Notice: Undefined index: cmdSubmit in /home/mrispeci/deployment/live/mri-specialists/order/index.php on line 21
MRI Specialists of the Carolinas

MRI Order Form


First Available
Belmont Open Gastonia Open Shelby

 



*For authorizations, please use the following: NPI # 1356324487; Tax ID # 560988142 (Gaston Radiology) Billing Address: 620 Summit Crossing, Ste. 106, Gastonia, NC 28054












Yes No


Yes No
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-9 Codes
Head / Neck: MRI Brain

Name CPT ICD-9
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 0
** MRI Any Joint / Extremity **
MRI OF
Name CPT ICD-9
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.