Scheduling Protocol Reference Manual

Scheduling Protocol Reference Manual 10/20/2009 2008-2009 Truxtun Radiology Medical Group, L.P.

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 2008-2009 Truxtun Radiology Medical Group, L.P. 2

Riverwalk/ Nuclear Medicine 9900 Stockdale Hwy, Ste 100 Bakersfield, CA. 93311 (661) 325-6800 (661) 616-3509 Fax Downtown 1817 Truxtun Avenue Bakersfield, CA. 93301 (661) 325-6800 (661) 616-3509 Fax Advanced MRI & CT Suite 1818 16 th Street Bakersfield, CA. 93301 (661) 325-6800 (661) 616-3509 Fax Interventional Suite 9900 Stockdale Hwy, Ste 109 Bakersfield, CA. 93311 (661) 325-6800 (661) 616-3509 Fax Taft 100 E North Street Taft, Ca 93268 (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 2008-2009 Truxtun Radiology Medical Group, L.P. 3

To prevent patient inconvenience, please reference equipment limitations below, and schedule the patients accordingly. Modality Downtown Advanced River Walk Tehachapi Taft Imaging 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 River Walk Tehachapi Taft Imaging 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 2008-2009 Truxtun Radiology Medical Group, L.P. 4

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 Will be added to every Mammogram Procedures 77052 Screening 77051 Diagnostic 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 2008-2009 Truxtun Radiology Medical Group, L.P. 5

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 NPO 6 hours prior to exam Projectile vomiting r/o pyloric stenosis Bring infant hungry with a bottle Abdomen limited 76705 Follow-up single organ NPO 6 hours prior to exam Breast 76645 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 Drink 48 ounces of water (1) hour prior to exam and hold Obstetrical > 14 weeks Second Trimester each additional gestation 76805 76810 Size/dates, anomaly, bleeding Fetal and maternal evaluation Drink 48 ounces of water (1) hour prior to exam and hold 2008-2009 Truxtun Radiology Medical Group, L.P. 6

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 Drink 48 ounces of water (1) hour prior to exam and hold Spinal Canal (Infant) 76800 Spinal defect / dimple No prep Testicular 76870 Torsion, mass, pain, swelling, Undescended teste Transvaginal 76830 Rule out ectopic pregnancy, molar pregnancy, abnormalities, cyst, fibroids No prep No prep; unless pelvic prior (see pelvic prep if applicable) Unlisted 76999 No prep Any body part not otherwise Specified Vein Mapping Upper Extremity 939701 For Dialysis No prep Venous Doppler Arterial Doppler 93970 DVT, cellulitis, calf tightness PVD, PAD No prep Venous Doppler Insufficiency Evaluation 939702 Reflux Consultation No prep 2008-2009 Truxtun Radiology Medical Group, L.P. 7

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 19285 G0206 Pre-operative placement of needle localization wire, breast Digital diagnostic unilateral mammogram US Breast Needle Wire Localization pre-operative 2 location 19285 19286 G0206 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 2008-2009 Truxtun Radiology Medical Group, L.P. 8

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 2008-2009 Truxtun Radiology Medical Group, L.P. 9

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 Arthrogram, Hip 73525 27093 Tear or lesion, history of joint pain, locking or limited range of motion Tear or lesion, history of joint pain, locking or limited range of motion No blood thinners (5) days prior No aspirin (3) days prior No blood thinners (5) days prior No aspirin (3) days prior Arthrogram, Knee 73580 27370 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, Shoulder 73040 23350 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, Wrist Note: Radiologist protocol arthrogram joint injections should be scheduled W arthrogram injection only. 73115 25246 Tear or lesion, history of joint pain, locking or limited range of motion No blood thinners (5) days prior No aspirin (3) days prior 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 2008-2009 Truxtun Radiology Medical Group, L.P. 10

Exam CPT Code Diagnostic Prep 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 3 days prior No aspirin (5) days prior Cisternography Note: Patient may remain at imaging center (2) hours post procedure 70015 NPO (4) hours prior No blood thinners (3) days prior Off Plavix at least (7) days prior No aspirin (5) days prior VCUG, Retrograde Cystogram 74430 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 Hysterosalpingogram (HSG) 74740 58340 76000 Infertility, blockage, essure placement Schedule on 10 th to 12 th after onset of menstrual cycle, no intercourse 24 hours prior Urography, Pyleography (IVP) Note: Must follow IV contrast guidelines, requires lab work BUN and Creatinine. 74400 Kidney stone, hematuria, painful urination, dysuria 24 hour prep required prep kit to be picked up (2) days 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) 2008-2009 Truxtun Radiology Medical Group, L.P. 11

