Request Phoenix Print Blank Form Please provide necessary information to perform exam. Additional documents can be faxed to 602.787.9729 Patient Information * Facility Name / Room # Date of Service ... SLF? ALF? IL / APT / Mobile Home? * Patient Full Name * Date of Birth ... * Sex SELECT PATIENT SEX MALE FEMALE * Physical Address * Patient Phone Number Patient Social Security # Guarantor / Guardian / Responsible Party Information Full Name Contact Phone # Hospice Carrier Hospice Covered Patient Insurance Information Primary Insurance Program Primary Insurance # Secondary Insurance Program Secondary Insurance # Clinical Information * Portable Exam Requested PLEASE SELECT AN EXAM Abdomen & Chest - 74022 Abdomen, 2 view - 74019 Abdomen, 3 view - 74021 Abdomen, single view - 74018 ANKLE, AP & LAT (L) - 73560 ANKLE, AP & LAT (R) - 73560 ANKLE, COMPLETE (L) - 73610 ANKLE, COMPLETE (R) - 73610 BLE, ARTERIAL - 93925 BLE, VENOUS - 93970 BUE, ARTERIAL - 93925 BUE, VENOUS - 93970 Chest, 2 view - 71046 Chest, 3 view - 71047 Chest, 4 view - 71048 CHEST, SINGLE VIEW - 71045 CLAVICLE, COMPLETE - 73000 DUP SCAN/AORTAL/INF VENA CAV LILIAC VASCULATURE OR BYPASS GRAFTS COMPLETE - 93978 DUP SCAN/AORTAL/INF VENA CAV LILIAC VASCULATURE OR BYPASS GRAFTS LIMITED - 93979 DUP SCAN/ARTERIAL INFLOW & OUTFLOW OF ABDOMINAL, PELVIS & RETROPERITONEAL (RENAL) ORGANS, COMPLETE - 93975 DUP SCAN/EXTRACRANIAL ARTERY COMPLETE BILATERAL STUDY - 93880 DUP SCAN/EXTRACRANIAL ARTERY FOLLOW UP OR LIMITED STUDY - 93882 ECHO EXTREMITY, NON-VASCULAR - 76881 ECHO, ABDOMINAL COMPLETE - 76700 ECHO, ABDOMINAL LIMITED - 76705 ECHO, BRACHIAL ARTERY BILATERAL - 93923 ECHO, BRACHIAL ARTERY UNILATERAL - 93922 ECHO, BREAST COMPLETE - 76641 ECHO, BREAST COMPLETE - 76642 ECHO, PALVIA (NON OB) - 76856 ECHO, RETROPERITONEAL (RENAL) COMPLETE - 76770 ECHO, RETROPERITONEAL (RENAL) LIMITED - 76775 ECHO, SCROTUM & CONCEPTS - 76870 ECHO, SOFT TISSUE, HEAD/NECK THYROID - 76536 ECHOCARDIOGRAM - 93306 Echography - 76881 EKG/ECG - 93000 ELBOW, 4AP & LAT (L) - 73070 ELBOW, 4AP & LAT (R) - 73070 ELBOW, COMPLETE (L) - 73080 ELBOW, COMPLETE (R) - 73080 FACIAL BONES, COMPLETE - 70150 FACIAL BONES, LIMITED - 70140 FEMUR (L) - 73552 FEMUR (R) - 73552 FINGER/FINGERS (L) - 73140 FINGER/FINGERS (R) - 73140 FOOT, AP & LAT (L) - 73620 FOOT, AP & LAT (R) - 73620 FOOT, COMPLETE (L) - 73630 FOOT, COMPLETE (R) - 73630 FOREARM, AP & LAT (L) - 73090 FOREARM, AP & LAT (R) - 73090 HAND, AP & LAT (L) - 73120 HAND, AP & LAT (R) - 73120 HAND, COMPLETE (L) - 73130 HAND, COMPLETE (R) - 73130 HEEL CALCANEUS (L) - 73650 HEEL CALCANEUS (R) - 73650 HIP, UNILATERAL COMPLETE (L) - 73502 HIP, UNILATERAL COMPLETE (R) - 73502 