Order Date: STAT, Please Call ROUTINE DISPATCH : 623-257-1399 FAX ORDER TO: 623-257-2133 patient information Name Phone No D.O.B. Address/Facility City, State, Zip Gender Ordering Physician client information: Name Ordering Contact Ordering Physician Phone No Fax Report to Doctor at *Physician Signature insurance Bill Facility OR Bill Insurance (or attach a Face-Sheet) Medicare # Medicaid # Other Insurance ID # GRP # Responsible Party Name/Address/Phone Reason for Portable Exam ICD 10 Diagnostic Codes Procedures Ordered chest/abdomen 71110 Rib, Bilateral, 3V 71045 Chest AP 71100 Rib, 2V LR 71046 Chest AP & Lat 71048 Abdomen, 1V spine & pelvis 72070 T-Spine, 2V 72170 Pelvis, AP only 72040 Cervical, 2V or 3V 72100 Lumbrosacral, 2V 72080 Thoraco Lumbar 2V 72200 Sacroiliac lower extremities 73620 Foot LR 73660 Toe(s), 2+V LR 73552 Femur LR 73560 Knee LR 73590 Tibia & Fibula LR 73600 Ankle LR 73501 Hip, Unil: 1V LR 73502 Hip, Complete: 2V LR upper extremities 73070 Elbow LR 73090 Forearm LR 73030 Shoulder LR 73060 Humerus LR 73000 Clavicle LR ultrasound 76856 US Pelvis (non-OB) 76870 US Scrotum 93975 US Testical 93880 US Carotid 76770 US Retroperitoneal 76882 US Ext Non Vascular LR 76805 US OB Pregnant Uterus 76536 US Thyroid/Neck 76641 US Breast LR 76604 US Chest 76700 US Abdominal 93922 Ankle/Brachial Index 93975 US Vascular Retroperitoneal 93923 Segmental Pressures Low Ext 93925 US Arterial LE LR 93930 US Arterial LE LR 93970 US Arterial LE LR 93970 US Arterial L=UE LR electrocardiogram 93000 EKG echocardiogram 93306 Echocardiogram other exam
