Orthopedics Sports Medicine Referral Guidelines | Patient Referrals | UC Davis Heatlh

Reason for Referral

• Oncology and Tumors

Required Medical Records

• History and physical (H&P) or 
• Visit notes related to reason for referral 
• X-ray, CT scan or MRI of body part in concern

Requested CPT Codes

• 99205 x 1
• 99245 x 5
• 99215 x 5
• 98007 x 5

Reason for Referral

• Sacrum and Pelvic

Required Medical records

• History and physical (H&P) or 
• Visit notes related to reason for referral  
• Recent (3 months) of X-rays of sacrum or pelvis

Requested CPT Codes

• 99205 x 1
• 99245 x 5
• 99215 x 5
• 98007 x 5

Reason for Referral

• Lower Extremities
• Leg and Knee

Required Medical Records

• History and physical (H&P) or
• Visit notes related to reason for referral 
• Recent (3 months) of X-rays of knee/leg
• **MRI needed for ACL or PCL

Requested CPT Codes

• 99205 x 1
• 99245 x 5
• 99215 x 5
• 98007 x 5
• 73564 x 1

Reason for Referral

• Hips

Required Medical Records

• History and physical (H&P) or
• Visit notes related to reason for referral 
• Recent (3 months) of X-rays of the hip

Requested CPT Codes

• 99205 x 1
• 99245 x 5
• 99215 x 5
• 98007 x 5
• 73502 x 1

Reason for Referral

• Foot and Ankle 

Required Medical Records

• History and physical (H&P) or 
• Visit notes related to reason for referral
• Recent (3 months) of X-rays of the ankle or foot injured

Requested CPT Codes

• 99205 x 1
• 99245 x 5
• 99215 x 5
• 98007 x 5
• 73600 x 1
• 73610 x 6
• 73620 x 3
• 73630 x 6

Reason for referral

• Upper Extremity
• Shoulder, Arm and Elbow 

Required Medical Records

• History and physical (H&P) or 
• Visit notes related to reason for referral 
• Recent (3 months) of X-rays of shoulder, arm, elbow, body parts impacted

Requested CPT Codes

• 99205 x 1
• 99245 x 5
• 99215 x 5
• 98007 x 5
• 73564 x 1

Reason for Referral

• Head Injuries

Required Medical Records

• History and physical (H&P) or 
• Visit notes related to reason for referral 

Requested CPT Codes

• 99205 x 1
• 99245 x 5
• 99215 x 5

Reason for referral

• Other compressive neuropathy

Required Medical Records

• History and physical (H&P) or 
• Visit notes related to reason for referral 

Requested CPT Codes

• 99205 x 1
• 99245 x 5
• 99215 x 5

Reason for Referral

• Hand and wrist

Direct the referral to the UC Davis Health Surgical Hand Service.

Reason for Referral

• Neck, back and spine-related 

Direct the referral to the UC Davis Health Spine Center.