radiology 101

NORTH STATE NORTH STATE RADIOLOGYRADIOLOGY

RADIOLOGY 101RADIOLOGY 101

RadiographyRadiography

The use of ionizing The use of ionizing radiation to view radiation to view objects.objects.

1895 – Discovery 1895 – Discovery of X-rays of X-rays (electromagnetic (electromagnetic radiation)radiation)

Medical ImagingMedical Imaging

Detect pathology of the skeletal Detect pathology of the skeletal system, as well as disease system, as well as disease processes of the soft tissue. processes of the soft tissue.

Radiographs vs. other modalitiesRadiographs vs. other modalities Diagnostic vs. ScreeningDiagnostic vs. Screening

North State RadiologyNorth State Radiology

North State ImagingNorth State Imaging

1702 Esplanade 1702 Esplanade 898-0500898-0500 251 Cohasset Rd. 251 Cohasset Rd. 898-0500898-0500

North Valley Advanced ImagingNorth Valley Advanced Imaging

1638 Esplanade 894-62001638 Esplanade 894-6200 Chico Spine & VascularChico Spine & Vascular

251 Cohasset Rd. 898-0520251 Cohasset Rd. 898-0520

North State ImagingNorth State Imaging

X-ray (Radiograph)X-ray (Radiograph)--Chest, bones, soft tissuesChest, bones, soft tissues

MammogramMammogram--screening vs. diagnosticscreening vs. diagnostic

UltrasoundUltrasound FluoroscopyFluoroscopy DEXA (Bone Density) – Cohasset Rd.DEXA (Bone Density) – Cohasset Rd.

X-ray (Radiograph)X-ray (Radiograph)

View bones and/or soft tissueView bones and/or soft tissue Complete vs. Limited StudyComplete vs. Limited Study Walk-in except bone surveyWalk-in except bone survey No patient prepNo patient prep No prior authorization requiredNo prior authorization required CR (Computed Radiography)CR (Computed Radiography)

**description and advantages**description and advantages

ANKLE X-RAYANKLE X-RAY

Normal FractureNormal Fracture

MammographyMammography

Digital MammographyDigital Mammography Advantages:Advantages:

-Faster image acquisition.-Faster image acquisition.-Improved image storage and -Improved image storage and

transmission.transmission.-Images can be enhanced by radiologist.-Images can be enhanced by radiologist.

-Increased accuracy screening women in -Increased accuracy screening women in certain groups.certain groups. CComputer omputer AAided ided DDetectionetection Screening vs. DiagnosticScreening vs. Diagnostic

MAMMOGRAMMAMMOGRAM

Negative PositiveNegative Positive

UltrasoundUltrasound

No ionizing radiation. No ionizing radiation. Images in “real time” – movement.Images in “real time” – movement. Guidance for minimally-invasive Guidance for minimally-invasive

procedures (ie: needle biopsies)procedures (ie: needle biopsies) LimitationsLimitations

-cannot penetrate bone-cannot penetrate bone -large patients may be difficult-large patients may be difficult -not good at imaging bowel -not good at imaging bowel

ULTRASOUNDULTRASOUND

Negative Breast UltrasoundNegative Breast Ultrasound

ULTRASOUNDULTRASOUND

Positive Breast UltrasoundPositive Breast Ultrasound

UltrasoundUltrasound

Patient Prep:Patient Prep: Fetal Age, Renal, and Pelvic:Fetal Age, Renal, and Pelvic:

-Drink 32 oz. water, finishing 1 hour prior to -Drink 32 oz. water, finishing 1 hour prior to exam.exam.

Do not urinate.Do not urinate.

AbdominalAbdominal: : NPO after midnight.NPO after midnight. Breast:Breast: No deodorant, powder, or perfume in No deodorant, powder, or perfume in

the the

axillary area. axillary area.

Thyroid:Thyroid: No prep. No prep.

FluoroscopyFluoroscopy

A “real time” x-ray (video) A “real time” x-ray (video)

Performed to view movement (of Performed to view movement (of

tissues or contrast agent) or to tissues or contrast agent) or to guide a medical intervention.guide a medical intervention.

FLUOROSCOPYFLUOROSCOPY

Upper GI Lower GI Upper GI Lower GI (BE)(BE)


Upper GIUpper GI -x-ray exam of the pharynx, -x-ray exam of the pharynx,

esophagus, stomach, and upper small esophagus, stomach, and upper small intestine (duodenum) using an orally intestine (duodenum) using an orally ingested barium contrast material. ingested barium contrast material.