Hips, bilateral - 73522 HUMERUS (L) - 73060 HUMERUS (R) - 73060 KNEE, 3 VIEW (L) - 73562 KNEE, 3 VIEW (R) - 73562 KNEE, AP & LAT (L) - 73560 KNEE, AP & LAT (R) - 73560 KNEE, COMPLETE (L) - 73564 KNEE, COMPLETE (R) - 73564 KNEES, BILATERAL STANDING (L) - 73565 KNEES, BILATERAL STANDING (R) - 73565 LLE, ARTERIAL - 93926 LLE, VENOUS - 93971 LUE, ARTERIAL - 93926 LUE, VENOUS - 93971 MANDIBLE, COMPLETE - 70110 MANDIBLE, LIMITED - 70100 NASAL BONES, COMPLETE - 70160 ORBITS, COMPETE - 70200 PELVIS, 3 VIEW - 72190 PELVIS, AP ONLY - 72170 PELVIS, LIMITED (BLADDER) - 76857 RLE, ARTERIAL - 93926 RLE, VENOUS - 93971 RUE, ARTERIAL - 93926 RUE, VENOUS - 93971 SACRUM & COCCYX - 72220 SCAPULA (L) - 73010 SCAPULA (R) - 73010 SHOULDER, COMPLETE (L) - 73030 SHOULDER, COMPLETE (R) - 73030 SHOULDER, PARTIAL (L) - 73020 SHOULDER, PARTIAL (R) - 73020 SI JOINTS, COMPLETE - 72202 SINUSES, COMPLETE - 70220 SINUSES, LIMITED - 70210 SKULL, COMPLETE - 70260 SKULL, LIMITED - 70250 SPINE, CERVICAL 4 OR 5 VIEW - 72050 SPINE, CERVICAL AP & LAT - 72040 SPINE, LUMBAR AP & LAT - 72100 SPINE, THORACIC AP & LAT - 72070 TIBIA/FIBULA (L) - 73590 TIBIA/FIBULA (R) - 73590 TMJ, BILATERAL - 70330 TMJ, UNILATERAL - 70320 TOES (L) - 73660 TOES (R) - 73660 Visceral Vascular, Aorta, complete - 93987 Visceral Vascular, Aorta, limited - 93987 WRIST, AP & LAT (L) - 73100 WRIST, AP & LAT (R) - 73100 WRIST, COMPLETE (L) - 73110 WRIST, COMPLETE (R) - 73110 * How Many Views * ICD-10 Code PLEASE SELECT AN ICD-10 CODE +PPD - R76.11 AAA W/O RUPTURE - I71.4 ABN CHEST SOUNDS - R09.89 ACUTE PULMONARY EDEMA - J81.0 ACUTE RESPIRATORY DISTRESS SYNDROME - J80 AFIB - I48.91 ANKLE PAIN (LEFT) - M25.572 ANKLE PAIN (RIGHT) - M25.571 BRADYCARDIA (UNSPECIFIED) - R001 BREAST LUMP - N63 CAD - I25.10 CARDIAC MURMUR - R01.1 CAROTID BRUIT - R09.89 CHEST PAIN - R07.9 CHF - I50.9 CONGESTION - R06.89 CONSTIPATION (UNSPECIFIED) - K59.00 COPD - J44.1 COUGH - R05 COUGH W/ HEMORRAGE - R04.89 DDD C SPINE - M50.30 DDD L SPINE - M51.36 DDD T SPINE - M51.34 DIZZINESS / GIDDINESS - R42 DVT (LEFT LOWER EXTREMITY) - I82.402 DVT (LEFT UPPER EXTREMITY) - I82.622 DVT (RIGHT LOWER EXTREMITY) - I82.401 DVT (RIGHT UPPER EXTREMITY) - I82.621 DYSPNEA - R06.09 EDEMA (GENERALIZED) - R60.1 EDEMA (LOCALIZED) - R60.0 ELBOW (LEFT) - M25.522 ELBOW (RIGHT) - M25.521 ENCOUNTER FOR OBSERVATION FOR OTHER SUSPECTED DISEASES AND CONDITIONS RULED OUT - Z03.89 ESSENTIAL HYPERTENSION (PRIMARY) - I10 FECAL IMPACTION - K56.49 FEMALE GENITAL SYMPTOMS - N94.89 FEVER - R50.9 FINGER PAIN (LEFT) - M79.645 FINGER PAIN (RIGHT) - M79.644 FOOT PAIN (LEFT) - M79.672 FOOT PAIN (RIGHT) - M79.671 FOREARM (LEFT) - M79.632 FOREARM (RIGHT) - M79.631 