Patient Referral
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Today’s Date
Referring Physician
Name
2121 Midpoint Dr., Suite 223
Fort Collins, CO 80525
Practice Name
Phone: (303) 390-1717
Fax: (303) 390-1717
(
)
Phone #
Patient Information
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Male
Female
Patient Name
Date of Birth
(mm/dd/yyyy)
Address
City, ST Zip
(
)
Preferred. Phone #
Email
Requested Tests
(CPT Code)
Duplex Scan of Extracranial Arteries
Limited AAA Study (76705)
Echocardiogram (93306)
(Carotid IMT) (93880)
Ankle Brachial Index (93923
Thyroid Ultrasound (76536)
Reason for Visit
Thyroid
Carotid
Echo (cont’d)
RIGHT Carotid Artery occlusion and stenosis
I65.21
Unspecified atrial flutter
I48.92
Abnormal results of thyroid function studies
R94.6
I65.22
Left anterior fascicular block
I44.4
LEFT Carotid Artery occlusion and stenosis
Iodine-deficiency related (endemic) goiter
E01.2
BILATERAL Carotid Artery occlusion and stenosis
I65.23
Left posterior fascicular block
I44.5
E04.9
Nontoxic goiter
Unspecified fascicular block
I44.60
UNSPECIFIED Carotid Artery occlusion and stenosis
I65.29
E06.0
Acute thyroiditis
Atherosclerotic heart disease of native coronary artery
I25.10
Other fascicular block
I44.69
Localized swelling, mass and lump, neck
R22.1
Other restrictive cardiomyopathy
I42.5
Coronary ATHEROSCLEROSIS due to lipid rich plaque
I25.83
Nontoxic single thyroid nodule
E04.1
Coronary ATHEROSCLEROSIS due to calcified coronary lesion
I25.84
Other cardiomyopathies
I42.8
Includes: Colloid nodule (cystic) (thyroid) Nontoxic
Intercostal pain
R07.82
uninodular goiter Thyroid (cystic) nodule NOS
ATHEROSCLEROSIS - right leg
I70.201
I70.202
Other chest pain
R07.89
ATHEROSCLEROSIS - left leg
AAA
I50.9
ATHEROSCLEROSIS - bilateral legs
I70.203
Heart failure, unspecified
I71.3
Abdominal Aortic Aneurysm, ruptured
Q20.9
ATHEROSCLEROSIS - other extremity (arms)
I70.208
Congenital malformation of cardiac chambers and connections
Abdominal Aortic Aneurysm, without rupture
I71.4
Q24.9
ATHEROSCLEROSIS - unspecified extremity
I70.209
Congenital malformation of heart, unspecified
R10.9
Abdominal Pain
System. lupus erythematosus, organ or system involve. unspec. M32.10
ATHEROSCLEROSIS of aorta
I70.0
Acute kidney failure
N17.9
Z82.49
Old Myocardial Infarction
I25.2
Family History of ischemic disease / diseases of the
ATHEROSCLEROSIS of aorta
circulatory system
I70.0
Other transient cerebral ischemic attacks
G45.8
Essential (primary) hypertension
I10
I38
Endocarditis, valve unspecified
G45.9
Transient cerebral ischemic attack, unspecified
Right upper quadrant abdominal lump
R19.01
R94.31
Abnormal electrocardiogram [ECG] [EKG]
Other cerebrovascular vasospasm and vasoconstriction
I67.848
Left upper quadrant abdominal lump
R19.02
I37.0
Nonrheumatic pulmonary valve stenosis
Other forms of angina pectoris
I20.8
Right lower quadrant abdominal lump
R19.03
I37.8
Other nonrheumatic pulmonary valve disorders
Carotid Artery Aneurysm
I72.0
R19.04
Left lower quadrant abdominal lump
R50.9
Fever, unspecified
Carotid Artery Dissection
I77.71
Nicotine dependence
F17.200
R01.1
Migraine (see ICD-10 for specific code)
G43.501
Cardiac murmur, unspecified
Personal history of nicotine dependence
Z87.891
Nonrheumatic mitral (valve) insufficiency
I34.0
Syncope and collapse
R55
I34.8
I10
Other nonrheumatic mitral valve disorders
Essential (primary) hypertension
ABI
I95.1
Pure hypercholesterolemia
E78.0
Orthostatic hypotension
Abdominal Aortic Aneurysm, ruptured
I71.3
Acute pulmonary edema
J81.0
Mixed hyperlipidemia
E78.2
Abdominal Aortic Aneurysm, without rupture
I71.4
Other symptoms and signs involv. the musculoskeletal system R29.898
Other hyperlipidemia includ. familial combined hyperlipidemia
E78.4
ATHEROSCLEROSIS - right leg
I70.201
Palpitations
R00.2
Hyperlipidemia, unspecified
E78.5
I70.202
ATHEROSCLEROSIS - left leg
Disease of pericardium, unspecified
I31.9
I70.203
ATHEROSCLEROSIS - bilateral legs
Echo
Heart failure, unspecified
I50.9
I70.208
ATHEROSCLEROSIS - other extremity (arms)
Old MYOCARDIAL Infarction
I25.2
Shortness of breath
R06.02
ATHEROSCLEROSIS - unspecified extremity
I70.209
Syncope and collapse
R55
Nonrheumatic aortic (valve) stenosis
I35.0
ATHEROSCLEROSIS of aorta
I70.0
Tachycardia, unspecified
R00.0
Nonrheumatic aortic (valve) insufficiency
I35.1
Peripheral vascular disease, unspecified
I73.9
Nonrheumatic aortic (valve) stenosis with insufficiency
Transient cerebral ischemic attack, unspecified
G45.9
I35.2
Pain in unspecified limb
M79.609
Other nonrheumatic aortic valve disorders
I35.8
Other cerebrovascular vasospasm and vasoconstriction
I67.848
Arterial fibromuscular dysplasia
I77.3
Nonrheumatic aortic valve disorder, unspecified
I35.9
Nonrheumatic tricuspid (valve) stenosis
I36.0
R09.89
Other specified symptoms and signs involving the
Unspecified atrial fibrillation
I48.91
Other nonrheumatic tricuspid valve disorders
I36.8
circulatory and respiratory systems
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