Pulmonary Function / EEG / EMG / Diagnostic Cardiology Order Form
(Only 1 procedure per category may be ordered on this form unless otherwise indicated)
Request Date: Inpatient / Area / Room:  Outpatient / Clinic: Date of Next Clinic Appointment:  
             
               
Clinical Diagnosis & Reason for Exam:  (Do not use R/O, Suspected or Possible) Test Setting (circle one):    
  Inpatient Outpatient  
     
  Test Status (circle one):    
  Stat Routine  
                   
Requesting Physican: (Please Print)              Physician ID #:   Physician Pager #: Physician Signature:  
           
           
PULMONARY FUNCTION  (467)
Lung Mechanics  TRANS CPT Misc. Pulmonary Studies TRANS CPT
(multiple procedures may be ordered in this category only)              
Flow Volume Loop 
 
01009 94375 Polysomnography w/CPAP/Split 
 
01298 95811
Spirometry before/after bronchodilator    00027 94060 Polysomnography    00555 95810
Spirometry w/MV   00019 94010 Cardiopulmonary Exercise Testing (CPET)   01132 94621
Maximum Voluntary Ventilation   00142 94200 Pulmonary Stress Testing, Simple    00522 94620
Thoracic Gas Vol (plethysmographic lung vol)    01157 94260 Gas Exchange    
Single Breath Nitrogen Washout    01017 94370 CO Diffusing Capacity (DLCO) 
 
00084 94270
Airway Resistance    01108 94360 Pulse Oximetry, single    00118 94760
Functional Residual Capacity (gas dilution)    00233 94240 Pulse Oximetry, multiple (exercise)    00092 94761
Methacholine Challenge    00191 94070 Arterial Puncture   01116 36600
Other Procedure    
Multi Sleep Latency Test for Narcolepsy
 
  95805
 
Cardiac Graphics (447)
EKG by EKG Personnel (No appointment necessary for outpatient studies)
 
00011 93005 EKG performed by Non-EKG Personnel
 
00037  
Rhythm ECG by EKG Personnel   00029 93041 Rhythm ECG by  Non-EKG Personnel   00045  
Transthoracic Echocardiogram (TTE)   00219 93307 Echo Stress Test     00276 93350
Cardiac Function (445)
Holter Monitoring (Call 404-616-4447 to schedule)
 
00031 93225 CV Exercise Stress Test  
 
30174 93017
Cardiac Event Recording (Call 404-616-4447 to schedule) 00056 93270          
EEG / EMG
Electromyography and Nerve
Conduction Studies (EMG)
        EEG       95860
Cardiovascular Lab  (446)   
Transesophageal Echocardiogram (TEE)
 
40076 93312 Dobutamine Stress Echo Test (DSE)
 
30150 93350
Cardiovascular Lab  (446)   Call 404-616-6719 For Scheduling Instructions
Prosthetic Valve Cine
 
01094 76000 Cardioversion  
 
01011 92960
Tilt Table Test     03660 93660          
OUTPATIENT ORDERS (unless otherwise noted)  
1) FAX Completed Order to 404-616-5090                 
2) Instruct patient to call 404-616-5800 #1 to schedule appointment     
INPATIENT ORDERS (unless otherwise noted)   Patient Label Here
1) Enter order into OAS Gold    
2) Place signed and dated order in Medical Record