GASTROSTOMY ATTENTION ENCOUNTER - Z43.1 GASTROSTOMY STATUS - Z93.1 GOITER - E04.2 HAND (LEFT) - M79.642 HAND (RIGHT) - M79.641 HIP PAIN (LEFT) - M25.552 HIP PAIN (RIGHT) - M25.551 KIDNEY CALCUNI - N20.0 KNEE PAIN (LEFT) - M25.562 KNEE PAIN (RIGHT) - M25.561 L SPINE - M54.5 NAUSEA - R11.0 NAUSEA W/ VOMITING - R11.2 OTHER ABNORMALITIES OF HEART RATE - R00.8 OTHER CONSTIPATION - K59.09 OTHER NONSPECIFIC FINDINGS OF THE LUNG - R91.8 PAIN ABDOMINAL (EPIGASTRIC) - R10.13 PAIN ABDOMINAL (GENERAL) - R10.84 PAIN ABDOMINAL (LEFT LOWER QUADRANT) - R10.32 PAIN ABDOMINAL (LEFT UPPER QUADRANT) - R10.12 PAIN ABDOMINAL (RIGHT LOWER QUADRANT) - R10.31 PAIN ABDOMINAL (RIGHT UPPER QUADRANT) - R10.11 PAIN C SPINE - M54.2 PAIN IN LIMB (LEFT LOWER EXTREMITY) - M79.605 PAIN IN LIMB (LEFT UPPER EXTREMITY) - M79.602 PAIN IN LIMB (RIGHT LOWER EXTREMITY) - M79.604 PAIN IN LIMB (RIGHT UPPER EXTREMITY) - M79.601 PICC LINE - Z45.09 PNUEMONIA (SPECIFIED ORGANISM) - J16.8 PNUEMONIA (UNSPECIFIED ORGANISM) - J18.9 PPD (OTHER SPECIFIED PERIPHERAL VASCULAR DISEASE) - I73.89 PPD (UNSPECIFIED) - I73.9 PRECORDIAL PAIN - R07.2 PULMONARY FIBROSIS - J84.10 PULMONARY NODULE - R91.1 RESPIRATORY FAILURE - J96.00 RESPIRATORY FAILURE (CHRONIC) - J96.90 SHOULDER PAIN (LEFT) - M25.512 SHOULDER PAIN (RIGHT) - M25.511 SOB - R06.02 SOFT TISSUE NECK LUMP - R22.1 STENOSIS CAROTID ARTERY - I65.29 SWELLING LIMB (BILATERAL LOWER EXTREMITY) - R22.43 SWELLING LIMB (BILATERAL UPPER EXTREMITY) - R22.33 SWELLING LIMB (LEFT LOWER EXTREMITY) - R22.42 SWELLING LIMB (LEFT UPPER EXTREMITY) - R22.32 SWELLING LIMB (RIGHT LOWER EXTREMITY) - R22.41 SWELLING LIMB (RIGHT UPPER EXTREMITY) - R22.31 SWELLING MASS LUMP (CHEST) - R22.9 SWELLING MASS LUMP (TRUNK) - R22.2 T SPINE - M54.6 TACHYCARDIA - R00.0 TB - A15.0 THIGH PAIN (LEFT) - M79.652 THIGH PAIN (RIGHT) - M79.651 THYROID NODULE - E04.1 TOES (LEFT) - M79.675 TOES (RIGHT) - M79.674 VASCULAR ACCESS DEVICE ADJUSTMENT/MANAGEMENT ENCOUNTER - Z45.2 VOMITING - R11.10 VOMITING (PROJECTILE) - R11.12 VOMITING W/O NAUSEA - R11.11 WHEEZING - R06.2 Portable Exam Requested #2 PLEASE SELECT AN EXAM Abdomen & Chest - 74022 Abdomen, 2 view - 74019 Abdomen, 3 view - 74021 Abdomen, single view - 74018 ANKLE, AP & LAT (L) - 73560 ANKLE, AP & LAT (R) - 73560 ANKLE, COMPLETE (L) - 73610 ANKLE, COMPLETE (R) - 73610 BLE, ARTERIAL - 93925 BLE, VENOUS - 93970 BUE, ARTERIAL - 93925 BUE, VENOUS - 93970 Chest, 2 view - 71046 Chest, 3 view - 71047 Chest, 4 view - 71048 CHEST, SINGLE VIEW - 71045 CLAVICLE, COMPLETE - 73000 DUP SCAN/AORTAL/INF VENA CAV LILIAC VASCULATURE OR BYPASS GRAFTS COMPLETE - 93978 DUP SCAN/AORTAL/INF VENA CAV LILIAC VASCULATURE OR BYPASS GRAFTS