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

Scheduling Protocol Reference Manual
10/20/2009
© 2008-2009 Truxtun Radiology Medical Group, L.P.
Revised 05/2014
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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
© 2008-2009 Truxtun Radiology Medical Group, L.P.
2
Revised 05/2014
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Riverwalk/ Nuclear Medicine
Downtown
Advanced MRI & CT Suite
9900 Stockdale Hwy, Ste 100
1817 Truxtun Avenue
1818 16 Street
Bakersfield, CA. 93311
Bakersfield, CA. 93301
Bakersfield, CA. 93301
(661) 325-6800
(661) 325-6800
(661) 325-6800
(661) 616-3509 Fax
(661) 616-3509 Fax
(661) 616-3509 Fax
Interventional Suite
Taft
9900 Stockdale Hwy, Ste 109
100 E North Street
Bakersfield, CA. 93311
Taft, Ca 93268
(661) 325-6800
(661) 616-3509 Fax
(661) 325-6800
(661) 616-3509 Fax
th
Tehachapi
20960 Sage Lane
Tehachapi, CA 93561
(661) 325-6800
(661) 616-3509 Fax
Scheduling
Medical Records
(661) 616-1488 Direct
(661) 616-1420 Direct
(661) 616-3509 Fax
(661) 325-4734 Fax
Authorizations
Billing Office
(661) 616-3160 Direct
(661) 616-3506 Fax
(661) 616-1460 Direct
© 2008-2009 Truxtun Radiology Medical Group, L.P.
3
Revised 05/2014
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To prevent patient inconvenience, please reference equipment limitations below, and schedule
the patients accordingly.
Modality
River Walk
Not Available
Advanced
Imaging
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.
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
CT
Downtown
Tehachapi
300 lbs
Taft
300 lbs
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
PET/CT
Not available
Advanced
Imaging
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
River Walk
Tehachapi
380 lbs.
Not available Not available
Revised 05/2014
Taft
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
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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
Digital Implants Bilateral Routine
Digital Bilateral Diagnostic
Digital Implants Bilateral Diagnostic
Digital Bilateral Magnification View
(coned down compression)
G0202
G0202
G0204
G0204
G0204
See Above
See Above
See Above
See Above
See Above
Digital Unilateral Routine / Diagnostic
Digital Unilateral Implant
Digital Unilateral Magnification View
(coned down compression)
G0206
G0206
G0206
See Above
See Above
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
77052 Screening
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)
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
Note: Microcalcifications schedule under
Stereo.
© 2008-2009 Truxtun Radiology Medical Group, L.P.
5
Revised 05/2014
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Exam
Abdomen U/S
CPT Code
76700
Diagnosis
Prep
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 xray
Duplex Arterial Doppler (legs)
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
Infertility, initial exam, follow-up exam
Schedule 12 days from onset of
menses
Note: Diagnosis PVD schedule
at River Walk office.
Follicular Study
76856-1
76856-3
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
Revised 05/2014
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Exam
Obstetrical 4D
CPT Code
Diagnosis
Prep
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
No prep
Transvaginal
76830
Rule out ectopic pregnancy, molar
pregnancy, abnormalities, cyst,
fibroids
No prep; unless pelvic prior
(see pelvic prep if applicable)
Unlisted
Any body part not otherwise
Specified
76999
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
Note: Schedule at River Walk
facility only
© 2008-2009 Truxtun Radiology Medical Group, L.P.
No prep
7
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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
19285
Pre-operative placement of needle localization
wire, breast
Digital diagnostic unilateral mammogram
G0206
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
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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
60100
76942
Biopsy thyroid
Guidance for needle placement
US Biopsy Thyroid
© 2008-2009 Truxtun Radiology Medical Group, L.P.
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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
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
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
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
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
Note: Radiologist protocol
arthrogram joint injections should
be scheduled W arthrogram
injection only.
Aspiration / Injection ankle,
elbow and wrist
Note: fax orders to imaging office
for lab specimen
Aspiration / Injection hip,
knee and shoulder
Note: fax orders to imaging office
for lab specimen
© 2008-2009 Truxtun Radiology Medical Group, L.P.
10
Revised 05/2014
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Exam
Barium Enema
CPT Code
Diagnostic
Prep
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.
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.
Note: if patient has colostomy
instruct patient to bring
extra colostomy bag.
Barium Enema with Air
Note: if patient has colostomy
instruct patient to bring
extra colostomy bag.