**NPO after midnight the day before **NPO after midnight the day before **scheduled in the a.m. at NSI**scheduled in the a.m. at NSI


Barium EnemaBarium Enema -x-ray exam of the lower GI tract (large intestine, -x-ray exam of the lower GI tract (large intestine,

aka colon) using a rectally administered barium aka colon) using a rectally administered barium contrast material. contrast material.

1) Single Contrast Prep: 24-hr Fleet kit 1) Single Contrast Prep: 24-hr Fleet kit needs needs

to be picked up at NSI-Esplanade 2 days to be picked up at NSI-Esplanade 2 days

prior to the exam.prior to the exam.

2) Double Contrast (w/ air) Prep: 48-hr Fleet 2) Double Contrast (w/ air) Prep: 48-hr Fleet

kit needs to be picked up 3 days prior. kit needs to be picked up 3 days prior.


Small Bowel: Small Bowel: NPO after NPO after midnightmidnight

Hysterosalpingogram (HSG):Hysterosalpingogram (HSG): --contrast enhanced x-ray of uterus and contrast enhanced x-ray of uterus and

fallopian tubes.fallopian tubes.

-must be 7-10 days from first day or -must be 7-10 days from first day or last menstrual cycle.last menstrual cycle.


ArthrographyArthrography--an x-ray exam of a joint (shoulder, an x-ray exam of a joint (shoulder, wrist, hip, knee, ankle) that uses wrist, hip, knee, ankle) that uses fluoroscopy and an iodine based fluoroscopy and an iodine based contrast material.contrast material.

**Mostly perform MR arthrograms. **Mostly perform MR arthrograms.

**No special prep required. **No special prep required.

DEXA DEXA (Bone (Bone Densitometry)Densitometry)

PATIENT PREPPATIENT PREP1) No calcium supplements for 24 hours 1) No calcium supplements for 24 hours prior.prior.

2) Loose, comfortable clothing and avoid 2) Loose, comfortable clothing and avoid zippers,zippers,

belts, or metal buttons. belts, or metal buttons.

3) Notify if recent barium or contrast-3) Notify if recent barium or contrast-enhanced enhanced

examination has been done. examination has been done.

4) Notify if pregnant.4) Notify if pregnant.

Interventional Interventional RadiologyRadiology*a subspecialty in which minimally invasive procedures *a subspecialty in which minimally invasive procedures

are performed using image guidance (fluoroscopy).are performed using image guidance (fluoroscopy).

www.chicospine.comwww.chicospine.com

**Tuesdays and Fridays 8:00-5:00pm**Tuesdays and Fridays 8:00-5:00pm 251 Cohasset Rd. Chico (530) 898-0520251 Cohasset Rd. Chico (530) 898-0520

Interventional Interventional RadiologyRadiology Spinal Injections for Pain Spinal Injections for Pain

ManagementManagement Off aspirin or blood thinners 7 days priorOff aspirin or blood thinners 7 days prior Must have recent MRI (within a year)Must have recent MRI (within a year) Must bring driver to take pt. home after Must bring driver to take pt. home after

injectioninjection No pain medication the morning of procedureNo pain medication the morning of procedure Any allergies to meds, Iodine, or Latex?Any allergies to meds, Iodine, or Latex? Is patient Diabetic?Is patient Diabetic? If sedation will be used, NPO 4 hrs. prior to inj.If sedation will be used, NPO 4 hrs. prior to inj.

Interventional Interventional RadiologyRadiology RFA (Radiofrequency Ablation):RFA (Radiofrequency Ablation): Does the patient have a pacemaker?Does the patient have a pacemaker? What is the patient’s weight?What is the patient’s weight? Any allergies to meds, Iodine, or Latex?Any allergies to meds, Iodine, or Latex? Off aspirin or blood thinners 7 days prior.Off aspirin or blood thinners 7 days prior. Must have recent MRI exam.Must have recent MRI exam. Prior injection.Prior injection. No pain medication the a.m. of the procedure.No pain medication the a.m. of the procedure. Must bring driver to take patient home after Must bring driver to take patient home after

proc.proc. NPO 4 hours prior.NPO 4 hours prior. What levels? What levels?

Interventional Interventional RadiologyRadiology VERTEBROPLASTY:VERTEBROPLASTY: Must have a recent MRI.Must have a recent MRI. Off aspirin or blood thinners 7 days prior.Off aspirin or blood thinners 7 days prior. No pain medication the a.m. of the No pain medication the a.m. of the

procedure.procedure. Must bring driver to take patient home after Must bring driver to take patient home after

proc.proc. NPO 4 hours prior to procedure.NPO 4 hours prior to procedure. Location of compression fracture? Location of compression fracture?

