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EXAM TO ORDERVASCULARSYMPTOMS/CONCERNSC PT CODEUS arterial - lower extremity only*Always includes bilateral extremityunless amputation. Cellulitis Claudication Edema Extremity pain PVD or PAD (Peripheral vascular/arterial disease)93925 Bilateral93926 UnilateralUS carotid duplex arteries bilateral Bruit Hypercholestremia Trauma Diplopia Hyperlipidemia Vertigo93880 Edema Swelling in extremity Pain in extremity Numbness Warm limb ThrombosisUS extremity venous studiesduplex scan of veins,UNILATERAL upper and lowerUS extremity venous studyduplex scan of veins,BILATERAL upper and lowerOTHERUS non-vascular extremity LTD93971Please indicate upper/lower extremity and right/left. Pain Swelling Redness Tenderness in both legs93970Please indicate upper/lower extremity and right/left. Lumps Soft tissue masses on extremities and axilla(document specific area of concern)76882

EXAM TO ORDERSYMPTOMS/CONCERNSBONE MINERALDENSITOMETRY Evaluate bone lossDEXA, Bone Density, one or more sites Osteoporosis(hips, pelvis, spine) OsteopeniaCT, Bone Density, QCTEXAM TO ORDERUS Obstetrical 14 weeksUS TransvaginalCPT CODE77080 Osteopenia Osteoporosis77078SYMPTOMS/CONCERNSCPT CODE Pregnancy LESS than 14 weeks Fetal demise76801, 76817 Pregnancy GREATER than 14 weeks Evaluation of fetal growthUS Obstetrical 14 weeksUS Obstetrical w/ imagingof additional fetusPlease include last menstrual period or establishedestimated date of delivery for OB ultrasound (morethan 14 weeks or for multiple fetus). Multiple fetus US obstetrical less than 14 weeks76805, 7681076801 (first)76802 (additional)BONE DENSITY& PREGNANCYPREGNANCYPlease include last menstrual period or establishedestimated date of delivery on all exams (less than14 weeks). *Preferred exam to include EV for early OB.

EXAM TO ORDERScreening: Bilateral AnnualMAMMOGRAMIncludes Computer Aided DetectionDiagnostic: Unilateral AnnualSYMPTOMS/CONCERNS Asymptomatic Women Age 40 (with or without BreastImplants); or for complaint of Generalized Pain/Burning(without Palpable Mass) Age 30 Patients that are Symptomatic OR Asymptomaticwith personal history of breast cancer Lump, Mass, Focal Pain or Spontaneous Nipple Discharge(Clear or bloody) Diagnostic Mammogram also requires Breast Ultrasound(Complete US, 76641)C PT CODE7706777065 Complete US, 76641OR Limited US, 76642(Limited US, 76642)*Breast US is ordered for affected laterality only.Order Bilateral Breast US only when patient symptoms are bilateral.Diagnostic: Bilateral Annual77066 Nipple Retraction or Symptoms of Mastitis do not requireUS and are evaluated with Diagnostic MG, Bilateral, OnlyComplete US, 76641OR Limited US, 76642High Risk Breast Assessment Family history of breast cancer: (Self or family memberknown to carry the BRCA 1/BRCA 2 gene)98968Screening: Bilateral Annual All Asymptomatic Women; Age 40 and older77063Diagnostic: BilateralBilateral AnnualDiagnostic: Symptomatic Women; Age 40 and older77062Diagnostic: Unilateral Symptomatic Women; Age 40 and older77061

T CODE Complete exam of all four quadrants of the breast,retroareolar region, and axilla Focused exam of the breast that is limited to no morethan three quadrants of the breast, retroareolar region,and axilla Palpable mass, women age 29 and younger76641 (unilateral)76641, 50 (bilateral)76641 (unilateral)76641, 50 (bilateral)*Breast US is ordered for affected laterality only. Order BilateralBreast US only when patient symptoms are bilateral.(A Mammogram is not recommended as initial exam.)OTHER - MRIMRI Breast (in addition to not as a replacement for)Annual ScreeningMammography orTomosynthesis High Risk Patients:- BRCA 1 or 2 carrier- History of chest radiation from ages 10-30- Lifetime risk of breast cancer 20-25% or greater- Untested patient w/ 1st degree relative positivefor BRCA 1 or 2 Dense Breast evaluation Evaluation suspected Breast Cancer Assessment of breast implants (Silicone/Saline) Preoperative evaluation of newly diagnosed breastcancer Evaluation of inconclusive clinical or imagingfindings Breast Implant Integrity. Without contrast only.Diagnostic:77048* Unilateral with andwithout contrast77049* Bilateral with andwithout contrastFor Breast Implant Integrity:77046 Unilateral withoutcontrast77047 Bilateral withoutcontrast(*Studies performed w/wocontrast, including CADComputer Aided Detection.)**Both code definitions include exam of the Axilla, if performed.MAMMOGRAPHYEXAM TO ORDER

