Ultrasound Exam Ordering Guide

If you are unsure which US Abdomen is appropriate for your patient, you can search "US Abdomen Order Guide" in APEX. It will list the details of each exam type: 

Order US Abdomen Limited* (includes main portal vein Doppler) for the following:

• RUQ pain (gallstones, biliary / pancreatic questions)
• Diffuse liver disease (fatty liver, abnormal LFT's)
• LUQ pain (splenic evaluation)
• Suspect pyloric stenosis, malrotation, intussusception, necrotizing enterocolitis, ascites
• Groin/inguinal hernia evaluation

Order US Appendix (RLQ) for appendicitis evaluation. (For ovarian torsion, please order pelvic US with Doppler in addition)
 
Order US Liver HCC Screening for HCC screening (outpatient)
 
Order US Abdomen Limited* with Doppler for the following:

• Pre and Post Liver Transplant
• TIPS evaluation
• Any Hepatic / Splenic vasculature assessment

 
Order US Abdomen Limited* with Elastography** for the following:

• Diffuse liver disease (fatty liver, abnormal LFT's) with concern for advanced fibrosis/cirrhosis

**To be performed as outpatient only, unless there is attending radiologist approval. Patients must be fasting for 4-6 hours.  
 
*US Abdomen Limited includes targeted evaluation of the abdomen (i.e. RUQ - – liver, gallbladder, main portal vein, pancreas, right kidney).
US Abdomen Complete includes evaluation of all solid abdominal organs (liver, gallbladder, main portal vein, pancreas kidneys, spleen, bladder). It is an “US Abdomen Limited” exam plus left kidney, spleen, and bladder evaluation. Spleen measurement is often added to abdomen limited if history suggests cirrhosis. 

WHEN to order a thyroid ultrasound

• Thyroid ultrasound is considered the gold standard imaging test for characterization of thyroid nodules.
• Incidental thyroid nodules are associated with up to 11% risk of malignancy. If multiple nodules are present, each nodule has an independent risk of malignancy.
• Thyroid ultrasounds are recommended for incidental nodules based on patient age, nodule size, and risk criteria as defined by the American College of Radiology.¹
• The decision to pursue evaluation of an incidental nodule also depends on patient’s clinical situation and goals of care.

HOW to order a thyroid ultrasound

• In Epic, order US Neck/Parathyroid/Thyroid (IMG1072)
  • This exam includes visualization and evaluation of the entire thyroid gland and bilateral cervical lymph nodes.
  • Any nodules will be characterized with further recommendations based on the American College of Radiology TI-RADS guidelines.²
• DO NOT order “US Biopsy Thyroid, Bilateral” (IMG2882) or “US Thyroid/Parathyroid Biopsy” (IMG2866). These orders are reserved for ultrasound-guided biopsies/FNA of the thyroid.

References:

1. Managing Incidental Thyroid Nodules Detected on Imaging: White Paper of the ACR Incidental Thyroid Findings Committee
2. ACR Thyroid Imaging, Reporting and Data System (TI-RADS): White Paper of the ACR TI-RADS Committee - Journal of the American College of Radiology (jacr.org)

For biopsies or other ultrasound-guided procedures, place a referral or consult - IP Consult for inpatient setting or Ambulatory
Referral for outpatient setting.

All patient orders regardless of the code can be found and change/cancelled under ANCILLARY ORDERS 

With the exception of a few procedures below, providers cannot place modality-specific procedure requests. The referral/consult requests will be reviewed by the radiologist and changed to the appropriate modality-, site-specific procedure. 

The general radiology ordering guide is available here:  APeX Guide for Placing Radiology Orders

• Hysterosonogram
• HyCoSy
• Fluoroscopic HSG

For most evaluations of the uterus and adnexa, it is usually most appropriate to order US Complete pelvic anatomy, female, transabdominal and endovaginal imaging.

• Order US Hysterosonogram IMG2875 if you are specifically interested in characterizing endometrial abnormalities (e.g., polyp, submucosal fibroid). Additional details below.
• Order US Hysterosonogram with CONTRAST ENHANCED IMG6311, also known as Hysterosalpingo Contrast Sonography (HyCoSy), to evaluate the endometrium as well as the fallopian tubes.
• A fluoroscopic HSG (FL Hysterosalpingogram (aka HSG)) IMG166 can be ordered to evaluate for uterine cavity and fallopian tube abnormalities. If fluoroscopic HSG is unavailable, US Hysterosonogram with CONTRAST ENHANCED (HyCoSy) IMG6311 can be performed as an alternative. Both FL Hysterosalpingogram and HyCoSy can evaluate tubal patency (“tube check”). Additional information below.

US Hysterosonogram (US HSG) - IMG2875 

This exam has two parts: a pelvic US followed by transvaginal US with distension of the uterine cavity (aka saline-infused sonohysterogram). A catheter is inserted through the cervical os to the uterine cavity, and the uterine cavity is distended with sterile saline. Distention of the uterine cavity allows better assessment of the endometrium and potential abnormalities such as polyps or submucosal fibroids. A common indication for this test is abnormal uterine bleeding.

• Contraindications: Active pelvic infection or untreated sexually transmitted infection, possible pregnancy
• Timing: 7-11 days after the beginning of a menstrual period

Patients may be referred to the UCSF web page “Preparing for an US Hysterosalpingogram (HSG) Exam” for additional information.

