Scheduling Protocol Reference Manual · indigestion, hernia Projectile vomiting r/o pyloric...

© Truxtun Radiology Medical Group, L.P. Revised 03/2015

Scheduling Protocol Reference Manual


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Table of Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Locations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Equipment Weight Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Mammography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Ultrasound (diagnostic) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-7

Ultrasound (biopsies) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-9

Fluoroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10-14

CT (diagnostic) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15-17

CT (myelograms) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

CT Pre-medication protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

CT Lab work requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

CT Self referral studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

CT (angiograms) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

CT (biopsies) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21-22

MRI Scheduling Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

MRI Head / Neck / MRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

MRI Spine / MRA Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

MRI Upper Extremities / MRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

MRI Lower Extremity / MRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

MRI Chest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

MRI Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

MRI Abdomen / Pelvis / MRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

MRI Achilles Tendon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

MRI Brachial Plexus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

MRI Biceps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Nuclear Medicine Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30-34

Return to Table of Contents | Email a scheduling request

http://www.truxtunrad.com/schedule-request.html


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Riverwalk/ Nuclear Medicine

9900 Stockdale Hwy, Ste 100

Bakersfield, CA. 93311

(661) 325-6800

(661) 616-3509 Fax

Downtown

1817 Truxtun Avenue


(661) 325-6800

(661) 616-3509 Fax

Advanced MRI & CT Suite

1818 16th Street


(661) 325-6800

(661) 616-3509 Fax

Tehachapi

20960 Sage Lane

Tehachapi, CA 93561

(661) 325-6800

(661) 616-3509 Fax

Scheduling

(661) 616-1488 Direct

(661) 616-3509 Fax

Medical Records

(661) 616-1420 Direct

(661) 325-4734 Fax

Authorizations

(661) 616-3160 Direct (661) 616-3506 Fax

Billing Office

(661) 616-1460 Direct

Interventional Suite

9900 Stockdale Hwy, Ste 109


(661) 325-6800

(661) 616-3509 Fax

Taft

100 E North Street

Taft, Ca 93268

(661) 325-6800

(661) 616-3509 Fax




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To prevent patient inconvenience, please reference equipment limitations below, and schedule the patients accordingly.

Modality Downtown Advanced

Imaging River Walk Tehachapi Taft

CT Not Available 400 lbs. 380 lbs. Not available Not available

Fluoroscopy 300 lbs. Not available 300 lbs. Not available Not available

X-Ray 400 lbs. Not available 500 lbs. 300 lbs 300 lbs

Tomography Not available Not available 300 lbs. Not available Not available

MRI Not Available 350 lbs. 600 lbs. Not available Not available

Ultrasound 500 lbs. Not available 500 lbs. Not available Not available

Stereotactic 250 lbs. Not available Not available Not available Not available

DexaScan Not available Not available 300 lbs. Not available Not available

Arterial Study Not available Not available 400 lbs. Not available Not available

Nuclear Medicine 9900 Stockdale Hwy Suite #100 Bakersfield, California

Downtown Advanced Imaging

River Walk Tehachapi Taft

PET/CT Not available Not available 380 lbs. Not available Not available

MG 1 Not available Not available 380 lbs Not available Not available

MG 2 Not available Not available 380 lbs Not available Not available

Treadmill Not available Not available 180 lbs. Not available Not available




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Must have previous films for comparison

If patient has implants, or are physically challenged, please notify scheduling personnel to ensure appointment is scheduled accurately.

Please wear separate tops, as patient will need to undress from the waist up.

Avoid mammography exams immediately prior to menstruation cycle, the exam may be painful.

Patients with an identified lump or pain or nipple discharge should be scheduled for a “diagnostic” mammogram, not a “routine”.

PREP – No powder, deodorant, antiperspirant, perfume or lotions on or around the breasts

Exam Digital CPT Code Diagnosis Prep Digital Bilateral Routine G0202 See Above

Digital Implants Bilateral Routine G0202 See Above

Digital Bilateral Diagnostic G0204 See Above

Digital Implants Bilateral Diagnostic G0204 See Above

Digital Bilateral Magnification View (coned down compression)

G0204 See Above

Digital Unilateral Routine / Diagnostic G0206 See Above

Digital Unilateral Implant G0206 See Above

Digital Unilateral Magnification View (coned down compression)

G0206 See Above

Note: When diagnosis is lump or mass a Diagnostic Mammography and Breast Ultrasound are recommended. CAD _- Computer Aided Detection 77052 Screening Will be added to every Mammogram 77051 Diagnostic

Procedures

Labs needed 1 week prior to procedure: CBC, PT, PTT / No blood thinners (5) days prior / No aspirin (3) days prior

CPT Code Preps

Stereotactic Breast Biopsy Vacuum Assist Schedule at Downtown office

19281

Lesion – mass – microcalcifications not seen by ultrasound

Diagnostic Mammogram Labs – CBC, PT, PTT

Ductogram Schedule at Downtown office

19030 77053

Nipple Discharge Important: Patient is not to massage breast to induce discharge

Breast Wire Localization (Pre-Op) Note: Microcalcifications schedule under

Stereo.

19281

Microcalcifications, mass

NPO for surgery, Labs needed 1 week prior to procedure: CBC, PT, PTT. No blood thinners (5) days prior No aspirin (3) days prior Current mammogram




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Exam CPT Code Diagnosis Prep

Abdomen U/S 76700 Biliary tract disease, gall bladder disease, epigastric pain, abdominal pain, Upper right quadrant pain, indigestion, hernia Projectile vomiting r/o pyloric stenosis

NPO 6 hours prior to exam Bring infant hungry with a bottle

Abdomen – limited Axillary

76705

76882

Follow-up single organ NPO 6 hours prior to exam

Breast 76642 Unilateral, Limited

76641

Mass, lump, cyst, patient under 30 years of age prefer to have this exam

Must have previous mammography and ultrasound films available

Biophysical Profile 76819 Fetal distress, large/small for dates Drink 8 ounces apple juice 20 minutes prior to exam

Carotid 93880 TIA, stroke, stenosis, ischemia No prep

Chest 76604 Pleural effusion No prep; bring most recent chest x-ray

Duplex Arterial Doppler (legs) Note: Diagnosis PVD schedule at River Walk office.

93923 Peripheral vascular disease (PVD) claudication

No smoking or exercise 4 hours prior to exam

Duplex Arterial Doppler (arms) 93930 Cold hands No prep

Extremity 76880 Arm or leg lump, mass, aneurysm No prep

Follicular Study 76856-1 76856-3

Infertility, initial exam, follow-up exam Schedule 12 days from onset of menses

Hips (infant) 76885 Hip displacement (hip click) For ages 0-6 months; bring infant hungry with bottle

Intracranial Neonatal 76506 Intracranial bleed / fluid No prep

Kidney 76770 Hematuria, UTI; renal stone, renal colic, hydronephrosis, kidney cyst

Drink 32 ounces of water (1) hour prior to exam and do not empty bladder.

