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Referral Order is attached:Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.The CIS location that is to receive this order:* Advanced Imaging of Lafayette - Lafayette LA Alliance - Clear Lake Alliance - Katy Alliance - Lake Houston Alliance - Lake Jackson Alliance - Montgomery County Alliance - Pearland Alliance - Spring Alliance - Woodforest Alliance - The Woodlands Ascension Open MRI - Gonzales LA Baton Rouge Imaging Center - Baton Rouge LA Bluebonnet Imaging Center - Baton Rouge LA Central Imaging Center - Baton Rouge LA Diagnostic Imaging Services - Covington, LA Highway 21 Diagnostic Imaging Services - Covington, LA Pinnacle Parkway Diagnostic Imaging Services - Marrero, LA Diagnostic Imaging Services - Metairie, LA Houma Boulevard Diagnostic Imaging Services - Metairie, LA Veterans Boulevard Diagnostic Imaging Services - Slidell, LA Diagnostic Imaging Services - Thibodaux, LA Doctors Imaging - Metairie LA Heritage Diagnostic Center - Cullman AL Homosassa Open MRI - Homosassa FL Houston Premier Radiology Center - Houston, TX Imaging Center of Columbus - Columbus MS Imaging Center of Meridian - Meridian MS Louisiana PET/CT Imaging of Lake Charles - Lake Charles LA M.R. Imaging Systems - Alexandria LA Northeast Imaging - Monroe LA Northwest Imaging - Shreveport LA Open Air MRI of CENLA - Alexandria LA Open MRI of Hammond - Hammond LA Open MRI of Mississippi - Flowood MS OPI - Atlanta OPI - Canton OPI - Decatur OPI - Fayetteville OPI - Kennestone OPI - Marietta OPI - Newnan OPI - Peachtree City OPI - Statesboro PARS Imaging - Baytown TX Radiology & Imaging - Alameda - Corpus Christi, TX Radiology & Imaging - South - Corpus Christi, TX River Bend Imaging - Laplace LA Southern Imaging Specialists - Montgomery AL Texarkana PET/CT imaging Institute - Texarkana TX Vestavia Hills Imaging Center - Vestavia Hills AL Patient's Name: First Last Patient's Date of Birth: Month Day Year Patient's Phone:Patient's Cell:Referring Clinician: Referring Clinician Address: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance: Policy Number: Authorization Number: Preferred Date: MM slash DD slash YYYY CPT Code:58340 Cath, HSG62328 CT or Fluoroscopic Guidance - lumbar puncture62329 CT or Fluoroscopic Guidance - drainage70100 X-ray, Mandible (Jaw), Less than 4 Views70110 X-ray, Mandible (Jaw), 4 or More Views70120 X-ray, Mastoids, Less than 3 Views per Side70130 X-ray, Mastoids, 3 or More Views per Side70160 X-ray, Nasal Bones, Minimum 3 Views70190 X-ray, Optic Foramina, Bilateral70200 X-ray, Orbits Bilateral, Minimum 4 Views70210 X-ray, Sinuses, Less than 3 Views70220 X-ray, Sinuses, 3 or More Views70240 X-ray, Sella Turcica (Pituitary)70250 X-ray, Skull, Less than 4 Views70260 X-ray, Skull, 4 or More Views70328 X-ray, TMJ, Open and Closed, Unilateral70330 X-ray, TMJ, Open and Closed, Billateral70336 MRI, TMJ(s)70360 X-ray, Neck, Soft Tissue70370 X-ray, Pharynx or Larynx, Soft Tissue, including Fluoroscopy70450 CT, Head or Brain s/ Contrast70460 CT, Head or Brain c/ Contrast70470 CT, Head or Brain c/s Contrast70480 CT, Orbit, Sella, Post Fossa or Ear s/ Contrast70481 CT, Orbit, Sella, Post Fossa or Ear c/ Contrast70482 CT, Orbit, Sella, Post Fossa or Ear c/s Contrast70486 CT, Maxillofacial Area s/ Contrast70487 CT, Maxillofacial Area c/ Contrast70488 CT, Maxillofacial Area c/s Contrast70490 CT, Soft Tissue Neck s/ Contrast70491 CT, Soft Tissue Neck c/ Contrast70492 CT, Soft Tissue Neck c/s Contrast70496 CT, Angiography Head c/s Contrast70498 CT, Angiography Neck c/s Contrast70540 MRI, Orbit, Face or Neck s/ Contrast70542 MRI, Orbit, Face or Neck c/ Contrast70543 MRI, Orbit, Face or Neck c/s Contrast70544 MRA, Angiography Head s/ Contrast70545 MRA, Angiography Head c/ Contrast70546 MRA, Angiography Head c/s Contrast70547 MRA, Angiography Carotid s/ Contrast70548 MRA, Angiography Neck c/ Contrast70549 MRA, Angiography Carotid c/s Contrast70551 MRI, Brain s/ Contrast70552 MRI, Brain c/ Contrast70553 MRI, Brain c/s Contrast71100 X-ray, Ribs, 2 Views, Unilateral71101 X-ray, Ribs, 2 Views, Unilateral plus PA Chest71110 X-ray, Ribs, 3 Views, Bilateral71111 X-ray, Ribs, 3 Views, Bilateral plus PA Chest71120 X-ray, Sternum, Minimum 2 Views71130 X-ray, SC Joint(s), Minimum 3 Views71250 CT, Thorax (Chest) s/ Contrast71260 CT, Thorax (Chest) c/ Contrast71270 CT, Thorax (Chest) c/s Contrast71275 CT, Angiography Chest c/s Contrast71550 MRI, Chest s/ Contrast71551 MRI, Chest c/ Contrast71552 MRI, Chest c/s Contrast71555 MRA, Angiography Chest c/ or s/ Contrast72020 X-ray, Spine, 1 View, Specify Level72070 X-ray, Thoracic Spine, 2 Views72072 X-ray, Thoracic Spine, 3 Views72074 X-ray, Thoracic Spine, Minimum 4 Views72080 X-ray, Thoracolumbar, 2 Views72081 X-ray, Thoracic, Lumbar, Cervical and Sacral Spine72082 X-ray, Thoracic, Lumbar, Cervical and Sacral Spine, 2 or 3 views72083 X-ray, Thoracic, Lumbar, Cervical and Sacral Spine, 4 or 5 views72084 X-ray, Thoracic, Lumbar, Cervical