LIMITED - 93979 DUP SCAN/ARTERIAL INFLOW & OUTFLOW OF ABDOMINAL, PELVIS & RETROPERITONEAL (RENAL) ORGANS, COMPLETE - 93975 DUP SCAN/EXTRACRANIAL ARTERY COMPLETE BILATERAL STUDY - 93880 DUP SCAN/EXTRACRANIAL ARTERY FOLLOW UP OR LIMITED STUDY - 93882 ECHO EXTREMITY, NON-VASCULAR - 76881 ECHO, ABDOMINAL COMPLETE - 76700 ECHO, ABDOMINAL LIMITED - 76705 ECHO, BRACHIAL ARTERY BILATERAL - 93923 ECHO, BRACHIAL ARTERY UNILATERAL - 93922 ECHO, BREAST COMPLETE - 76641 ECHO, BREAST COMPLETE - 76642 ECHO, PALVIA (NON OB) - 76856 ECHO, RETROPERITONEAL (RENAL) COMPLETE - 76770 ECHO, RETROPERITONEAL (RENAL) LIMITED - 76775 ECHO, SCROTUM & CONCEPTS - 76870 ECHO, SOFT TISSUE, HEAD/NECK THYROID - 76536 ECHOCARDIOGRAM - 93306 Echography - 76881 EKG/ECG - 93000 ELBOW, 4AP & LAT (L) - 73070 ELBOW, 4AP & LAT (R) - 73070 ELBOW, COMPLETE (L) - 73080 ELBOW, COMPLETE (R) - 73080 FACIAL BONES, COMPLETE - 70150 FACIAL BONES, LIMITED - 70140 FEMUR (L) - 73552 FEMUR (R) - 73552 FINGER/FINGERS (L) - 73140 FINGER/FINGERS (R) - 73140 FOOT, AP & LAT (L) - 73620 FOOT, AP & LAT (R) - 73620 FOOT, COMPLETE (L) - 73630 FOOT, COMPLETE (R) - 73630 FOREARM, AP & LAT (L) - 73090 FOREARM, AP & LAT (R) - 73090 HAND, AP & LAT (L) - 73120 HAND, AP & LAT (R) - 73120 HAND, COMPLETE (L) - 73130 HAND, COMPLETE (R) - 73130 HEEL CALCANEUS (L) - 73650 HEEL CALCANEUS (R) - 73650 HIP, UNILATERAL COMPLETE (L) - 73502 HIP, UNILATERAL COMPLETE (R) - 73502 Hips, bilateral - 73522 HUMERUS (L) - 73060 HUMERUS (R) - 73060 KNEE, 3 VIEW (L) - 73562 KNEE, 3 VIEW (R) - 73562 KNEE, AP & LAT (L) - 73560 KNEE, AP & LAT (R) - 73560 KNEE, COMPLETE (L) - 73564 KNEE, COMPLETE (R) - 73564 KNEES, BILATERAL STANDING (L) - 73565 KNEES, BILATERAL STANDING (R) - 73565 LLE, ARTERIAL - 93926 LLE, VENOUS - 93971 LUE, ARTERIAL - 93926 LUE, VENOUS - 93971 MANDIBLE, COMPLETE - 70110 MANDIBLE, LIMITED - 70100 NASAL BONES, COMPLETE - 70160 ORBITS, COMPETE - 70200 PELVIS, 3 VIEW - 72190 PELVIS, AP ONLY - 72170 PELVIS, LIMITED (BLADDER) - 76857 RLE, ARTERIAL - 93926 RLE, VENOUS - 93971 RUE, ARTERIAL - 93926 RUE, VENOUS - 93971 SACRUM & COCCYX - 72220 SCAPULA (L) - 73010 SCAPULA (R) - 73010 SHOULDER, COMPLETE (L) - 73030 SHOULDER, COMPLETE (R) - 73030 SHOULDER, PARTIAL (L) - 73020 SHOULDER, PARTIAL (R) - 73020 SI JOINTS, COMPLETE - 72202 SINUSES, COMPLETE - 70220 SINUSES, LIMITED - 70210 SKULL, COMPLETE - 70260 SKULL, LIMITED - 70250 SPINE, CERVICAL 4 OR 5 VIEW - 72050 SPINE, CERVICAL AP & LAT - 72040 SPINE, LUMBAR AP & LAT - 72100 SPINE, THORACIC AP & LAT - 72070 TIBIA/FIBULA (L) - 73590 TIBIA/FIBULA (R) - 73590 TMJ, BILATERAL - 70330 TMJ, UNILATERAL - 70320 TOES (L) - 73660 TOES (R) - 73660 Visceral Vascular, Aorta, complete - 93987 Visceral Vascular, Aorta, limited - 93987 WRIST, AP & LAT (L) - 73100 WRIST, AP & LAT (R) - 73100 WRIST, COMPLETE (L) - 73110 WRIST, COMPLETE (R) - 73110 How Many Views ICD-10 Code PLEASE SELECT AN ICD-10 CODE +PPD - R76.11 AAA W/O RUPTURE - I71.4 ABN CHEST SOUNDS - R09.89 ACUTE PULMONARY EDEMA - J81.0 ACUTE RESPIRATORY DISTRESS SYNDROME - J80 AFIB - I48.91 ANKLE PAIN (LEFT) - M25.572 ANKLE PAIN (RIGHT) - M25.571 BRADYCARDIA (UNSPECIFIED) - R001 BREAST LUMP - N63 CAD - I25.10 CARDIAC MURMUR - R01.1 CAROTID BRUIT - R09.89 CHEST PAIN - R07.9 CHF - I50.9 CONGESTION - R06.89 CONSTIPATION (UNSPECIFIED) - K59.00 COPD - J44.1 COUGH - R05 COUGH W/ HEMORRAGE - R04.89 DDD C SPINE - M50.30 DDD L SPINE - M51.36 DDD T SPINE - M51.34 DIZZINESS / GIDDINESS - R42 DVT (LEFT LOWER EXTREMITY) - I82.402 DVT (LEFT UPPER EXTREMITY) - I82.622 DVT (RIGHT LOWER EXTREMITY) - I82.401 DVT (RIGHT UPPER EXTREMITY) - I82.621 DYSPNEA - R06.09 EDEMA (GENERALIZED) - R60.1 EDEMA (LOCALIZED) - R60.0 ELBOW (LEFT) - M25.522 ELBOW (RIGHT) - M25.521 ENCOUNTER FOR OBSERVATION FOR OTHER SUSPECTED DISEASES AND CONDITIONS RULED OUT - Z03.89 ESSENTIAL HYPERTENSION (PRIMARY) - I10 FECAL IMPACTION - K56.49 FEMALE GENITAL SYMPTOMS - N94.89 FEVER - R50.9 FINGER PAIN (LEFT) - M79.645 FINGER PAIN (RIGHT) - M79.644 FOOT PAIN (LEFT) - M79.672 FOOT PAIN (RIGHT) - M79.671 FOREARM (LEFT) - M79.632 FOREARM (RIGHT) - M79.631 GASTROSTOMY ATTENTION ENCOUNTER - Z43.1 GASTROSTOMY STATUS - Z93.1 GOITER - E04.2 HAND (LEFT) - M79.642 HAND (RIGHT) - M79.641 HIP PAIN (LEFT) - M25.552 HIP PAIN (RIGHT) - M25.551 KIDNEY CALCUNI - N20.0 KNEE PAIN (LEFT) - M25.562 KNEE PAIN (RIGHT) - M25.561 L SPINE - M54.5 NAUSEA - R11.0 NAUSEA W/ VOMITING - R11.2 OTHER ABNORMALITIES OF HEART RATE - R00.8 OTHER CONSTIPATION - K59.09 OTHER NONSPECIFIC FINDINGS OF THE LUNG - R91.8 PAIN ABDOMINAL (EPIGASTRIC) - R10.13 PAIN ABDOMINAL (GENERAL) - R10.84 PAIN ABDOMINAL (LEFT LOWER QUADRANT) - R10.32 PAIN ABDOMINAL (LEFT UPPER QUADRANT) - R10.12 PAIN ABDOMINAL (RIGHT LOWER QUADRANT) - R10.31 PAIN ABDOMINAL (RIGHT UPPER QUADRANT) - R10.11 PAIN C SPINE - M54.2 PAIN IN LIMB (LEFT LOWER EXTREMITY) - M79.605 PAIN IN LIMB (LEFT UPPER EXTREMITY) - M79.602 PAIN IN LIMB (RIGHT LOWER EXTREMITY) - M79.604 PAIN IN LIMB (RIGHT UPPER EXTREMITY) - M79.601 PICC LINE - Z45.09 PNUEMONIA (SPECIFIED ORGANISM) - J16.8 PNUEMONIA (UNSPECIFIED ORGANISM) - J18.9 PPD (OTHER SPECIFIED PERIPHERAL VASCULAR DISEASE) - I73.89 PPD (UNSPECIFIED) - I73.9 PRECORDIAL PAIN - R07.2 PULMONARY FIBROSIS - J84.10 PULMONARY NODULE - R91.1 RESPIRATORY FAILURE - J96.00 RESPIRATORY FAILURE (CHRONIC) - J96.90 SHOULDER PAIN (LEFT) - M25.512 