Aorta / Kidney 76770 Abdominal Aortic Aneurysm NPO 6 hours prior to exam. May have clear liquids

Neck Soft Tissue; Thyroid 76536 Thyroid disease; neck mass, soft

tissue mass No prep

Obstetrical < 14 wks

each additional gestation

76801 76802

Size/dates, anomaly, bleeding Fetal and maternal evaluation

Drink 48 ounces of water (1) hour prior to exam and hold

Obstetrical < 14 wks Early OB

76801 Size/dates, anomaly, bleeding Fetal and maternal evaluation





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Obstetrical > 14 weeks

Second Trimester each additional gestation

76805 76810

Size/dates, anomaly, bleeding Fetal and maternal evaluation


Exam CPT Code Diagnosis Prep

Obstetrical 4D Note: Schedule at River Walk facility only

76811 Cash pay only, not diagnostic, must have had previous OB ultrasound

Must be 24-32 weeks pregnant, 48 ounces of water (1) hr prior and hold

Obstetrical / Transvaginal 76817 Abnormalities; early OB No prep

Pelvic (ovaries) 76856 Pain, mass, ectopic pregnancy, dysfunctional bleeding, fibroids, hernia, cyst


Spinal Canal (Infant) 76800 Spinal defect / dimple No prep

Testicular 76870 Torsion, mass, pain, swelling, Undescended teste

No prep

Transvaginal 76830 Rule out ectopic pregnancy, molar pregnancy, abnormalities, cyst, fibroids

No prep; unless pelvic prior (see pelvic prep if applicable)

Unlisted 76999 No prep

Any body part not otherwise

Specified

Vein Mapping Upper Extremity 93970 For Dialysis No prep

Venous Doppler Arterial Doppler

93970

DVT, cellulitis, calf tightness PVD, PAD

No prep

Venous Doppler Insufficiency Evaluation

93970

Reflux Consultation

No prep




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All biopsy exams require pre-procedure lab work

All patients are to have a CBC, PT, and PTT within (1) week of the procedure; radiologist may waive the lab requests in selected patients

Patients can eat prior to biopsy procedures

Patients must be off blood thinners (5) days prior

Patients must not take aspirin (3) days prior

Consult for all biopsy procedures CPT to be used 99241

Biopsy CPT Code Description / Procedure

US Abscess, Percutaneous, Drainage 49041 75989

Percutaneous abscess drainage Guidance w/placement catheter

US Biopsy Abdomen, Percutaneous, Needle

49180 76942

Biopsy abdomen or retroperitoneal mass Guidance for needle placement

US Aspiration of Renal Cyst or Breast 19000 76942

Puncture Aspiration of cyst Guidance for needle placement

US Aspiration of Renal Cyst or Pelvis 50390 76942

Aspiration renal cysts or pelvis Guidance for needle placement

US Aspiration of Thyroid Cyst 60001 76942

Aspiration thyroid cyst Guidance for needle placement

US Breast Needle Wire Localization – pre-operative 1 location US Breast Needle Wire Localization – pre-operative 2 location

19285

G0206

19285

19286 G0206

Pre-operative placement of needle localization wire, breast Digital diagnostic unilateral mammogram Pre-operative placement of needle localization wire, breast Additional location Digital diagnostic unilateral mammogram

US Biopsy Breast, 1 Location

19083 G0206

Biopsy breast needle core percutaneous Guidance for needle placement

US Biopsy Breast , 2 Locations 19083 19084 G0206

Biopsy breast needle core percutaneous Additional location Digital diagnostic unilateral mammogram




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Exam CPT Code Description / Procedure

US Biopsy Extremity Soft Tissue 20206

76942

Biopsy muscle percutaneous needle Guidance for needle placement

US Biopsy Lymph Node Superficial 38505 76942

Biopsy lymph node by needle (superficial) Guidance for needle placement

US Biopsy Neck / Thorax Soft Tissue 21550 76942

Biopsy soft tissue neck or thorax Guidance for needle placement

US Paracentesis Abdomen 49080 76942

Abdominal paracentesis Guidance for needle placement

US Thoracentesis 32555

71010 71010

Thoracentesis puncture of pleural cavity for aspiration Chest x-ray single view / pre procedure Chest x-ray single view / post procedure

US Biopsy Thyroid 60100 76942

Biopsy thyroid Guidance for needle placement




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Oral Gastrograffin should be given when there is a suspicion of bowel perforation and it is important to specify when Gastrograffin in indicated

Patients preferably should not have a Barium Enema the day after an UGI Series, Barium Swallow,

Small Bowel Series. Should not have UGI, Small Bowel the day after a Barium Enema

Patient scheduled for a small bowel series will be required to be at the imaging facility 2-4 hours

Patients scheduled for lumbar epidural and myelograms will be at the imaging facility 2-4 hours and will be required to lay flat for the remainder of the day with limited mobility (using restroom is fine)

Patients scheduled for spinal puncture will be required to remain at the imaging facility 2-4 hours

Patient who have had non-life threatening allergic reactions to IV contrast must be pre-medicated

reference page 14

Patient scheduled for IV contrast studies are required to have lab work prior to the exam

Exam CPT Code Diagnostic Prep

Arthrogram, Ankle 73615

27648 Tear or lesion, history of joint pain, locking or limited range of motion

No blood thinners (5) days prior No aspirin (3) days prior

Arthrogram, Hip 73525 27093

Tear or lesion, history of joint pain, locking or limited range of motion


Arthrogram, Knee 73580 27370



Arthrogram, Shoulder 73040 23350



Arthrogram, Wrist Note: Radiologist protocol arthrogram joint injections should be scheduled W arthrogram injection only.

73115 25246



Aspiration / Injection ankle, elbow and wrist

Note: fax orders to imaging office

for lab specimen

20605 77002

Fluid in joint, joint pain Requires labs: CBC, PT, PTT to be Done within (7) days of procedure. No blood thinners 3 days prior, no aspirin (5) days prior

Aspiration / Injection hip, knee and shoulder

Note: fax orders to imaging office

for lab specimen

20610 77002

Fluid in joint, joint pain Requires labs: CBC, PT, PTT to be Done within (7) days of procedure. No blood thinners 3 days prior, no aspirin (5) days prior




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Barium Enema

Note: if patient has colostomy

instruct patient to bring extra colostomy bag.

74270 Incomplete colonoscopy, cancer, pain, Diverticulitis, blood in stool, chronic diarrhea, anemia, change in bowel habits

2 day bowel prep required. Prep kit to be picked up (3) days prior to procedure.

Barium Enema with Air

Note: if patient has colostomy

instruct patient to bring extra colostomy bag.