and Sacral Spine, Minimum 6 views72090 X-ray, Thoracolumbar Supine & Erect, Scoliosis72110 X-ray, Lumbosacral, Minimum 4 Views72114 X-ray, Lumbosacral, Compl c/ Bend, Min 6V72125 CT, Cervical Spine s/ Contrast72126 CT, Cervical Spine c/ Contrast72127 CT, Cervical Spine c/s Contrast72128 CT, Thoracic Spine s/ Contrast72129 CT, Thoracic Spine c/ Contrast72130 CT, Thoracic Spine c/s Contrast72131 CT, Lumbar Spine s/ Contrast72132 CT, Lumbar Spine c/ Contrast72133 CT, Lumbar Spine c/s Contrast72141 MRI, Cervical Spine s/ Contrast72142 MRI, Cervical Spine c/ Contrast72146 MRI, Thoracic Spine s/ Contrast72147 MRI, Thoracic Spine c/ Contrast72148 MRI, Lumbar Spine s/ Contrast72149 MRI, Lumbar Spine c/ Contrast72156 MRI, Cervical Spine c/s Contrast72157 MRI, Thoracic Spine c/s Contrast72158 MRI, Lumbar Spine c/s Contrast72159 MRA, Angiography Spinal Canal c/ or s/ Contrast72170 X-ray, Pelvis, 1 or 2 Views72190 X-ray, Pelvis, Minimum 3 Views72191 CT, Angiography Pelvis c/s Contrast72192 CT, Pelvis s/ Contrast72193 CT, Pelvis c/ Contrast72194 CT, Pelvis c/s Contrast72195 MRI, Pelvis s/ Contrast72196 MRI, Pelvis c/ Contrast72197 MRI, Pelvis c/s Contrast72198 MRA, Angiography Pelvis c/ or s/ Contrast72200 X-ray, SI Joints, Less than 3 Views72202 X-ray, SI Joints, 3 or More Views72220 X-ray, Sacrum & Coccyx, Minimum 2 Views73010 X-ray, Scapula, Complete73020 X-ray, Shoulder, 1 View73030 X-ray, Shoulder, Minimum 2 Views73092 X-ray, Upper Ext, Infant, Minimum 2 Views73100 X-ray, Wrist, 2 Views73110 X-ray, Wrist, Minimum 3 Views73200 CT, Upper Extremity s/ Contrast73201 CT, Upper Extremity c/ Contrast73202 CT, Upper Extremity c/s Contrast73206 CT, Angiography, Upper Ext. c/s Contrast73218 MRI, Upper Ext. Non-Joint s/ Contrast73219 MRI, Upper Ext. Non-Joint c/ Contrast73220 MRI, Upper Ext. Non-Joint c/s Contrast73221 MRI, Upper Ext, Joint s/ Contrast73222 MRI, Upper Ext. Joint c/ Contrast73223 MRI, Upper Ext. Joint c/s Contrast73225 MRA, Angiography Upper Ext. c/ or s/ Contrast73590 X-ray, Tibia and Fibula, 2 Views73660 X-ray, Toe(s), Minimum 2 Views73700 CT, Lower Extremity s/ Contrast73701 CT, Lower Extremity c/ Contrast73702 CT, Lower Extremity c/s Contrast73706 CT, Angiography Lower Ext. c/s Contrast73718 MRI, Lower Ext. Non-Joint s/ Contrast73719 MRI, Lower Ext. Non-Joint c/ Contrast73720 MRI, Lower Ext. Non-Joint c/s Contrast73721 MRI, Lower Ext. Joint s/ Contrast73722 MRI, Lower Ext. Joint c/ Contrast73723 MRI, Lower Ext. Joint c/s Contrast73725 MRA, Angiography, Lower Ext. c/ or s/ Contrast74018 X-ray, Abdomen, 1 view74019 X-ray, Abdomen, 2 views74021 X-ray, Abdomen, 3 or more views74150 CT, Abdomen s/ Contrast74160 CT, Abdomen c/ Contrast74170 CT, Abdomen c/s Contrast74174 CT, Angiography Abd/Pelvis c/s Contrast74175 CT, Angiography, Abdomen c/s Contrast74176 CT, Abd/Pelvis s/Contrast74177 CT, Abd /Pelvis c/Contrast74178 CT, Abd /Pelvis c/s Contrast74181 MRI, Abdomen s/ Contrast74182 MRI, Abdomen c/ Contrast74183 MRI, Abdomen c/s Contrast74185 MRA, Angiography, Abd/Renal c/ or s/ Contrast74410 X-ray, Urography c/ Contrast, Infusion74740 X-ray, Fluoro Hysterosalpingography c/ Contrast75571 CT, Calcium Scoring75635 CT, Angiography Aorta & Bilat Iliofemor run off c/s Contrast76536 US, Soft/T.Head, Neck, B-Scan /or Real Time76604 US, Chest, B-Scan and/or Real Time76641 US, Breast, Unilateral, Complete76642 US, Breast, Unilteral, Limited76700 US, Abdominal Complete, B-Scan and/or Real Time76705 US, Abdominal Limited, Single Organ76770 US, Renal/Aorta Complete B-Scan and/or Real Time76775 US, Retroperitoneal, Limited76776 US, Transplanted Kidney, B-Scan and/or Real Time76800 US, Spinal Canal & Contents76801 US, Pregnant Uterus, Single Gestation, 1st Trimester76802 US, Preg Uterus, 1st Trimester, Each Additional Gestation76805 US, Pregnant Uterus, Single Gestation, after 14 weeks76810 US, Pregnant Uterus, Multiple Gestation, after 14 weeks76811 US, Pregnant Uterus, Fetal Eval, Single Gestation76812 US, Pregnant Uterus, Fetal Detail, Additional Gestation76815 US, Pregnant Uterus, Limited Single Gestation76816 US, Pregnany Uterus, Follow Up or Repeat76817 US, Pregnant Uterus, TV76830 US, Transvaginal76831 US, Hysterosonography76856 US, Pelvic Non OB, B-Scan and or Real Time76857 US, Pelvic Non OB, Follow Up or Repeat (Bladder)76870 US, Scrotum and Contents76881 US, Extrem, Non Vasc, Complete76882 US, Extrem, Non Vasc. Lmtd77046 MRI, Breast Unilateral s/ Contrast77047 MRI, Breast Bilateral s/ Contrast77048 MRI, Breast Unilateral c/s Contrast77049 MRI, Breast Bilateral c/s Contrast77053 Mammogram, Ductogram or Galactogram, Single77054 Mammogram, Ductogram or Galactogram, Multiple77063 Digital Screening Mammogram, Tomosynthesis, Bilateral77065 Digital Diagnostic Mammogram Unilateral77066 Digital Diagnostic Mammogram Bilateral77067 Digital Screening Mammogram77074 X-ray, Osseous Survey, Limited77075 X-Ray, Osseous Survey, Complete77076 X-ray, Osseous Survey, Infant77080 DEXA, Bone Density, 1 Sites, Axial