Case 2:10-md CJB-SS Document Filed 05/03/12 Page 1 of 5 EXHIBIT 12
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1 Case 2:10-md CJB-SS Document Filed 05/03/12 Page 1 of 5 EXHIBIT 12
2 Case 2:10-md CJB-SS Document Filed 05/03/12 Page 2 of 5 Components of the PERIODIC MEDICAL CONSULTATION PROGRAM Medical Evaluation Comprehensive medical, occupational and environmental history, and physical examination including vision screening. Blood / Urine Tests (To be performed at the discretion of the Program physician performing the examination, taking into account the individual s age, reported symptoms, personal and family history, and clinical presentation. Young children may not be able to perform blood/urine tests.): Complete blood count (CBC) automated to include hemoglobin (Hgb), hematocrit (HCT), red blood cell (RBC) indices, white blood cell (WBC) count with differential, and platelet count Comprehensive metabolic panel to include serum glucose, calcium, human serum albumin, serum total protein (TP), sodium, potassium, carbon dioxide (CO2), chloride, blood urea nitrogen (BUN), creatinine, alkaline phosphatase (ALP), alanine amino transferase (ALT or SGPT), aspartate amino transferase (AST or SGOT), and bilirubin b-2 micro globulin (urine) Gamma glutamyl Transferase (also known as Gamma-glutamyl Transpeptidase; GGTP) Urinalysis automated with microscopy C-reactive protein, high sensitivity (hs-crp) Hemoglobin A1c (HgBA1c) Lipid panel (including total cholesterol, triglycerides, HDL cholesterol, non HDL cholesterol and calculated LDL) Fecal occult blood test (FOBT) high sensitivity (for adults 50 years old and over) Prostate-specific antigen (PSA) (for males 40 years old and over) Cardiac/Respiratory Tests (To be performed at the discretion of the Program physician performing the examination, taking into account the individual s age, reported symptoms, personal and family history, and clinical presentation. Young children may not be able to perform cardiac/respiratory tests.): 12-lead electrocardiogram (EKC, ECG) - resting Spirometry (baseline and, if indicated, post bronchodilator) Pulse oximetry Chest x-ray Six minute walk test (for individuals with clinical indication of dyspnea (shortness of breath or difficulty breathing))
3 Case 2:10-md CJB-SS Document Filed 05/03/12 Page 3 of 5 Description of Components of the PERIODIC MEDICAL CONSULTATION PROGRAM Medical Evaluation Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures, new patient. Current Procedural Terminology (CPT) codes: Child 1-4 years old = Child 5-11 years old = Adolescence years old = Adult years = Adult years = Adult 65 years = Blood / Urine Tests The following outlines the list of tests available to the MEDICAL BENEFITS SETTLEMENT CLASS MEMBER, to be performed at the discretion of the Program physician performing the examination, taking into account the individual s age, reported symptoms, personal and family history, and clinical presentation. Young children may not be able to perform blood/urine tests. Complete blood count (CBC) automated to include hemoglobin (Hgb), hematocrit (HCT), red blood cell (RBC) indices, white blood cell (WBC) count with differential, and platelet count. o CPT code = Comprehensive metabolic panel to include serum glucose, calcium, human serum albumin, serum total protein (TP), sodium, potassium, carbon dioxide (CO2), chloride, blood urea nitrogen (BUN), creatinine, alkaline phosphatase (ALP), alanine amino transferase (ALT or SGPT), aspartate amino transferase (AST or SGOT), and bilirubin. o CPT code = 80053
4 Case 2:10-md CJB-SS Document Filed 05/03/12 Page 4 of 5 b-2 micro globulin (urine) o CPT code = Gamma glutamyl Transferase (also known as Gamma-glutamyl Transpeptidase; GGTP) o CPT code = Urinalysis automated with microscopy o CPT code = C-reactive protein, high sensitivity (hs-crp) o CPT code = Hemoglobin A1c (HgBA1c) o CPT code = Lipid panel (including total cholesterol, triglycerides, HDL cholesterol, non-hdl cholesterol and calculated LDL) o CPT code = Fecal occult blood test (FOBT) high sensitivity o For adults 50 years old and over o CPT code = Prostate-specific antigen (PSA) o For males 40 years old and over o CPT code = 84153
5 Case 2:10-md CJB-SS Document Filed 05/03/12 Page 5 of 5 Cardiac/Respiratory Tests The following outlines the list of tests available to the MEDICAL BENEFITS SETTLEMENT CLASS MEMBER, to be performed at the discretion of the Program physician performing the examination, taking into account the individual s age, reported symptoms, personal and family history, and clinical presentation. Electrocardiogram (EKC, ECG) - resting o Lowest age limit at the discretion of the treating physician. o CPT code = Routine ECG with at least 12 leads with interpretations and report. Spirometry o For ages 7 years old o CPT codes: Baseline: Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), and/or maximal voluntary ventilation (94010) With post bronchodilator: Pre and post spirometry, also charge for bronchodilator (94060) Administration of bronchodilator; aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes; initial demonstration and/or evaluation (94664) o Meeting American Thoracic Society criteria (ATS 2005) Pulse oximetry (resting) o For ages 7 years old o CPT codes: Noninvasive ear/pulse oximetry single determination (94760) Chest x-ray, two views, frontal and lateral o CPT code = minute walk test o For individuals with clinical indication of dyspnea (shortness of breath or difficulty breathing) o CPT code = Pulmonary stress testing; simple (e.g., 6-minute walk test, prolonged exercise test for bronchospasm with pre- and post-spirometry and oximetry) (94620)
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