74280 Incomplete colonoscopy, cancer, pain, Diverticulitis, blood in stool, chronic diarrhea

2 day bowel prep required. Prep kit to be picked up (3) days prior to procedure. Hirschsprungs Disease NO PREP

Cholangiography, T-tube, Post Op 47505 74305

Status Post gallbladder removal, Gallstones in common duct

No prep

Cholangiography, Percutaneous, Transhepatic

47500 74320

NPO (6) hours prior to exam No blood thinners (5) days prior No aspirin (3) days prior

Cisternography Note: Patient may remain at

imaging center (2) hours post procedure

70015 NPO (4) hours prior No blood thinners (5) days prior Off Plavix at least (7) days prior No aspirin (5) days prior

VCUG, Retrograde Cystogram 74430 No Prep

Esophagram or Barium Swallow Note: No prep if STAT Study

74220 Difficulty swallowing, cough, acid reflux, GERD

NPO (6) hours prior. If bottle fed infant, must bring extra disposable bottle

Fistula, Abscess, Sinus Tract Study

76080 49424 76080

Fistula, Abscess No Prep

Hysterosalpingogram (HSG) 74740 58340

Infertility, blockage, essure placement Schedule on 10th

to 12th after

onset of menstrual cycle, no intercourse 24 hours prior

Lab Band Adjustment Schedule at River Walk

43999 76000

74240

Status Post Lab Band procedure Nothing to eat or drink from midnight prior to procedure.

Patients scheduled for lumbar epidural and myelograms will be at the imaging facility 2-4 hours and will be required to lay flat for the remainder of the day with limited mobility (using restroom is fine)




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Lumbar Epidural Note: Patient to remain at imaging

center (2) to (4) hours following procedure. Patient will be required to have a driver. Patient must lie on back for the remainder of the day

62311 77003

Back pain No blood thinners (5) days prior No aspirin (3) days prior Confirm there is no history of contrast allergy

Myelogram, Cervical Note: Patient to remain at imaging


62302 Herniated disc, stenosis, mass, tumor, infection, lesion

No blood thinners (5) days prior No aspirin (3) days prior Confirm there is no history of contrast allergy

Myelogram, Thoracic Note: Patient to remain at imaging




Myelogram, 2 or more regions Note: Patient to remain at imaging




PICC Placement Note: Lab requirements may be

waived by radiologist

36569 76937 77001 71010

Administering antibiotics, IV feeding or frequent blood draws

Labs required: CBC, PT, PTT No blood thinners (5) days prior No aspirin (3) days prior Patient needs to be well hydrated (16 ounces water prior to exam)




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Porta Cath Study Note: Must follow IV contrast

guidelines, requires lab work BUN and Creatinine.

36005 76000

Check patency, cannot inject or Cannot pull back

No blood thinners (5) days prior No aspirin (3) days prior Patient must have Huber needle in place.

Sialogram 70390 42550

Evaluation of salivary ducts Patient must bring small lemon for procedure

Small Bowel (SBFT) Note: Patient will be required to be

at imaging center 2-6 hours

74250 Obstruction, constipation, abdominal pain, anemia

NPO as of midnight prior to exam

Sniff Test 76000 Evaluation of diaphragm No Prep

Spinal Puncture, Lumbar (spinal tap) Note: Fax special order

Patient may be required to remain at imaging center up to (2) hours post procedure

62270 77003

Meningitis Labs required: CBC, PT, PTT (7) days prior to procedure No blood thinners (5) days prior No aspirin (3) days prior NPO (6) hours prior to procedure

UGI, with air, without KUB 74246 Reflux, GERD, abdominal pain, ulcer, Tumor, hiatal hernia, blockage, difficulty swallowing

NPO from midnight before exam If infant is bottle-feeding must bring infant hungry with a disposable bottle.

UGI with Small Bowel

Note: Patient may be in imaging

center up to (6) hours

74249 Reflux, GERD, abdominal pain, ulcer, Tumor, hiatal hernia, blockage, difficulty swallowing

NPO from midnight before exam If infant is bottle-feeding must bring infant hungry with a disposable bottle.

Urography, Info/Bolus 74410 2 day prep required – prep kit to be picked up (2) days prior.

Urography, Antegrade, Loopogram Note: Patient to provide additional

urine bag

74425 No prep

Urethrocystography 74450 No prep

Venogram – unilateral

Note: Patient must have already had

positive venous doppler, requires lab work BUN and Creatinine

36005 75820 76000

Blood Clots Requires BUN & Creatinine prior Confirm there is no history of contrast allergy




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Venogram – bilateral Note: Patient must have already had

positive venous doppler requires lab work BUN and Creatinine

36005 75820 76000

Blood Clots Requires BUN & Creatinine prior Confirm there is no history of contrast allergy

Voiding Urethrocystography (VCUG) 51600 74455 76000

VU reflux, UTI, blockage to the bladder, incomplete emptying of bladder

No prep

Premedication Protocol: Guidelines for pre-treatment of patients who have had non-life threatening allergic reactions to IV contrast agents.

50 mg prednisone PO 13 hours prior to procedure.


50 mg prednisone PO plus a single dose of 50 mg of benadryl PO or IV 1 hour prior to procedure Lab work requirements for IV contrast: BUN, Creatinine within 30 day of procedure Lab work is required only if the patient meets any of the following criteria:

Any patient that is diabetic.

Any patient that has lupus.

All patients with congestive heart failure or heart disease.

If patient has renal disease.

Any patient who has only on kidney or prior kidney surgery

If a patient is on dialysis, in this case, exam preferably should be done same day as dialysis and before their dialysis treatment.

Any hospital patient

It is advised to avoid the use of the intravenous iodine contrast agents in patients with a history of

moderate to severe life threatening contrast reactions. In these instances, please contact the Radiologist

to discuss alternative imaging strategies.

If a patient currently takes any metformin products, such as but not limited to Glucovance, Glyburide,

Glucophage, Metaglip, Metformin/Glipizide or Avandament, inform the radiology scheduler to ensure proper

precautions.




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If 3D rendering is desired please specify on the referral.

Patients scheduled for CT myelogram exams cannot be on blood thinners or aspirin for 5 days prior to the scheduled exam. Patients and or scheduling personnel are requested to inform the referring physician of this protocol.

