Work Flow for Radiology Research Orders

Work Flow for Radiology Research Orders

PREPARATORY RESEARCH (OPTIONAL)

Purpose:

To understand what radiology services will be performed for a particular protocol. It is not uncommon that radiology services are not clearly detailed in the text of the protocol, potentially resulting in additional unanticipated charges at the point of service.

The Department of Radiology supports and encourages clinical research at UCDMC. Investigators (PIs) are encouraged to perform preparatory research in order to understand what Radiology services will be before submitting a new research/grant budget.Department of Radiology will provide you with their assessment of the required Radiology Services with CPT Codes.

• The Department of Radiology highly recommends the PI work with a specific radiologist to discuss the research study. This will help determine procedures required and assist with more accurate cost estimates. Department of Radiology will also assist with CPT/GL codes.

• Non-Routine Imaging Procedures: All research protocols/studies that involve non-routine imaging studies, e.g. studies involving modified acquisition, processing, analysis, display, and/or storage, must be reviewed and approved prior to study initiation.

To perform an evaluation of the Radiology Procedures please submit the following:

What to submit:

1. Research protocol
2. Research Procedure Request Form
3. Check box “Preparatory Research”
4. Fill only sections 1-10a
5. Signatures are not required

Send to:

Desirée Lazo

Administrative Research Coordinator, Department of Radiology,

4860 Y Street, ACC, Suite 3100; Sacramento, CA 95817

Phone: (916)734-3651

Work Flow for Radiology Research Orders

PROCEDURE REQUEST (MANDATORY)

Purpose:

Procedure Requests are approved by the Department of Radiology and stored on file. The EMR-based orders are compared with the request forms at the point of service. If the Procedure Request is not on file with Radiology, the service will not be performed.

1. Before beginning the Procedure Request form, you need to obtain DaFIS account, bulk account, and Signature account (for professional fees).The Signature account is opened by checking “Type of Charges: Professional” on the bulk account application form. These are necessary to complete the request form process.

1. What to Submit:

1. Completed Department of Radiology Research Procedure Request Form.

2. Copy of sponsor’s imagingprotocol or a summary of imaging procedures

requested. If the PI is uncertain of the exams necessary, he/she must contact a radiologist directly to obtain this information.

3. Copy of Human Subjects Review Committee (aka IRB) approval

4. Copy(s) of consent form(s)

5. Copy of the approved UCDMC bulk account application form with the DaFIS

account number. Signature Account is required for billing professional fees. The Signature account is opened by checking “Type of Charges: Professional”. For information on Bulk Accounts, contact Tom Rempfer at 734-9179, or .

ALL Radiology Research Procedure Request (Preparatory Research & Procedure Request) packets should be submitted to:

Desirée Lazo

Administrative Research Coordinator, Department of Radiology,

4860 Y Street, ACC, Suite 3100; Sacramento, CA 95817

Phone: (916)734-3651

Contact Information for Scheduling Radiology Research Orders

The Department of Radiology is often confused with the Radiation Use Committee (RUC) when it comes to the IRB request for an RUC approval letter. See for information regarding the RUC.

The Imaging Center is no longer under the direction of the Dept of Radiology. If you desire their services, you will need to contact them directly. This form may be used to request reads only on exams obtained at the Imaging Center, but not for the services themselves.)

DEPARTMENT OF RADIOLOGY

Research Procedure Request Form

Request Date: Preparatory Research(Please fill in 1-10a) Procedure Request(Please fill in 1-10b)

NOTE: The Department of Radiology will no longer provide services for human research patients without a valid UCDHS medical record number. It is the responsibility of the referring department to ensure that the patient is properly registered.

1. Principal Investigator: Dept. Ph/fax: Pager:

2. Contact Person: Dept. Ph/fax: Pager:

3. Alternate Contact Person: Dept. Ph/fax: Pager:

4. Physician on Study (if not PI): Dept. Ph/fax: Pager:

5. Has the PI discussed this study with a Radiology faculty member? If yes, please name radiologist:

6. Description generally the goals of the study (please be brief):

7. What exam(s) are you requesting of Radiology (include CPT code(s), if known).

 Location of study to be performed: Main Hospital ACC Other:

 Preferred time of study: AM Weekend Time requirements of procedure:

PM

 Modality requested: CT Diagnostic Interventional Nuclear Vascular Lab

MRI Ultrasound Mammo DEXA

8. Anticipated No. of Patients:

 # of exams per patient:

1. List any special requirements of Radiology services : none special reports special views new pulse sequences

Explanation for item(s) selected:

Image storage requested: Routine Procedure (Stentor) Film Videotape Disk DAT Special Formatting

Image transfer: yes To: no

10a. Type of Research requested: Does the PI want to receive a copy of the report? Yes No

10b. List Funding Source(s) for Radiology services: (if funding is pending, please note that next to category)

NIH Grant Private Sponsor Professional Society UCD/UCDMC Other (specify):

DaFIS Account No.: Bulk Account No.: Sub Acct.: IRB number

(If applicable)

Please return completed form to:Desirée Lazo, Administrative Research Coordinator, Department of Radiology, 4860 Y Street, ACC, Suite 3100; Sacramento, CA95817

; Phone: (916)734-3651