiomyopathy
425.4 Other primary cardiomyopathies
425.5 Alcoholic cardiomyopathy
425.8 Cardiomyopathy in other diseases
classified elsewhere
428.0 Congestive heart failure
428.1 Left heart failure
429.0 Myocarditis, unspecified
MYOCARDIAL IMAGING (REST/EXERCISE/SPECT) (Codes 881 and A881)
[With Gated
Imaging (Codes 881G and A881G)]
[With Gated Imaging and
Ejection Fraction (Codes 881E and A881E)]
EXAMINATION: MYOCARDIAL IMAGING (REST/EXERCISE/SPECTŒ/WITH GATED IMAGING AND EJECTION FRACTION MEASUREMENT)
DATE OF STUDY: _________
RADIOPHARMACEUTICAL: _____ mCi Tl-201 chloride i.v. and ____ mCi
Tc-99m ___¨_____ i.v.
HISTORY: _________.
The electrocardiographic portion of today’s exercise stress examination
was ___Ž_____ for ischemia.
FINDINGS: Standard
myocardial perfusion images were obtained after resting injection of
Tl-201. Subsequently, a standard ___¸_____ exercise tolerance
test was performed by the patient under the supervision of attending staff from
the Cardiovascular Division. The
patient exercised for _________ minutes and ___ seconds and achieved _________%
of maximum predicted heart rate. At peak
exercise, Tc-99m ___¨_____ was injected intravenously and standard
myocardial perfusion images were obtained.
Comparison is made
with a prior study dated________________________.
There is normal distribution of activity in the left and right
ventricular myocardium on both rest and post-exercise images. Gated post-stress
images demonstrate normal left ventricular wall thickening. The left ventricular volume is normal and the left ventricular
ejection fraction is _______% (normal >45%).
OPINION:
1. Normal rest and exercise
myocardial perfusion images.
2.
ΠIf appropriate, change: SPECT to PLANAR
¨ Insert:
sestamibi or tetrofosmin
Ž Insert:
negative or positive or indeterminate
¸
Insert: treadmill or upright bicycle or arm ergometer
If
appropriate, insert: Additional prone post-stress images also were
obtained to allow for better evaluation of the inferior wall.
MYOCARDIAL IMAGING (DELAYED-REST/EXERCISE/SPECT) (Codes 883 and A883)
[With Gated
Imaging (Codes 883G and A883G)]
[With Gated Imaging and
Ejection Fraction (Codes 883E and A883E)]
EXAMINATION: MYOCARDIAL IMAGING
(DELAYED-REST/EXERCISE/SPECTŒ/WITH GATED IMAGING AND EJECTION FRACTION MEASUREMENT)
DATE STARTED: _________
DATE COMPLETED: _________
RADIOPHARMACEUTICAL: _____ mCi Tl-201 chloride i.v. and ____ mCi
Tc-99m ___¨_____ i.v.
HISTORY: _________.
The electrocardiographic portion of today’s exercise stress examination
was ___Ž_____ for ischemia.
FINDINGS: Standard
myocardial perfusion images were obtained after resting injection of Tl-201 on
the previous evening (to allow complete redistribution of the
radiopharmaceutical and optimal identification of viable myocardium). Subsequently, a standard ____¸_____exercise tolerance test
was performed by the patient under the supervision of attending staff from the
Cardiovascular Division. The patient
exercised for ____ minutes and ___ seconds and achieved _________% of maximum
predicted heart rate. At peak exercise,
Tc-99m ___¨_____ was injected intravenously and standard myocardial perfusion
images were obtained.
There is normal distribution of activity in the left and right
ventricular myocardium on both delayed-rest and post-exercise images. Gated post-stress
images demonstrate normal left ventricular wall thickening. The left ventricular volume is normal and the left ventricular
ejection fraction is _______% (normal >45%).
OPINION:
1. Normal delayed-rest and
exercise myocardial perfusion images.
2.
ΠIf appropriate, change: SPECT to PLANAR
¨ Insert:
sestamibi or tetrofosmin
Ž Insert:
negative or positive or indeterminate
¸
Insert: treadmill or upright bicycle or arm ergometer
If
appropriate, insert: Additional prone post-stress images also were
obtained to allow for better evaluation of the inferior wall.
MYOCARDIAL IMAGING (REST/PHARMACOLOGIC STRESS/SPECT)
(Codes 884 and A884)
[With Gated
Imaging (Codes 884G and A884G)]
[With Gated Imaging and
Ejection Fraction (Codes 884E and A884E)]
EXAMINATION: MYOCARDIAL IMAGING
(REST/PHARMACOLOGIC-STRESS/SPECTŒ/WITH GATED IMAGING AND EJECTION FRACTION MEASUREMENT)
DATE OF STUDY: _________
RADIOPHARMACEUTICAL: _____ mCi Tl-201 chloride i.v. and ____ mCi
Tc-99m ___¨_____ i.v.
HISTORY: _________. The electrocardiogram during
infusion of the pharmacologic agent today was ___Ž_____ for ischemia.
FINDINGS: Standard
myocardial perfusion images were obtained after resting injection of
Tl-201. Subsequently, an intravenous
infusion of _____¸______ was performed under the
supervision of attending staff from the Cardiovascular Division. At the peak effect of the
drug, Tc-99m ___¨_____ was injected intravenously and standard
myocardial perfusion images were obtained.
‘
Comparison is made
with a prior study dated________________________.
There is normal distribution of activity in the left and right
ventricular myocardium on both rest and pharmacologic stress images. Gated post-stress
images demonstrate normal left ventricular wall thickening. The left ventricular volume is normal and the left ventricular
ejection fraction is _______% (normal >45%).
OPINION:
1. Normal rest and
pharmacologic-stress myocardial perfusion images.
2.
ΠIf appropriate, change: SPECT to PLANAR
¨ Insert:
sestamibi or tetrofosmin
Ž Insert:
negative or positive or indeterminate
¸ Insert adenosine, dipyridamole, or dobutamine as
appropriate.
If
the study was performed with dobutamine, add the following sentence: “The patient achieved _________% of maximum
predicted heart rate.”
‘ If appropriate, insert: Additional
prone post-stress images also were obtained to allow for better evaluation of
the inferior wall.
MYOCARDIAL IMAGING (DELAYED-REST/PHARMACOLOGIC STRESS/SPECT)
(Codes 886 and A886)
[With Gated
Imaging (Codes 886G and A886G)]
[With Gated Imaging and
Ejection Fraction (Codes 886E and A886E)]
EXAMINATION: MYOCARDIAL IMAGING
(DELAYED-REST/PHARMACOLOGIC-STRESS/ SPECTŒ/WITH GATED IMAGING AND EJECTION FRACTION MEASUREMENT)
DATE STARTED: _________
DATE COMPLETED: _________
RADIOPHARMACEUTICAL: _____ mCi Tl-201 chloride i.v. and ____ mCi
Tc-99m ___¨_____ i.v.
HISTORY: _________. The electrocardiogram during
infusion of the pharmacologic agent today was ___Ž_____ for ischemia.
FINDINGS: Standard
myocardial perfusion images were obtained after resting injection of Tl-201 on
the previous evening (to allow complete redistribution of the
radiopharmaceutical and optimal identification of viable myocardium). Subsequently, an intravenous infusion of ______¸____
was performed
under the supervision of attending staff from the Cardiovascular Division. At the peak effect of the
drug, Tc-99m ___¨_____ was injected intravenously and standard
myocardial perfusion images were obtained.
‘
There is normal distribution of activity in the left and right
ventricular myocardium on both delayed-rest and pharmacologic stress
images. Gated post-stress images demonstrate normal left ventricular wall
thickening. The left ventricular volume is normal and the
left ventricular ejection fraction is _______% (normal >45%).
OPINION:
1. Normal delayed-rest and
pharmacologic-stress myocardial perfusion images.
2.
ΠIf appropriate, change: SPECT to PLANAR
¨ Insert:
sestamibi or tetrofosmin
Ž Insert:
negative or positive or indeterminate
¸ Insert adenosine, dipyridamole, or dobutamine as
appropriate.
If
the study was performed with dobutamine, add the following sentence: “The patient achieved _________% of maximum
predicted heart rate.”
‘ If appropriate, insert: Additional
prone post-stress images also were obtained to allow for better evaluation of
the inferior wall.
MYOCARDIAL IMAGING (REST/SPECT) (Codes 887 and A887)
[Tc-99m Sestamibi]
[With Gated
Imaging (Codes 887G and A887G)]
[With Gated Imaging and
Ejection Fraction (Codes 887E and A887E)]
ICD-9 CODE:
__________
EXAMINATION:
MYOCARDIAL IMAGING (REST/SPECTŒ/WITH GATED IMAGING AND EJECTION FRACTION MEASUREMENT)
DATE OF STUDY:
___________
RADIOPHARMACEUTICAL: ____ mCi
Tc-99m ___¨_____ i.v.
HISTORY: ___________
FINDINGS: Standard myocardial perfusion images obtained
after injection of Tc-99m ___¨_____ under resting
conditions Ž demonstrate uniform distribution of activity in the left
ventricular myocardium. Gated images demonstrate normal left
ventricular wall thickening. The left ventricular volume is normal and the
left ventricular ejection fraction is _______% (normal >45%).
OPINION:
1. Normal rest myocardial perfusion images.
2.
ΠIf appropriate, change: SPECT to PLANAR. Also, indicate if PORTABLE.
¨ Insert:
sestamibi or tetrofosmin
Ž If appropriate, insert: “while the patient
was having chest pain”. Also, describe this in history.
MYOCARDIAL IMAGING (REST/SPECT) (Codes 890 and A890)
[Tl-201]
ICD-9 CODE:
__________
EXAMINATION:
MYOCARDIAL IMAGING (REST/SPECT)Œ
DATE OF STUDY:
___________
RADIOPHARMACEUTICAL: ____ mCi Tl-201 chloride i.v.