** Truxtun Radiology Medical Group recommend this exam as the preferred protocol.


Abdomen without 74150 76376

Renal stones NPO 4 hrs prior

Abdomen with contrast

74160 76376

Use w/wo; Use only if w/o done recently

NPO (4) hours prior to exam NPO requirement may be waived in STAT cases at radiologist’s discretion

**Abdomen with and without Note: with diagnosis of appendicitis

schedule Abdomen w/wo and Pelvis w

74170 76376

Pain, obstruction, cancer, mass, metastatic disease, pancreatitis, Liver disorders

NPO (4) hours prior to exam

** Cervical Spine without 72125 76376

Degenerative disc disease, arthritis, fracture

Be well hydrated

Cervical Spine with contrast 72126 76376

IV Contrast for mass Be well hydrated

Cervical Spine with and without 72127 76376

IV Contrast for mass, lump, lesion Be well hydrated

Head without 70450 Trauma, rule out bleed, headaches, macrocephaly

Be well hydrated

Head with contrast 70460 76376

Use w/wo Use only if w/o done recently Be well hydrated

Head with and without 70470 76376

Mass, cancer, lesion, severe headaches

Be well hydrated

**Lower extremity without Note: any part of leg or hip

73700 76376

Pain, fracture Be well hydrated

Lower extremity with contrast 73701 76376

Mass Be well hydrated

Lower extremity with and without 73702 76376

Mass, cancer Be well hydrated




16



** Lumbar spine without 72131 76376

Degenerative disc disease, fracture Be well hydrated

Lumbar spine with contrast 72132 76376

IV contrast for mass Be well hydrated

Lumbar spine with and without 72133 76376

IV contrast for mass, lump, lesion Be well hydrated

Neck without 70490 76376

Soft tissue neck, throat, larynx, pharynx Be well hydrated

** Neck with contrast 70491 76376

Mass, parotiditis, Lymphodenopathy Be well hydrated

Neck with and without 70492 76376

Mass, cancer Be well hydrated

Nephrogram

Note: Schedule Abdomen w/wo and

Pelvis w/wo contrast

74170 72193 76376

Hematuria, kidney stone, hydronephrosis of ureter


Pelvic without 72192 76376

Fracture NPO (4) hours prior to exam

**Pelvic with contrast 72193 76376

Metastatic disease, mass, pelvic pain NPO (4) hours prior to exam

Pelvic with and without 72194 76376

Appendicitis, or abdominal aortic aneurysm


Sella, Orbit, Posterior Fossa, Ear (outer, inner or middle) without Note: Mastoids are always without

contrast, Pituitary is always with contrast(better visualized in MRI w/wo contrast). Specify area of interest

70480 76376

Pituitary, Sella Turcica, Eye, Ear, Temporal Bones, Mastoids Elevated prolactin levels

Be well hydrated

Sella / Orbit with contrast 70481 76376

Mass, Cancer Be well hydrated

Sella / Orbit with and without 70482 76376

Mass, Cancer

Be well hydrated

Sinus without contrast (Maxillofacial) Note: Sinus study always scheduled

without contrast

70486 76376

Sinusitis, Sinus Polyp, deviated septum Fracture

Be well hydrated




17



Thorax (Chest) without contrast 71250 76376

Fibrosis, Interstitial Lung Disease, , Cough

Be well hydrated; also includes high resolution imaging for ILD

**Thorax (Chest) with 71260 76376

Pulmonary Embolism, Mass, Cancer, Nodule, Shortness of breath

Be well hydrated

Thorax (Chest) with and without 71270 76376

Pulmonary Embolism, Mass, Cancer, Nodule

Be well hydrated

**Thoracic Spine without contrast 72128 76376

Fracture, Degenerative Disc Disease, DJD

Be well hydrated

Thoracic Spine with contrast 72129 76376

IV Contrast for Mass Be well hydrated

Thoracic Spine with and without 72130 76376

IV Contrast for Mass, Lump, Lesion Be well hydrated

**Upper Extremity without contrast Note: Any part of arm or shoulder

73200 76376

Fracture, Pain Be well hydrated

Upper Extremity with contrast 73201 76376


Upper Extremity with and without 73202 76376


Urogram Note: Schedule Abdomen w/wo and

Pelvic w/wo contrast CT Nephrogram or Urogram

74178

Hematuria, kidney stone, kidney/ureter disorder


Virtual Colonoscopy Screening Virtual Colonoscopy Diagnostic With Contrast Virtual Colonoscopy Diagnostic Without Contrast

74263

74262

74261

Cancer, polyp, failed colonoscopy, diverticulitis, diverticulosis, chronic diarrhea Cancer, polyp, failed colonoscopy, diverticulitis, diverticulosis, chronic diarrhea Cancer, polyp, failed colonoscopy, diverticulitis, diverticulosis, chronic diarrhea

Bowel prep kit required. Prep kit must be picked up 3 days prior to scheduled exam Bowel prep kit required. Prep kit must be picked up 3 days prior to scheduled exam Bowel prep kit required. Prep kit must be picked up 3 days prior to scheduled exam

CT Abdomen and Pelvis Combo Codes CT Abdomen and Pelvis With Contrast 74177 CT Abdomen and Pelvis With and Without Contrast 74178 CT Abdomen and Pelvis Without Contrast 74176




18

** Truxtun Radiology Medical Group recommend this exam as the preferred protocol. If a CT myelogram is ordered, keep in mind this procedure consists of a spinal cord injection in fluoroscopy and is not IV Contrast. Patients will be at the imaging facility up to (4) hours following the procedure and these patients will be not be permitted to drive following the exam and will be required to have a driver available. These patients must lay flat on their backs for the remainder of the day.

Cervical Myelogram Note: Reference above

72126 62284 72240

Herniation of disc, stenosis, mass No aspirin (3) days prior No blood thinners (5) days prior

Thoracic Myelogram Note: Reference above

72129 62284 72255


Lumbar Myelogram Note: Reference above

72132 62284 72265


Pre-medication Protocol:

Guidelines for pre-treatment of patients who have had non-life threatening allergic reactions to IV contrast agents.

50 mg prednisone by mouth 13 hours prior to procedure.

50 mg prednisone by mouth 7 hours prior to procedure.

50 mg prednisone by mouth, plus a single dose of 50 mg of benadryl by mouth or IV 1 hour prior to procedure Lab work requirements for IV contrast: BUN, Creatinine within 30 days of procedure

Lab work is required only if the patient meets any of the following criteria:


Any patient that has lupus.

All patients with congestive heart failure or heart disease.


Any patient who has only on kidney or prior kidney surgery

If a patient is on dialysis, in this case, exam preferably should be done same day as dialysis and before their dialysis treatment.


It is advised to avoid the use of the intravenous iodine contrast agents in patients with a history of moderate to

severe life threatening contrast reactions. In these instances, please contact the Radiologist to discuss

alternative imaging strategies.

If a patient currently takes any metformin products, such as but not limited to Glucovance, Glyburide,

Glucophage, Metaglip, Metformin/Glipizide or Avandament, inform the radiology scheduler to ensure proper

precautions.