SHOULDER PAIN (RIGHT) - M25.511 SOB - R06.02 SOFT TISSUE NECK LUMP - R22.1 STENOSIS CAROTID ARTERY - I65.29 SWELLING LIMB (BILATERAL LOWER EXTREMITY) - R22.43 SWELLING LIMB (BILATERAL UPPER EXTREMITY) - R22.33 SWELLING LIMB (LEFT LOWER EXTREMITY) - R22.42 SWELLING LIMB (LEFT UPPER EXTREMITY) - R22.32 SWELLING LIMB (RIGHT LOWER EXTREMITY) - R22.41 SWELLING LIMB (RIGHT UPPER EXTREMITY) - R22.31 SWELLING MASS LUMP (CHEST) - R22.9 SWELLING MASS LUMP (TRUNK) - R22.2 T SPINE - M54.6 TACHYCARDIA - R00.0 TB - A15.0 THIGH PAIN (LEFT) - M79.652 THIGH PAIN (RIGHT) - M79.651 THYROID NODULE - E04.1 TOES (LEFT) - M79.675 TOES (RIGHT) - M79.674 VASCULAR ACCESS DEVICE ADJUSTMENT/MANAGEMENT ENCOUNTER - Z45.2 VOMITING - R11.10 VOMITING (PROJECTILE) - R11.12 VOMITING W/O NAUSEA - R11.11 WHEEZING - R06.2 Portable Exam Requested #3 PLEASE SELECT AN EXAM Abdomen & Chest - 74022 Abdomen, 2 view - 74019 Abdomen, 3 view - 74021 Abdomen, single view - 74018 ANKLE, AP & LAT (L) - 73560 ANKLE, AP & LAT (R) - 73560 ANKLE, COMPLETE (L) - 73610 ANKLE, COMPLETE (R) - 73610 BLE, ARTERIAL - 93925 BLE, VENOUS - 93970 BUE, ARTERIAL - 93925 BUE, VENOUS - 93970 Chest, 2 view - 71046 Chest, 3 view - 71047 Chest, 4 view - 71048 CHEST, SINGLE VIEW - 71045 CLAVICLE, COMPLETE - 73000 DUP SCAN/AORTAL/INF VENA CAV LILIAC VASCULATURE OR BYPASS GRAFTS COMPLETE - 93978 DUP SCAN/AORTAL/INF VENA CAV LILIAC VASCULATURE OR BYPASS GRAFTS LIMITED - 93979 DUP SCAN/ARTERIAL INFLOW & OUTFLOW OF ABDOMINAL, PELVIS & RETROPERITONEAL (RENAL) ORGANS, COMPLETE - 93975 DUP SCAN/EXTRACRANIAL ARTERY COMPLETE BILATERAL STUDY - 93880 DUP SCAN/EXTRACRANIAL ARTERY FOLLOW UP OR LIMITED STUDY - 93882 ECHO EXTREMITY, NON-VASCULAR - 76881 ECHO, ABDOMINAL COMPLETE - 76700 ECHO, ABDOMINAL LIMITED - 76705 ECHO, BRACHIAL ARTERY BILATERAL - 93923 ECHO, BRACHIAL ARTERY UNILATERAL - 93922 ECHO, BREAST COMPLETE - 76641 ECHO, BREAST COMPLETE - 76642 ECHO, PALVIA (NON OB) - 76856 ECHO, RETROPERITONEAL (RENAL) COMPLETE - 76770 ECHO, RETROPERITONEAL (RENAL) LIMITED - 76775 ECHO, SCROTUM & CONCEPTS - 76870 ECHO, SOFT TISSUE, HEAD/NECK THYROID - 76536 ECHOCARDIOGRAM - 93306 Echography - 76881 EKG/ECG - 93000 ELBOW, 4AP & LAT (L) - 73070 ELBOW, 4AP & LAT (R) - 73070 ELBOW, COMPLETE (L) - 73080 ELBOW, COMPLETE (R) - 73080 FACIAL BONES, COMPLETE - 70150 FACIAL BONES, LIMITED - 70140 FEMUR (L) - 73552 FEMUR (R) - 73552 FINGER/FINGERS (L) - 73140 FINGER/FINGERS (R) - 73140 FOOT, AP & LAT (L) - 73620 FOOT, AP & LAT (R) - 73620 FOOT, COMPLETE (L) - 73630 FOOT, COMPLETE (R) - 73630 FOREARM, AP & LAT (L) - 73090 FOREARM, AP & LAT (R) - 73090 HAND, AP & LAT (L) - 73120 HAND, AP & LAT (R) - 73120 HAND, COMPLETE (L) - 