Hirschsprungs Disease NO PREP
Cholangiography, T-tube, Post Op
47505
74305
Cholangiography, Percutaneous,
Transhepatic
47500
74320
NPO (6) hours prior to exam
No blood thinners 3 days prior No
aspirin (5) days prior
Cisternography
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
No Prep
Esophagram or Barium Swallow
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
76000
Infertility, blockage, essure placement
Schedule on 10 to 12 after
onset of menstrual cycle, no
intercourse 24 hours prior
Urography, Pyleography (IVP)
74400
Kidney stone, hematuria, painful
urination, dysuria
24 hour prep required – prep kit to
be picked up (2) days prior.
43999
76000
74240
Status Post Lab Band procedure
Nothing to eat or drink from
midnight prior to procedure.
Status Post gallbladder removal,
Gallstones in common duct
No prep
Note: Patient may remain at
imaging center (2) hours
post procedure
Note: No prep if STAT Study
th
th
Note: Must follow IV contrast
guidelines, requires lab work
BUN and Creatinine.
Lab Band Adjustment
Schedule at River Walk

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
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Exam
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
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
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
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
PICC Placement
Note: Lab requirements may be
waived by radiologist
CPT Code
62311
77003
Diagnostic
Prep
Back pain
No blood thinners (5) days prior
No aspirin (3) days prior
Confirm there is no history of
contrast allergy
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
72255
62284
Herniated disc, stenosis, mass, tumor,
infection, lesion
No blood thinners (5) days prior
No aspirin (3) days prior
72270
62284
Herniated disc, stenosis, mass, tumor,
infection, lesion
No blood thinners (5) days prior
No aspirin (3) days prior
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.
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Exam
Diagnostic
Prep
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)
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)
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
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.
Porta Cath Study
Note: Must follow IV contrast
guidelines, requires lab
work BUN and Creatinine.
CPT Code
Note: Patient will be required to be
at imaging center 2-6 hours
Note: Fax special order
Patient may be required to remain at
imaging center up to (2) hours post
procedure
Note: Patient may be in imaging
center up to (6) hours
Urography, Info/Bolus
74410
2 day prep required – prep kit to be
picked up (2) days prior.
Urography, Antegrade, Loopogram
74425
No prep
Urethrocystography
74450
No prep
Venogram – unilateral
36005
75820
76000
Note: Patient to provide additional
urine bag
Note: Patient must have already had
positive venous doppler,
requires lab work BUN and
Creatinine
© 2008-2009 Truxtun Radiology Medical Group, L.P.
Blood Clots
Requires BUN & Creatinine prior
Confirm there is no history of
contrast allergy
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Exam
Venogram – bilateral
Note: Patient must have already had
positive venous doppler
requires lab work BUN and
Creatinine
Voiding Urethrocystography (VCUG)
CPT Code
Diagnostic
Prep
36005
75820
76000
Blood Clots
Requires BUN & Creatinine prior
51600
74455
76000
VU reflux, UTI, blockage to the bladder,
incomplete emptying of bladder
Confirm there is no history of
contrast allergy
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:
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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
Revised 05/2014
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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.
Exam
CPT Code
Diagnostic
Prep
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
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
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
Note: with diagnosis of appendicitis
schedule Abdomen w/wo and Pelvis w
Note: any part of leg or hip
© 2008-2009 Truxtun Radiology Medical Group, L.P.
15
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** Truxtun Radiology Medical Group recommend this exam as the preferred protocol.
Exam
CPT Code
Diagnostic
Prep
** 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
74170
72193
76376
Hematuria, kidney stone,
hydronephrosis of ureter
NPO (4) hours prior to exam
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
NPO (4) hours prior to exam
Sella, Orbit, Posterior Fossa, Ear
(outer, inner or middle) without
70480
76376
Pituitary, Sella Turcica, Eye, Ear,
Temporal Bones, Mastoids
Be well hydrated
Note: Schedule Abdomen w/wo and
Pelvis w/wo contrast
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
76376
Mass, Cancer
Be well hydrated
Sella / Orbit with and without
70482
76376
Mass, Cancer
Be well hydrated
Sinus without contrast
(Maxillofacial)
70486
76376
Sinusitis, Sinus Polyp, deviated septum
Fracture
Be well hydrated
Note: Sinus study always scheduled
without contrast
© 2008-2009 Truxtun Radiology Medical Group, L.P.
16
Revised 05/2014
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** Truxtun Radiology Medical Group recommend this exam as the preferred protocol.