Skeleton77081 DEXA, Appendicular77085 DEXA, Bone Density, Anxial Skeleton, include IVA77086 DEXA, Bone Density, IVA78015 NM, Thyroid CA Mets Imaging, Limited78016 NM, Thyroid CA Mets Imaging, c/ Additional Studies78018 NM, Thyroid CA Mets Imaging, Whole Body78070 NM, Parathyroid Imaging78071 NM, Parathyroid Planar Imaging, SPECT78075 NM, Adrenal Imaging, Cortex and/or Medulla, I-123 MIBG78201 NM, Liver Imaging, Static Only78202 NM, Liver Imaging, c/ Vascular Flow78215 NM, Liver and Spleen, Static Only78216 NM, Liver and Spleen, c/ Vascular Flow78226 NM, Hepatolbiliary Imaging78227 NM, Hepatobiliary Imaging, with Pharm iInter, icl Quant78261 NM, Gastric Mucosa Imaging78262 NM, Gastroesophageal Reflux Study78264 NM, Gastric Emptying Study78278 NM, Acute GI Blood Loss Imaging-Hemangioma78290 NM, Intestine Imaging (Meckels)78300 NM, Bone, Joint Imaging, Limited Area78305 NM, Bone, Joint Imaging, Multiple Areas78306 NM, Bone, Joint Imaging, Whole Body78315 NM, Bone, Joint Imaging, Three Phase78399 NM, Unlisted Musculoskeletal Procedure78700 NM, Kidney Imaging, Static Only78701 NM, Kidney Imaging, c/ Vascular Flow78707 NM, Kidney c/ Flow & Function, s/ Pharm ,Mag 3, Single78708 NM, Kidney c/ Flow & Function, c/ Phar MAG3 c LASIX,single78709 NM, Kidney c/ Flow & Function, c/s Pharm, Mult (Captopril)78725 NM, Kidney Function, Non Imaging78800 NM, Radiopharm Local, Tumor, single area78801 NM, Radiopharm Local, Tumor, two or more areas78802 NM, Radiopharm Local, Tumor, whole body78803 NM, Radiopharm Local, Tumor SPECT single area78804 NM, Radiopharm Local, Tumor, whole body, 2 or more days78811 PET, Limited Area (chest, head/neck)78814 PET/CT, Limited Area (chest, head/neck)78815 PET/CT, Skull Base to Mid Thigh78816 PET/CT, Whole Body93880 US, Duplex, Carotid Arteries, Bilateral93882 US, Duplex, Carotid Arteries, Unilateral93886 US, Doppler, Transcranial Arteries, Complete93888 US, Doppler, Transcranial Arteries, Limited93922 US, Doppler, Up or Low Ext. Artery, Single Level93923 US, Doppler, Up or Low Ext. Artery, Multi Level93925 US, Duplex Lower Ext. Arterial or Bypass, Bilateral93926 US, Duplex Lower Ext. Arterial or Bypass, Unilateral93930 US, Duplex Upper Ext. Arterial or Bypass, Bilateral93931 US, Duplex Upper Ext. Arterial or Bypass, Unilateral93970 US, Duplex,Up or Low Ex.Vein, Comp. Bil.93971 US, Duplex,Up orLow Ext. Vein,Ltd. Unil.93975 US, Duplex, Arterial/Venous Flow, Abdomen/Pelvis, Complete93976 US, Duplex, Arterial/Venous Flow, Abdomen/Pelvis, Limited93978 US, Duplex, Aorta, IVC, Iliac or Bypass, Complete93979 US, Duplex, Aorta, IVC, Iliac or Bypass, Limited or Unilater93980 US, Duplex, Arterial/Venous Flow of Penis, Complete93981 US, Duplex, Arterial/Venous Flow of Penis, Limited or Follow93985 US, Duplex Arterial/Venous Flow Upper Extremity for Preop Hemodialysis Access - Bilateral93986 US, Duplex Arterial/Venous Flow Upper Extremity for Preop Hemodialysis Access - Unilateral93990 US, Duplex Scan of Hemodialysis AccessOther CPT Code: ICD-10 Code:B20 AIDS/symptomatic HIV diseaseE04.1 Goiter, uninodular (nontoxic)E04.2 Goiter, multinodular (nontoxic)G31.84 Mild cognitive impairmentG43.909 Migraine – unspecifiedG45.9 Transient ischemic attackG89.3 Pain, neoplasm-relatedG89.4 Chronic pain syndromeG93.9 Brain lesionH53.8 Blurred visionH54.7 Loss of vision, NOSH90.5 Hearing loss, central NOSH90.5 Hearing loss, perceptive NOSH90.5 Hearing loss, sensory NOSI05.0 Stenosis mitral valveI10 Hypertension NOSI20.0 Angina, unstableI20.9 Angina, not otherwise specifiedI21.3 Acute MI unspecifiedI25.10 Coronary atherosclerosisI26.99 Embolism, pulmonary (acute)I34.0 Nonrheumatic mitral (valve) insufficiencyI34.1 Nonrheumatic mitral (valve) prolapseI34.2 Nonrheumatic mitral (valve) stenosisI34.8 Other nonrheumatic mitral valve disordersI34.9* Nonrheumatic mitral valve disorder, unspecifiedI35.0 Nonrheumatic aortic (valve) stenosisI35.1 Nonrheumatic aortic (valve) insufficiencyI35.2 Nonrheumatic aortic (valve) stenosis with insufficiencyI35.8 Other nonrheumatic aortic valve disordersI35.9* Nonrheumatic aortic valve disorder, unspecifiedI48.91 Atrial Fibrillation NOSI49.01 Ventricular fibrillationI49.02 Ventricular flutterI49.1 Atrial premature depolarizationI49.2 Junctional premature depolarizationI49.3 Ventricular premature depolarizationI49.40 Unspecified premature depolarizationI49.49 Other premature depolarizationI49.5 Sick sinus syndromeI49.8 Other specified cardiac arrhythmiasI49.9* Cardiac arrhythmia, unspecifiedI50.1 Failure, heart (congestive), left ventricularI50.9 Failure, heart (congestive)I51.7 Cardiomegaly, idiopathicI61.9 Hemorrhage, intracerebral (non-traumatic)I62.00 Hemorrhage, subdural (non-traumatic)I63.9 Cerebrovascular accidentI65.23 Carotid stenosis, bilateralI70.1 Renal artery stenosisI71.3 Abdominal aortic aneurysm with ruptureI71.4 Abdominal aortic aneurysm without ruptureI73.9 Peripheral vascular disease NOSJ01.90 Sinusitis, acuteJ02.8 Acute pharyngitis due to other specified