Referring Provider Clinical History Needs for ICD-10

We provide a reference sheet for common imaging indications related to ICD-10 to help referring physicians provide our radiologists with the clinical history needed to make the most accurate evaluations and interpretations.

PLEASE NOTE: Specify clinical indication/symptoms: Cannot accept “evaluate for “as the only reason for imaging.

Head:

• Headache:
  • Chronic
  • Migraine- with or w/o Aura
  • Tension
  • Acute- post traumatic
• Dizziness, visual change

Neck:

• Pain: specify location and laterality
• Swelling or lump: specify location and laterality medial/lateral, anterior/posterior
• Difficulty swallowing

Chest:

• Cough, Shortness of Breath
• Pain: specify location and laterality

Abdominal/Pelvic/Flank:

• Pain: specify location (quadrant):
  • RUQ, LUQ, RLQ, LLQ, RT, LT, Bilateral, Generalized
• Diabetes Type:
  • Complication (retinopathy, nephropathy, neuropathy)
• Kidney Disease:
  • Chronic
  • Stage: 1 2 3 4 5
  • ESRD (end stage with chronic dialysis)
  • Dialysis: Y/N

Hypertension (HTN):

• Is it related to heart disease or chronic kidney disease?

Pregnancy:

• Reason for visit (routine, complaint)
• Pt. complication/condition i.e bleeding, small for dates, large for dates, pain, etc.
• Trimester/weeks of pregnancy

Back Pain/Lumbar Pain:

• Specify location: (level and laterality of spine)
  • Low Back Pain RT/LT
  • Low Back with Sciatica RT/LT
  • Radiculopathy Lumbar
  • Radiculopathy Lumbosacral Region
  • Radiculopathy Leg RT/LT
  • Sciatica RT/LT, Bilateral
• Specify other known spinal disease or complication

Venous US Lower Extremity:

• Pain, swelling, ulcer: specify location and laterality

Neoplasm:

• Current cancer or history of cancer
• Define: Primary, Secondary, CA in Situ, Benign, Unspecified
• Secondary Cancer:
  • Define primary with secondary
• Current treatment or completed treatment:
  • Type: Chemo or Rad. Therapy MM/YY

History of CA: Previously excised or eradicated and no further treatment is directed to that site and no evidence of any existing primary malignancy Type and year

Injury: How? When? Symptom?

• Work Comp or Auto accident
• Pain, injury, swelling
• Specify location and laterality: Proximal/distal, medial/ lateral, anterior/posterior

Fracture status:

• Initial visit for evaluation or encounter for active treatment of a fracture
• Subsequent treatment (follow up fracture - NO active treatment)
• Fracture location:
  • Laterality: proximal/distal, medial/lateral
  • Define type of fracture
  • Open or closed
• Pathologic FX:
  • Due to neoplasm or other chronic disease

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