19

** Truxtun Radiology Medical Group recommend this exam as the preferred protocol. The following CT screening studies are available by self referral (Cash Pay Only)

Whole Body Screening CT Schedule at the River Walk office

Includes CT of chest, abdomen and pelvis

No Prep if non-contrast study

Coronary Artery Calcium Scoring Schedule at the River Walk office

No caffeine (12) hours prior No smoking (8) hours prior

CT Lung Screening No Prep

CT Brain Screening No Prep

CT Virtual Colonoscopy 48 hour bowel prep required; prep kit must be picked up (3) days prior to exam

Whole Body and CACS Schedule at the River Walk office

NPO (4) hours prior No caffeine (24) hours prior No smoking (8) hours prior

CT Angio Coronary Schedule at the River Walk office

NPO (4) hours prior No caffeine (12) hours prior No smoking (8) hours prior




20


Abdomen Angiography 74175

Hypertension, renal disease, ischemic bowel disease, abdominal aortic aneurysm

NPO (4) hours prior

Chest Angiography 71275

Aneurysm, chest pain Dissection ( needs to include abdomen)

NPO (4) hours prior

Head Angiography 70496

Aneurysm, headache, bleed NPO (4) hours prior

Heart Angiography Coronary Schedule at the River Walk office Note: Pre- op Ablation

75572

Chest pain, coronary artery disease, calcification, no prior surgery

Need average resting heart rate Bring list of medications Patient to bring beta blocker Arrive (1) hour prior to exam NPO (4) hours prior No smoking (24) hours prior No caffeine (24) hours prior

Heart Angiography Coronary Schedule at the River Walk office

75574

Chest pain, coronary artery disease, calcification, with prior surgery

Need average resting heart rate Bring list of medications Patient to bring beta blocker Arrive (1) hour prior to exam NPO (4) hours prior No smoking (24) hours prior No caffeine (24) hours prior

Lower Extremity Angiography Note: Most commonly will need

abdomen and pelvis included

73706

Peripheral vascular disease, leg pain, weakness, swelling, claudication, abnormal doppler studies

NPO (4) hours prior

Lower Extremity Angiography Angiography including abdomen and pelvis Schedule at the River Walk office

75635

Abdominal aortic aneurysm, peripheral vascular disease

NPO (4) hours prior

Neck Angiography Arch and Carotid

70498

Carotid stenosis NPO (4) hours prior

Pelvic Angiography 72191

Aneurysm NPO (4) hours prior

Upper Extremity Angiography 73206

Peripheral vascular disease, brachial artery syndrome

NPO (4) hours prior




21

All biopsy exams require pre-procedure lab work

All patients are to have a CBC, PT, and PTT within (1) week of the procedure

Patients to be NPO (4) hours prior to procedure

Patients must be off blood thinners (5) days prior

Patients must not take aspirin (3) days prior

Consult for all biopsy procedures CPT to be used 99241 Exam CPT Code Description / Procedure

Biopsy Abdomen Note: May use conscious sedation

49180 77012

Biopsy abdomen, percutaneous CT guidance for needle placement

Biopsy bone, trocar, or needle, superficial, Ilium, sternum, spinous process, ribs Note: May use conscious sedation

20220 77012

Biopsy bone, trocar, or needle, superficial CT guidance for needle placement

Biopsy Bone Deep Vertebral body, femur Note: May use conscious sedation

20225 77012

Biopsy bone deep CT guidance for needle placement

Biopsy Extremity Soft Tissue Note: May use conscious sedation

20206 77012

Biopsy muscle, percutaneous needle CT guidance for needle placement

Biopsy Liver Note: May use conscious sedation

47000 77012

Biopsy Liver, needle, percutaneous CT guidance for needle placement

Biopsy Maxillofacial Note: May use conscious sedation

10022 77012

Fine needle aspiration with imaging guidance CT guidance for needle placement

Biopsy Muscle Note: May use conscious sedation

20206 77012

Biopsy muscle, percutaneous needle CT guidance for needle placement

Biopsy Neck Soft Tissue Note: May use conscious sedation

21550 77012

Biopsy soft tissue of neck or thorax CT guidance for needle placement




22

Exam CPT Code Description / Procedure

Biopsy Pancreas Note: May use conscious sedation

48102 77012

Biopsy pancreas percutaneous needle CT guidance for needle placement

Biopsy Pelvic / Hip Deep Note: May use conscious sedation

27041 77012

Biopsy soft tissue pelvis/hip area deep Code will change to fit body part

Drainage Renal Abscess Note: May use conscious sedation

50021 75989

Drainage perirenal or renal abscess percutaneous CT guidance for percutaneous drainage

Biopsy Renal Note: May use conscious sedation

50200 77012

Biopsy renal percutaneous, trocar or needle CT guidance for percutaneous drainage

Biopsy Thorax / Lung Note: May use conscious sedation

32405 77012

Biopsy lung or mediastinum percutaneous needle CT guidance for needle placement




23

MRI patients that are claustrophobic (and require medication) must arrive 1 hour prior and must have a designated driver.

Patients scheduled for MRCP exams need to arrive 1 hour prior to scheduled appointment time to receive oral iron medication which is necessary for the exam.

Patients that have had previous back surgery and are scheduled for an MRI of the Thoracic or lumbar spine should be scheduled as a with and without study.

If scheduling a patient for any MRI joint with contrast – route must be indicated 0 intraarticular (in the joint) or intravenous (I.V.)

** Truxtun Radiology Medical Group recommends this exam as the preferred exam for protocol.

++ Additional scan is required BLUE: MRA Studies (Artery Studies)

Pre-medication Protocol: Guidelines for pre-treatment of patients who have had non-life threatening allergic reactions to IV contrast agents, although allergic reactions to IV contrast is extremely uncommon for MRI contrast.



50 mg prednisone PO plus a single dose of 50 mg of benadryl PO or IV 1 hour prior to procedure

Lab work requirements for IV contrast: BUN, Creatinine within 30 days of exam Lab work is required only if the patient meets any of the following criteria:

Any patient on dialysis.


All patients with severe liver disease.


Any patient who has only one kidney or prior kidney transplant

If a patient is on dialysis, in this case, exam must be done same day as dialysis and before their dialysis treatment.


If a patient is scheduled for an MRI upper or lower extremity JOINT with Arthrogram, patient should not take

any blood thinners or aspirin 5 days prior to exam. Patients should check with primary care physician prior to

discontinuing any blood thinners or aspirin.