More information is available at: https://www.radiologyinfo.org/en/info/hysterosono

Fluoroscopic Hysterosonogram (FL HSG) - IMG166

Fluoroscopic HSG is an examination of the uterus and fallopian tubes using a special form of x-ray called fluoroscopy and iodinated contrast material. The main purpose of the exam is to evaluate the shape or inner cavity of the uterus and for tubal obstruction and/or hydrosalpinx. A catheter is inserted into the uterine cavity (see US HSG above) and contrast is injected into the uterine cavity and fallopian tubes.

• Contraindications: Pregnancy or possible pregnancy, active pelvic infection or untreated sexually transmitted infection, allergy or allergic-like reaction to iodinated contrast
• Timing: 7-10 days after the beginning of a menstrual period

Patients may be referred to the UCSF web page “Preparing for a Fluoroscopic Hysterosalpingogram (HSG) Exam” for additional information.

US Hysterosonogram (US HSG) with CONTRAST ENHANCED aka Hysterosalpingo-Contrast Sonography (HyCoSy) - IMG6311

In recent years, ultrasound with an intra-cavitary ultrasound contrast agent has been added as an alternative to fluoroscopic HSG. Hysterosalpingo-Contrast Sonography (HyCoSy) involves instilling ultrasound contrast through a transcervical catheter to assess the uterine cavity for filling defects and for tubal patency. Like US hysterosonogram and fluoroscopic HSG, the exam is minimally invasive with rare complications. Advantages include the lack of ionizing radiation and more comprehensive evaluation with ultrasound evaluation of the uterus, endometrial cavity, ovaries, fallopian tubes, and pelvis in one setting.

HyCoSy PPT info sheet 1.14.20 UCSF Medical Center.pdf

• Contraindications: Pregnancy or possible pregnancy, active pelvic infection or untreated sexually transmitted infection, allergy or allergic-like reaction to the microbubble contrast agent Lumason© or Polyethyl glycol (PEG)
• Timing: 7-11 days after the beginning of a menstrual period

Patients may be referred to the UCSF web page “Preparing for a Hysterosalpingo-Contrast Sonography (HyCoSy) Exam” for additional information.

MSK & Neuro Ordering Guidelines for Physicians.pdf

The correct exam to order for evaluation of a palpable abnormality, such as localized swelling or mass, is US Soft Tissue (Radiology Performed) (Mass or Lump Evaluation) - Procedure Code: IMG6330. This includes ultrasound of the extremities (arm and leg). 

• Ultrasound Musculoskeletal (Joint/Tendon/Muscle) - Procedure Code: IMG6208 offers detailed ultrasound evaluation of joints (shoulder, hip, knee, ankle), tendinous or ligamentous structures (e.g. flexor/extensor tendons of the hand, hamstring tendons), or peripheral nerves. Examples of indications include: rotator cuff pathology, joint effusion, trigger/mallet finger, athletic pubalgia, median neuropathy, etc. These exams get scheduled with sonographers and radiologists with subspecialty musculoskeletal ultrasound training. 
• US Soft Tissue evaluation is intended for more general lumps and bumps, such as lipomas, abscess, fluid collections, or localized edema. This exam does not involve detailed, functional evaluation of tendons and ligaments.

Microbubble contrast agents can be injected to evaluate vessel or tube patency and characterize lesion enhancement. Ultrasound contrast agents (Lumason) are not nephrotoxic, as they contain gas, which is breathed out. Example indications include: assessment of renal or liver lesions, checking for perutaneous nephrostomy/ureteral patency, fallopian tube patency (HyCoSy), etc. They can be ordered as: US Abdomen Limited with Contrast IMG5488 or US Abdomen Complete with Contrast IMG5485. US Hysterosonogram with CONTRAST ENHANCED IMG6311 should be used for fallopian tube checks. Please call a radiologist to discuss the exam indication if you are uncertain if contrast is needed. 

US Hysterosonogram with CONTRAST ENHANCED IMG6311 ("HyCoSy") evaluates for fallopian tube patency under ultrasound. This procedure involves cannulating the cervix with an HSG catheter and instilling saline and ultrasound contrast agent. It can evaluate the endometrial lining and the fallopian tubes. This procedure will be performed by specially trained sonographers and radiologists. 

The correct exam to order to evaluate for breast abscess is US Chest/Mediastinum IMG521. This exam is intended for urgent or acute cases of suspected infection. This exam will be performed by the ultrasound section, rather than the breast imaging center. If you have any concern for a breast mass, please refer the patient to our breast imaging department.

Both Interventional Radiology and Ultrasound services can perform percutaneous drainage of an abscess, but only IR will place a drainage catheter for ongoing drainage. For ultrasound, this order is US Guided Abscess Drain IMG508 - this includes percutaneous aspiration of the abscess under ultrasound guidance. For placement of drainage catheters, please consult Interventional Radiology. 

Arterial Duplex or Doppler ultrasounds are performed by the Vascular Lab at UCSF.
Please select one of the following:

• Vascular Lab US Abdominal Imaging (Aorta/Renal/Mesenteric)
• Vascular Lab US Cerebrovascular Imaging (Carotid Arteries/TCD)
• Vascular Lab US Extremity Arterial (Imaging/Pressures)

These arterial Doppler exams are NOT performed by Radiology at UCSF.

Contact the Vascular Lab with questions about vascular ultrasound.