EXAM TO ORDERBONE SCANSWHITE BLOOD CELL(WBC) SCANSPARATHYROIDSCANSYMPTOMS/CONCERNSCPT CODEWhole Body Bone Scan Metastatic disease78306Limited Bone Scan Occult fracture, stress reaction, arthritis78300 Known or suspected joint replacement loosening,Bone graft viability, Avascular necrosis, ReflexSympathetic Dystrophy (RSD)78315Limited Bone Scan with SPECT Occult Fracture, stress reaction, arthritis Pars defect78803White Blood Cell (WBC)Indium-111 (IN-111) Limited Known or suspected infection/inflammation Osteomyelitis78800White Blood Cell (WBC) Indium-111(IN-111) Multiple Known or suspected infection/inflammation areas78801White Blood Cell (WBC)Indium-111 (IN-111) Whole Body Known or suspected infection/inflammation78802Parathyroid Scan Evaluate for parathyroid adenomas and patients withhyperparathyroidism and hypercalcemia.78071 (with SPECT)Three Phase Bone Scan Paget's disease Bone lesions

EXAM TO ORDERPreferred Post thyroidectomy, diagnostic scan for thyroidcancer metastases or residual thyroid tissue.Whole Body I-131 Scan Metastatic Post thyroidectomy, diagnostic scan for thyroidSurvey (with or w/o thyrogen). Thyrogencancer metastases or residual thyroid tissue.is given at the referring provider’s officeCPT CODE7801878018THYROID SCANSTechnetium 99m (Tc-99m)Thyroid Scan Only Evaluate thyroid gland structure, location of ectopicthyroid tissue, evaluation of congenital hypothyroidism,evaluation of neck or substernal mass78013Iodine-123 (I-123)Single 24 Hour Uptake and Scan Suspected hyperthyroidism, thyroid masses,evaluate thyroid nodules function78014Iodine-123 (I-123) Suspected hyperthyroidism, thyroid masses,Multiple 4 & 24 Hour Uptake and Scan evaluate thyroid nodules function78014THYROIDTHERAPYIodine-131 (I-131) Thyroid Therapy Treatment for Graves Disease, toxic nodules,and nontoxic nodular goiter. Thyroid Cancer,treatment for residual tissue after thyroidectomy.79005NUCLEARMEDICINEI-131 WHOLE BODY SCANSWhole Body I-123 Scan MetastaticSurvey (with or w/o thyrogen).Thyrogen is given at the referringprovider’s officeSYMPTOMS/CONCERNS

C PT CODELung V/Q (Ventilation and Perfusion) Suspected pulmonary embolism78582Hepatobiliary Scan Evaluate for cystic duct obstruction and foracute cholecystitis78226Hepatobiliary Scan with gallbladderejection fraction analysis Evaluate for gallbladder dysmotility orbiliary dyskinesia78227Gastric Emptying Study Evaluate gastric motility and emptying.78264CARDIACSCANSCardiac Blood Pool (MUGA) Scan Evaluate cardiac function78472LYMPHOSCINTIGRAPHYLymphoscintigraphy Lymphatic NGEXAM TO ORDERHEPATOBILIARYSCANS

EXAM TO ORDERLIVER SCANSLIVERHEMANGIOMASYMPTOMS/CONCERNSCPT CODELiver Spleen Scan Without SPECT(Planar) Evaluate focal liver masses such as HCC, FNH, adenomaand hemangioma when MRI is indeterminate.78215Liver Spleen Scan With SPECT(Tomography) Evaluate focal liver masses such as HCC, FNH, adenomaand hemangioma when MRI is indeterminate. SPECT ispreferred over planar study.78803Liver Red Blood Cell Scan SPECT Evaluate liver mass for possible hemangioma whenMRI is indeterminate78803RENAL SCANSPreferredBRAINIMAGINGRenal Flow and FunctionWithout and With Lasix Evaluate for renal function, renal ureter obstruction,post surgical evaluation78708Renal Flow and Function Evaluate renal function78707Brain DaTScan Evaluate for Parkinson’s Disease, MSA, CBD, and PSP Tremors78803, A9584

CPT CODESkull Base to Mid-Thigh Oncology staging, restaging, recurrence, and therapyresponse (Please refer to the IHS PETCT coverage guidefor more information)78815, A9552Whole Body Oncology staging, restaging, recurrence, and therapyresponse for melanoma or sarcoma of the long bones78816, A9552Ga-68 Dotatate Scan(Skull to Mid-Thigh) Staging and restaging neuroendocrine tumors78815, A9587BONE SCAN WITH F-18SODIUM FLUORIDEWhole Body Bone Scanwith F-18 NaF Detection and evaluation of skeletal metastaticdisease (more sensitive alternative than conventionalbone scans)78816, A9580TUMOR IMAGINGWITH FDGSYMPTOMS/CONCERNSTUMOR IMAGINGWITH GA-68EXAM TO ORDER

