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FD-947 (Rev. 12/31/2010) FBI Hazardous Material Response Team - Periodic
TO:
FROM: FBI Field Office
Examinee: _________________________________________ D.O.B. ____________________________ 67 Number:
Job Position: ___________________________________
Appointment Date: _________________ Time: ________________
Bring all shots record (CDC –731, International Certificate of Vaccination)
| CPT Codes |
| Required |
| Core Components (lab) |
| 80061 |
| Required |
| Lipid panel |
| 80053 |
| Required |
| Comprehensive Metabolic Panel |
| 81001 |
| Required |
| Urinalysis |
| 82480 |
| Required |
| Plasma cholinesterase |
| 82482 |
| Required |
| RBC cholinesterase |
| 85025 |
| Required |
| Complete blood count with differential |
| CPT Codes |
| Required |
| Core Components (Screening Tests) |
| 86580 |
| Required |
| Mantoux TB test, unless prior hx of conversion |
| 92551 |
| Required |
| Audiometry |
| 93000 |
| Required |
| Resting EKG 12 leads with interpretation |
| 94010 |
| Required |
| Pulmonary function test |
| 99172 |
| Required |
| Distant & near visual acuity with and without corrections |
| 99172 |
| Required |
| Visual fields, strabismus |
| 99172 |
| Required |
| Color vision – If not already documented |
| 99385, 86, 87 |
| Required |
| History, PE, vitals (ht, wt, B/P, pulse, temp), written summary of findings |
| FD-899, FD-900 |
| Required |
| Completion of FD-899 and FD-900 |
| CPT codes |
| If Indicated |
| Supplemental Components |
| 84153 |
| Required |
| Prostate specific antigen –Males > 40 years |
| 45999 |
| Offer |
| Digital rectal exam –Males >40 years |
| 82270 |
| Offer |
| Stool for Occult Blood X 3 |
| 82955 |
| If indicated |
| G6PD – if not on record |
| 88141 |
| Offer |
| If pap > 12 months offer complete GYN exam -Females |
| 77057 |
| Offer |
| Mammography, offer if > 40 years, in conjunction with GYN Breast Exam performed within 1 year, on record - Females |
| 71020 |
| If indicated |
| Chest x-ray P/A & lateral – REQUIRES FBIHQ APPROVAL |
| 83655 |
| If indicated |
| Blood lead – REQUIRES FBIHQ APPROVAL |
| 84202 |
| If indicated |
| Zinc Protoporphyrin (ZPP) – REQUIRES FBIHQ APPROVAL |
| 93015 |
| Required–age specific |
| Exercise stress test Bruce protocol at ages 40, 44, 48, 50, 52, 54 &56 |
| 92120 |
| Offer |
| Tonometry > 40 years |
| 93015, 78465, 78478, 78480, A9505, A9502 |
| Requires Approval |
| Thallium stress test – follows abnormal screening |
| 93350, 93015 |
| Requires Approval |
| Stress Echo – preferred-follows abnormal screen |
| CPT Codes |
| Per Instructions |
| Vaccinations – PHYSICIAN REVIEW AND UPDATE AS NEEDED |
| 90632 |
| Update as needed |
| Hepatitis A vaccine, basic series |
| 90746 |
| Update as needed |
| Hepatitis B vaccine – basic |
| 90636 |
| Update as needed |
| Twinrix |
| 90690 or 90691 |
| Update as needed |
| Typhoid (injection Q 2 yrs or oral Q 5) |
| 90707 |
| Update as needed |
| MMR (once as adult) |
| 90713 |
| Update as needed |
| Inactive polio (IPV) one dose as an adult |
| 90658 |
| Update as needed |
| Influenza, annually |
| 90718 |
| Update as needed |
| Tetanus/diphtheria q 10 years OR |
| 90715 |
| Update as needed |
| Tdap, tetanus/diphtheria/pertussis q 10 years |
| 90717 |
| Approval Required |
| Yellow fever q 10 years |
| 90733 or 90734 |
| Update as needed |
| Meningococcal vaccine – per manufacturers recommended frequency |
| 4120F |
| Screening dose |
| Mefloquine trial, one dose & record reaction |
| 90581 |
| As available |
| Anthrax, FBI supplied – special series |
| 90675 |
| Approval required |
| Rabies – special series |
| 90749 |
| As available |
| Smallpox – special series |
| 99401,02,03,04 |
| As needed |
| Travel Medicine Consultation |
