WAKE FOREST UNIVERSITY WAKE FOREST UNIVERSITY Patient

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					     WAKE FOREST UNIVERSITY                                                                    Patient Name:    ___________________________________
     BAPTIST MEDICAL CENTER                                                                            MRN:     ___________________________________
     CARDIOVASCULAR CT                                                                                  Date:   ___________________________________
     IMAGING REQUEST FORM                                                                      Referring MD:    ___________________________________

     CALL to schedule at (336) 716-8663 then                                           This form is not for medical records, for internal use only.
     FAX form & SCRIPT to (336) 716-8683

     STUDY REQUESTED: Place an “X” in each appropriate box
X        STUDY                                                                                                                                             ORDER CODES
                                                                                                                                                           (WFUBMC use only)

                              CARDIAC COMPUTED TOMOGRAPHY
                  Heart CTA and Artery W/O Calcium                                                                                                         51017

                  Heart CTA and Calcium                                                                                                                    51018
                  Cardiac Structure Morphology                                                                                                             21019

                  Cardiac Function                                                                                                                         51011
                  Cardiac W/O Infusion                                                                                                                     51016

                  Heart CTA and Chest W/O and Calcium                                                                                                      51024
PATIENT INSTRUCTIONS FOR STRESS PROCEDURES:
  1. NPO for 6 hours, except for medications.
  2. No caffeine OR nicotine for 6 hours, including tea, soft drinks, chocolate, and decaffeinated products.
RELEVANT SIGNS/SYMPTOMS DIAGNOSIS: (Mandatory – Must be in ICD-9 Numeric Code) **Circle below or enter code in this space




               Code           Sign/Symptom                                                            Code          Sign/Symptom
              786.50          Chest pain, unspecified
              786.51          Precordial chest pain                                                   746.89        Other congenital anomaly, heart
              786.59          Pressure, tightness in chest                                            745.2         Tetralogy of Fallot
              412.            Old myocardial infarction                                               745.4         VSD
              410.12          AMI, anterior wall                                                      745.5         Ostium Secundum, ASD
              414.9           Chronic ischemic heart disease                                          746.2         Other endocardial defects
              413.1           Prinzmetal angina                                                       746.9         Unspecified congenital anomaly of the heart
              411.1           Unstable angina                                                         745.10        Complete transposition, great vessels
              411.89          Coronary artery disease                                                 745.12        Corrected transposition, great vessels
                                                                                                      746.89        Other congenital anomaly, heart
                                                                                                      746.85        Coronary artery anomaly, congenital
              746.4           Congenital insufficiency of aortic valve
              424.0           Mitral valve disorders
              424.1           Aortic valve disorders                                                  427.0         Paroxysmal supraventricular tachycardia
              424.2           Tricuspid valve disorders                                               427.1         Paroxysmal ventricular tachycardia
              785.2           Undiagnosed cardiac murmur                                              780.2         Syncope and collapse, vasovagal attack
              424.90          Endocarditis, valve Unspecified, cause unspecified                      427.31        Atrial fibrillation
                                                                                                      427.1         Paroxysmal ventricular tachycardia
                                                                                                      426.3         Left bundle branch block
              786.05          Shortness of breath                                                     427.9         Arrhythmia
              416.0           Primary pulmonaryhypertension                                           426.7         Wolfe-Parkinson White syndrome
              425.4           Other primary cardiomyopathies                                          785.1         Palpitations
              428.1           Left heart failure                                                      780.4         Dizziness
              429.3           Cardiomegaly
              402.10          Hypertensive heart disease, benign, without CHF
              782.3           Edema, localized NOS                                                    441.4         Abdominal aneurysm w/o mention of rupture
              402.91          Hypertensive heart disease, with congestive heart failure               747.3         Anomalies of pulmonary artery
              786.09          Other respiratory distress                                              747.29        Other anomalies of aorta
              428.0           Congestive heart failure                                                759.82        Marfan’s syndrome
              425.1           Hypertrophic obstructive cardiomyopathy                                 441.2         Thoracic aneurysmw/o tention of rupture
              674.84          Postpartum cardiomyopathy                                               417.0         Arteriovenous fistula of pulmonary vessels
              429.0           Myocarditis                                                             747.1         Coarctation of aorta
              277.3           Amyloidosis
              963.1           Exposure to antineoplastic drugs and immunosuppressive drugs
              250.0           Diabetes                                                                861.01        Cardiac contusion
              276.6           Fluid overload disorder                                                 997.1         Cardiac complications


              164.1           Malignant neoplasm, heart
              212.7           Benign neoplasm, heart
              423.2           Constrictive pericarditis
              423.9           Unspecified disease of pericardium
              999.9           Other

     {revised 05-06-08}




                                     Physician (or Designee) Signature:                          _____________________________________________

				
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