Appointment Scheduling
To Pre-Register, call 704-834-2914     Monday-Friday  8:30am-9:00pm
 
Previous studies/films?    Location:
Send  CD/Films with patient (Except mamms)
     Stat Procedure  (MUST BE ORDERED OVER PHONE.  CALL 704-834-2941)
 
PREFERRED LOCATION
 
PATIENT INFORMATION
Patient Name:        
Date of Birth:
 (##/##/####)  
SS#:
 (###-##-####)
Contact #'(s):
 (###-###-####)		       
Preferred Exam Time: 
Ordering Physician(s):    
Diagnosis & Symptoms:
Special Instructions:
Insurance Name:
Insurance Phone:
Insured:  
Insurance ID#:  
Insurance Group #:
Authorization Code (if required): 
 
Patient's Weight:
Patient's Allergies:
***Preparations for studies will be given at time of scheduling***

QUESTIONS?  CALL 704-834-2942(GMH), 704-834-2050(DXC), 704-671-7730(CIS)
 

GENERAL X-RAY            ICD-9 CODES
*No scheduling required
chest
abdomen(kub)
abdomen(flat and erect)
cervical spine
thorasic spine
lumbar spine
ribs
skull
sinuses
extremity
                       
other  
   
MRI   ICD-9 CODES
MRI of (plain film if necessary)
MRA of
*with and without contrast
without contrast
*MR Arthrogram
  Previous surgery on area being scanned?
  History of cancer?
  Metal in body?
  Does patient have pacemaker??
  Is patient claustrophobic?
   
ULTRASOUND ICD-9 CODES
obstetric
thyroid
carotid
abdomen
testicular
pyloric
pelvic (transvag if necessary)
venous extremity
 
venous closure (Summit only)
doppler vascular
renal
aortic
hips
breast
 
other  
   
FLUOROSCOPY ICD-9 CODES
ugi
barium swallow
small bowel study
barium enema
IVP
other  
   
NUCLEAR MEDICINE ICD-9 CODES
bone scan (plain film if necessary)
gastric emptying
lung scan(V-Q) (plain film if necessary)
renal scan
thyroid scan
biliary scan (HIDA)
biliary scan (Kinevac)
P.E.T.
other  
   
C.T. ICD-9 CODES
C.T. of
(IV contrast if indicated) (reconstructions if needed)
Serum Creatinine as indicated below:
with Contrast
without contrast
with & without contrast
biopsy of
drainage of
appendix
urogram
* Patients having a CT abd and/or Pelvis must pick-up oral prep before day of appointment.  (Available at any CaroMont location)
   
SPECIALS ICD-9 CODES
*angiography   

*myelography
with post CT (recons if indicated)

  
lumbar puncture
PICC placement
*fistulagram
biopsy 
other  
   
MAMMOGRAPHY
 (Belmont, GMH & Summit only)		 ICD-9 CODES
Implants?  
screening mammogram
diagnostic mammogram (U/S if indicated)
diagnostic mammogram (Biopsy if Needed)
 
Steriotactic Biopsy
 
Needle Localization
 
Galactograms
other 
   
   
BONE DENSITY
 (Summit only)		 ICD-9 CODES
bone density test
   
LAB
 (DXC or Presurgical Suite only)		 ICD-9 CODES
   
*** Any patient meeting the following criteria should have a serum creatinine and BUN level obtained and available within a 30 day period prior to administration of IV Contrast:
1. History of renal failure;
2. History of renal tumor or transplant;
3. Insulin-dependent diabetes mellitus of 2 years or greater duration;
4. Non insulin-dependent diabetes mellitus of over 5 years duration if on diabetic meds for that time; or
5. Myeloma or other paraprotienemia syndromes.

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