HISTORY: ___________
FINDINGS: Standard myocardial perfusion images obtained
after injection of Tl-201 chloride under resting conditions demonstrate uniform distribution of activity in the left
ventricular myocardium.
OPINION:
ΠIf appropriate, change: SPECT to PLANAR. Also, indicate if PORTABLE.
MYOCARDIAL IMAGING (REST/REDISTRIBUTION/SPECT) (Codes 891 and A891)
[Tl-201 Viability Study]
ICD-9 CODE:
__________
EXAMINATION:
MYOCARDIAL IMAGING (REST/REDISTRIBUTION/SPECT)Œ
DATE OF STUDY:
___________
RADIOPHARMACEUTICAL: ____ mCi Tl-201 chloride i.v.
HISTORY: ___________
FINDINGS: Standard myocardial perfusion images were
obtained approximately _____ minutes after injection of Tl-201 chloride under
resting conditions. Delayed images were obtained approximately ______ hours
later to evaluate for redistribution of the radiopharmaceutical. The images demonstrate
uniform distribution of activity in the
left ventricular myocardium on both initial and delayed images.
OPINION:
ΠIf appropriate, change: SPECT to PLANAR. Also, indicate if PORTABLE.
MYOCARDIAL IMAGING (EXERCISE/REDISTRIBUTION/SPECT) (Codes 892 and A892)
ICD-9 CODE:
________
EXAMINATION:
MYOCARDIAL IMAGING (EXERCISE/REDISTRIBUTION/SPECT)Œ
DATE OF STUDY:
________
RADIOPHARMACEUTICAL:
____mCi Tl-201 chloride i.v.
HISTORY:
________
FINDINGS: A standard ____¨____ exercise tolerance test
was performed by the patient under supervision of attending staff of the
Cardiovascular Division. The patient
exercised for ___ minutes and ___ seconds and achieved ____% of maximum
predicted heart rate. At peak exertion
Tl-201 was injected intravenously and thereafter standard myocardial perfusion
images were obtained. Delayed images
also were obtained to evaluate redistribution of the radiopharmaceutical.
There is
normal distribution of activity in the left and right ventricular myocardium on
both initial and delayed images.
OPINION:
ΠIf appropriate, change: SPECT to PLANAR.
¨ Insert:
treadmill or upright bicycle or arm ergometer
MYOCARDIAL IMAGING (EXERCISE AND RE-INJECTION/SPECT) (Codes 894 and
A894)
[TL-201 RE-INJECTION]
ICD-9 CODE:
________
EXAMINATION:
MYOCARDIAL IMAGING (EXERCISE AND RE-INJECTION/SPECT)Œ
DATE OF STUDY:
___________
RADIOPHARMACEUTICAL: ____ mCi Tl-201 chloride i.v. and ____ mCi
Tl-201 chloride i.v.
HISTORY: ___________
FINDINGS: A standard ____¨____ exercise tolerance test
was performed by the patient under the supervision of attending staff from the
Cardiovascular Division. The patient exercised for __ minutes and ___ seconds
and achieved _____% of maximum predicted heart rate. At peak exertion Tl-201
was injected intravenously and thereafter standard myocardial perfusion images
were obtained. Images also were obtained several hours later after re-injection
of Tl-201 under resting conditions.
There is
normal distribution of activity in the left and right ventricular myocardium on
both initial and delayed images.
OPINION:
ΠIf appropriate, change: SPECT to PLANAR
¨ Insert:
treadmill or upright bicycle or arm ergometer
MYOCARDIAL IMAGING (PHARMACOLOGIC-STRESS/REDISTRIBUTION/SPECT)
(Codes 895 and A895)
[TL-201 RE-INJECTION]
ICD-9 CODE:
________
EXAMINATION:
MYOCARDIAL IMAGING (PHARMACOLOGIC-STRESS/REDISTRIBUTION/ SPECT)Œ
DATE OF STUDY:
___________
RADIOPHARMACEUTICAL: ____ mCi Tl-201 chloride i.v.
HISTORY: ___________
FINDINGS: An intravenous infusion of ___¨_____ was performed under the
supervision of attending staff from the Cardiovascular Division. At the peak effect of the drug, Tl-201 was
injected intravenously and thereafter standard myocardial perfusion images were
obtained. Delayed images also were
obtained to evaluate redistribution of the radiopharmaceutical.
There is normal distribution of activity in the left and right
ventricular myocardium on both initial and delayed images.
OPINION:
ΠIf appropriate, change: SPECT to PLANAR
¨ Insert adenosine, dipyridamole, or dobutamine as
appropriate.
MYOCARDIAL IMAGING (EXERCISE AND RE-INJECTION/SPECT) (Codes 897 and
A897)
[Tc-99m AGENT ONLY STUDY]
EXAMINATION: Myocardial
Imaging (Exercise AND
RE-INJECTION/SPECTŒ/WITH GATED IMAGING
AND EJECTION FRACTION MEASUREMENT)
DATE OF STUDY:
__________
RADIOPHARMACEUTICAL:
____ mCi Tc-99m ___¨_____ i.v. and _____ mCi Tc-99m ___¨_____ i.v.
HISTORY:
_____________FINDINGS: A standard
___Ž___ exercise tolerance test
was performed by the patient under the supervision of attending staff from the
Cardiovascular Division. The patient
exercised for __ minutes and ___ seconds and achieved ___% of the maximum
predicted heart rate. At peak exercise,
Tc-99m ___¨_____ was injected intravenously, and standard myocardial perfusion
images were obtained approximately 1 hour later. ¸ Images were obtained later after re-injection
of Tc-99m ___¨_____ to evaluate resting distribution of the radiopharmaceutical.
There is normal distribution of activity
in the left and right ventricular myocardium on both post-exercise and
re-injection images. Gated post-stress images
demonstrate normal left ventricular wall thickening. The left ventricular volume is normal and the
left ventricular ejection fraction is _______% (normal >45%).
OPINION:
1. Normal exercise and rest myocardial
perfusion images.
2.
ΠIf appropriate, change: SPECT to PLANAR
¨ Insert:
sestamibi or tetrofosmin
¸ If
appropriate, insert: Additional prone post-stress images also were
obtained to allow for better evaluation of the inferior wall.
MYOCARDIAL IMAGING (PHARMACOLOGIC-STRESS AND RE-INJECTION/SPECT)
(Codes 899 and A899)
[Tc-99m AGENT ONLY STUDY]
EXAMINATION: Myocardial Imaging (PHARMACOLOGIC-STRESS AND RE-INJECTION/SPECT)Œ/
WITH GATED IMAGING AND EJECTION FRACTION MEASUREMENT)
DATE OF STUDY:
__________
RADIOPHARMACEUTICAL:
____ mCi Tc-99m ___¨_____i.v. and _____ mCi Tc-99m ___¨_____i.v.
HISTORY:
_____________
FINDINGS: An intravenous infusion of ____¨
______was performed under the
supervision of attending staff from the Cardiovascular Division. At the peak effect of the drug, Tc-99m ___¨_____ was injected
intravenously and thereafter standard myocardial perfusion images were
obtained. ¸ Images were obtained later after re-injection
of Tc-99m ___¨_____ to evaluate the resting distribution of the radiopharmaceutical.
There is normal distribution of activity in the left and right
ventricular myocardium on both pharmacologic-stress and re-injection images. Gated
images demonstrate normal left ventricular wall thickening. The left ventricular volume is normal and the
left ventricular ejection fraction is _______% (normal >45%).
OPINION:
1. Normal pharmacologic-stress
and rest myocardial perfusion images.
2.
ΠIf appropriate, change: SPECT to PLANAR
¨ Insert:
sestamibi or tetrofosmin
Ž Insert adenosine, dipyridamole, or dobutamine as
appropriate.
¸ If
appropriate, insert: Additional prone post-stress images also were
obtained to allow for better evaluation of the inferior wall.
MYOCARDIAL INFARCT SCINTIGRAPHY (Codes 850 and A850)
ICD-9 CODE:
________
EXAMINATION:
MYOCARDIAL INFARCT SCINTIGRAPHY Œ
DATE OF STUDY:
___________
RADIOPHARMACEUTICAL: _____ mCi Tc-99m pyrophosphate i.v.
HISTORY: ___________
FINDINGS: There
is no abnormal accumulation of Tc-99m pyrophosphate in the myocardium.
OPINION:
Œ
Add: “(SPECT)” if appropriate.
******************************************************************************
ICD-9 Codes
245.9 Secondary cardiomyopathy, unspecified
277.3 Amyloidosis
410.X0 Acute myocardial infarction, episode of
care unspecified
410.X1 Acute myocardial infarction, initial
episode of care
410.X2 Acute myocardial infarction, subsequent
episode of care
0=anterolateral; 1=other anterior; 2=inferolateral; 3=inferoposterior; 4=other
inferior; 5=other lateral; 6=true posterior; 7=subendocardial; 9=unspecified
site (avoid if possible)
411.1 Intermediate coronary syndrome (unstable angina)
413.9 Angina pectoris
428.0 CHF
786.50 Chest pain, NOS
786.51 Precordial pain
790.5 Abnormal serum enzyme level
794.31 Abnormal electrocardiogram
MYOCARDIAL PET IMAGING (METABOLISM) (Code 852)
ICD-9 CODE: ________
EXAMINATION:
MYOCARDIAL PET IMAGING (METABOLISM)
DATE OF STUDY:
_______
RADIOPHARMACEUTICAL:
_______ mCi C-11 acetate i.v.
HISTORY:
_______
FINDINGS: The
patient was positioned in the PET scanner and then underwent transmission
imaging of the thorax for attenuation correction of the subsequent myocardial
emission images. C-11 acetate was
injected intravenously and, thereafter, sequential emission tomographic images
of the heart were obtained over 30 minutes.