Exam
CPT Code
Diagnostic
Prep
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
73200
76376
Fracture, Pain
Be well hydrated
Upper Extremity with contrast
73201
76376
Mass, Cancer
Be well hydrated
Upper Extremity with and without
73202
76376
Mass, Cancer
Be well hydrated
Urogram
74170
72194
76376
Hematuria, kidney stone, kidney/ureter
disorder
NPO (4) hours prior to exam
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
Note: Any part of arm or shoulder
Note: Schedule Abdomen w/wo and
Pelvic w/wo contrast
CT Nephrogram or Urogram
© 2008-2009 Truxtun Radiology Medical Group, L.P.
17
Revised 05/2014
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** 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
Thoracic Myelogram
Note: Reference above
Lumbar Myelogram
Note: Reference above
72126
62284
72240
76376
Herniation of disc, stenosis, mass
No aspirin (3) days prior
No blood thinners (5) days prior
72129
62284
72255
76376
Herniation of disc, stenosis, mass
No aspirin (3) days prior
No blood thinners (5) days prior
72132
62284
72265
76376
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
Radiology
Medical Group, L.P.
05/2014
Metaglip,
Metformin/Glipizide
or Avandament,
scheduler
to ensure proper
18 inform the radiology Revised
precautions.
Return to Table of Contents | Email a scheduling request
** 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
© 2008-2009 Truxtun Radiology Medical Group, L.P.
19
Revised 05/2014
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Exam
CPT Code
Diagnostic
Prep
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
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
Note: Most commonly will need
abdomen and pelvis included
© 2008-2009 Truxtun Radiology Medical Group, L.P.
20
Revised 05/2014
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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
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
Biopsy Abdomen
Description / Procedure
49180
77012
Biopsy abdomen, percutaneous
CT guidance for needle placement
20220
77012
Biopsy bone, trocar, or needle, superficial
CT guidance for needle placement
20225
77012
Biopsy bone deep
CT guidance for needle placement
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
10022
77012
Fine needle aspiration with imaging guidance
CT guidance for needle placement
20206
77012
Biopsy muscle, percutaneous needle
CT guidance for needle placement
21550
77012
Biopsy soft tissue of neck or thorax
CT guidance for needle placement
Note: May use conscious sedation
Biopsy bone, trocar, or needle,
superficial, Ilium, sternum, spinous
process, ribs
Note: May use conscious sedation
Biopsy Bone Deep
Vertebral body, femur
Note: May use conscious sedation
Biopsy Extremity Soft Tissue
Note: May use conscious sedation
Note: May use conscious sedation
Biopsy Muscle
Note: May use conscious sedation
Biopsy Neck Soft Tissue
Note: May use conscious sedation
© 2008-2009 Truxtun Radiology Medical Group, L.P.
21
Revised 05/2014
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Exam
CPT Code
Biopsy Pancreas
Description / Procedure
48102
77012
Biopsy pancreas percutaneous needle
CT guidance for needle placement
27041
77012
Biopsy soft tissue pelvis/hip area deep
Code will change to fit body part
50021
75989
Drainage perirenal or renal abscess percutaneous
CT guidance for percutaneous drainage
50200
77012
Biopsy renal percutaneous, trocar or needle
CT guidance for percutaneous drainage
32405
77012
Biopsy lung or mediastinum percutaneous needle
CT guidance for needle placement
Note: May use conscious sedation
Biopsy Pelvic / Hip Deep
Note: May use conscious sedation
Drainage Renal Abscess
Note: May use conscious sedation
Biopsy Renal
Note: May use conscious sedation
Biopsy Thorax / Lung
Note: May use conscious sedation
© 2008-2009 Truxtun Radiology Medical Group, L.P.
22
Revised 05/2014
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
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
Revised 05/2014
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** Truxtun Radiology Medical Group recommend this exam as the preferred protocol.
Exam Head / Neck
CPT Code
Brain without
70551
Brain with
Brain with and without
70552
70553
**
**
Diagnostic
Prep
Headaches, lymphoma,
rule out metastasis
No Prep
No Prep
No Prep
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
Orbit, Face, Neck with
70540
70542
Diplopia (double vision)
mass, lesion, other indications as
noted
Orbit, Face, Neck with & without
70543
No Prep
No Prep
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)
70336
Popping or clicking of jaw
No Prep
Note: Schedule TMJ studies at the
Downtown office
NOTE: MRI exams and MRA exams are to be scheduled on separate days
**
MRA Head without
MRA Head with
MRA Head with & without
Key Words:
**
70544
70545
70546
Aneurysm, headaches
No Prep
No Prep
No Prep
C.O.W. (Circle of Willis), MR vein, cranial arteries, basilar artery, brain vein
MRA Neck without
MRA Neck with
MRA Neck with & without
70547
70548
70549
Syncope, dizziness, fainting,
occlusion of carotid artery
No Prep
No Prep
No Prep
Key words: Carotids, neck arteries, vertebral arteries
© 2008-2009 Truxtun Radiology Medical Group, L.P.