Exam CPT Code Diagnostic Prep 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 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 72240 62284 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 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 72255 62284 Herniated disc, stenosis, mass, tumor, infection, lesion No blood thinners (5) days prior No aspirin (3) days prior Myelogram, 2 or more regions 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 72270 62284 Herniated disc, stenosis, mass, tumor, infection, lesion No blood thinners (5) days prior No aspirin (3) days prior 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) 2008-2009 Truxtun Radiology Medical Group, L.P. 12

Exam CPT Code Diagnostic Prep 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 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 (3) days prior No aspirin (5) days prior NPO (6) hours prior to procedure Tomograms, Independent (TMJ) 76100 Pain No prep 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 74425 No prep Note: Patient to provide additional urine bag 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 2008-2009 Truxtun Radiology Medical Group, L.P. 13

Exam CPT Code Diagnostic Prep 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 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. 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 7 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 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. 2008-2009 Truxtun Radiology Medical Group, L.P. 14

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. Exam CPT Code Diagnostic Prep Abdomen without 74150 Renal stones NPO 4 hrs prior Abdomen with contrast 74160 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 Pain, obstruction, cancer, mass, metastatic disease, pancreatitis, Liver disorders NPO (4) hours prior to exam ** Cervical Spine without 72125 Degenerative disc disease, arthritis, fracture Cervical Spine with contrast 72126 IV Contrast for mass Cervical Spine with and without 72127 IV Contrast for mass, lump, lesion Head without 70450 Trauma, rule out bleed, headaches, macrocephaly Head with contrast 70460 Use w/wo Use only if w/o done recently Head with and without 70470 Mass, cancer, lesion, severe headaches **Lower extremity without Note: any part of leg or hip 73700 Pain, fracture Lower extremity with contrast 73701 Mass Lower extremity with and without 73702 Mass, cancer 2008-2009 Truxtun Radiology Medical Group, L.P. 15

** Truxtun Radiology Medical Group recommend this exam as the preferred protocol. Exam CPT Code Diagnostic Prep ** Lumbar spine without 72131 Lumbar spine with contrast 72132 Lumbar spine with and without 72133 Degenerative disc disease, fracture IV contrast for mass IV contrast for mass, lump, lesion Neck without 70490 ** Neck with contrast 70491 Neck with and without 70492 Soft tissue neck, throat, larynx, pharynx Mass, parotiditis, Lymphodenopathy Mass, cancer Nephrogram Note: Schedule Abdomen w/wo and Pelvis w/wo contrast 74170 72193 Hematuria, kidney stone, hydronephrosis of ureter NPO (4) hours prior to exam Pelvic without 72192 **Pelvic with contrast 72193 Pelvic with and without 72194 Fracture Metastatic disease, mass, pelvic pain Appendicitis, or abdominal aortic aneurysm NPO (4) hours prior to exam NPO (4) hours prior to exam NPO (4) hours prior to exam Sella, Orbit, Posterior Fossa, Ear (outer, inner or middle) without 70480 Pituitary, Sella Turcica, Eye, Ear, Temporal Bones, Mastoids Note: Mastoids are always without contrast, Pituitary is always with contrast(better visualized in MRI w/wo contrast). Specify area of interest Elevated prolactin levels Sella / Orbit with contrast 70481 Sella / Orbit with and without 70482 Mass, Cancer Mass, Cancer Sinus without contrast (Maxillofacial) 70486 Sinusitis, Sinus Polyp, deviated septum Fracture Note: Sinus study always scheduled without contrast 2008-2009 Truxtun Radiology Medical Group, L.P. 16