North Valley Advanced North Valley Advanced ImagingImaging MRIMRI Breast MRIBreast MRI

-including MR-guided breast -including MR-guided breast biopsybiopsy

CTCT MRA and CTAMRA and CTA PET/CTPET/CT

MRI – MRI – Magnetic Resonance Magnetic Resonance ImagingImaging

Does not use ionizing radiation.Does not use ionizing radiation. Magnetic Field + Radio Waves + Magnetic Field + Radio Waves +

Computer Computer Patient must lie stillPatient must lie still Fasting guidelines vary based on Fasting guidelines vary based on

examexam May require contrast May require contrast

enhancement.enhancement.

MRI - BRAINMRI - BRAIN


Possible Contraindications:Possible Contraindications: 1) Metal or electronic objects1) Metal or electronic objects

*both external or internal implants, etc.*both external or internal implants, etc. 2) Pregnancy2) Pregnancy 3) Claustrophobia3) Claustrophobia

*short-bore scanner*short-bore scanner*sedation options*sedation options

4) Size of Patient – weight limit 350 lbs. 4) Size of Patient – weight limit 350 lbs. 5) Children *must speak to nurse to determine5) Children *must speak to nurse to determine 6) Renal Insufficiency (Kidney Disease)6) Renal Insufficiency (Kidney Disease)


Contrast Enhancement:Contrast Enhancement: -Gadolinium-Gadolinium -Pre-screening (within 6 weeks) -Pre-screening (within 6 weeks)

* Past or present renal disease* Past or present renal disease * Diabetes* Diabetes * Over age 60* Over age 60 -Creatinine Clearance-Creatinine Clearance -Possible Side Effects / Reactions-Possible Side Effects / Reactions

CT – CT – Computed TomographyComputed Tomography

Produces multiple cross-sectional Produces multiple cross-sectional images of internal organs, bone, images of internal organs, bone, soft tissue, and blood vessels at soft tissue, and blood vessels at same time same time

3D Reformatted Images3D Reformatted Images Greater clarity and detail than Greater clarity and detail than

regular x-rays. “ALARA”regular x-rays. “ALARA” Fasting guidelines vary by exam. Fasting guidelines vary by exam.

CT - BRAINCT - BRAIN

BrainBrain


Possible Contraindications:Possible Contraindications: 1) Pregnancy1) Pregnancy

2) Renal Insufficiency (Kidney Disease)2) Renal Insufficiency (Kidney Disease)

3) Allergy to Iodine or shellfish3) Allergy to Iodine or shellfish

4) Children4) Children

5) Size of patient5) Size of patient

**weight limit of scanner is 450 lbs.**weight limit of scanner is 450 lbs.


Contrast Enhancement:Contrast Enhancement:

-Iodine based-Iodine based

-Oral (EZ-CAT), I.V., or enema. -Oral (EZ-CAT), I.V., or enema.

**Creatinine clearance needed if:**Creatinine clearance needed if:

-past or present renal disease-past or present renal disease

-diabetic-diabetic

-over age 60.-over age 60.

PET/CT PET/CT

PPositron ositron EEmission mission TTomographyomography Nuclear Medicine ImagingNuclear Medicine Imaging PET evaluates metabolic functionPET evaluates metabolic function CT images anatomy (size, shape)CT images anatomy (size, shape)

**Must give patients weight.**Must give patients weight.

PET/CTPET/CT

Negative PET/CT Scan Positive PET/CT Scan

PET/CTPET/CT

PrepPrep

*Fast for 4-6 hours prior to scan*Fast for 4-6 hours prior to scan

*No strenuous exercise the day *No strenuous exercise the day before before

and day of exam.and day of exam.

PET/CTPET/CT Possible Contraindications:Possible Contraindications: 1) Pregnancy1) Pregnancy 2) Diabetes2) Diabetes

**special instructions**special instructions

New CMS Guidelines (4/09)New CMS Guidelines (4/09) 1) Additional covered indications1) Additional covered indications 2) New Framework2) New Framework

*initial treatment strategies (diagnosis, *initial treatment strategies (diagnosis, staging)staging)

*subsequent treatment strategies (re-staging, *subsequent treatment strategies (re-staging, monitor)monitor)

Scheduling ProcessScheduling Process

General X-ray General X-ray ((NOTNOT scheduled) except bone scheduled) except bone surveysurvey

****FFax the order to NSIax the order to NSI All OthersAll Others

1) 1) OObtain prior auth if required.btain prior auth if required. 2) 2) CCall facility to schedule exam.all facility to schedule exam. 3) 3) FFax order, auth, medical records.ax order, auth, medical records. 4) 4) NNotify patient of prep, instructions.otify patient of prep, instructions.