EXAM TO ORDERBRAIN IMAGINGCPT CODEBrain Scan with FDG Evaluate Mild Cognitive Impairment and Dementia.Help differentiate Alzheimer’s Disease fromFronto-Temporal Dementia (FTD)78814Brain Scan with Florbetapir F-18Amyloid Imaging (Amyvid) Evaluate for Alzheimer’s Disease and differentiatefrom FTD78814Prostate Scan with FluciclovineF-18 (Axumin) Prostate cancer re-staging after patient has completedtreatment and has a rising PSA78815, A9588PET/CTPROSTATE SCANSYMPTOMS/CONCERNS

hours before exam and 2 hours prior toexam. IHS recommends that the referringphysician order the prednisone forthe patient.Age 70 and overMRI with IV ContrastCoag Panel: PT, PTT, INR STAT COAG PANEL must be drawn the dayprior to scheduled procedure, with resultsreceived to IHS no later than 9 a.m. onthe day of the exam.MISSING LABS may result in therescheduling of the patient exam orchanged to a non-contrast exam.*Dialysis appointment must be scheduledwithin 24 hours after the examination.History of kidney/renal disease(any age)Dialysis patient*Age 70 and overHistory of kidney/renal diseaseCT with IV ContrastDialysis patient*Coumadin: Patient must discontinue Coumadin 5days prior to any biopsy. Anti-coagulantmedications cannot be discontinuedwithout notification of prescribingphysician.Diabetic patientStandardCT Guided BiopsyPatient on CoumadinLines (picc, ports) forreplacement, changes,or removalsStandardTubes (G tubes, J tubes)for replacement, changes,or removalsStandardPatient on CoumadinPatient on CoumadinNO LABSPATIENT INDICATIONSDISCONTINUECOUMADINEXAMSSTATCOAG PANEL Prednisone 40mg by mouth taken 12COAG PANELW/IN 30 DAYSCurrent Pre Medication Prescription:CREATININEW/IN 3 MONTHSSpecial Requirements forContrast Exams

EXAM TO ORDERSYMPTOMS/CONCERNSCPT CODEAngiography: Femoral-PoplitealTerritoryInitial Vessel: 37224Atherectomy angio: 37225Stent angio: 37226Stent atherec angio: 37227 Pain with ambulation or pain at rest tolower extremities; non-healing wounds;skin discolorationAngiography: Tibial-PeronealTerritoryT-Spine: 22513, each add’l level use22515 (if biopsy is performed onseparate vertebrae, use 20225)Kyphoplasty Back pain stemming from a fracture/generalized back pain;Spine MalformationVertebroplastyInitial Vessel: 37228Atherec angio: 37229Stent angio: 37230Stent atherec angio: 37231Each addl vess angio: 37232Each addl vess atherec angio: 37233Each addl vess stent angio: 37234Each addl vess strent atherec angio: 37235L-Spine: 22514, each add’l level use22515 (if biopsy is performed onseparate vertebrae, use 20225)T-Spine: 22510, each add’l level use22512 (if biopsy is performed onseparate vertebrae, use 20225)L-Spine: 22511, each add’l level use22512 (if biopsy is performed onseparate vertebrae, use 20225)IRAngiography: Illiac TerritoryRevasc w/ angio: 37220Stent w/ angio: 37221Each addl vess angio: 37222Each addl vess stent angio: 37223

EXAM TO ORDERSYMPTOMS/CONCERNSCPT CODEIVC Filter Placement Known DVT; pre-surg and at risk for DVT37191: Placement37192: Repositioning37210: RemovalUterine Fibroid Embolization Heavy menstruation; abdominal pain;disturbance to urinary flow; bloating37210PICC Line Placement Long-term antibioticsVenogram Mapping of vessels for pre-opVaricose VeinAblation Therapy Painful bulging veins in legs36482: Chemical adhesive first vein36483: Chemical adhesive subsq vein36475: Radiofrequency first vein36476: Radiofrequency subsq veinPort Large volume infusions (ex: chemo)36561: Placement36598: Management36590: RemovalBiliary Tube Generalized abdominal pain; imaging/lab values necessitating need47533: Placement47536: Replacement47537: RemovalTunneled Pleural Catheter(ASPIRA) Shortness of breath; frequent occurrenceof pleural fluid buildupTunneled Pleural Catheter(ASPIRA) Shortness of breath; frequent occurrence ofabdominal cavity fluid buildup; bloating;discomfort32557: Insertion32555: Thoracentesis (drainage)32552: Removal of drain49418: Insertion49083: Paracentesis (drainage)49422: RemovalGastrostomy Tube DysphagiaInsertion: 36569Fluoro Guidance: 77001US Guidance: 76937Unilateral: 75820, 36005Bilateral: 75822, 36005 (x2)49440: Insertion49465: Maintenance43762: Removal

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EXAM TO ORDER SYMPTOMS/CONCERNS CPT CODE CT angiography chest Pulmonary embolism Aneurysm Chest pain Dyspnea Elevated D-Dimer Ascending aorta or aortic arch dissection 71275 CT chest high-resolution chest w/o contrast Interstitial lung disease 71250 CT