organismsJ02.9* Acute pharyngitis, unspecifiedJ06.9* Acute upper respiratory infection, unspecifiedJ18.9 Pneumonia, unspecifiedJ20.0 Acute bronchitis due to Mycoplasma pneumoniaeJ20.1 Acute bronchitis due to Hemophilus influenzaJ20.2 Acute bronchitis due to streptococcusJ20.3 Acute bronchitis due to coxsackievirusJ20.4 Acute bronchitis due to parainfluenza virusJ20.5 Acute bronchitis due to respiratory syncytial virusJ20.6 Acute bronchitis due to rhinovirusJ20.7 Acute bronchitis due to echovirusJ20.8 Acute bronchitis due to other specified organismsJ20.9* Acute bronchitis, unspecifiedJ32.9 Sinusitis, chronicJ32.9 Sinusitis, unspecifiedJ34.2 Deviated nasal septumJ40 BronchitisJ42 Bronchitis, chronicJ43.9 EmphysemaJ44.9 COPDJ45.901 Asthma NOS with acute exacerbationJ45.902 Asthma NOS with status asthmaticusJ45.909 Asthma NOSJ80 ARDSJ81.0 Pulmonary edema NOS acuteJ81.1 Pulmonary edema NOSJ84.10 Pulmonary fibrosisJ84.9 Interstitial lung disease NOSJ90 Pleural effusion – NECJ93.0 tension (spontaneous)J93.9 PneumothoraxJ95.811 postproceduralJ96.90 Respiratory failure unspecifiedJ98.11 AtelectasisJ98.4 Lung calcificationK21.0 GERD – Reflux, with esophagitisK21.9 GERD – RefluxK31.1 Stenosis pyloric (acquired)K35.80 Appendicitis, acute NOSK40.90 Hernia, inguinal NOSK42.9 Hernia, umbilicalK44.9 Hernia, hiatalK57.90 DiverticulosisK57.91 Diverticulosis, with hemorrhageK57.92 DiverticulitisK57.93 Diverticulitis, with hemorrhageK59.00 ConstipationK76.0 Fatty liverK76.89 Cyst, liverK80.20 Cholelithiasis, gallbladderK80.21 Cholelithiasis, gallbladder, with obstructionK80.70 Cholelithiasis, gallbladder, gallbladder/bile ductK80.71 Cholelithiasis, gallbladder without obstructionK81.0 Cholecystitis, acuteK81.1 Cholecystitis, chronicK81.9 CholecystitisK92.2 Hemorrhage, gastrointestinal NOSM16.0 Bilateral primary osteoarthritis of hipM16.10* Unilateral primary osteoarthritis, unspecified hipM16.11 Unilateral primary osteoarthritis, right hipM16.12 Unilateral primary osteoarthritis, left hipM16.2 Bilateral osteoarthritis resulting from hip dysplasiaM16.30* Unilateral osteoarthritis resulting from hip dysplasia, unspecified hipM16.31 Unilateral osteoarthritis resulting from hip dysplasia, right hipM16.32 Unilateral osteoarthritis resulting from hip dysplasia, left hipM16.4 Bilateral post-traumatic osteoarthritis of hipM16.50* Unilateral post-traumatic osteoarthritis, unspecified hipM16.51 Unilateral post-traumatic osteoarthritis, right hipM16.52 Unilateral post-traumatic osteoarthritis, left hipM16.6 Other bilateral secondary osteoarthritis of hipM16.7 Other unilateral secondary osteoarthritis of hipM16.9* Osteoarthritis of hip, unspecifiedM17.0 Bilateral primary osteoarthritis of kneeM17.10* Unilateral primary osteoarthritis, unspecified kneeM17.11 Unilateral primary osteoarthritis, right kneeM17.12 Unilateral primary osteoarthritis, left kneeM17.2 Bilateral post-traumatic osteoarthritis of kneeM17.30* Unilateral post-traumatic osteoarthritis, unspecified kneeM17.31 Unilateral post-traumatic osteoarthritis, right kneeM17.32 Unilateral post-traumatic osteoarthritis, left kneeM17.4 Other bilateral secondary osteoarthritis of kneeM17.5 Other unilateral secondary osteoarthritis of kneeM17.9* Osteoarthritis of knee, unspecifiedM19.90 Arthritis NOSM25.40 Effusion, joint, unspecifiedM25.48 Effusion, joint, other siteM25.50 Pain, joint (unspecified)M25.50* Pain in unspecified jointM25.511 Pain in right shoulderM25.521 Pain in right elbowM25.522 Pain in left elbowM25.529* Pain in unspecified elbowM25.531 Pain in right wristM25.532 Pain in left wristM25.539* Pain in unspecified wristM25.551 Pain in right hipM25.552 Pain in left hipM25.559* Pain in unspecified hipM25.561 Pain in right kneeM25.562 Pain in left kneeM25.569* Pain in unspecified kneeM25.571. Pain in right ankle and joints of right footM25.572 Pain in left ankle and joints of left footM25.579* Pain in unspecified ankle and joints of unspecified footM41.9 ScoliosisM43.12 Spondylolithesis (non-traumatic) cervicalM43.14 Spondylolithesis (non-traumatic) thoracicM43.15 Spondylolithesis (non-traumatic) thoracolumbarM43.16 Spondylolithesis (non-traumatic) lumbarM43.17 Spondylolithesis (non-traumatic) lumbosacralM43.19 Spondylolithesis (non-traumatic) multiple sitesM47.22 Spondylosis, cervical with radiculopathyM47.24 Spondylosis, thoracic with radiculopathyM47.26 Spondylosis, lumbar with radiculopathyM47.812 Spondylosis, cervicalM47.814 Spondylosis, thoracicM47.816 Spondylosis, lumbarM48.02 Stenosis, spinal cervicalM48.04 Stenosis, spinal thoracicM48.06 Spinal stenosis, lumbar regionM48.06 Stenosis, spinal lumbarM48.07 Spinal stenosis, lumbosacral regionM50.00* Cervical disc disorder with myelopathy, unspecified cervical regionM50.01 Cervical disc disorder with myelopathy, occipito-atlanto-axial regionM50.02 Cervical disc disorder with myelopathy, mid-cervical regionM50.03 Cervical disc disorder with myelopathy, cervicothoracic regionM50.10* Cervical disc disorder