Relative regional myocardial perfusion was assessed based on the early
myocardial uptake of C-11 acetate.
Regional myocardial oxidative metabolism was assessed based on rate of
myocardial clearance of the tracer.
Under resting conditions, regional myocardial
pefusion was _______.
Regional myocardial oxidative metabolism was _______.
OPINION:
_______
******************************************************************************
ICD-9 Codes
410.X0 Acute myocardial infarction, episode of
care unspecified
410.X1 Acute myocardial infarction, initial
episode of care
410.X2 Acute myocardial infarction, subsequent
episode of care
0=anterolateral; 1=other anterior; 2=inferolateral; 3=inferoposterior; 4=other
inferior; 5=other lateral; 6=true posterior; 7=subendocardial; 9=unspecified
site (avoid if possible)
411.1 Intermediate coronary syndrome (unstable
angina)
412 Old myocardial infarction
413.9 Angina pectoris
414.01 Coronary atherosclerosis of native vessel
(PTCA)
414.02 Coronary atherosclerosis of autologous
biological bypass graft (CABG)
414.10 Ventricular aneurysm
425.4 Cardiomyopathy,
primary
425.9 Cardiomyopathy,
secondary
428.0 CHF
429.0 Myocarditis, NOS
VENTILATION-PERFUSION SCINTIGRAPHY (Codes 845 and A845)
[XENON IMAGING]
ICD-9 CODE: ________
EXAMINATION:
VENTILATION-PERFUSION SCINTIGRAPHY
DATE OF STUDY:
___________
RADIOPHARMACEUTICAL: ____ mCi Xe-133 gas by inhalation and _____
mCi Tc-99m MAA i.v.
HISTORY: ___________
FINDINGS: The
comparison chest radiograph performed on _______ demonstrates no pulmonary
infiltrates or pleural fluid. The Xe-133
ventilation images show a uniform distribution of activity on single-breath and
washin images. There is no abnormal
Xe-133 retention during the washout phase.
The perfusion images show a physiologic distribution of pulmonary
perfusion.
OPINION:
******************************************************************************
ICD-9 Codes
415.19 Pulmonary embolism/infarction
Chronic
pulmonary heart disease, NOS
427.31 Atrial fibrillation
427.5 Cardiac arrest
428.0 Heart failure
451.2 DVT of lower extremities, NOS
451.9 DVT, site unspecified
485 Pneumonia, organism unspecified
511.9 Pleural effusion
518.0 Atelectasis, collapse
518.4 Acute pulmonary edema, NOS
518.82 ARDS
786.09 Dyspnea, tachypnea
786.2 Cough
786.3 Hemoptysis
786.50 Chest pain, NOS
786.52 Pleuritic chest pain
793.2 Abnormal chest radiograph (or echocardiogram)
794.31 Abnormal electrocardiogram
799.0 Hypoxia
VENTILATION-PERFUSION SCINTIGRAPHY
(Codes 846 and A846)
[AEROSOL]
ICD-9 CODE: ________
EXAMINATION:
VENTILATION-PERFUSION SCINTIGRAPHY (PORTABLE) Œ
DATE OF STUDY:
___________
RADIOPHARMACEUTICAL: Less than 2 mCi Tc-99m DTPA aerosol by
inhalation and _____ mCi Tc-99 MAA i.v.
HISTORY: ___________
FINDINGS: The
comparison portable Πchest radiograph performed
on _______ demonstrates no pulmonary infiltrates or pleural fluid. The Tc-99m DTPA aerosol images show uniform
deposition of the aerosol. The perfusion
images show a physiologic distribution of pulmonary perfusion.
OPINION:
ΠIf applicable, delete: (PORTABLE)
******************************************************************************
ICD-9 Codes
415.19 Pulmonary embolism/infarction
416.9 Chronic pulmonary heart disease, NOS
427.31 Atrial fibrillation
427.5 Cardiac arrest
428.0 Heart failure
451.2 DVT of lower extremities, NOS
451.9 DVT, site unspecified
485 Pneumonia, organism unspecified
511.9 Pleural effusion
518.0 Atelectasis, collapse
518.4 Acute pulmonary edema, NOS
518.82 ARDS
786.09 Dyspnea, tachypnea
786.2 Cough
786.3 Hemoptysis
786.50 Chest pain, NOS
786.52 Pleuritic chest pain
793.2 Abnormal chest radiograph (or echocardiogram)
794.31 Abnormal electrocardiogram
799.0 Hypoxia
VENTILATION-PERFUSION SCINTIGRAPHY (QUANTITATIVE) (Codes 848 and A848)
ICD-9 CODE: ________
EXAMINATION:
VENTILATION-PERFUSION SCINTIGRAPHY (QUANTITATIVE)
DATE OF STUDY:
___________
RADIOPHARMACEUTICAL: ____ mCi Xe-133 gas by inhalation and _____
mCi Tc-99m MAA i.v.
HISTORY: ___________
FINDINGS: The
comparison chest radiograph performed on _______ demonstrates no pulmonary
infiltrates or pleural fluid. The Xe-133
washin ventilation images show a uniform distribution of activity. There is no abnormal Xe-133 retention
during the washout phase. The perfusion
images show a physiologic distribution of pulmonary perfusion.
Based on the distribution of
Xe-133 during the early washin phase, the right lung contributes ______% and
the left lung contributes ______% of total pulmonary ventilation. The right lung receives ______% and the left
lung receives ______% of total pulmonary perfusion.
OPINION:
******************************************************************************
ICD-9 Codes
162.9 Carcinoma of lung
277.00 Cystic fibrosis
416.0 Primary pulmonary hypertension
416.8 Secondary pulmonary hypertension
416.9 Chronic pulmonary heart disease, NOS
491.9 Chronic bronchitis, NOS
492.8 Emphysema
516.3 Idiopathic pulmonary fibrosis
746.9 Congenital heart disease, NOS
786.09 Dyspnea, tachypnea
786.2 Cough
793.2 Abnormal chest radiograph (or echocardiogram)
799.0 Hypoxia
996.84 Lung transplantation, complications
V59.8 Lung donor
V67.0 Follow-up examination after surgery
PULMONARY PERFUSION SCINTIGRAPHY (QUANTITATIVE) (Codes 849 and A849)
ICD-9 CODE: ________
EXAMINATION: PULMONARY PERFUSION SCINTIGRAPHY
(QUANTITATIVE)
DATE OF STUDY:
___________
RADIOPHARMACEUTICAL: _____ mCi Tc-99m MAA i.v.
HISTORY: ___________
FINDINGS: The
comparison chest radiograph performed on _______ demonstrates no pulmonary
infiltrates or pleural fluid. The
perfusion images show a physiologic distribution of pulmonary perfusion.
The right lung receives
______% and the left lung receives ______% of total pulmonary perfusion.
OPINION:
******************************************************************************
ICD-9 Codes
162.9 Carcinoma of lung
277.00 Cystic fibrosis
416.0 Primary pulmonary hypertension
416.8 Secondary pulmonary hypertension
416.9 Chronic pulmonary heart disease, NOS
491.9 Chronic bronchitis, NOS
492.8 Emphysema
516.3 Idiopathic pulmonary fibrosis
746.9 Congenital heart disease, NOS
786.09 Dyspnea, tachypnea
786.2 Cough
793.2 Abnormal chest radiograph (or echocardiogram)
799.0 Hypoxia
996.84 Lung transplantation, complications
V59.8 Lung donor
V67.0 Follow-up examination after surgery
BRAIN SCINTIGRAPHY (Codes 834 and A834)
ICD-9 CODE: ________
EXAMINATION:
BRAIN SCINTIGRAPHY
DATE OF STUDY:
___________
RADIOPHARMACEUTICAL: ____ mCi Tc-99m DTPA i.v.
HISTORY: ___________
FINDINGS: The ___Œ_____ cerebral radionuclide
angiogram demonstrates symmetric perfusion through the carotid arteries and of
the cerebral hemispheres. Immediate and
delayed static images show a normal distribution of activity.
OPINION:
ΠIndicate whether anterior or posterior.
******************************************************************************
ICD-9 Codes
054.3 Herpes encephalitis
323.9 Encephalitis, NOS
780.01 Coma
793.0 Abnormal head CT or MRI
BRAIN DEATH STUDY (Code BDE)
ICD-9 CODE:
________
EXAMINATION:
BRAIN SCINTIGRAPHY (PORTABLE)
DATE OF STUDY:
__________ (______ - _____ hours)
RADIOPHARMACEUTICAL:
_____ mCi Tc-99m DTPA i.v.
HISTORY:
______________
FINDINGS: The anterior cerebral radionuclide angiogram
demonstrates good perfusion through the common carotid arteries and branches of
the external carotid arteries, but there is no visualization of the internal
carotid arteries, anterior or middle cerebral arteries, a cerebral capillary
phase, or the superior sagittal sinus.
The subsequent static images in anterior and ____Œ__ lateral projections
demonstrate ___¨___ visualization of the dural sinuses.
These findings indicate absence of effective cerebral perfusion.
OPINION: No effective cerebral perfusion.
ΠInsert:
right or left or both
¨ Insert:
no or faint
******************************************************************************
ICD-9 Codes
348.1 Anoxic brain damage
348.3 Encephalopathy, NOS
348.4 Compression of brain (herniation)
348.8 Brain death
780.01 Coma
854.05 Intracranial injury, NOS (without open wound)
854.15 Intracranial injury, NOS (with open wound)
RADIONUCLIDE CISTERNOGRAPHY (Code 871)
ICD-9 CODE:
________
EXAMINATION:
________
DATE STARTED:
________
DATE COMPLETED:
________
RADIOPHARMACEUTICAL:
_____µCi In-111 DTPA by lumbar subarachnoid injection
HISTORY:
________
FINDINGS: The
radiopharmaceutical was injected into the lumbar subarachnoid space by staff of
the Section of Neuroradiology.
