MRI Order Form


First Available
Gastonia Open

 



*For authorizations, please use the following: NPI # 1356324487; Tax ID # 560988142 (Gaston Radiology) Billing Address: 336 Burtonwood Dr, Gastonia, NC 28054










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Note: By signing this field with your full name, you attest that all information in this patient order is accurate.


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Yes No
Yes No
Yes if needed No
Pacemaker Aneurysm Clip Implant Stent Other
Yes No
At least one item in this list is required. View ICD-10 Codes
Head / Neck: MRI Brain

Name CPT ICD-10
MRI - brain w/o 70551
MRI - brain with 70552
MRI - brain w/o & w 70553
MRI - other - IAC / Pituitary / Trigeminal 70553
Head / Neck: MRI Orbit Face & Neck

MRI - TMJ 70336
MRI - orbit, face, neck w/o 70540
MRI - orbit, face, neck with 70542
MRI - orbit, face, and neck w/o & w 70543
Head/Neck: MR Angiography

MRA - head w/o 70544
MRA - neck w/o 70547
MRA - neck with 70548
MRA - neck w/o & w 70549
Spine: MRI Spinal Canal

MRI - C-spine w/o 72141
MRI - C-spine with 72142
MRI - C-spine w/o & w 72156
MRI - L-spine w/o 72148
MRI - L-spine with 72149
MRI - L-spine w/o & w 72158
MRI - T-spine w/o 72146
MRI - T-spine with 72147
MRI - T-spine w/o & w 72157
MRI - sacrum 72195
** MRI Any Joint / Extremity **
MRI OF
Name CPT ICD-10
R L MRI - Arthrogram of 0
R L MRI - upper extremity (OTJ) w/o 73218
R L MRI - upper extremity (OTJ) with 73219
R L MRI - upper extremity (OTJ) w/o & w 73220
R L MRI - upper extremity (joint) w/o 73221
R L MRI - upper extremity (joint) with 73222
R L MRI - upper extremity (joint) w/o & w 73223
R L MRI - upper extremity with or w/o 73225
R L MRI - lower extremity (OTJ) w/o 73718
R L MRI - lower extremity (OTJ) with 73719
R L MRI - lower extremity (OTJ) w/o & w 73720
R L MRI - lower extremity (joint) w/o 73721
R L MRI - lower extremity (joint) with 73722
R L MRI - lower extremity (joint) w/o & w 73723
R L MRA - lower extremity with or w/o 73725
R L MRI - Brachial Plexus 0
Body: Chest
MRI - chest w/o 71550
MRI - chest with 71551
MRI - chest w/o & w 71552
MRA - chest / aorta 71555
Body: Abdomen/Pelvis
MRI - abdomen w/o 74181
MRI - abdomen with 74182
MRI - abdomen w/o & w 74183
MRA Abdomen with or w/o 74185
MRI - pelvis w/o 72195
MRI - pelvis with 72196
MRI - pelvis w/o & w 72197
MRA - pelvis with or w/o 72198
MRI OTHER
MRI - other of 0
Contrast at Radiologist Discretion

Contrast requires a Creatinine for anyone over 60, diabetes, kidney disease, chemotherapy, etc* This can be done onsite prior to start of exam.


** Extremities / Joints with history of infection, abscess, ulcer, cyst or mass usually require w/o & w contrast agent per radiologist.

Federal Necessity: Federal Regulations require that only the tests that are necessary for diagnosis and treatment of a patient’s condition be ordered. The ICD-9 code is required to prove medical necessity.

© 2009 MRI Specialists of the Carolinas. All Rights Reserved.