with radiculopathy, unspecified cervical regionM50.11 Cervical disc disorder with radiculopathy, occipito-atlanto-axial regionM50.12 Cervical disc disorder with radiculopathy, mid-cervical regionM50.13 Cervical disc disorder with radiculopathy, cervicothoracic regionM50.20* Other cervical disc displacement, unspecified cervical regionM50.21 Other cervical disc displacement, occipito-atlanto-axial regionM50.22 Other cervical disc displacement, mid-cervical regionM50.23 Other cervical disc displacement, cervicothoracic regionM50.30* Other cervical disc degeneration, unspecified cervical regionM50.31 Other cervical disc degeneration, occipito-atlanto-axial regionM50.32 Other cervical dis degeneration, mid-cervical regionM50.33 Other cervical disc degeneration, cervicothoracic regionM50.80* Other cervical disc disorders, unspecified cervical regionM50.81 Other cervical disc disorders, occipito-atlanto-axial regionM50.82 Other cervical disc disorders, mid-cervical regionM50.83 Other cervical disc disorders, cervicothoracic regionM50.90* Cervical disc disorder, unspecified, unspecified cervical regionM50.91 Cervical disc disorder, unspecified,occipito-atlanto-axial regionM50.92 Cervical disc disorder, unspecified, mid-cervical regionM50.93 Cervical disc disorder, unspecified, cervicothoracic regionM51.04 Intervertebral disc disorders with myelopathy, thoracic regionM51.05 Intervertebral disc disorders with myelopathy, thoracolumbar regionM51.06 Intervertebral disc disorders with myelopathy, lumbar regionM51.07 Intervertebral disc disorders with myelopathy, lumbosacral regionM51.14 Intervertebral disc disorders with radiculopathy, thoracic regionM51.15 Intervertebral disc disorders with radiculopathy, thoracolumbar regionM51.16 Intervertebral disc disorders with radiculopathy, lumbar regionM51.17 Intervertebral disc disorders with radiculopathy, lumbosacral regionM51.24 Other intervertebral disc displacement, thoracic regionM51.25 Other intervertebral disc displacement, thoracolumbar regionM51.26 Other intervertebral disc displacement, lumbar regionM51.27 Other intervertebral disc displacement, lumbosacral regionM51.34 Other intervertebral disc degeneration, thoracic regionM51.35 Other intervertebral disc degeneration, thoracolumbar regionM51.36 Other intervertebral disc degeneration, lumbar regionM51.37 Other intervertebral disc degeneration, lumbosacral regionM51.44 Schmorl’s nodes, thoracic regionM51.45 Schmorl’s nodes, thoracolumbar regionM51.46 Schmorl’s nodes, lumbar regionM51.47 Schmorl’s nodes, lumbosacral regionM51.84 Other intervertebral disc disorders, thoracic regionM51.85 Other intervertebral disc disorders, thoracolumbar regionM51.86 Other intervertebral disc disorders, lumbar regionM51.87 Other intervertebral disc disorders, lumbosacral regionM51.9* Unspecified thoracic, thoracolumbar and lumbosacral intervertebral disc disorderM52.512 Pain in left shoulderM52.519* Pain in unspecified shoulderM54.10* Radiculopathy, site unspecifiedM54.11 Radiculopathy, occipito-atlanto-axial regionM54.12 Radiculopathy, cervical regionM54.13 Radiculopathy, cervicothoracic regionM54.14 Radiculopathy, thoracic regionM54.15 Radiculopathy, thoracolumbar regionM54.16 Radiculopathy, lumbar regionM54.17 Radiculopathy, lumbosacral regionM54.18 Radiculopathy, sacral and sacrococcygeal regionM54.2 CervicalgiaM54.30* Sciatica, unspecified sideM54.31 Sciatica, right sideM54.32 Sciatica, left sideM54.5 Low back painM54.6 Pain in thoracic spineM54.89 Other dorsalgiaM54.9 Dorsalgia, unspecifiedM62.81 Muscle weakness (generalized)M62.81 Weakness (generalized) muscle (generalized)M62.838 Muscle spasmM66.211 Spontaneous rupture of extensor tendons, right shoulderM66.212 Spontaneous rupture of extensor tendons, left shoulderM66.219* Spontaneous rupture of extensor tendons, unspecified shoulderM66.811 Spontaneous rupture of other tendons, right shoulderM66.812 Spontaneous rupture of other tendons, left shoulderM66.819* Spontaneous rupture of other tendons, unspecified shoulderM71.50 Bursitis, unspecified site, NECM75.00* Adhesive capsulitis of unspecified shoulderM75.01 Adhesive capsulitis of right shoulderM75.02 Adhesive capsulitis of left shoulderM75.100* Unspecified rotator cuff tear or rupture of unspecified shoulder, not specified as traumaticM75.101* Unspecified rotator cuff tear or rupture of right shoulder, not specified as traumaticM75.102* Unspecified rotator cuff tear or rupture of left shoulder, not specified as traumaticM75.110* Incomplete rotator cuff tear or rupture of unspecified shoulder, not specified as traumaticM75.111 Incomplete rotator cuff tear or rupture of right shoulder, not specified as traumaticM75.112 Incomplete rotator cuff tear or rupture of left shoulder, not specified as traumaticM75.120* Complete rotator cuff tear or rupture of unspecified shoulder, not specified as traumaticM75.121 Complete rotator cuff tear or rupture of right shoulder, not specified as traumaticM75.122 Complete rotator