** Truxtun Radiology Medical Group recommend this exam as the preferred protocol. Exam CPT Code Diagnostic Prep Thorax (Chest) without contrast 71250 **Thorax (Chest) with 71260 Thorax (Chest) with and without 71270 Fibrosis, Interstitial Lung Disease,, Cough Pulmonary Embolism, Mass, Cancer, Nodule, Shortness of breath Pulmonary Embolism, Mass, Cancer, Nodule ; also includes high resolution imaging for ILD **Thoracic Spine without contrast 72128 Thoracic Spine with contrast 72129 Fracture, Degenerative Disc Disease, DJD IV Contrast for Mass Thoracic Spine with and without 72130 IV Contrast for Mass, Lump, Lesion **Upper Extremity without contrast Note: Any part of arm or shoulder 73200 Fracture, Pain Upper Extremity with contrast 73201 Upper Extremity with and without 73202 Mass, Cancer Mass, Cancer Urogram Note: Schedule Abdomen w/wo and Pelvic w/wo contrast 74170 72194 Hematuria, kidney stone, kidney/ureter disorder NPO (4) hours prior to exam CT Nephrogram or Urogram Virtual Colonoscopy Screening 74263 Cancer, polyp, failed colonoscopy, diverticulitis, diverticulosis, chronic diarrhea Bowel prep kit required. Prep kit must be picked up 3 days prior to scheduled exam Virtual Colonoscopy Diagnostic With Contrast 74262 Cancer, polyp, failed colonoscopy, diverticulitis, diverticulosis, chronic diarrhea Bowel prep kit required. Prep kit must be picked up 3 days prior to scheduled exam Virtual Colonoscopy Diagnostic Without Contrast 74261 Cancer, polyp, failed colonoscopy, diverticulitis, diverticulosis, chronic diarrhea Bowel prep kit required. Prep kit must be picked up 3 days prior to scheduled exam 2008-2009 Truxtun Radiology Medical Group, L.P. 17

** 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 Herniation of disc, stenosis, mass No aspirin (3) days prior No blood thinners (5) days prior Lumbar Myelogram Note: Reference above 72132 62284 72265 Herniation of disc, stenosis, mass No aspirin (3) days prior No blood thinners (5) days prior 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. 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 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 If a patient currently takes any metformin products, such as but not limited to Glucovance, Glyburide, Glucophage, 2008-2009 Truxtun Metaglip, Radiology Metformin/Glipizide Medical Group, L.P. or Avandament, inform the radiology Revised scheduler 05/2014 to ensure proper precautions. 18

** 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 Coronary Artery Calcium Scoring Schedule at the River Walk office CT Lung Screening CT Brain Screening CT Virtual Colonoscopy Whole Body and CACS Schedule at the River Walk office CT Angio Coronary Schedule at the River Walk office Includes CT of chest, abdomen and pelvis if non-contrast study No caffeine (12) hours prior No smoking (8) hours prior 48 hour bowel prep required; prep kit must be picked up (3) days prior to exam NPO (4) hours prior No caffeine (24) hours prior No smoking (8) hours prior NPO (4) hours prior No caffeine (12) hours prior No smoking (8) hours prior 2008-2009 Truxtun Radiology Medical Group, L.P. 19

Exam CPT Code Diagnostic Prep Abdomen Angiography 74175 Hypertension, renal disease, ischemic bowel disease, abdominal aortic aneurysm Chest Angiography 71275 Aneurysm, chest pain Dissection ( needs to include abdomen) NPO (4) hours prior 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 Lower Extremity Angiography Angiography including abdomen and pelvis Schedule at the River Walk office 73706 Peripheral vascular disease, leg pain, weakness, swelling, claudication, abnormal doppler studies 75635 Abdominal aortic aneurysm, peripheral vascular disease NPO (4) hours prior 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 2008-2009 Truxtun Radiology Medical Group, L.P. 20

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 2008-2009 Truxtun Radiology Medical Group, L.P. 21

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 2008-2009 Truxtun Radiology Medical Group, L.P. 22

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 13 hours prior to procedure. 50 mg prednisone PO 7 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 days of exam Lab work is required only if the patient meets any of the following criteria: Any patient on dialysis. Any patient that is diabetic. All patients with severe liver disease. If patient has renal 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. Any hospital patient 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. 2008-2009 Truxtun Radiology Medical Group, L.P. 23

** Truxtun Radiology Medical Group recommend this exam as the preferred protocol. Exam Head / Neck CPT Code Diagnostic Prep Brain without 70551 Headaches, lymphoma, rule out metastasis Brain with 70552 ** Brain with and without 70553 Key Words: Posterior fossa, IAC (internal auditory canal) Note: Pituitary is always w & w/o pituitary, temporal bones, sella, sella turcica Orbit, Face, Neck without 70540 Diplopia (double vision) Orbit, Face, Neck with 70542 mass, lesion, other indications as noted ** Orbit, Face, Neck with & without 70543 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 Temporomandibular Joint(s) 70336 Popping or clicking of jaw Note: Schedule TMJ studies at the Downtown office NOTE: MRI exams and MRA exams are to be scheduled on separate days ** MRA Head without 70544 Aneurysm, headaches MRA Head with 70545 MRA Head with & without 70546 Key Words: C.O.W. (Circle of Willis), MR vein, cranial arteries, basilar artery, brain vein ** MRA Neck without 70547 Syncope, dizziness, fainting, MRA Neck with 70548 occlusion of carotid artery MRA Neck with & without 70549 Key words: Carotids, neck arteries, vertebral arteries 2008-2009 Truxtun Radiology Medical Group, L.P. 24