____________(describe)_______________.
OPINION:
________.
******************************************************************************
ICD-9 Codes
294.8 Chronic organic brain syndrome
320.9 Bacterial meningitis, NOS
322.9 Meningitis, NOS
331.0 Alzheimer’s disease
331.2 Senile degeneration of brain (atrophy)
331.3 Communicating hydrocephalus
331.4 Obstructive hydrocephalus
349.81 CSF rhinorrhea
388.60 Otorrhea, NOS
388.61 CSF otorrhea
478.1 Rhinorrhea, NOS
793.0 Abnormal head CT or MRI
RADIONUCLIDE CISTERNOGRAPHY - CEREBRAL ATROPHY: MODEL REPORT
ICD-9
CODE: 331.2
EXAMINATION: RADIONUCLIDE CISTERNOGRAPHY
DATE
STARTED:
DATE
COMPLETED:
RADIOPHARMACEUTICAL: 540 µCi In-111 DTPA by lumbar subarachnoid
injection
HISTORY: 67 year old man with seizures, gait
disturbance, incontinence, and hydrocephalus on CT and MRI. The study is requested to evaluate for
communicating obstructive hydrocephalus.
FINDINGS: The radiopharmaceutical was injected into the
lumbar subarachnoid space by staff of the Section of Neuroradiology. Images of the spine were obtained 3 hours
later. Anterior and right lateral images
of the head were obtained at 3 hours and 24 hours. No leakage of the radiopharmaceutical is
demonstrated at the injection site.
There is normal ascent of tracer into the basal cisterns. No ventricular reflux is seen. At 24 hours, there is nearly complete ascent
of tracer over the cerebral convexities in the subarachnoid space. Parasagittal concentration of tracer is not
evident, however.
OPINION: The scintigraphic pattern of mildly delayed
flow of tracer in the cerebral subarachnoid space, without evidence for
ventricular reflux, is most consistent with cerebral atrophy.
RADIONUCLIDE CISTERNOGRAPHY - CSF RHINORRHEA: MODEL REPORT
ICD-9
CODE: 349.81
EXAMINATION: RADIONUCLIDE CISTERNOGRAPHY
DATE
STARTED:
DATE
COMPLETED:
RADIOPHARMACEUTICAL: 490 µCi In-111 DTPA by lumbar subarachnoid
injection
HISTORY: 56 year old woman with history of
transsphenoidal hypophysectomy 8 years ago.
The patient recently had meningitis.
The study is requested to evaluate for a CSF leak.
FINDINGS: Prior to injection of the
radiopharmaceutical, the patient underwent placement of pledgets in the nasal
cavity by Dr. Jones of the Department of Otolaryngology. Cottonoid pledgets were placed bilaterally
in the apices of the nasal cavity, in the superior meatus, and in the middle
meatus. Thereafter, the
radiopharmaceutical was injected into the lumbar subarachnoid space by staff of
the Section of Neuroradiology. Images of
the spine and head were obtained 1 hour later.
These images showed no leakage of the radiopharmaceutical at the
injection site. There is normal ascent
of tracer into the basal cisterns.
Subsequent images of the head were obtained at 3 hours, 6 hours, and 24
hours. These images show asymmetrical
ascent of tracer in the cerebral subarachnoid space, normal on the right but
only to the level of the Sylvian cistern on the left. There is no ventricular reflux, however. Additionally, a small amount of activity is
seen at 6 hours and at 24 hours inferior to the middle fossa, in the region of
the posterior nasopharynx. On the 24
hours images, pooling of tracer in the region of the parasellar cistern and
sphenoid sinus is noted. An anterior
image of the abdomen at 24 hours shows activity within the colon, most likely
as a result of swallowing of CSF that had leaked into the nasopharynx.
Following the
images obtained at 6 hours, the nasal pledgets were removed, weighed, and
counted in vitro along with a simultaneously obtained plasma sample. The ratio of pledget activity (counts/g
accumulated fluid) to that of plasma activity (counts/mL) is markedly elevated
in all pledgets. The greatest activity
was found on the pledget in the apex of the nasal cavity on the right side.
OPINION:
1. The scintigraphic findings and results of
pledget counts indicate the presence of a CSF leak, most likely via the sella
turcica into the sphenoid sinus.
2. Abnormal flow of tracer in the subarachnoid
space over the left cerebral hemisphere, most likely related to
post-inflammatory changes in this patient with a recent history of meningitis.
CSF SHUNT STUDY (Code 872)
ICD-9 CODE:
________
EXAMINATION: CSF SHUNT STUDY
DATE OF STUDY: ________
RADIOPHARMACEUTICAL: _____mCi Tc-99m DTPA injected into the ___Œ_____ of the shunt system.
HISTORY: ________
FINDINGS: The radiopharmaceutical was injected into the
___Œ_____ of the shunt system by Dr. ________ of the
Department of Neurosurgery.
_____________________________
OPINION: _______________
ΠInsert valve or reservoir
******************************************************************************
ICD-9 Codes
331.3 Communicating hydrocephalus
331.4 Obstructive hydrocephalus
784.0 Headache
789.30 Abdominal mass or lump
793.0 Abnormal head CT or MRI
996.2 Complication of CSF drainage device
V45.2 Evaluation of CSF drainage device
PERFUSION BRAIN IMAGING (TOMOGRAPHIC) (Code 873)
ICD-9 CODE:
________
EXAMINATION: PERFUSION BRAIN IMAGING (TOMOGRAPHIC)
DATE OF
STUDY: ________
RADIOPHARMACEUTICAL: ____ mCi Tc-99m bicisate i.v.
HISTORY: ________
FINDINGS: ________
OPINION: ____________________
******************************************************************************
ICD-9 Codes
Malignant neoplasm of:
141.9 Tongue, NOS
142.9 Salivary Gland, NOS
143.9 Gum, NOS
144.9 Floor of mouth, NOS
145.9 Mouth, NOS
146.9 Oropharynx, NOS
147.9 Nasopharynx, NOS
148.9 Hypopharynx, NOS
191.9 Brain, NOS
225.0 Benign neoplasm of brain
225.2 Benign neoplasm of meninges
345.41 Intractable partial epilepsy, with
impairment of consciousness
345.51 Intractable partial epilepsy, without
impairment of consciousness
345.71 Intractable epilepsia partialis continua
345.91 Intractable epilepsy, NOS
PERFUSION BRAIN IMAGING (TOMOGRAPHIC/ICTAL AND INTERICTAL) (Code 873A)
ICD-9 CODE: ________
EXAMINATION:
PERFUSION BRAIN IMAGING (TOMOGRAPHIC/ICTAL AND INTERICTAL)
DATE STARTED:
_______
DATE COMPLETED:
_______
RADIOPHARMACEUTICAL:
_______ mCi Tc-99m bicisate i.v. on _______ and _______ mCi Tc-99m
bicisate i.v. on _______
HISTORY:
_______
FINDINGS: An
ictal examination was performed first on _______. During continuous video and
electroencephalographic monitoring, the patient sustained a seizure
characterized by _____________________.
Tc-99m bicisate was injected intravenously approximately ___ seconds
after the clinical onset of the seizure and ___ seconds after the
electroencephalographic onset of the seizure.
Approximately __ hours later, the patient was taken to the Division of
Nuclear Medicine and underwent standard tomographic imaging (SPECT) of the
brain.
For comparison with the ictal study, an interictal
study was performed on _______. Standard
tomographic images were obtained approximately __ hours after injection of
Tc-99m bicisate. At the time of this
study, the patient had been seizure free for __ hours.
The ictal and interictal SPECT studies were compared
with _______.
______________
OPINION: The
combined ictal and interictal SPECT findings are most consistent with _______.
******************************************************************************
ICD-9 Codes
345.41 Intractable partial epilepsy, with
impairment of consciousness
345.51 Intractable partial epilepsy, without
impairment of consciousness
345.71 Intractable epilepsia partialis continua
345.91 Intractable epilepsy, NOS
PERFUSION BRAIN IMAGING (TOMOGRAPHIC/INTERICTAL AND ICTAL) (Code 873B)
ICD-9 CODE:
________
EXAMINATION:
PERFUSION BRAIN IMAGING (TOMOGRAPHIC/INTERICTAL AND ICTAL)
DATE STARTED:
_______
DATE COMPLETED:
_______
RADIOPHARMACEUTICAL:
_______ mCi Tc-99m bicisate i.v. on _______ and _______ mCi Tc-99m
bicisate i.v. on _______
HISTORY:
_______
FINDINGS: An
interictal examination was performed first on _______. Standard tomographic images were obtained
approximately __ hours after injection of Tc-99m bicisate. At the time of this study, the patient had
been seizure free for __ hours.
An ictal examination was performed on _______. During continuous video and
electroencephalographic monitoring, the patient sustained a seizure
characterized by _____________________.
Tc-99m bicisate was injected intravenously approximately ___ seconds
after the clinical onset of the seizure and ___ seconds after the electroencephalographic
onset of the seizure. Approximately __
hours later, the patient was taken to the Division of Nuclear Medicine and
underwent standard tomographic imaging (SPECT) of the brain.
The ictal and interictal SPECT studies were compared
with _______.
______________
OPINION: The
combined ictal and interictal SPECT findings are most consistent with _______.