24
Revised 05/2014
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** Truxtun Radiology Medical Group recommend this exam as the preferred protocol.
Exam Spine
**
CPT Code
MRI C Spine without
MRI C Spine with
MRI C Spine with & without
72141
72142
72156
Diagnostic
Prep
Neck pain, radioculopathy,
numbness of upper extremity
No Prep
No Prep
No Prep
Numbness in chest area
No Prep
No Prep
No Prep
Low back pain, radioculopathy
No Prep
No Prep
No Prep
Key Words: Cervical, C1 to C7, ++brachial plexus++
**
MRI T Spine without
MRI T Spine with
MRI T Spine with & without
72146
72147
72157
Key Words: Thoracic spine, dorsal spine, T1 to T 12
**
MRI L Spine without
MRI L Spine with
MRI L Spine with & without
72148
72149
72158
Key Words: Lumbar, L-S spine, lumbar-sacral, L5 to S1, sacral area
MRA Spine with OR without
72159
No Prep
Note: Schedule at Downtown site ONLY
© 2008-2009 Truxtun Radiology Medical Group, L.P.
25
Revised 05/2014
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** 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
**
73221
73222
73223
See Fluoro
Pain in joint, tear, sports
injury, trauma
Mass, infection, lesion, lump
No Prep
No Prep
No Prep
MRI Upper Extremity JOINT without
MRI Upper Extremity JOINT with
MRI Upper Extremity JOINT With & without
Arthrogram, you must also use Fluoro Arthro
Injection for sites.
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
No Prep
73219
No Prep
73220
Mass, infection, lesion, lump
No Prep
Key Words: Hand, forearm, ulna, radius, humerus, ++Biceps++ ++Triceps++
MRA Upper Extremity with OR without
73225
Poor circulation, coldness of
hands
No Prep
Note: Schedule at Downtown site ONLY
Exam Lower Extremity
CPT Code
Diagnostic
Prep
**
73721
73722
73723
See Fluoro
Tear, sports injury, trauma
No Prep
No Prep
No Prep
MRI Lower Extremity Joint without
MRI Lower Extremity Joint with
MRI Lower Extremity Joint With & without,
Arthrogram, uoe must also use Fluoro Arthro
Injection for sites.
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
No Prep
73719
No Prep
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
73725
PVD (peripheral vascular
disease) PAD (peripheral
artery disease) poor
circulation, coldness of feet
Note: Schedule at Downtown site ONLY
No Prep
Key Words: Femoral artery, tibial artery, run offs, dorsalis pedis artery, popliteal artery
© 2008-2009 Truxtun Radiology Medical Group, L.P.
26
Revised 05/2014
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** Truxtun Radiology Medical Group recommend this exam as the preferred protocol.
Exam Chest
**
MRI Chest without
MRI Chest with
MRI Chest With & without
CPT Code
Diagnostic
Prep
71550
71551
71552
Mass, lesion
No Prep
No Prep
No Prep
Key Words: Hilar, mediastinal, thorax, sternum, clavicle, ribs, Sterno-clavicular joints
MRI Cardiac for Morphology/function w/o
MRI Cardiac for Morphology/function with
and without
75557
75561
Heart mass
No Prep
No Prep
No Prep
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)
Without contrast
With contrast
With and Without contrast
77058
Lump, pain, cancer,
abnormal mammogram
abnormal Ultrasound
No Prep
MRI Breast Bilateral (any of the following)
Without contrast
With contrast
With and Without contrast
77059
Lump, pain, cancer,
abnormal mammogram
abnormal Ultrasound
No Prep
MRI Guided Breast Biopsy, 1 location
19085
Biopsy breast needle
core percutaneous
Digital diagnostic
unilateral mammogram
Labs needed: CBC, PT, PTT,
BUN, Creatinine
Biopsy breast needle
core percutaneous
Additional location
Digital diagnostic
unilateral mammogram
Labs needed: CBC, PT, PTT,
BUN, Creatinine
G0206
MRI Guided Breast Biopsy, 2 locations
19085
19086
G0206
© 2008-2009 Truxtun Radiology Medical Group, L.P.
