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Date & Time
|
Patient Name
|
|
Patient DOB
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Phone Number
|
|
Weight ___KG
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Height ___CM
|
|
Guarantor
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Relationship to Patient
|
|
Insurance (Primary)
|
Policy Number
|
|
Referral / Authorization Number
|
Date Range
|
|
Insurance (Secondary)
|
Policy Number
|
|
Referral / Authorization Number
|
Date Range
|
|
Ordering Office
|
Ordering Office Phone
|
|
Ordering Provider
|
Ordering Office Fax
|
|
Echocardiogram
|
Diagnosis
|
|
Echocardlogram (w/ or w/o contrast) - (93306, Q9957)
|
Strain - (93356) further evaluation of heart function, ie.: chemotherapy, cardiomyopathy evaluation, etc.
|
|
Echocardiogtam Limited (w/ or w/o contrast) - (93308, 93321, 93326, Q9957)
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Strain - (93356) further evaluation of heart function, ie.: chemotherapy, cardiomyopathy evaluation, etc.
|
|
Echocardlogram w/ Bubble Study (w/ or w/o contrast) - (93306. Q9957)
|
|
|
Stress Echocardiogram (w/ or w/o contrast)-(93351, 93352, 93320, 93321, 93325, Q9957)
|
|
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Dobutamine Stress Echocardlogram (w/ orw/o contrast) - (93351, 93352, 93320, 93321, 93325, J1250, Q9957)
|
|
|
Treadmill (w/o imaging) -
|
Diagnosis
|
|
• Patient prep required, KHC will provide instructions
|
Exercise Stress Test (ETT) - (93016, 93017, 93018)
|
|
Nuclear Stress Test
|
Diagnosis
|
|
• Patient prep required, KHC will provide instructions
|
Nuclear Stress Test - (78452, 93016, 93017, 93018)
|
|
Exercise (Treadmill)
|
Pharmacological
|
|
MUGA (Gated Blood Pool) - (78472)
|
|
|
Ambulatory Event Monitor
• • •
|
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