******************************************************************************
ICD-9 Codes
345.41 Intractable partial epilepsy, with
impairment of consciousness
345.51 Intractable partial epilepsy, without impairment
of consciousness
345.71 Intractable epilepsia partialis continua
345.91 Intractable epilepsy, NOS
ICTAL/INTERICTAL PERFUSION BRAIN IMAGING: MODEL REPORT
ICD-9 CODE: 345.51
EXAMINATION: PERFUSION BRAIN IMAGING (TOMOGRAPHIC/ICTAL
AND INTERICTAL)
DATE STARTED:
DATE COMPLETED:
RADIOPHARMACEUTICAL:
24.8 mCi Tc-99m bicisate i.v. on
HISTORY: This
is a 34-year-old woman with intractable partial complex epilepsy. The patient is currently undergoing
evaluation for possible surgical treatment.
FINDINGS: An
ictal examination was performed first on
For comparison with the ictal study, an interictal
study was performed on
The ictal and interictal SPECT studies were compared
with the brain MRI examination performed on
The ictal SPECT images demonstrate a discrete focus
of increased activity in the right anteromesial temporal cortex. The distribution of radiopharmaceutical
elsewhere in the brain is normal. On the
interictal SPECT study, there is mild hypoperfusion of the entire right
temporal lobe.
OPINION: The combined
ictal and interictal SPECT findings are most consistent with an epileptogenic
focus in the anteromesial right temporal cortex.
BRAIN FDG-PET PET IMAGING (Code 868)
[EMISSION AND TRANSMISSION]
EXAMINATION:
BRAIN FDG-PET IMAGING
DATE OF STUDY:
___________
PET ID NUMBER:
___________
RADIOPHARMACEUTICAL: ____ mCi F-18 Fluorodeoxyglucose i.v.
HISTORY: ___________
FINDINGS: After positioning of the patient’s head,
standard (47-slice) transmission PET imaging was performed. F-18 fluorodeoxyglucose (FDG) was then
administered intravenously with the patient in a quiet, darkened room. The patient’s fasting blood glucose level,
measured by glucometer before injection of FDG, was ______ mg/dL. Approximately 30 minutes later, standard
(47-slice) emission PET imaging was performed.
The PET images were compared
with the ____Œ____ examination dated ______.
___________________________________.
OPINION:
_________________.
ΠInsert:
CT or MRI
******************************************************************************
ICD-9 Codes
191.9 Malignant neoplasm of brain, NOS
198.3 Metastatic neoplasm of brain
225.0 Benign neoplasm of brain
225.2 Benign neoplasm of meninges
345.41 Intractable partial epilepsy, with
impairment of consciousness
345.51 Intractable partial epilepsy, without
impairment of consciousness
345.71 Intractable epilepsia partialis continua
345.91 Intractable epilepsy, NOS
BRAIN FDG-PET IMAGING (Code 868M)
[ADULT/EMISSION ONLY]
EXAMINATION:
BRAIN FDG-PET IMAGING
DATE OF STUDY:
___________
PET ID NUMBER:
___________
RADIOPHARMACEUTICAL: ____ mCi F-18 Fluorodeoxyglucose i.v.
HISTORY: ___________
FINDINGS: F-18 fluorodeoxyglucose (FDG) was
administered intravenously with the patient in a quiet, darkened room. The
patient’s fasting blood glucose level, measured by glucometer before injection
of FDG, was ______ mg/dL. Approximately
30 minutes later, after positioning of the patient’s head, standard (47-slice)
emission PET imaging was performed. A
mathematical attenuation correction was performed.
The PET images were compared
with the ____Œ____ examination dated ______.
___________________________________.
OPINION:
_________________.
ΠInsert:
CT or MRI
******************************************************************************
ICD-9 Codes
191.9 Malignant neoplasm of brain, NOS
198.3 Metastatic neoplasm of brain
225.0 Benign neoplasm of brain
225.2 Benign neoplasm of meninges
345.41 Intractable partial epilepsy, with
impairment of consciousness
345.51 Intractable partial epilepsy, without
impairment of consciousness
345.71 Intractable epilepsia partialis continua
345.91 Intractable epilepsy, NOS
BRAIN FDG-PET/CT IMAGING (Code 868CT)
EXAMINATION:
BRAIN FDG-PET/CT IMAGING
DATE OF STUDY:
___________
PET ID NUMBER:
___________
RADIOPHARMACEUTICAL: ____ mCi F-18 Fluorodeoxyglucose i.v.
HISTORY: ___________
FINDINGS: F-18 fluorodeoxyglucose (FDG) was
administered intravenously with the patient in a quiet, darkened room. The
patient’s fasting blood glucose level, measured by glucometer before injection
of FDG, was ______ mg/dL. Approximately
30 minutes later, after positioning of the patient’s head, noncontrast CT images were obtained for attenuation
correction and for fusion with emission PET images. [The noncontrast CT images
are not of diagnostic quality and are not used to diagnose disease
independently of the PET images.] Standard emission PET
imaging was then performed.
The PET images were compared
with the ____Œ____ examination dated ______.
___________________________________.
OPINION:
_________________.
ΠInsert:
CT or MRI
******************************************************************************
ICD-9 Codes
191.9 Malignant neoplasm of brain, NOS
198.3 Metastatic neoplasm of brain
225.0 Benign neoplasm of brain
225.2 Benign neoplasm of meninges
345.41 Intractable partial epilepsy, with
impairment of consciousness
345.51 Intractable partial epilepsy, without
impairment of consciousness
345.71 Intractable
epilepsia partialis continua
345.91 Intractable
epilepsy, NOS
BRAIN FDG-PET IMAGING (Code 869)
[PEDIATRIC/EMISSION ONLY]
EXAMINATION:
BRAIN FDG-PET IMAGING
DATE OF STUDY:
___________
PET ID NUMBER:
___________
RADIOPHARMACEUTICAL: ____ mCi F-18 Fluorodeoxyglucose i.v.
HISTORY: ___________
FINDINGS: F-18 fluorodeoxyglucose (FDG) was
administered intravenously with the patient in a quiet, darkened room. The
patient’s fasting blood glucose level, measured by glucometer before injection
of FDG, was ______ mg/dL. Approximately
30 minutes later, after the FDG-uptake phase, sedation was induced by the staff
of the St. Louis Children's Hospital Ambulatory and
The PET images were compared
with the ____Œ____ examination dated ______.
___________________________________.
OPINION:
_________________.
ΠInsert:
CT or MRI
******************************************************************************
ICD-9 Codes
191.9 Malignant neoplasm of brain, NOS
198.3 Metastatic neoplasm of brain
225.0 Benign neoplasm of brain
225.2 Benign neoplasm of meninges
345.41 Intractable partial epilepsy, with
impairment of consciousness
345.51 Intractable partial epilepsy, without
impairment of consciousness
345.71 Intractable epilepsia partialis continua
345.91 Intractable epilepsy, NOS
GLOMERULAR FILTRATION RATE (Code GFR)
EXAMINATION: GLOMERULAR FILTRATION RATE MEASUREMENT
DATE OF STUDY: ______
RADIOPHARMACEUTICAL: _____ uCi I-125 iothalamate i.v.and ___ drops
saturated potassium iodide solution p.o.
HISTORY: __________
FINDINGS: After the bolus intravenous administration of
I-125 iothalamate, multiple timed blood samples were obtained over the next 4
hours. The glomerular filtration rate
(GFR) was calculated by bi-exponential fitting of the plasma clearance
curve. At the time of this study, the
patient's height, weight, and body surface were ____ cm, ____ kg, and ____
sq-m, respectively. The calculated GFR
is ____ mL/min. The calculated GFR,
adjusted for body surface area, is ____ mL/min/1.73 sq-m (normal >90
mL/min/1.73 sq-m).
OPINION: ________
******************************************************************************
ICD-9 Codes
283.11 Hemolytic-uremic syndrome
580.9 Acute glomerulonephritis, NOS
582.9 Chronic glomerulonephritis, NOS
584.9 Acute renal failure, NOS
585 Chronic renal failure
586 Uremia, NOS
590.00 Chronic pyelonephritis
591 Hydronephrosis
V58.69 Long-term current use of high-risk
medication (e.g., chemotherapy)
RENAL SCINTIGRAPHY (Codes 856 and A856)
ICD-9 CODE:
________
EXAMINATION:
RENAL SCINTIGRAPHY
DATE OF STUDY:
___________
RADIOPHARMACEUTICAL: ____ mCi Tc-99m MAG3 i.v.Œ
HISTORY: ___________
FINDINGS: The
posterior abdominal radionuclide angiogram demonstrates prompt, symmetrical
perfusion of the kidneys. Sequential renal images show the kidneys to be of
normal size and morphology. There is prompt uptake and excretion of the
radiopharmaceutical by both kidneys. The
estimated contribution of the right kidney to total renal function is _______%
and that of the left kidney is ______%. There are no abnormalities of the ureters or
bladder.
OPINION:
ΠIf appropriate, change to Tc-99m DTPA
******************************************************************************
ICD-9 Codes
189.0 Malignant neoplasm of
kidney
189.1 Malignant neoplasm of
renal pelvis
580.9 Acute
glomerulonephritis, NOS
582.9 Chronic
glomerulonephritis, NOS
584.5 Acute tubular necrosis
584.9 Acute renal failure,
NOS
585 Chronic renal failure
586 Uremia, NOS
589.0 Unilateral small
kidney, unknown cause
589.1 Bilateral small
kidneys, unknown cause
590.00 Chronic pyelonephritis
590.10 Acute pyelonephritis
591 Hydronephrosis
592.0 Renal calculus
592.1 Ureteral calculus
593.81 Vascular disorder of
kidney (e.g., infarct)
753.19 Multicystic dysplastic
kidney
788.5 Oliguria, anuria
793.5 Abnormal imaging study
of GU tract
996.1 Mechanical complication
of vascular graft
996.30 Mechanical complication
of GU tract device
RENAL TRANSPLANT SCINTIGRAPHY (Codes 843 and A843)
ICD-9 CODE:
________
EXAMINATION:
RENAL TRANSPLANT SCINTIGRAPHY
DATE OF STUDY:
___________
RADIOPHARMACEUTICAL: ____ mCi Tc-99m MAG3 i.v.Œ
HISTORY: ___________
FINDINGS: The
anterior pelvic radionuclide angiogram demonstrates prompt perfusion of the
transplanted kidney in the _______ iliac
fossa. The initial images demonstrate normal transplant size, morphology, and
tracer accumulation. The sequential
images and renogram curve show prompt uptake and excretion of the
radiopharmaceutical by the transplant.
