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Referral Form Patient Name Indication/Symptoms Date Referring Provider ID Signature Provider Phone Provider Fax Circl e Musculoskeletal (MSK) Ultrasound Exam 7688 1 Shoulder with Dynamic Imaging Rotator Cuff Tear Biceps Tendon pathology Shoulder Impingement Tendonitis Bursitis / Effusion 7688 1 Elbow with Dynamic Imaging Epicondylitis “Tennis Elbow” “Golfer’s Elbow” Bursitis / Effusion 76881 Wrist and Hand with Dynamic Imaging Carpal Tunnel Syndrome / Median Nerve Flexor Tendonitis Extensor Tendonitis De Quiverain’s Disease Trigger Digit 7688 1 Hip or Hernia Snapping Hip Syndrome Bursitis / Effusion Inguinal Hernia 7688 1 Knee MCL / LCL Tear Patellar Tendonitis Medial / Lateral Meniscus Tear Baker’s Cysts Bursitis / Effusion 76881 Ankle and Foot Achille’s Tendinopathy Tendon Tears Ligament Tears Plantar Faciitis 76536 Neck – Soft Tissue Ultrasound 76705 Lower Back – Soft Tissue Ultrasound (Spine) 76942 Ultrasound Guided Joint A+ Mobile Ultrasound Services LLC P.O. Box 13012 Seattle, WA 206.799.3301 phone 206.299.1200 fax www.APlusUltrasound.com [email protected] Vascular Ultrasound Exam 9388 0 Carotid Duplex 9392 2 Ankle Brachial Index (ABI) 9392 3 ABI and Toe Brachial Index (TBI) with PPG 9392 5 9392 2 Lower Extremity Arterial Duplex with ABI 9397 0 Lower Extremity Venous Duplex (DVT) 9397 0 Upper Extremity Venous Duplex (DVT) 9397 5 Renal Arterial Duplex 9397 5 Mesenteric Arterial Duplex 9397 8 Aorta/iliac Arterial Duplex Abdominal Ultrasound Exam 7670 0 Complete Abdomen 7677 0 5179 8 Retroperitoneal – Kidneys And Post Void Bladder G038 9 AAA Screening Small Parts Ultrasound Exam 76536 Thyroid 76870 Scrotum 93976 Scrotum with Doppler 76882 Superficial Lesion Comments

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Referral Form Patient Name Indication/Symptoms Date Referring Provider ID Signature Provider Phone Provider Fax. Comments. A+ Mobile Ultrasound Services LLC P.O. Box 13012 Seattle, WA 206.799.3301 phone 206.299.1200 fax www.APlusUltrasound.com [email protected]. - PowerPoint PPT Presentation

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Page 1: Referral Form Patient Name Indication/Symptoms Date Referring Provider ID Signature

Referral Form

Patient Name Indication/Symptoms Date Referring Provider

ID Signature

Provider Phone Provider Fax Circle Musculoskeletal (MSK) Ultrasound Exam

76881

Shoulder with Dynamic Imaging Rotator Cuff Tear Biceps Tendon pathology Shoulder Impingement Tendonitis Bursitis / Effusion

76881

Elbow with Dynamic Imaging Epicondylitis “Tennis Elbow” “Golfer’s Elbow” Bursitis / Effusion

76881

Wrist and Hand with Dynamic Imaging Carpal Tunnel Syndrome / Median Nerve Flexor Tendonitis Extensor Tendonitis De Quiverain’s Disease Trigger Digit

76881

Hip or Hernia Snapping Hip Syndrome Bursitis / Effusion Inguinal Hernia

76881

Knee MCL / LCL Tear Patellar Tendonitis Medial / Lateral Meniscus Tear Baker’s Cysts Bursitis / Effusion

76881

Ankle and Foot Achille’s Tendinopathy Tendon Tears Ligament Tears Plantar Faciitis

76536 Neck – Soft Tissue Ultrasound

76705 Lower Back – Soft Tissue Ultrasound (Spine)

76942 Ultrasound Guided Joint Injection or Aspiration

A+ Mobile Ultrasound Services LLC P.O. Box 13012

Seattle, WA 206.799.3301 phone

206.299.1200 faxwww.APlusUltrasound.com

[email protected]

Vascular Ultrasound Exam

93880 Carotid Duplex

93922 Ankle Brachial Index (ABI)

93923 ABI and Toe Brachial Index (TBI) with PPG

93925 93922

Lower Extremity Arterial Duplex with ABI

93970 Lower Extremity Venous Duplex (DVT)

93970 Upper Extremity Venous Duplex (DVT)93975 Renal Arterial Duplex93975 Mesenteric Arterial Duplex93978 Aorta/iliac Arterial Duplex Abdominal Ultrasound Exam

76700 Complete Abdomen7677051798

Retroperitoneal – KidneysAnd Post Void Bladder

G0389 AAA Screening

Small Parts Ultrasound Exam

76536 Thyroid

76870 Scrotum

93976 Scrotum with Doppler

76882 Superficial Lesion

Comments

http://www.aplusultrasound.com/
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