**photo ID and insurance card**photo ID and insurance card

Scheduling ProcessScheduling Process

Centralized SchedulingCentralized Scheduling Faxed info scanned into systemFaxed info scanned into system The day before the exam:The day before the exam:

1. Confirmation call to patient1. Confirmation call to patient

2. Order/Auth/Records verification 2. Order/Auth/Records verification

3. Radiologist “protocols” the 3. Radiologist “protocols” the exam.exam.

-“ALARA”-“ALARA”

Prior AuthorizationPrior Authorization

Code Specificity v. “Family” of Code Specificity v. “Family” of CodesCodes

Obtain before schedulingObtain before scheduling Send clinical info at time of auth Send clinical info at time of auth

requestrequest NPI vs. Tax ID#NPI vs. Tax ID# Retroactive authorizationsRetroactive authorizations


FACILITY REFERENCE INFORMATIONFACILITY REFERENCE INFORMATIONFACILITY NPI: 1699927988FACILITY NPI: 1699927988MEDI CAL TAR NPI: 1033151931MEDI CAL TAR NPI: 1033151931TAX ID: 68-0358482TAX ID: 68-0358482BILLING DEPARTMENT: (530) 345-6067BILLING DEPARTMENT: (530) 345-6067

CPT CODE “FAMILIES”CPT CODE “FAMILIES”

CPT® Code Families

Code Description Corresponding Code Family

70336 MRI Temporomandibular Joint 7033670450 CT Head/Brain 70450, 70460,

70470 70480 CT Orbit 70480, 70481, 70482

70486 CT Maxillofacial/Sinus 70486, 70487, 70488, 76380

70490 CT Soft Tissue Neck 70490, 70491, 70492

70496 CT Angiography, Head 7049670498 CT Angiography, Neck 7049870540 MRI Orbit, Face, Neck 70540, 70542,

70543


Medi-CalMedi-Cal eTAReTAR-enter our Medi-cal NPI# as ref provider.-enter our Medi-cal NPI# as ref provider.-notification of status (approved, -notification of status (approved,

denied, or deferred) not sent to us.denied, or deferred) not sent to us.-we can only check status – no changes.-we can only check status – no changes.

-common errors:-common errors: 1) Modifier ZS (missing or incorrect)1) Modifier ZS (missing or incorrect)

2) Incorrect Provider #. Must use our MCal NPI#.2) Incorrect Provider #. Must use our MCal NPI#. 3) No clinical information given.3) No clinical information given.


RBM’s (Radiology Benefits RBM’s (Radiology Benefits Management)Management)

-NIA - National Imaging Associates-NIA - National Imaging Associates

www.radmd.comwww.radmd.com - “Clinical Guidelines” - “Clinical Guidelines”

-AIM – American Imaging Management-AIM – American Imaging Management

www.anthem.com/cawww.anthem.com/ca - Prior Auth List - Prior Auth List

-Med Solutions -Med Solutions

www.medsolutionsonline.comwww.medsolutionsonline.com

-TriWest-TriWest

www.triwest.comwww.triwest.com - Prior Auth List - Prior Auth List

PECOSPECOS

PProvider rovider EEnrollment, nrollment, CChain and hain and OOwnership wnership SSystemystem

Enrollment required by CMS by Enrollment required by CMS by April 1, 2010April 1, 2010

https://pecos.cms.hhs.gov/pecos/login.https://pecos.cms.hhs.gov/pecos/login.dodo

http://www.cms.hhs.gov/MedicareProvihttp://www.cms.hhs.gov/MedicareProviderSupEnroll/04_InternetbasedPECOS.derSupEnroll/04_InternetbasedPECOS.aspasp

Materials PacketMaterials Packet

Brochures Brochures Referral SlipsReferral Slips Facility Reference CardFacility Reference Card NVAI CPT Code ListNVAI CPT Code List Insurance Company Reference Insurance Company Reference

SheetSheet MiscellaneousMiscellaneous

QUESTIONSQUESTIONS

radiology 101

Health & Medicine

xray exam

contrast agent

imaging bowel

lower gi tract large

real time movement

bone large patients

days prior

soft tissueschest