No abnormalities of the ureter or bladder are seen. There is no evidence for urine extravasation
or perirenal mass.
OPINION:
ΠIf appropriate, change to Tc-99m DTPA
******************************************************************************
ICD-9 Codes
584.5 Acute tubular necrosis
584.9 Acute renal failure, NOS
788.5 Oliguria, anuria
793.5 Abnormal imaging study of GU tract
996.81 Complication of renal transplantation
DIURETIC RENAL SCINTIGRAPHY (Code 857)
ICD-9 CODE:
________
EXAMINATION:
DIURETIC RENAL SCINTIGRAPHY
DATE OF STUDY:
___________
RADIOPHARMACEUTICAL: ____ mCi Tc-99m MAG3 i.v.Πand ____ mg furosemide i.v.
HISTORY: ___________
FINDINGS: ___________
OPINION: ________
ΠIf appropriate, change to Tc-99m DTPA
******************************************************************************
ICD-9 Codes
589.0 Unilateral small
kidney, unknown cause
589.1 Bilateral small
kidneys, unknown cause
591 Hydronephrosis
592.0 Renal calculus
592.1 Ureteral calculus
593.3 Stricture or kinking
of ureter
593.4 Other ureteric
obstruction
593.5 Hydroureter
593.70 Vesicoureteral reflux
without reflux nephropathy
593.72 Vesicoureteral reflux
with reflux nephropathy
753.2 Congenital obstructive
lesion of kidney or ureter
793.5 Abnormal imaging study
of GU tract
996.30 Mechanical complication
of GU tract device
V67.0 Follow-up examination
after surgery
V67.9 Follow-up examination, NOS
(e.g., after stent removal)
DIURETIC RENAL SCINTIGRAPHY - HYDRONEPHROSIS: MODEL REPORT
ICD-9
CODE: 591
EXAMINATION: DIURETIC RENAL SCINTIGRAPHY
DATE OF
STUDY:
RADIOPHARMACEUTICAL: 7.4 mCi Tc-99m MAG3 i.v. and 40 mg furosemide
i.v.
HISTORY: 34 year old man with intermittent right flank
pain associated with beer drinking and dilated right pelvicalyceal system on
ultrasonography. Evaluate for
obstruction.
FINDINGS: The patient was hydrated orally before the
examination was begun. The posterior
abdominal radionuclide angiogram demonstrates normal renal perfusion
bilaterally. Sequential renal images
through 20 minutes demonstrate the kidneys to be of normal size. There is normal uptake and excretion of
tracer by the left kidney. On the right,
the initial cortical uptake is mildly decreased, and there is relatively
decreased activity centrally corresponding to the dilated pelvicalyceal
system. There is progressive
accumulation of tracer in the collecting system on the right. This persisted on a post-void image obtained
approximately 25 minutes after injection of the radiopharmaceutical. The left ureter appears normal. The right ureter is not visualized. The bladder appears normal.
The right
kidney contributes 42% and the left kidney 58% of total renal function.
To evaluate
for obstruction, the patient was given 40 mg furosemide via slow intravenous
injection approximately 30 minutes after the start of the examination. Sequential images were obtained for an
additional 20 minutes. There is prompt
clearance of residual pelvicalyceal activity on the left after diuretic
administration. On the right, there is
markedly delayed clearance of activity from the dilated pelvicalyceal
system. The right ureter is not visualized
after diuretic administration. After
diuretic administration, the half-time of tracer clearance from the right
kidney is 87 minutes and from the left
kidney is 6 minutes.
OPINION:
1. Right ureteropelvic junction obstruction with
mild impairment of relative function of the right kidney.
2.
RENAL SCINTIGRAPHY (AFTER ANGIOTENSIN-CONVERTING-ENZYME INHIBITION)
(Code 874)
ICD-9
CODE: ________
EXAMINATION: RENAL SCINTIGRAPHY (AFTER
ANGIOTENSIN-CONVERTING-ENZYME INHIBITION
DATE OF STUDY: ________
RADIOPHARMACEUTICAL: ___ mg enalaprilat i.v. and ____ mCi Tc-99m
MAG3 i.v.
HISTORY: ________
FINDINGS: _________________ .
OPINION: _________________ .
******************************************************************************
ICD-9 Codes
401.9 Essential hypertension, NOS
403.90 Hypertensive renal disease, without renal
failure
403.91 Hypertensive renal disease, with renal
failure
405.91 Renovascular hypertension
440.1 Atherosclerosis of renal arteries
447.3 Fibromuscular hyperplasia of renal artery
586 Renal failure, NOS
589.0 Unilateral small kidney
593.81 Vascular disorders of kidney (e.g.
infarction)
793.5 Abnormal imaging study of GU tract
RENAL SCINTIGRAPHY (AFTER ANGIOTENSIN-CONVERTING-ENZYME
INHIBITION): MODEL REPORT
ICD-9
CODE: 405.91
EXAMINATION: RENAL SCINTIGRAPHY (AFTER
ANGIOTENSIN-CONVERTING-ENZYME INHIBITION)
DATE OF
STUDY:
RADIOPHARMACEUTICAL: 2.4 mg enalaprilat i.v and 7.2 mCi Tc-99m
MAG3 i.v.
HISTORY: 42 year old woman with recent onset of
hypertension poorly controlled by antihypertensive medications. Maintenance medications include lisinopril,
which was discontinued 3 days prior to this study. The patient’s serum creatinine is within
normal limits at 1.0 mg/dL. Evaluate for
renovascular hypertension.
FINDINGS: The patient was hydrated by administration of
both oral and intravenous fluid before and during the examination. After initial hydration, the patient
underwent an infusion of 2.4 mg enalaprilat (0.04 mg/kg) over 5 minutes. Renal scintigraphy was performed with Tc-99m
MAG3 beginning 15 minutes later. The
posterior radionuclide angiogram demonstrates normal, symmetrical renal
perfusion. Radiopharmaceutical uptake by
both kidneys is normal. There is normal
excretion of the tracer on the right. On
the left, however, there is prolonged parenchymal retention of Tc-99m MAG3 and
markedly delayed excretion; only slight pelvicalyceal activity is seen at 20
minutes. The estimated contribution of
the right kidney to total renal function is 53% and that of the left kidney is
47%. The patient’s blood pressure was
140/95 mm Hg at baseline and decreased to 120/80 mm Hg approximately 30 minutes
after administration of enalaprilat. The
patient tolerated the procedure well.
OPINION:
1. Marked prolongation of tracer clearance from
the left kidney after administration of enalaprilat. In the absence of known renal parenchymal
disease on this side, these findings are most consistent with renin-mediated
hypertension due to left renal artery stenosis . If clinically appropriate, a repeat conventional
study (without angiotensin-converting-enzyme inhibition) could be obtained to
increase the certainty of this diagnosis.
2. Normal right renal perfusion and function.
RENAL SCINTIGRAPHY (BEFORE AND AFTER ANGIOTENSIN-
CONVERTING-ENZYME INHIBITION) (Code 875)
ICD-9
CODE: ________
EXAMINATION: RENAL SCINTIGRAPHY (BEFORE AND AFTER
ANGIOTENSIN-CONVERTING-ENZYME INHIBITION
DATE OF STUDY: ________
RADIOPHARMACEUTICAL: ____ mCi Tc-99m MAG3 i.v. and ___ mg
enalaprilat i.v. and ____ mCi Tc-99m MAG3 i.v.
HISTORY: ________
FINDINGS: _________________ .
OPINION: _________________ .
******************************************************************************
ICD-9 Codes
401.9 Essential hypertension, NOS
403.90 Hypertensive renal disease, without renal
failure
403.91 Hypertensive renal disease, with renal
failure
405.91 Renovascular hypertension
440.1 Atherosclerosis of renal arteries
447.3 Fibromuscular hyperplasia of renal artery
586 Renal failure, NOS
589.0 Unilateral small kidney
593.81 Vascular disorders of kidney (e.g.
infarction)
793.5 Abnormal imaging study of GU tract
RENAL SCINTIGRAPHY (BEFORE AND AFTER ANGIOTENSIN-
CONVERTING-ENZYME INHIBITION):
MODEL REPORT
ICD-9
CODE: 405.91
EXAMINATION: RENAL SCINTIGRAPHY (BEFORE AND AFTER
ANGIOTENSIN-CONVERTING-ENZYME INHIBITION)
DATE OF
STUDY:
RADIOPHARMACEUTICAL: 1.1 mCi Tc-99m MAG3 i.v.; 2.4 mg enalaprilat i.v.; and 9.3 mCi Tc-99m
MAG3 i.v.
HISTORY: 42 year old woman with recent onset of
hypertension poorly controlled by antihypertensive medications. Maintenance medications include lisinopril,
which was discontinued 3 days prior to this study. The patient’s serum creatinine is within
normal limits at 1.0 mg/dL. Evaluate for
renovascular hypertension.
FINDINGS: The patient was hydrated by administration of
both oral and intravenous fluid before and during the examination. Baseline renal scintigraphy was performed
first. The posterior abdominal
radionuclide angiogram demonstrates normal renal perfusion bilaterally. Sequential renal images through 20 minutes
demonstrate the kidneys to be of normal size.