cuff tear or rupture of left shoulder, not specified as traumaticM75.20* Bicipital tendinitis, unspecified shoulderM75.21 Bicipital tendinitis, right shoulderM75.22 Bicipital tendinitis, left shoulderM75.30* Calcific tendinitis of unspecified shoulderM75.31 Calcific tendinitis of right shoulderM75.32 Calcific tendinitis of left shoulderM75.40* Impingement syndrome of unspecified shoulderM75.41 Impingement syndrome of right shoulderM75.42 Impingement syndrome of left shoulderM75.50* Bursitis of unspecified shoulderM75.51 Bursitis of right shoulderM75.52 Bursitis of left shoulderM75.80* Other shoulder lesions, unspecified shoulderM75.81 Other shoulder lesions, right shoulderM75.82 Other shoulder lesions, left shoulderM75.90* Shoulder lesion, unspecified, unspecified shoulderM75.91* Shoulder lesion, unspecified, right shoulderM75.92* Shoulder lesion, unspecified, left shoulderM77.9 Bone spur NOSM79.571 Pain in right footM79.572 Pain in left footM79.573* Pain in unspecified footM79.574 Pain in right toe(s)M79.575 Pain in left toe(s)M79.576* Pain in unspecified toe(s)M79.601 Pain in right armM79.602 Pain in left armM79.603* Pain in arm, unspecifiedM79.604 Pain in right legM79.605 Pain in left legM79.606* Pain in leg, unspecifiedM79.609 Pain in unspecified limbM79.621 Pain in right upper armM79.622 Pain in left upper armM79.629* Pain in unspecified upper armM79.631 Pain in right forearmM79.632 Pain in left forearmM79.639* Pain in unspecified forearmM79.641 Pain in right handM79.642 Pain in left handM79.643* Pain in unspecified handM79.644 Pain in right finger(s)M79.645 Pain in left finger(s)M79.646* Pain in unspecified finger(s)M79.651 Pain in right thighM79.652 Pain in left thighM79.659* Pain in unspecified thighM79.661 Pain in right lower legM79.662 Pain in left lower legM79.669* Pain in unspecified lower legM81.0 OsteoporosisM83.9 Malacia, bone (adult)M85.60 Cyst, bone NECM99.23 Subluxation stenosis of neural canal or lumbar regionM99.33 Ossecus stenosis of neural canal of lumbar regionM99.43 Connective tissue stenosis of neural canal of lumbar regionM99.53 Intervetebral disc stenosis of neural canal of lumbar regionM99.63 Ossecus and subluxation stenosis of intervertebral foramina of lumbar regionM99.73 Connective tissue and disc stenosis of intervertebral foramina of lumbar regionN13.30 HydronephrosisN17.9 Renal failure acuteN18.6 ESRDN18.9 CKD, unspecifiedN19 Renal failure unspecifiedN23 Pain, kidneyN28.1 Cyst, kidney (acquired)N28.89 Mass, kidneyN30.00 Acute cystitis without hematuriaN30.01 Acute cystitis with hematuriaN30.10 Interstitial cystitis (chronic) without hematuriaN30.11 Interstitial cystitis (chronic) with hematuriaN30.20 Other chronic cystitis without hematuriaN30.21 Other chronic cystitis with hematuriaN30.30 Trigonitis without hematuriaN30.31 Trigonitis with hematuriaN30.40 Irradiation cystitis without hematuriaN30.41 Irradiation cystitis with hematuriaN30.80 Other cystitis without hematuriaN30.81 Other cystitis with hematuriaN30.90 Cystitis, unspecified without hematuriaN30.91 Cystitis, unspecified with hematuriaN35.9 Stenosis urethra NOSN39.0* Urinary tract infection, site not specifiedN40.0 Enlarged prostateN43.3 HydroceleN63* Unspecified lump in breastN64.0 Fissure and fistula of nippleN64.1 Fat necrosis of breastN64.2 Atrophy of breastN64.3 Galactorrhea not associated with childbirthN64.4 Breast pain, tendernessN64.4 MastodyniaN64.51 Induration of breastN64.52 Nipple dischargeN64.53 Retraction of nippleN64.59 Other signs and symptoms in breastN64.81 Ptosis of breastN64.82 Hypoplasia of breastN64.89 Breast other specified disorderN64.89 Other specified disorders of breastN64.9* Disorder of breast, unspecifiedN83.0 Follicular cyst of ovaryN83.1 Corpus luteum cystN83.20 Cyst, ovaryN83.20* Unspecified ovarian cystsN83.29 Other ovarian cystsN83.31 Acquired atrophy of ovaryN83.32 Acquired atrophy of fallopian tubeN83.33 Acquired atrophy of ovary and fallopian tubeN83.4 Prolapse and hernia of ovary and fallopian tubeN83.51 Torsion of ovary and ovarian pedicleN83.52 Torsion of fallopian tubeN83.53 Torsion of ovary, ovarian pedicle and fallopian tubeN83.6 HematosalpinxN83.7 Hematoma of broad ligamentN83.8 Other noninflammatory disorders of ovary, fallopian tube & broad ligamentN83.9* Noninflammatory disorder of ovary, fallopian tube and broad ligament, unspecifiedN85.2 Uterine enlargementN92.0 Excessive and frequent menstruation with regular cycleN92.1 Excessive and frequent menstruation with irregular cycleN92.2 Excessive menstruation at pubertyN92.3 Ovulation bleedingN92.4 Excessive bleeding in the premenopausal periodN92.5 Other specified irregular menstruationN92.6* Irregular menstruation, unspecifiedN93.9 Vaginal bleedingN94.6 DysmenorrheaN95.0 Postmenopausal bleedingN95.1 Menopausal and female climatcteric statesN95.2 Postmenopausal atrophic vaginitisN95.8 Other specified menopausal and perminenopausal disordersN95.9* Unspecified menopausal and perimenopausal disorderN97.9 