24


Exam Head / Neck CPT Code Diagnostic Prep Brain without 70551 Headaches, lymphoma,

rule out metastasis No Prep

Brain with 70552 No Prep ** Brain with and without

70553 No Prep

Key Words: Posterior fossa, IAC (internal auditory canal) pituitary, temporal bones, sella, sella turcica

Note: Pituitary is always w & w/o

Orbit, Face, Neck without 70540 Diplopia (double vision) No Prep

Orbit, Face, Neck with 70542 mass, lesion, other indications as noted

No Prep

** Orbit, Face, Neck with & without 70543 No Prep

Key Words: Optic nerve, sinuses, soft tissue neck, tongue, parotid salivary glands, mandible, pharynx, thyroid,

facial bones, eyes, larynx, vocal cords, voice box, mouth

Spectroscopy (Brain Spect)

76390 Previous abnormal CT or MRI, mass

No Prep

Temporomandibular Joint(s) Note: Schedule TMJ studies at the Downtown office

70336 Popping or clicking of jaw No Prep

NOTE: MRI exams and MRA exams are to be scheduled on separate days

** MRA Head without 70544 Aneurysm, headaches No Prep MRA Head with 70545 No Prep MRA Head with & without 70546 No Prep Key Words: C.O.W. (Circle of Willis), MR vein, cranial arteries, basilar artery, brain vein

** MRA Neck without 70547 Syncope, dizziness, fainting, No Prep

MRA Neck with 70548 occlusion of carotid artery No Prep

MRA Neck with & without 70549 No Prep

Key words: Carotids, neck arteries, vertebral arteries




25


Exam Spine CPT Code Diagnostic Prep

** MRI C Spine without 72141 Neck pain, radioculopathy, No Prep MRI C Spine with 72142 numbness of upper extremity No Prep MRI C Spine with & without 72156 No Prep Key Words: Cervical, C1 to C7, ++brachial plexus++

** MRI T Spine without 72146 Numbness in chest area No Prep MRI T Spine with 72147 No Prep MRI T Spine with & without 72157 No Prep Key Words: Thoracic spine, dorsal spine, T1 to T 12

** MRI L Spine without 72148 Low back pain, radioculopathy No Prep MRI L Spine with 72149 No Prep MRI L Spine with & without 72158 No Prep Key Words: Lumbar, L-S spine, lumbar-sacral, L5 to S1, sacral area

MRA Spine with OR without Note: Schedule at Downtown site ONLY

72159 No Prep




26


***Radiologist protocol: Joints and extremities when ordered with IV contrast should be w & w/o IV contrast

Exam Upper Extremity CPT Code Diagnostic Prep

** MRI Upper Extremity JOINT without 73221 Pain in joint, tear, sports No Prep MRI Upper Extremity JOINT with 73222 injury, trauma No Prep MRI Upper Extremity JOINT With & without

Arthrogram, you must also use Fluoro Arthro Injection for sites.

73223 See Fluoro

Mass, infection, lesion, lump No Prep

Key Words: Shoulder, elbow, wrist, finger, thumb

** MRI Upper Extremity other than joint Without

73218

No Prep

MRI Upper Extremity other than joint With

73219 No Prep

MRI Upper Extremity other than joint With and without

73220 Mass, infection, lesion, lump No Prep

Key Words: Hand, forearm, ulna, radius, humerus, ++Biceps++ ++Triceps++

MRA Upper Extremity with OR without Note: Schedule at Downtown site ONLY

73225 Poor circulation, coldness of hands

No Prep

Exam Lower Extremity CPT Code Diagnostic Prep

** MRI Lower Extremity Joint without 73721 Tear, sports injury, trauma No Prep MRI Lower Extremity Joint with 73722 No Prep MRI Lower Extremity Joint With & without,

Arthrogram, uoe must also use Fluoro Arthro Injection for sites.

73723 See Fluoro

Mass, infection, lesion, lump No Prep

Key Words: Toe, ankle, knee, hip, ++Achilles tendon++ Note: Foot Specify which part of the foot

** MRI Lower Extremity other than joint without

73718 No Prep

MRI Lower Extremity other than Joint with

73719 No Prep

MRI Lower Extremity other than Joint with and without

73720 Mass, infection, lump. diabetic ulcer

No Prep

Key Words: Foot, metatarsals, tarsals, calcaneus, talus, tib-fib, tibia, fibula, femur, thigh, hamstring, quadriceps, calf

MRA Lower Extremity with OR without Note: Schedule at Downtown site ONLY

73725 PVD (peripheral vascular disease) PAD (peripheral artery disease) poor circulation, coldness of feet

No Prep

Key Words: Femoral artery, tibial artery, run offs, dorsalis pedis artery, popliteal artery




27


Exam Chest CPT Code Diagnostic Prep

MRI Chest without 71550 Mass, lesion No Prep MRI Chest with 71551 No Prep ** MRI Chest With & without 71552 No Prep Key Words: Hilar, mediastinal, thorax, sternum, clavicle, ribs, Sterno-clavicular joints

MRI Cardiac for Morphology/function w/o 75557 Heart mass No Prep MRI Cardiac for Morphology/function with

and without 75561 No Prep

No Prep

MRA Chest excluding myocardium

With OR without 71555 Aortic arch / Aortic Trunk

Schedule above @ downtown site ONLY Key Words: Heart, myocardium, pericardium, ventricles, atrium, valves, bicuspid valve, mitral valve, subclavian artery,

ascending aorta/descending aorta, brachiocephalic artery

Exam Breast CPT Code Diagnostic Prep

MRI Breast Unilateral (any of the following) 77058 Lump, pain, cancer, No Prep Without contrast abnormal mammogram With contrast abnormal Ultrasound With and Without contrast ** MRI Breast Bilateral (any of the following) 77059 Lump, pain, cancer, No Prep Without contrast abnormal mammogram With contrast abnormal Ultrasound With and Without contrast MRI Guided Breast Biopsy, 1 location

MRI Guided Breast Biopsy, 2 locations

19085

G0206

19085

19086 G0206

Biopsy breast needle core percutaneous Digital diagnostic unilateral mammogram Biopsy breast needle core percutaneous Additional location Digital diagnostic unilateral mammogram

Labs needed: CBC, PT, PTT, BUN, Creatinine Labs needed: CBC, PT, PTT, BUN, Creatinine




28


Exam Abdomen / Pelvis CPT Code Diagnostic Prep

MRI Abdomen without 74181 Mass, lesion, lump No Prep MRI Abdomen with 74182 No Prep ** MRI abdomen with & without 74183 No Prep Key Words: MRCP, kidneys, liver, pancreas, spleen, Biliary system/gallbladder

Note: MRCP is scheduled w/o contrast

MRA Abdomen with OR without 74185 aneurysm No Prep

Key Words: Kidneys, renals, IMA, SMA, inferior mesenteric artery, splenic artery, abdominal aorta, descending aorta,

superior mesenteric artery

MRI Pelvis without 72195 Mass, bleeding, cancer No Prep MRI Pelvis with 72196 of prostate No Prep ** MRI Pelvis with & without 72197 No Prep Key Words: Uterus, ovaries, bladder, prostate, rectum, scrotum, testes, penis, cervix

MRA Pelvis with OR without Note: Schedule at Downtown site ONLY

72198 aneurysm No Prep




29


Exam Miscellaneous CPT Code Diagnostic Prep ** MRI Achilles Tendon without contrast 73721