27
Revised 05/2014
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** Truxtun Radiology Medical Group recommend this exam as the preferred protocol.
Exam Abdomen / Pelvis
**
MRI Abdomen without
MRI Abdomen with
MRI abdomen with & without
CPT Code
74181
74182
74183
Diagnostic
Prep
Mass, lesion, lump
No Prep
No Prep
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
MRI Pelvis with
MRI Pelvis with & without
72195
72196
72197
Mass, bleeding, cancer
of prostate
No Prep
No Prep
No Prep
Key Words: Uterus, ovaries, bladder, prostate, rectum, scrotum, testes, penis, cervix
MRA Pelvis with OR without
72198
aneurysm
No Prep
Note: Schedule at Downtown site ONLY
© 2008-2009 Truxtun Radiology Medical Group, L.P.
28
Revised 05/2014
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** Truxtun Radiology Medical Group recommend this exam as the preferred protocol.
Exam Miscellaneous
**
**
Diagnostic
Prep
MRI Achilles Tendon without contrast
73721
&
73718
Tear, pain, ruptured tendon
No Prep
MRI Achilles Tendon with contrast
73722
&
73719
Tear, pain, ruptured tendon
No Prep
MRI Achilles tendon with & without contrast
73723
&
73720
Tear, pain, ruptured tendon
No Prep
MRI Brachial Plexus without
72141
&
73221
72142
&
73222
72156
&
73223
Upper extremity atrophy,
weakness of upper extremity
No Prep
Upper extremity atrophy,
weakness of upper extremity
No Prep
Upper extremity atrophy,
weakness of upper extremity
No Prep
73221
&
73218
73222
&
73219
73223
&
73220
Trauma, ruptured tendon
No Prep
Trauma, ruptured tendon
No Prep
Trauma, ruptured tendon
No Prep
MRI Brachial Plexus with
MRI Brachial Plexus with and without contrast
**
CPT Code
MRI Bicep without contrast
MRI Bicep with contrast
MRI Bicep with and without contrast
© 2008-2009 Truxtun Radiology Medical Group, L.P.
29
Revised 05/2014
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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
Exam
Diagnostic
Prep
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
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
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
Bone Scan, 3 Phase, inject patient take
pictures, return 3-5 hours later to scan for 30
minutes
CPT Code
Note: Usually done on upper and lower
Extremities. Hands- feet-ankles
(5 hour delay for imaging)
All others is 3 hour delay.
Note: Usually done on Spine C, T. L
© 2008-2009 Truxtun Radiology Medical Group, L.P.
30
Revised 05/2014
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Exam
CPT Code
Diagnostic
Prep
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
th
the 6 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
© 2008-2009 Truxtun Radiology Medical Group, L.P.
31
Revised 05/2014
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Exam
CPT Code
Diagnostic
Prep
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
No 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.
78804
78803
A4642
Imaging lesion within the chest and
abdomen
Parathyroid Scan, inject patient wait 20
st
minutes, 1 image takes 10 minutes, patient
leaves and returns 2 and 4 hours later for
another 10minutes imaging.
78070
A9500
Hyperparathyroidism,
hypercalcemia, abnormal labs,
adenoma
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.
78701
78710
A9551
Evaluation of renal function, kidney
transplant
Must be well hydrated
Drink as much water as possible
May use restroom when needed
78707
A9562
Evaluation of kidney for transplant,
renal function
Must be well hydrated
Recommend 40 ounces of water
May use restroom when needed
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.
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
Note: This study performed on children
Renogram with vascular flow and function
Note: No pharmaceuticals
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
Note: Scintography
© 2008-2009 Truxtun Radiology Medical Group, L.P.
32
Revised 05/2014
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Exam
CPT Code
Diagnostic
Prep
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
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
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
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
78814
See whole body PET/CT
A9552
© 2008-2009 Truxtun Radiology Medical Group, L.P.
NPO 6 hours prior
Does not have to be off thyroid
medication
Referring physician to obtain
medication
Diagnosis and staging of cancer
Please see PET/CT appointment
Limited sugar intake for 24 hours
checklist
Revised 05/2014
33
PET/CT APPOINTMENT CONFIRMATION 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: ______________________
© 2008-2009 Truxtun Radiology Medical Group, L.P.
Date: ________________________
34
Revised 05/2014