There is normal uptake and excretion of tracer by both kidneys. The estimated contribution of the right
kidney to total renal function is 52% and that of the left kidney is 48%. The ureters and bladder are normal in
appearance.
Approximately
15 minutes after completion of the baseline study, the patient underwent an
infusion of 2.4 mg enalaprilat (0.04 mg/kg) over 5 minutes. Repeat renal scintigraphy was performed with
Tc-99m MAG3 beginning 15 minutes later.
The posterior radionuclide angiogram again demonstrates normal,
symmetrical renal perfusion.
Radiopharmaceutical uptake by both kidneys is again normal. There is normal excretion of the tracer on
the right. On the left, however, there
is now prolonged parenchymal retention of Tc-99m MAG3 and markedly delayed
excretion; only slight pelvicalyceal activity is seen at 20 minutes. The estimated contribution of the right
kidney to total renal function is 53% and that of the left kidney is 47%. The patient’s blood pressure was 140/95 mm
Hg at baseline and decreased to 120/80 mm Hg approximately 30 minutes after
administration of enalaprilat. The
patient tolerated the procedure well.
OPINION:
1. Marked prolongation of tracer clearance from
the left kidney after administration of enalaprilat. These findings are most consistent with
renin-mediated hypertension due to left renal artery stenosis .
2. Renal perfusion and function is otherwise normal
bilaterally.
RENAL CORTICAL SCINTIGRAPHY (Codes DMSA and ADMSA)
ICD-9 CODE:
________
EXAMINATION:
RENAL CORTICAL SCINTIGRAPHY Œ
DATE OF STUDY:
___________
RADIOPHARMACEUTICAL: ____ mCi Tc-99m DMSA i.v.¨
HISTORY: ___________
FINDINGS: Delayed _____Ž______ images of the kidneys
were obtained approximately ____ hours after injection of the
radiopharmaceutical. The kidneys are of
normal size and configuration and there is uniform cortical tracer uptake
bilaterally.
OPINION:
Œ
Add:
“(TOMOGRAPHIC)” if SPECT was performed
¨ If appropriate, change to Tc-99m
Glucoheptonate. (will then also need to modify report if early imaging sequence
used.
Ž Indicate whether:
conventional planar and/or
pinhole-collimation magnified and/or
SPECT
******************************************************************************
ICD-9 Codes
590.10 Acute pyelonephritis
593.70 Vesicoureteral reflux
without reflux nephropathy
593.72 Vesicoureteral reflux
with reflux nephropathy
593.81 Vascular disorder of
kidney (e.g., infarct)
793.5 Abnormal imaging study
of GU tract
RADIONUCLIDE CYSTOGRAPHY (Codes 878 and A878)
ICD-9 CODE:
________
EXAMINATION:
RADIONUCLIDE CYSTOGRAPHY
DATE OF STUDY:
___________
RADIOPHARMACEUTICAL: ____ mCi Tc-99m pertechnetate instilled via
catheter into the urinary bladder
HISTORY: ___________
FINDINGS: The patient's bladder was catheterized by the
standard aseptic technique with a _____ Fr Foley catheter. After drainage of residual bladder urine,
Tc-99m pertechnetate was instilled via the catheter followed by instillation of
______ ml of 0.9% sterile saline solution (containing 1 ml of Neosporin GU
irrigant per 500 ml saline)Œ. Sequential scintillation images were obtained
during filling of the bladder, when the bladder was full, during voiding after
removal of the catheter, and after completion of voiding.
No vesicoureteral reflux was seen during any phase of the study. The calculated residual bladder volume was ______
ml.
OPINION:
ΠDelete parenthetical phrase, if Neosporin not used.
******************************************************************************
ICD-9 Codes
590.10 Acute pyelonephritis
591 Hydronephrosis
593.5 Hydroureter
593.70 Vesicoureteral reflux
without reflux nephropathy
593.72 Vesicoureteral reflux
with reflux nephropathy
595.0 Acute cystitis
599.0 Urinary tract
infection, site NOS
753.19 Multicystic dysplastic
kidney
753.9 Urinary tract
congenital anomaly, NOS
793.5 Abnormal imaging study
of GU tract
V67.0 Follow-up examination
after surgery
V67.9 Follow-up examination,
NOS
TESTICULAR SCINTIGRAPHY (Codes 817 and A817)
ICD-9 CODE:
________
EXAMINATION:
TESTICULAR SCINTIGRAPHY
DATE OF STUDY:
___________
RADIOPHARMACEUTICAL:
____ mCi Tc-99m pertechnetate i.v.
HISTORY:
___________
FINDINGS: The
anterior radionuclide angiogram of the scrotal region demonstrates normal,
symmetric perfusion of the scrotal contents. Static magnification images show a
normal distribution of radiopharmaceutical.
OPINION:
******************************************************************************
ICD-9 Codes
603.90 Hydrocele, NOS
604.0 Scrotal abscess
604.90 Orchitis and/or epididymitis without
abscess
608.2 Torsion of testis
608.9 Disorder of male genitalia, NOS (includes scrotal
pain/swelling or acute scrotum)
959.1 Scrotal trauma
ICD-9 CODES FOR TUMOR AND INFLAMMATION IMAGING
Primary Malignant Neoplasm of:
141.9 Tongue, NOS
142.9 Salivary Gland, NOS
143.9 Gum, NOS
144.9 Floor of mouth, NOS
145.9 Mouth, NOS
146.9 Oropharynx, NOS
147.9 Nasopharynx, NOS
148.9 Hypopharynx, NOS
150.9 Esophagus, NOS
151.9 Stomach, NOS
152.9 Small intestine, NOS
153.9
154.1 Rectum
155.0 Liver, primary
156.9 Biliary tract, NOS
157.4 Islets of Langerhans
157.9 Pancreas, NOS
158.0 Retroperitoneum
160.9 Sinuses, NOS
161.9 Larynx, NOS
162.X Bronchus and lung
(3=upper lobe, 4=middle lobe; 5=lower lobe; 9=NOS)
163.9 Pleura, NOS
164.9 Mediastinum, NOS
170.9 Bone and cartilage, NOS
171.9 Soft tissues, NOS
172.9 Melanoma, NOS
174.9 Female breast, NOS
175.9 Male breast, NOS
179 Uterus
180.9 Cervix, NOS
183.0 Ovary
184.9 Female GU tract, NOS
185 Prostate
186.9 Testis
187.9 Male GU tract, NOS
188.9 Bladder, NOS
189.0 Kidney (except pelvis)
189.9 Urinary organ, NOS
191.9 Brain, NOS
193 Thyroid
194.0 Adrenal
195.0 Head, face, and neck, NOS
195.1 Thorax, NOS
195.2 Abdomen, NOS
195.3 Pelvis
Metastatic Neoplasms of:
196.9 Lymph nodes, NOS
197.0 Lung
197.7 Liver
198.3 Brain and spinal cord
198.5 Bone and bone marrow
199.0 Disseminated carcinomas
Other Tumors
200.00 Non-Hodgkin’s lymphoma, NOS
201.90 Hodgkin’s disease, NOS
203.00 Multiple myeloma
204.90 Lymphoid leukemia
205.90 Myeloid leukemia
213.X Benign Neoplasm of bone and cartilage (0=skull and face;
1=mandible; 2=vertebral column; 3=ribs, sternum, clavicle; 4=scapula and UE
long bones; 5=UE short bones; 6=pelvic bones, sacrum, coccyx; 7=LE long bones,
8=LE short bones; 9=site unspecified)
Follow-up Evaluation
V67.0 After surgery
V67.1 After radiotherapy
V67.2 After chemotherapy
Infection
031.9 Atypical myobacterial infection, NOS (including M. avium-intracellulare)
042 HIV infection (AIDS)
078.5 CMV infection
163.3 Pneumocystis carinii pneumonia
322.9 Meningitis, NOS
324.1 Intraspinal abscess
380.10 Infective otitis
externa, NOS
380.14 Malignant otitis
externa
421.9 Acute endocarditis,
NOS
422.90 Acute myocarditis, NOS
461.9 Acute sinusitis, NOS
473.9 Chronic sinusitis, NOS
485 Bronchopneumonia, NOS
540.1 Appendiceal abscess
562.11 Diverticulitis
567.9 Peritonitis, NOS
583.9 Nephritis, NOS (e.g., allergic interstitial nephritis)
590.01 Chronic pyelonephritis
590.11 Acute pyelonephritis
590.2 Renal and perinephric
abscess
682.9 Cellulitis, NOS
711.0X Pyogenic arthritis
730.0X Acute osteomyelitis
730.1X Chronic osteomyelitis
Musculoskeletal
System Diseases
Where
5th digit required as indicated by X:
0=site NOS; 1=shoulder; 2=arm; 3=forearm; 4=hand and wrist;
5=pelvis/thigh; 6=leg; 7=ankle and foot; 8=other site (including ribs,
vertebrae, skull); 9=multiple sites.