Infertility, female NOSQ66.3 Hallux varus, congenitalQ66.6 Hallux valgus, congenitalR00.0 Tachycardia, unspecifiedR00.1 Bradycardia, unspecifiedR00.2 PalpitationsR00.8 Other abnormalities of heart beatR00.9* Unspecified abnormalities of heart beatR05 CoughR06.00 DyspneaR06.00 Respiratory distressR06.02 Shortness of breathR06.2 WheezingR07.1 Chest pain on breathingR07.2 Pain, chest, precordialR07.81 PleurodyniaR07.82 Intercostal painR07.89 Pain, chest, pressure/tightnessR07.89 Pain, chest, wallR07.9* Chest pain, unspecifiedR09.89 Abnormal chest soundsR10.0 Acute abdomenR10.10 Upper abdominal pain, unspecifiedR10.11 Pain, abdominal (unspecified), right upper quadrantR10.12 Pain, abdominal (unspecified), left upper quadrantR10.13 Pain, abdominal (unspecified), epigastricR10.2 Pelvic and perineal painR10.30 Lower abdominal painR10.31 Pain, abdominal (unspecified), right lower quadrantR10.32 Pain, abdominal (unspecified), left lower quadrantR10.33 Pain, abdominal (unspecified), periumbilicR10.84 Pain, abdominal (unspecified), generalizedR10.9* Unspecified abdominal painR11.0 Nausea w/o vomitingR11.10 VomitingR11.2 with nauseaR13.10 Dysphagia, unspecifiedR16.0 Mass, liverR16.1 SplenomegalyR18.0 Ascites, malignantR18.8 Ascites, abdominalR19.00 Abdominal/pelvic swelling, mass unspecified siteR19.01 Abdominal/pelvic swelling, mass right upper quadrantR19.02 Abdominal/pelvic swelling, mass left upper quadrantR19.03 Abdominal/pelvic swelling, mass right lower quadrantR19.04 Abdominal/pelvic swelling, mass left lower quadrantR19.05 Abdominal/pelvic swelling, mass periumbilicR19.06 Abdominal/pelvic swelling, mass epigastricR19.07 Abdominal/pelvic swelling, mass generalizedR19.09 Abdominal/pelvic swelling, mass other specified siteR20.0 NumbnessR20.2 ParesthesiaR22.0 Mass, headR22.1 Mass, neckR22.2 Mass, chestR22.9 Mass, superficialR26.9 Gait abnormality (unspecified)R27.0 AtaxiaR29.810 Weakness (generalized) facial NOSR30.0 DysuriaR31.9 HematuriaR41.0 Confusion NOSR41.3 Memory lossR41.82 Altered mental status (AMS)R42 Dizziness/lightheadednessR47.01 AphasiaR47.02 DysphasiaR47.81 Slurred speechR50.9 Fever (with chills)R51 HeadacheR55 Syncope and collapseR55 Syncope/faintingR56.9 Seizure NOSR59.1 LymphadenopathyR60.0 Edema, localizedR60.1 Edema, generalizedR60.9 Edema, unspecifiedR63.4 Weight lossR68.83 Chills (without fever)R68.84 Pain, jawR76.11 Positive PPDR91.1 Findings, abnormal, solitary lung noduleR91.8 Findings, abnormal, other lung field findingR91.8 Infiltrate, lungR92.0 Breast. microcalcificationR92.1 Breast, calcificationR92.2 Breast, denseR92.8 Findings, abnormal, mammogramR93.2 Findings, abnormal, biliary tract/liverR93.3 Findings, abnormal, GI tractR93.7 Findings, abnormal, musculoskeletalR93.9 Inconclusive test – due to excess body fatS39.91 Injury, unspecified type, abdomenS43.421A Sprain of right rotator cuff capsule, initial encounterS43.421D Sprain of right rotator cuff capsule, subsequent encounterS43.421S Sprain of right rotator cuff capsule, sequelaS43.422A Sprain of left rotator cuff capsule, initial encounterS43.422D Sprain of left rotator cuff capsule, subsequent encounterS43.422S Sprain of left rotator cuff capsule, sequelaS43.429A* Sprain of unspecified rotator cuff capsule, initial encounterS43.429D* Sprain of unspecified rotator cuff capsule, subsequent encounterS43.429S* Sprain of unspecified rotator cuff capsule, sequelaS83.501A* Sprain of unspecified cruciate ligament of right knee, initial encounterS83.501D* Sprain of unspecified cruciate ligament of right knee, subsequent encounterS83.501S* Sprain of unspecified cruciate ligament of right knee, sequelaS83.502A* Sprain of unspecified cruciate ligament of left knee, initial encounterS83.502D* Sprain of unspecified cruciate ligament of left knee, subsequent encounterS83.502S* Sprain of unspecified cruciate ligament of left knee, sequelaS83.509A* Sprain of unspecified cruciate ligament of unspecified knee, initial encounterS83.509D* Sprain of unspecified cruciate ligament of unspecified knee, subsequent encounterS83.509S* Sprain of unspecified cruciate ligament of unspecified knee, sequelaS83.511A Sprain of anterior cruciate ligament of right knee, initial encounterS83.511D Sprain of anterior cruciate ligament of right knee, subsequent encounterS83.511S Sprain of anterior cruciate ligament of right knee, sequelaS83.512A Sprain of anterior cruciate ligament of left knee, initial encounterS83.512D Sprain of anterior cruciate ligament of left knee, subsequent encounterS83.512S Sprain of anterior cruciate ligament of left knee, sequelaS83.519A* Sprain of anterior cruciate ligament of unspecified knee, initial encounterS83.519D* Sprain of anterior cruciate ligament of unspecified knee, subsequent encounterS83.519S* Sprain of anterior cruciate ligament of unspecified knee, sequelaS83.521A Sprain of posterior cruciate ligament of right knee, initial encounterS83.521D Sprain of posterior cruciate ligament of right knee, subsequent