** Truxtun Radiology Medical Group recommend this exam as the preferred protocol. Exam Spine CPT Code Diagnostic Prep ** MRI C Spine without 72141 Neck pain, radioculopathy, MRI C Spine with 72142 numbness of upper extremity MRI C Spine with & without 72156 Key Words: Cervical, C1 to C7, ++brachial plexus++ ** MRI T Spine without 72146 Numbness in chest area MRI T Spine with 72147 MRI T Spine with & without 72157 Key Words: Thoracic spine, dorsal spine, T1 to T 12 ** MRI L Spine without 72148 Low back pain, radioculopathy MRI L Spine with 72149 MRI L Spine with & without 72158 Key Words: Lumbar, L-S spine, lumbar-sacral, L5 to S1, sacral area MRA Spine with OR without 72159 Note: Schedule at Downtown site ONLY 2008-2009 Truxtun Radiology Medical Group, L.P. 25

** Truxtun Radiology Medical Group recommend this exam as the preferred protocol. ***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 MRI Upper Extremity JOINT with 73222 injury, trauma MRI Upper Extremity JOINT With & without Arthrogram, you must also use Fluoro Arthro Injection for sites. 73223 See Fluoro Mass, infection, lesion, lump Key Words: Shoulder, elbow, wrist, finger, thumb ** MRI Upper Extremity other than joint Without MRI Upper Extremity other than joint With MRI Upper Extremity other than joint With and without 73218 73219 73220 Mass, infection, lesion, lump 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 Exam Lower Extremity CPT Code Diagnostic Prep ** MRI Lower Extremity Joint without 73721 Tear, sports injury, trauma MRI Lower Extremity Joint with 73722 MRI Lower Extremity Joint With & without, Arthrogram, uoe must also use Fluoro Arthro Injection for sites. 73723 See Fluoro Mass, infection, lesion, lump Key Words: Toe, ankle, knee, hip, ++Achilles tendon++ Note: Foot Specify which part of the foot ** MRI Lower Extremity other than joint without MRI Lower Extremity other than Joint with MRI Lower Extremity other than Joint with and without 73718 73719 73720 Mass, infection, lump. diabetic ulcer 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 Key Words: Femoral artery, tibial artery, run offs, dorsalis pedis artery, popliteal artery 2008-2009 Truxtun Radiology Medical Group, L.P. 26

** Truxtun Radiology Medical Group recommend this exam as the preferred protocol. Exam Chest CPT Code Diagnostic Prep MRI Chest without 71550 Mass, lesion MRI Chest with 71551 ** MRI Chest With & without 71552 Key Words: Hilar, mediastinal, thorax, sternum, clavicle, ribs, Sterno-clavicular joints MRI Cardiac for Morphology/function w/o 75557 Heart mass MRI Cardiac for Morphology/function with and without 75561 MRA Chest excluding myocardium With OR without Schedule above @ downtown site ONLY 71555 Aortic arch / Aortic Trunk 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, Without contrast abnormal mammogram With contrast abnormal Ultrasound With and Without contrast ** MRI Breast Bilateral (any of the following) 77059 Lump, pain, cancer, Without contrast abnormal mammogram With contrast abnormal Ultrasound With and Without contrast MRI Guided Breast Biopsy, 1 location 19085 G0206 Biopsy breast needle core percutaneous Digital diagnostic unilateral mammogram Labs needed: CBC, PT, PTT, BUN, Creatinine MRI Guided Breast Biopsy, 2 locations 19085 19086 G0206 Biopsy breast needle core percutaneous Additional location Digital diagnostic unilateral mammogram Labs needed: CBC, PT, PTT, BUN, Creatinine 2008-2009 Truxtun Radiology Medical Group, L.P. 27

** Truxtun Radiology Medical Group recommend this exam as the preferred protocol. Exam Abdomen / Pelvis CPT Code Diagnostic Prep MRI Abdomen without 74181 Mass, lesion, lump MRI Abdomen with 74182 ** MRI abdomen with & without 74183 Key Words: MRCP, kidneys, liver, pancreas, spleen, Biliary system/gallbladder Note: MRCP is scheduled w/o contrast MRA Abdomen with OR without 74185 aneurysm 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 MRI Pelvis with 72196 of prostate ** MRI Pelvis with & without 72197 Key Words: Uterus, ovaries, bladder, prostate, rectum, scrotum, testes, penis, cervix MRA Pelvis with OR without 72198 aneurysm Note: Schedule at Downtown site ONLY 2008-2009 Truxtun Radiology Medical Group, L.P. 28