& 73718

Tear, pain, ruptured tendon No Prep

MRI Achilles Tendon with contrast 73722 &

73719


MRI Achilles tendon with & without contrast 73723

& 73720


** MRI Brachial Plexus without 72141

& 73221

Upper extremity atrophy, weakness of upper extremity

No Prep

MRI Brachial Plexus with 72142 &

73222


No Prep

MRI Brachial Plexus with and without contrast 72156 &

73223


No Prep

** MRI Bicep without contrast 73221

& 73218

Trauma, ruptured tendon No Prep

MRI Bicep with contrast 73222 &

73219


MRI Bicep with and without contrast 73223 &

73220





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All nuclear Medicine Studies may need multiple visits

Bone Scan – injection performed – patient to return 3 hours later for scan

Thyroid Scan – patient given oral dose – patient returns 6 hours later for scan and 24 hours later for scan

Gallium, Octreotide, MIGB, I131 – requires patient to return multiple days to finalize exam

The patients will be charged for radionuclide cost if the patient does not keep the appointment


Bone Scan, 3 Phase, inject patient take pictures, return 3-5 hours later to scan for 30 minutes Note: Usually done on upper and lower

Extremities. Hands- feet-ankles (5 hour delay for imaging) All others is 3 hour delay.

78315 A9561

Tumor, trauma, fracture, osteomyelitis, lesion

Patient needs be well hydrated

Bone Scan, Whole Body, inject patient, return 3-5 hours later for 1 hour scan

78306 A9561

Coccidiomycosis, valley fever, cancer, rheumatoid arthritis


Bone Spect, inject patient , return 3 hours later. Note: Usually done on Spine C, T. L

78320 A9561

Tumor, trauma, fracture, osteomyelitis, lesion


Cardiac Stress, iv injection, wait 20 minutes then resting pictures(20 minutes). Stress portion 20 minutes. Leave for 1 hour for lunch, return for 20 minutes for stress pictures. Approx time 3 – 3.5 hours total.

78452 93015 A9500 A9505

Chest pain, shortness of breath, angina, abnormal ECG, Pre-op

NPO 6 hours prior to exam No caffeine 24 hours prior If Dobutamine or exercise test, patient to be off beta blockers 24-48 hours prior to exam

Cisternogram, lumbar puncture under fluoro to inject isotope, wait 4 hours then scan for 30 minutes. Patient returns 24, 48, and possibly 72 hours post injection. Each scan takes 30 minutes each.

78630 61055 A9548 70015

Evaluation of cerebrospinal fluid flow in the spinal column, hydrocephalus, shunt obstruction or patency

No blood thinners 48 hours prior to exam

Gallium Lung, inject patient, return 48 hours later then scan 20 – 30 minutes and have a chest x-ray

78804 A9556

Pulmonary disorders

No prep




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Gallium Whole Body, inject patient, return 24 and 48 hours later, scan takes 1 hour each day.

78804 A9556

Detection of lymphoma, tumors, Hodgkin’s disease, fever of unknown origin, evaluation of abscess, osteomyelitis

No prep

Gastric Emptying Study Solid Study, patient eats food and takes first image then returns every hour for 4 hours, each image takes 1 minute.

78264 A9541

Evaluation of nausea, vomiting, and weight loss

NPO 6 hours prior to exam Patient to bring 2 hard boiled eggs and 2 slices of toast w/o butter , with jelly or jam

GI Bleed Study, draw blood – tagging process 30 minutes, image for 2 hours.

78278 A9512

Detection of gastrointestinal bleed No Prep

Hemangioma, draw blood – tagging process 30 minutes then image for 1 hour, patient leaves returning 1 ½ hours later for imaging 30 minutes .

78140 A9560

Hemangioma No Prep

P-Hida Scan, image for 1 hour 78223 A9537

Evaluation of abdominal pain, gallstones, cholecystitis, biliary diskensia

NPO 6 hours prior to exam No pain medication 12 hours prior to exam

P-Hida Scan with CCK, image for 1 ½ hours with possibility of delayed images up to 4 hours.

78223 A9537 J2805

Evaluation of abdominal pain, cholecystitis, Biliary diskensia, gallstones

NPO 6 hours prior to exam No pain medication 12 hours prior to exam

Liver / Spleen Scan, image for 1 hour 78216 A9541

Assessment of chronic liver or spleen disease, liver tumor, cirrhosis, hepatitis

No Prep

Liver / Spleen Spect Scan, image for 1 hour 78205 A9541

Assessment of chronic liver or spleen disease, liver tumor, cirrhosis, hepatitis

No Prep

Lymphoscintography, patient injected imaging time 1 ½ to 4 hours.

78195 A9541

Melanoma, breast cancer, sentinel node imaging

No Prep

Meckels Study, exam takes approx 11/2 hours.

78290 A9512

Localization of Meckels diverticulum, abdominal pain, diverticulitis, intestinal obstruction, GI Bleed

NPO 6-12 hours prior to exam Patient cannot have any barium studies 48 hours prior

MIBG Scan Adrenal Gland, patient injected then returns 24, 48, and 72 hours later each day images take approx 1 hour.

78075 A9508

Cancer Referring doctor must write Prescription for Lugols Solution 1 drop daily to begin the day before exam continuing through the 6

th day after the exam.

The day before exam 2 ounces of castor oil at 4:00 p.m. and begin clear liquid diet. Patient to pick up prep sheet at 9900 Stockdale Hwy #100

MUGA Gated Blood Pool Study, draw blood – tagging process ½ hour, images takes ½ hour.

78473 A9560

Evaluation of left (sometimes right) ventricle wall motion. Evaluation of heart condition for pending surgery, chemo or radiation

No Prep




32


Octrescan, patient injected, returns 4 hours later then 24, 48 and possibly 72 hours later, each day images take 1 -2 hours based on Dr’s request.

78804 78803 A4642

Imaging lesion within the chest and abdomen

Referring doctor must write The day before exam 2 ounces of castor oil at 4:00 p.m. and begin clear liquid diet. Patient to pick up prep sheet at 9900 Stockdale Hwy #100

Parathyroid Scan, inject patient wait 20 minutes, 1

st image takes 10 minutes, patient

leaves and returns 2 and 4 hours later for another 10minutes imaging.

78070 A9500

Hyperparathyroidism, hypercalcemia, abnormal labs, adenoma

No Prep

Pulmonary Quantitative Ventilation / Profusion Study, patient breaths thru tube 8 minutes, images taken of lungs, then injection, more images takes approx 1 hour.

78596 A9540 A9567

Lung Cancer, pulmonary embolism Differential function.