encounterS83.521S Sprain of posterior cruciate ligament of right knee, sequelaS83.522A Sprain of posterior cruciate ligament of left knee, initial encounterS83.522D Sprain of posterior cruciate ligament of left knee, subsequent encounterS83.522S Sprain of posterior cruciate ligament of left knee, sequelaS83.529A* Sprain of posterior cruciate ligament of unspecified knee, initial encounterS83.529D* Sprain of posterior cruciate ligament of unspecified knee, subsequent encounterS83.529S* Sprain of posterior cruciate ligament of unspecified knee, sequelaS93.401A* Sprain of unspecified ligament of right ankle, initial encounterS93.401D* Sprain of unspecified ligament of right ankle, subsequent encounterS93.401S* Sprain of unspecified ligament of right ankle, sequelaS93.402A* Sprain of unspecified ligament of left ankle, initial encounterS93.402D* Sprain of unspecified ligament of left ankle, subsequent encounterS93.402S* Sprain of unspecified ligament of left ankle, sequelaS93.409A* Sprain of unspecified ligament of unspecified ankle, initial encounterS93.409D* Sprain of unspecified ligament of unspecified ankle, subsequent encounterS93.409S* Sprain of unspecified ligament of unspecified ankle, sequelaS93.411A Sprain of calcaneofibular ligament of right ankle, initial encounterS93.411D Sprain of calcaneofibular ligament of right ankle, subsequent encounterS93.411S Sprain of calcaneofibular ligament of right ankle, sequelaS93.412A Sprain of calcaneofibular ligament of left ankle, initial encounterS93.412D Sprain of calcaneofibular ligament of left ankle, subsequent encounterS93.412S Sprain of calcaneofibular ligament of left ankle, sequelaS93.419A* Sprain of calcaneofibular ligament of unspecified ankle, initial encounterS93.419D* Sprain of calcaneofibular ligament of unspecified ankle, subsequent encounterS93.419S* Sprain of calcaneofibular ligament of unspecified ankle, sequelaS93.421A Sprain of deltoid ligament of right ankle, initial encounterS93.421D Sprain of deltoid ligament of right ankle, subsequent encounterS93.421S Sprain of deltoid ligament of right ankle, sequelaS93.422A Sprain of deltoid ligament of left ankle, initial encounterS93.422D Sprain of deltoid ligament of left ankle, subsequent encounterS93.422S Sprain of deltoid ligament of left ankle, sequelaS93.429A* Sprain of deltoid ligament of unspecified ankle, initial encounterS93.429D* Sprain of deltoid ligament of unspecified ankle, subsequent encounterS93.429S* Sprain of deltoid ligament of unspecified ankle, sequelaS93.431A Sprain of tibiofibular ligament of right ankle, initial encounterS93.431D Sprain of tibiofibular ligament of right ankle, subsequent encounterS93.431S Sprain of tibiofibular ligament of right ankle, sequelaS93.432A Sprain of tibiofibular ligament of left ankle, initial encounterS93.432D Sprain of tibiofibular ligament of left ankle, subsequent encounterS93.432S Sprain of tibiofibular ligament of left ankle, sequelaS93.439A* Sprain of tibiofibular ligament of unspecified ankle, initial encounterS93.439D* Sprain of tibiofibular ligament of unspecified ankle, subsequent encounterS93.439S* Sprain of tibiofibular ligament of unspecified ankle, sequelaS93.491A Spain of other ligament of right ankle, initial encounterS93.491D Spain of other ligament of right ankle, subsequent encounterS93.491S Spain of other ligament of right ankle, sequelaS93.492A Spain of other ligament of left ankle, initial encounterS93.492D Spain of other ligament of left ankle, subsequent encounterS93.492S Spain of other ligament of left ankle, sequelaS93.499A* Spain of other ligament of unspecified ankle, initial encounterS93.499D* Spain of other ligament of unspecified ankle, subsequent encounterS93.499S* Spain of other ligament of unspecified ankle, sequelaT07 Injury, unspecified type, multiple NOST14.8 Contusion; NOST14.90 Injury, unspecified type, unspecified siteZ04.1 Observation following accident; transportZ04.3 Observation following accident; transport, other accidentZ12.31 Mammogram, screeningZ13.820 Osteoporosis, screeningZ36 Ultrasound, OB, routineZ45.2 Catheter check; vascularZ78.0 Postmenopausal state (NOS)Z79.818 Long-term drug therapy; estrogenZ80.3 Family history, breast cancerZ82.49 Family history, other cardiovascular diseaseZ82.62 Family history, osteoporosisZ85.118 Personal history lung cancer NECZ85.3 Personal history breast cancerZ85.46 Personal history prostate cancerZ85.51 Personal history bladder cancerZ86.718 Personal history DVTZ86.73 Personal history transient ischemic attackZ91.81 History of fallingZ95.0 Status post pacemakerZ95.1 Status post CABGOther ICD-10 Code: Other ICD-10 Code Description: Patient insurance card copy is attached:Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.Patient lab results are attached:Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.Other related documents: Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB, Max. files: 4. 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