Inflammatory Diseases
135 Sarcoidosis
505 Pneumoconiosis, NOS
516.3 Idiopathic pulmonary
fibrosis
555.9 Crohn’s disease, NOS
665.9 Ulcerative colitis,
NOS
Infection/Inflammation due
to:
996.61 Cardiac device,
implant, graft
996.62 Vascular device,
implant, graft
996.63 Nervous system device,
implant, graft
996.65 GU system device,
implant, graft
996.66 Joint prosthesis
996.69 Other device, implant,
graft
Other Postsurgical
Complications
996.81 Complication, kidney
transplant
996.82 Complication, liver
transplant
996.83 Complication, heart
transplant
996.84 Complication, lung
transplant
998.3 Wound dehiscence
998.5 Postoperative
infection
Symptoms/Signs
288.8 Leukocytosis
729.81 Swelling of limb
780.6 Fever (including FUO)
785.6 Lymphadenopathy
786.2 Cough
789.00 Abdominal pain, NOS
790.1 Elevated ESR
790.7 Bacteremia
793.X Radiological
abnormality of: 0=head and neck; 1=lung; 2=other chest; 3=biliary tract; 4=GI
tract; 5=GU tract; 6=abdomen or retroperitoneum; 7=musculoskeletal system;
9=other
LEUKOCYTE SCINTIGRAPHY (Code WBC)
ICD-9 CODE:
________
EXAMINATION:
LEUKOCYTE SCINTIGRAPHY Œ
DATE STARTED:
________
DATE COMPLETED:
________
RADIOPHARMACEUTICAL:
____ µCi In-111 ¨ labeled autologous leukocytes i.v.
HISTORY:
________
FINDINGS:
________
OPINION:
________
Œ Add: “(LIMITED)” if appropriate
¨ Change to Tc-99m if
appropriate
BONE SCINTIGRAPHY AND LEUKOCYTE SCINTIGRAPHY (LIMITED) (Code BSWBC)
EXAMINATION: BONE
SCINTIGRAPHY AND LEUKOCYTE SCINTIGRAPHY (LIMITED)
DATE STARTED:
________
DATE COMPLETED:
________
RADIOPHARMACEUTICAL:
____ mCi Tc-99m MDP i.v. and ____ µCi In-111 labeled autologous
leukocytes i.v.
HISTORY:
________
FINDINGS: A limited bone scintigraphy examination of the
_______________ was performed, consisting of radionuclide angiography,
immediate post-injection images, and delayed images. After completion of these
initial bone scintigraphy images, In-111 leukocytes were injected. The patient returned the next day, and simultaneous
dual-tracer imaging was performed approximately ___ hours after injection of
In-111 leukocytes and ___ hours after injection of Tc-99m MDP. Images of __________________ were obtained in
the ____________________________ projections.
OPINION:
________
LEUKOCYTE SCINTIGRAPHY AND BONE MARROW SCINTIGRAPHY (LIMITED) (Code
WBCBM)
EXAMINATION:
LEUKOCYTE SCINTIGRAPHY AND BONE MARROW SCINTIGRAPHY (LIMITED)
DATE STARTED:
________
DATE COMPLETED:
________
RADIOPHARMACEUTICAL:
____ µCi In-111 labeled autologous leukocytes i.v. and ____ mCi
millipore-filtered Tc-99m sulfur colloid i.v.
HISTORY:
________
FINDINGS: Simultaneous dual-tracer
imaging was performed approximately ___ hours after injection of In-111
leukocytes and ___ minutes after injection of Tc-99m sulfur colloid. Images of __________________ were obtained in
the ____________________________ projections. The distribution of In-111
leukocytes was compared with that of Tc-99m sulfur colloid, which delineates
the reticuloendothelial function of the bone marrow.
OPINION:
________
GALLIUM SCINTIGRAPHY (Code GAL)
ICD-9 CODE: ________
EXAMINATION:
GALLIUM SCINTIGRAPHY Œ
DATE STARTED:
________
DATE COMPLETED:
________
RADIOPHARMACEUTICAL:
____ mCi Ga-67 citrate, i.v.
HISTORY:
________
FINDINGS:
________
OPINION:
________
Œ Add: “(LIMITED)” if appropriate
PROSTATE TUMOR RADIOIMMUNOSCINTIGRAPHY (Codes PROST and APROST)
ICD-9 CODE: 185
EXAMINATION: PROSTATE TUMOR RADIOIMMUNOSCINTIGRAPHY (WITH
TOMOGRAPHIC IMAGING)
DATE STARTED: __________
DATE COMPLETED: __________
RADIOPHARMACEUTICAL: __________ mCi In-111 capromab pendetide i.v
on __________ and __________ mCi Tc-99m in vitro labeled red cells i.v. on
__________.
HISTORY: __________
FINDINGS: In-111 capromab pendetide (Prostascint) was
administered by slow intravenous infusion.
The patient experienced no adverse effects. Anterior and posterior planar whole-body images
were obtained ______Œ____ days post infusion. SPECT images of the abdomen and of the pelvis
also were obtained following the injection of Tc-99m labeled red cells to allow
for simultaneous assessment of the distribution of the monoclonal antibody and
blood pool activity. The monoclonal
antibody images and blood pool images were fused for viewing. In addition, the SPECT images were fused with
the CT images of the abdomen and pelvis obtained on ___________. ¨
There is expected In--111
capromab pendetide activity in the blood pool, liver, bone marrow, and
gastrointestinal tract. No foci of abnormal In-111 capromab
pendetide are seen.
OPINION: No
evidence for antibody-avid sites of prostatic carcinoma.
ΠInsert the time (in days post infusion) of delayed
imaging.
¨ Delete sentence concerning fusion with CT if
this was not done.
******************************************************************************
ICD-9 Codes
185 Malignant
neoplasm of prostate
ANTI-CEA RADIOIMMUNOSCINTIGRAPHY (Codes CEA and ACEA)
ICD-9 CODE:
EXAMINATION: ANTI-CEA RADIOIMMUNOSCINTIGRAPHY (WITH
TOMOGRAPHIC IMAGING)
DATE STARTED: __________
DATE COMPLETED: __________
RADIOPHARMACEUTICAL: __________ mCi Tc-99m arcitumomab i.v.
HISTORY: __________
FINDINGS: Tc-99m arcitumomab was administered by slow
intravenous injection. The patient
experienced no adverse effects. Planar
images of the whole body, as well as SPECT images of the
Œ were obtained ___¨_______ hours post injection. Additional planar images of the
Œ were obtained at ¨ hours post injection. There is the expected Tc-99m arcitumomab
activity in the blood pool, liver,
kidneys, and gastrointestinal
tract. No foci of abnormal Tc-99m arcitumomab uptake are seen.
OPINION: No
evidence for antibody-avid sites of Ž .
ΠInsert body region(s) imaged.
¨ Insert the time (in hours post injection) of delayed
imaging.
Ž Insert type of tumor.
******************************************************************************
ICD-9 Codes
153.9 Primary
malignant neoplasm of colon, NOS
154.1 Primary
malignant neoplasm of rectum, NOS
193 Primary
malignant neoplasm of thyroid
See detailed listing of ICD-9 codes for tumor and
inflammation imaging for additional codes.
TUMOR FDG-PET IMAGING (Code 870)
[With Foley
Catheter (Code 870F)]
EXAMINATION:
TUMOR FDG-PET IMAGING
DATE OF STUDY:
___________
PET ID NUMBER:
___________
RADIOPHARMACEUTICAL: ____ mCi F-18 Fluorodeoxyglucose i.v.
HISTORY: ___________
FINDINGS: After intravenous administration of F-18
fluorodeoxyglucose (FDG), a series of overlapping emission and transmission PET
images were obtained beginning
approximately ______ minutes after injection of FDG. The patient’s fasting
blood glucose level, measured by glucometer before injection of FDG, was ______
mg/dL. The area imaged spanned the
region from the _______ to the _______.
Before administration of
FDG, intravenous access was established for patient hydration. In addition, a ____-French Foley catheter was
inserted into the urinary bladder using standard aseptic technique. Furosemide, 20 mg, was administered by slow
intravenous injection approximately 20 minutes after the injection of FDG. At the conclusion of the procedure, the
intravenous line and Foley catheter were removed without incident. The patient tolerated the procedure well,
without apparent complications.
Comparison is made
with ________________________.
___________________________________.
OPINION:
_________________.
TUMOR FDG-PET/CT IMAGING (Code 870CT)
[With Foley
Catheter (Code 870CTF)]
EXAMINATION:
TUMOR FDG-PET/CT IMAGING
DATE OF STUDY:
___________
PET ID NUMBER:
___________
RADIOPHARMACEUTICAL: ____ mCi F-18 Fluorodeoxyglucose i.v.
HISTORY: ___________
FINDINGS:
After oral administration of
MD-Gastroview andŒ
intravenous administration of F-18 fluorodeoxyglucose (FDG), noncontrast CT
images were obtained for attenuation correction and for fusion with emission
PET images. [The noncontrast CT images are not of diagnostic quality and are
not used to diagnose disease independently of the PET images.] A series of overlapping emission PET images
was then obtained beginning approximately ______ minutes after
injection of FDG. The patient’s fasting
blood glucose level, measured by glucometer before injection of FDG, was ______
mg/dL. The area imaged spanned the
region from the _______ to the _______.
Before administration of
FDG, intravenous access was established for patient hydration. In addition, a ____-French Foley catheter was
inserted into the urinary bladder using standard aseptic technique. Furosemide, 20 mg, was administered by slow
intravenous injection approximately 20 minutes after the injection of FDG. At the conclusion of the procedure, the
intravenous line and Foley catheter were removed without incident. The patient tolerated the procedure well,
without apparent complications.
Comparison is made
with ________________________.
___________________________________.
OPINION:
_________________.
ΠDelete this phrase if oral contrast agent was not
administered.
C-11 ACETATE PET/CT TUMOR IMAGING (Code ACETATE)
EXAMINATION: C-11 ACETATE TUMOR PET/CT IMAGING
DATE OF STUDY: _________
PET ID NUMBER: _________
RADIOPHARMACEUTICAL: _____
mCi C-11 acetate i.v.
HISTORY: ____________.
FINDINGS: After oral administration of MD-Gastroview
andΠintravenous
administration of C-11 acetate, noncontrast CT images were obtained for
attenuation correction and for fusion with emission PET images. [The noncontrast CT images are not of
diagnostic quality and are not used to diagnose disease independently of the
PET images.] A series of overlapping
emission PET images was then obtained.
The area imaged spanned the region from the ________ to the ________.
___________
OPINION:
ΠDelete this phrase if oral
contrast agent was not administered.