No Prep

Renogram DMSA, patient injected then imaged for approx 1 hour. Note: This study performed on children

78701 78710 A9551

Evaluation of renal function, kidney transplant

Must be well hydrated Drink as much water as possible May use restroom when needed

Renogram with vascular flow and function Note: No pharmaceuticals

78707 A9562

Evaluation of kidney for transplant, renal function

Must be well hydrated Recommend 40 ounces of water May use restroom when needed

Renogram with vascular flow and function Note: Mag 3 / Captopril, patient given captopril, blood pressure monitored for 1 hour, given injection and imaged for 45 minutes

78708 A9562 A4641

Hypertension, renal function Must be well hydrated Recommend 40 ounces of water May use restroom when needed

Renogram with Lasix, patient injected and imaged for 45 minutes.

78708 A9562 J1940

Evaluate for renal artery stenosis, renovascular hypertension

Must be well hydrated Recommend 40 ounces of water May use restroom when needed

Sestamibi Breast, patient injected wait 20 minutes and imaged for 1 hour. Note: Scintography

78801 A9500

Detection and localization of breast carcinoma, breast mass, abnormal mammogram or breast ultrasound

No Prep

Testicular Scan with Vascular flow, patient injected then imaged for 1 hour.

78761 A9512

Torsion No Prep

Thromboscintogram, patient injected and imaged for approx 1 -3 hours.

78458 A9504

Venous thrombosis imaging, blood clot

No Prep

Thyroid Ablation (I-131 Therapy), patient arrives and is given I-131 capsule by Dr then able to leave Thyroid Ca – patients returns 10 days later for follow up image (1 hour)

79005 99243 A9517

Thyroidtoxicosis, thyroid storm hyperthyroidism, thyroid cancer

Must have had recent thyroid uptake & scan. NPO 6 hours prior to exam No seafood 24 hours prior Must be off all thyroid mediation

Thyroid Cytomel Suppression Study Patient takes cytomel prescribed by referring Dr, given I-123 capsule then returns 6 hours later for images approx 30 minutes, patient to return next day for approx 5 minutes.

78003 A9516

Evaluation of thyroid nodules, masses, hyperthyroidism, cancer, hypothyroidism, abnormal labs

NPO 6 hours prior to exam No seafood 24 hours prior Must be off thyroid medication Must have not had a contrast study 4-6 weeks prior to study




33


Thyroid Technesium Study, patient injected than scanned takes approx 45 minutes.

78013 A9512

Nodules No Prep

Thyroid Whole Body (I-131 diagnostic) patient takes I-131 pill, returns 24,48 and possibly 72 hours. Scan takes 45minutes each day

78018 78020 A9528

Evaluation for metastasizing or recurrent thyroid cancer, or for residual functioning thyroid tissue after thyroidectomy

NPO 6 hours prior to exam Must be off all thyroid medication

Thyrogen, injection on Monday and Tuesday, patient takes I-131 pill on Wednesday, scan on Friday for 45 minutes.

Same NPO 6 hours prior Does not have to be off thyroid medication Referring physician to obtain medication

Thyroid Imaging with Uptake I-123, patient takes I-123 pill, returns 6 hours later for images (30 minutes), returns 24 hours later for uptake (5 minutes).

78014 A9516

Evaluation of thyroid, nodules, masses, hyperthyroidism, cancer hypothyroidism, abnormal labs

NPO 6 hours prior to exam No seafood 24 hours prior Must be off thyroid medication Must have not had a contrast study 4-6 weeks prior to study

Treadmill ONLY, walks on treadmill allow 30 minutes

93015 Chest pain, shortness of breath No beta blockers 24 to 48 hours prior to exam

VQ Scan Non-Quantitative, patient breaths isotope 10 minutes then images 20 minutes, patient is injected with isotope and takes another set of images 20 minutes, then has chest x-ray.

78588 A9567 A9540 71020

Evaluation of shortness of breath, pulmonary embolism, chest pain, lung cancer, low blood oxygen levels

No Prep

Whole Body Abscess Study, patient injected returns 24 and 48 hours later, scan takes 1 hour each day.

78806 A9569

Infection, fever of unknown origin No Prep

Whole Body PET/CT, patient has iv started is injected with isotope, wait 1 hour in recliner then is put on camera for ½ hour scan.

78816 A9552

Diagnosis and staging of cancer Please see PET/CT appointment confirmation checklist

PET/CT skull base to mid thigh See whole body PET/CT

78815 A9552

Diagnosis and staging of cancer Please see PET/CT appointment checklist

PET/CT limited area, chest, head See whole body PET/CT

78814 A9552

Diagnosis and staging of cancer Limited sugar intake for 24 hours

Please see PET/CT appointment checklist

PET/CT skull base to mid thigh See whole body PET/CT

78815 A9552

Diagnosis and staging of cancer Please see PET/CT appointment checklist




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Facility: ________________________

PET/CT APPOINTMENT CONFIRMATION CHECKLIST

Patient Name: _______________________________ Referring Physician: Appointment Date: _____________________ Patient Preps- For the most accurate results, these instructions must be followed!!! GENERAL PATIENTS Diet and fluids

NPO 6 hours. *if insulin dependent diabetic, see below. No food, chewing gum, soda, juice, cough drops or anything that has sugar in it.

2. Increase fluids 48 hours before exam. (Water only 6 hours before exam) 3. Low carb/high protein/high fat diet-24 hours prior to exam. 4. No Caffeine/Nicotine/Alcohol: 24 hours prior to the exam. 5. Discontinue Lomotil 24 hours prior to exam if possible. 6. Stop G tube of parental feeding 4 hours before exam.

Exercise No strenuous exercise for at least 24 hours prior to exam.

Temperature Avoid cold temperatures and dress warmly for 48 hours prior to exam.

Pregnancy All women of childbearing age, prescreened for pregnancy at scheduling.

Breast Feeding See special instructions in PET/CT Scheduling Manual.

Other Medications OK to take other medication (With water only) on day of exam.

Colostomy Patients Bring additional colostomy bag.

DIABETIC PATIENTS 1. On oral medication

→Must remain NPO 6 hours prior to exam. →Take diabetic medication and follow protein diet 24 hours prior to appointment.

2. Insulin dependent →Patients to eat and follow special diet 24 hours prior to day of appointment. →NO insulin administration for 1 hour before FDG injection.. →Patient can receive their long tasting insulin in the morning if 1 hour before exam. →NO REGULAR insulin (Humulin R & Novolin R) should be given within 1 hour of PET/CT scan to prevent driving FDG into muscle tissue. →Patient to bring insulin to PET/CT appointment.

3. On Insulin Pump →Patient to eat and follow special diet 24 hours prior to day of appointment. →Patient on insulin pump, which is not regular insulin and is a small dose, should continue on pump as usual-can also eat food. 24 hours prior to exam

1. Copy of order stating specific exam requested in facility. 2. Need reports of all relevant previous studies, this exam will not be read without all

previous reports for the radiologist to review. 3. Confirm appointment and prep for patients 24 hours prior to exam. 4. Discuss co-payment issues if payment is due the day of the exam.

Confirmed by: ______________________ Date: ________________________

PET

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T/C

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PP

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