** Truxtun Radiology Medical Group recommend this exam as the preferred protocol. Exam Miscellaneous CPT Code Diagnostic Prep ** MRI Achilles Tendon without contrast 73721 & 73718 MRI Achilles Tendon with contrast 73722 & 73719 MRI Achilles tendon with & without contrast 73723 & 73720 ** MRI Brachial Plexus without 72141 & 73221 MRI Brachial Plexus with 72142 & 73222 MRI Brachial Plexus with and without contrast 72156 & 73223 ** MRI Bicep without contrast 73221 & 73218 MRI Bicep with contrast 73222 & 73219 MRI Bicep with and without contrast 73223 & 73220 Tear, pain, ruptured tendon Tear, pain, ruptured tendon Tear, pain, ruptured tendon Upper extremity atrophy, weakness of upper extremity Upper extremity atrophy, weakness of upper extremity Upper extremity atrophy, weakness of upper extremity Trauma, ruptured tendon Trauma, ruptured tendon Trauma, ruptured tendon 2008-2009 Truxtun Radiology Medical Group, L.P. 29

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 Exam CPT Code Diagnostic Prep Bone Scan, 3 Phase, inject patient take pictures, return 3-5 hours later to scan for 30 minutes 78315 A9561 Tumor, trauma, fracture, osteomyelitis, lesion Patient needs be well hydrated Note: Usually done on upper and lower Extremities. Hands- feet-ankles (5 hour delay for imaging) All others is 3 hour delay. Bone Scan, Whole Body, inject patient, return 3-5 hours later for 1 hour scan 78306 A9561 Coccidiomycosis, valley fever, cancer, rheumatoid arthritis Patient needs be well hydrated Bone Spect, inject patient, return 3 hours later. 78320 A9561 Tumor, trauma, fracture, osteomyelitis, lesion Patient needs be well hydrated Note: Usually done on Spine C, T. L 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 2008-2009 Truxtun Radiology Medical Group, L.P. 30

Exam CPT Code Diagnostic Prep Gallium Whole Body, inject patient, return 24 and 48 hours later, scan takes 1 hour each day. Gastric Emptying Study Solid Study, patient eats food and takes first image then returns every hour for 4 hours, each image takes 1 minute. 78804 A9556 78264 A9541 Detection of lymphoma, tumors, Hodgkin s disease, fever of unknown origin, evaluation of abscess, osteomyelitis Evaluation of nausea, vomiting, and weight loss No prep 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 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 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 Liver / Spleen Spect Scan, image for 1 hour 78205 A9541 Assessment of chronic liver or spleen disease, liver tumor, cirrhosis, hepatitis Assessment of chronic liver or spleen disease, liver tumor, cirrhosis, hepatitis Lymphoscintography, patient injected imaging time 1 ½ to 4 hours. 78195 A9541 Melanoma, breast cancer, sentinel node imaging 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 2008-2009 Truxtun Radiology Medical Group, L.P. 31

Exam CPT Code Diagnostic Prep 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. 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. 78804 78803 A4642 78070 A9500 Imaging lesion within the chest and abdomen Hyperparathyroidism, hypercalcemia, abnormal labs, adenoma 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 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. 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 Testicular Scan with Vascular flow, patient injected then imaged for 1 hour. 78761 A9512 Torsion Thromboscintogram, patient injected and imaged for approx 1-3 hours. 78458 A9504 Venous thrombosis imaging, blood clot 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 2008-2009 Truxtun Radiology Medical Group, L.P. 32 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

Exam CPT Code Diagnostic Prep Thyroid Technesium Study, patient injected than scanned takes approx 45 minutes. 78013 A9512 Nodules 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 White Blood Cell Scan (Indium)/Ceretec, patient has blood drawn it is sent to pharmacy, leaves and returns 2 to 3 hours later then injected with blood, leaves and returns. 78805 A9569 Detection and localization of acute and chronic osteomyelitis, acute abscesses, fever of unknown origin 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 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 78814 Diagnosis and staging of cancer Please see PET/CT appointment See whole body PET/CT A9552 Limited sugar intake for 24 hours checklist 2008-2009 Truxtun Radiology Medical Group, L.P. 33

PET/CT APPOINTMENT CONFIRMATION CHECKLIST Return to Table of Contents Email a scheduling request 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: 2008-2009 Truxtun Radiology Medical Group, L.P. 34