73130 HAND, COMPLETE (R) - 73130 HEEL CALCANEUS (L) - 73650 HEEL CALCANEUS (R) - 73650 HIP, UNILATERAL COMPLETE (L) - 73502 HIP, UNILATERAL COMPLETE (R) - 73502 Hips, bilateral - 73522 HUMERUS (L) - 73060 HUMERUS (R) - 73060 KNEE, 3 VIEW (L) - 73562 KNEE, 3 VIEW (R) - 73562 KNEE, AP & LAT (L) - 73560 KNEE, AP & LAT (R) - 73560 KNEE, COMPLETE (L) - 73564 KNEE, COMPLETE (R) - 73564 KNEES, BILATERAL STANDING (L) - 73565 KNEES, BILATERAL STANDING (R) - 73565 LLE, ARTERIAL - 93926 LLE, VENOUS - 93971 LUE, ARTERIAL - 93926 LUE, VENOUS - 93971 MANDIBLE, COMPLETE - 70110 MANDIBLE, LIMITED - 70100 NASAL BONES, COMPLETE - 70160 ORBITS, COMPETE - 70200 PELVIS, 3 VIEW - 72190 PELVIS, AP ONLY - 72170 PELVIS, LIMITED (BLADDER) - 76857 RLE, ARTERIAL - 93926 RLE, VENOUS - 93971 RUE, ARTERIAL - 93926 RUE, VENOUS - 93971 SACRUM & COCCYX - 72220 SCAPULA (L) - 73010 SCAPULA (R) - 73010 SHOULDER, COMPLETE (L) - 73030 SHOULDER, COMPLETE (R) - 73030 SHOULDER, PARTIAL (L) - 73020 SHOULDER, PARTIAL (R) - 73020 SI JOINTS, COMPLETE - 72202 SINUSES, COMPLETE - 70220 SINUSES, LIMITED - 70210 SKULL, COMPLETE - 70260 SKULL, LIMITED - 70250 SPINE, CERVICAL 4 OR 5 VIEW - 72050 SPINE, CERVICAL AP & LAT - 72040 SPINE, LUMBAR AP & LAT - 72100 SPINE, THORACIC AP & LAT - 72070 TIBIA/FIBULA (L) - 73590 TIBIA/FIBULA (R) - 73590 TMJ, BILATERAL - 70330 TMJ, UNILATERAL - 70320 TOES (L) - 73660 TOES (R) - 73660 Visceral Vascular, Aorta, complete - 93987 Visceral Vascular, Aorta, limited - 93987 WRIST, AP & LAT (L) - 73100 WRIST, AP & LAT (R) - 73100 WRIST, COMPLETE (L) - 73110 WRIST, COMPLETE (R) - 73110 How Many Views ICD-10Code PLEASE SELECT AN ICD-10 CODE +PPD - R76.11 AAA W/O RUPTURE - I71.4 ABN CHEST SOUNDS - R09.89 ACUTE PULMONARY EDEMA - J81.0 ACUTE RESPIRATORY DISTRESS SYNDROME - J80 AFIB - I48.91 ANKLE PAIN (LEFT) - M25.572 ANKLE PAIN (RIGHT) - M25.571 BRADYCARDIA (UNSPECIFIED) - R001 BREAST LUMP - N63 CAD - I25.10 CARDIAC MURMUR - R01.1 CAROTID BRUIT - R09.89 CHEST PAIN - R07.9 CHF - I50.9 CONGESTION - R06.89 CONSTIPATION (UNSPECIFIED) - K59.00 COPD - J44.1 COUGH - R05 COUGH W/ HEMORRAGE - R04.89 DDD C SPINE - M50.30 DDD L SPINE - M51.36 DDD T SPINE - M51.34 DIZZINESS / GIDDINESS - R42 DVT (LEFT LOWER EXTREMITY) - I82.402 DVT (LEFT UPPER EXTREMITY) - I82.622 DVT (RIGHT LOWER EXTREMITY) - I82.401 DVT (RIGHT UPPER EXTREMITY) - I82.621 DYSPNEA - R06.09 EDEMA (GENERALIZED) - R60.1 EDEMA (LOCALIZED) - R60.0 ELBOW (LEFT) - M25.522 ELBOW (RIGHT) - M25.521 ENCOUNTER FOR OBSERVATION FOR OTHER SUSPECTED DISEASES AND CONDITIONS RULED OUT - Z03.89 ESSENTIAL HYPERTENSION (PRIMARY) - I10 FECAL IMPACTION - K56.49 FEMALE GENITAL SYMPTOMS - N94.89 FEVER - R50.9 FINGER PAIN (LEFT) - M79.645 FINGER PAIN (RIGHT) - M79.644 FOOT PAIN (LEFT) - M79.672 FOOT PAIN (RIGHT) - M79.671 FOREARM (LEFT) - M79.632 FOREARM (RIGHT) - M79.631 GASTROSTOMY ATTENTION ENCOUNTER - Z43.1 GASTROSTOMY STATUS - Z93.1 GOITER - E04.2 HAND (LEFT) - M79.642 HAND (RIGHT) - M79.641 HIP PAIN (LEFT) - M25.552 HIP PAIN (RIGHT) - M25.551 KIDNEY CALCUNI - N20.0 KNEE PAIN (LEFT) - M25.562 KNEE PAIN (RIGHT) - M25.561 L SPINE - M54.5 NAUSEA - R11.0 NAUSEA W/ VOMITING - R11.2 OTHER ABNORMALITIES OF HEART RATE - R00.8 OTHER CONSTIPATION - K59.09 OTHER NONSPECIFIC FINDINGS OF THE LUNG - R91.8 PAIN ABDOMINAL (EPIGASTRIC) - R10.13 PAIN ABDOMINAL (GENERAL) - R10.84 PAIN ABDOMINAL (LEFT LOWER QUADRANT) - R10.32 PAIN ABDOMINAL (LEFT UPPER QUADRANT) - R10.12 PAIN ABDOMINAL (RIGHT LOWER QUADRANT) - R10.31 PAIN ABDOMINAL (RIGHT UPPER QUADRANT) - R10.11 PAIN C SPINE - M54.2 PAIN IN LIMB (LEFT LOWER EXTREMITY) - M79.605 PAIN IN LIMB (LEFT UPPER EXTREMITY) - M79.602 PAIN IN LIMB (RIGHT LOWER EXTREMITY) - M79.604 PAIN IN LIMB (RIGHT UPPER EXTREMITY) - M79.601 PICC LINE - Z45.09 PNUEMONIA (SPECIFIED ORGANISM) - J16.8 PNUEMONIA (UNSPECIFIED ORGANISM) - J18.9 PPD (OTHER SPECIFIED PERIPHERAL VASCULAR DISEASE) - I73.89 PPD (UNSPECIFIED) - I73.9 PRECORDIAL PAIN - R07.2 PULMONARY FIBROSIS - J84.10 PULMONARY NODULE - R91.1 RESPIRATORY FAILURE - J96.00 RESPIRATORY FAILURE (CHRONIC) - J96.90 SHOULDER PAIN (LEFT) - M25.512 SHOULDER PAIN (RIGHT) - M25.511 SOB - R06.02 SOFT TISSUE NECK LUMP - R22.1 STENOSIS CAROTID ARTERY - I65.29 SWELLING LIMB (BILATERAL LOWER EXTREMITY) - R22.43 SWELLING LIMB (BILATERAL UPPER EXTREMITY) - R22.33 SWELLING LIMB (LEFT LOWER EXTREMITY) - R22.42 SWELLING LIMB (LEFT UPPER EXTREMITY) - R22.32 SWELLING LIMB (RIGHT LOWER EXTREMITY) - R22.41 SWELLING LIMB (RIGHT UPPER EXTREMITY) - R22.31 SWELLING MASS LUMP (CHEST) - R22.9 SWELLING MASS LUMP (TRUNK) - R22.2 T SPINE - M54.6 TACHYCARDIA - R00.0 TB - A15.0 THIGH PAIN (LEFT) - M79.652 THIGH PAIN (RIGHT) - M79.651 THYROID NODULE - E04.1 TOES (LEFT) - M79.675 TOES (RIGHT) - M79.674 VASCULAR ACCESS DEVICE ADJUSTMENT/MANAGEMENT ENCOUNTER - Z45.2 VOMITING - R11.10 VOMITING (PROJECTILE) - R11.12 VOMITING W/O NAUSEA - R11.11 WHEEZING - R06.2 * Completed By * Ordering Physician (electronically signed by) * Fax Results TO Phone Results TO Comments (75 chars left) Attach File STAT Same Day Service Routine (noon tomorrow) * Portable x-ray(s) are required because the patient is unable to travel to a physician's office or other outpatient radiology facility due to the following clinical condition: submit Please turn on javascript to submit your data. 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