RACE (SEE BACK) ETHNICITY (SEE BACK) DIAGNOSIS CODE ADDRESS OF RESPONSIBLE PARTY APT # DATE OF BIRTH

Transcription

1 Date } ACCOUNT INFORMATION NAME ADDRESS PHONE ORDERING PHYSICIAN BILL TO: ACCOUNT PATIENT/INSURANCE ALTERNATE PATIENT DEPARTMENT OF LABORATORIES St. Louis, Missouri PHONE: (314) FAX: (314) PATIENT S NAME (LAST) (FIRST) (MI) SEX DATE OF BIRTH PATIENT S SS # RACE (SEE BACK) ETHNICITY (SEE BACK) DIAGNOSIS CODE PATIENT S ADDRESS PHONE PATIENT S RELATIONSHIP TO RESPONSIBLE PARTY 1-SELF 2-SPOUSE 3-CHILD 4-OTHER NAME OF RESPONSIBLE PARTY (IF DIFFERENT FROM PATIENT) SOCIAL SECURITY (INSURED SS#): ADDRESS OF RESPONSIBLE PARTY APT # DATE OF BIRTH MEDICAID # STATE MEDICARE # (INCLUDE PREFIX/SUFFIX) PRIMARY MEDICARE RETIREMENT OR DISABILITY SECONDARY DATE: STAT FAX REPORT TO: COLLECTION TIME FASTING AM : PM YES NO BJH REGISTRATION # CALL RESULTS TO: (# ) COLLECTION DATE COMPLETE AND ATTACH STAT FLYER URINE hrs/vol hrs vol INSURANCE COMPANY NAME PLAN CARRIER CODE SUBSCRIBER / MEMBER # LOCATION GROUP # INSURANCE ADDRESS PHYSICIAN S PROVIDER # FORM NO (4/02/15) REGISTERED EMPLOYER S NAME OR NUMBER WORKER S COMP BY YES NO NOTE TO PHYSICIAN: When seeking payment from Medicare or Medicaid, Physicians should only order tests that are medically necessary for the diagnosis or treatment of the patient, for instance, Medicare does not cover routine screening, testing that is investigative or research use only, testing with quantity limits. Components of the organ or disease panels/combinations printed below are shown on the reverse side and may also be ordered individually below. Components may be billed separately if allowed by the payer. ORGAN OR DISEASE PANELS CODE (See Reverse for Components) Electrolyte Panel Basic Metabolic Panel Comprehensive Metabolic Panel Hepatic Function Panel Renal Function Panel Acute Hepatitis Panel RED Lipid Panel (*) Obstetric Panel ALPHABETICAL/COMBINATION TESTS SST ACID PHOSPHATASE, PROSTATIC ICE 2LAV/ 2RED ALBUMIN ALKALINE PHOSPHATASE ALPHA FETOPROTEIN (AFP) (Tumor Marker) RED AMYLASE ANA Refl ex (Antinuclear Ab)* see back RED ANA Qualitative (Antinuclear Ab) see back RED ANTI-DS-DNA ANTIBODY RED BILIRUBIN, DIRECT BILIRUBIN, TOTAL BUN C3, COMPLEMENT RED C4, COMPLEMENT RED CALCIUM CARCINOEMBRYONIC ANTIGEN (CEA) RED CBC w DIFF w PLT (see back) LAV CBC EXPRESS (see back) LAV CHLORIDE CHOLESTEROL CK (CPK) TOTAL CMV, IgG RED CORTISOL GRN C-PEPTIDE RED CREATININE DRUG SCREEN PRENATAL see back URN ENA SCREEN (*) RED ESR (SEDIMENTATION RATE) LAV ESTRADIOL RED FERRITIN RED FOLATE GRN FSH, BLOOD GRN GAMMA-GT FASTING RANDOM TOL 50G-SCREEN TOL 100G-DIAGNOSTIC TOL 75G-NONPREGNANT PREDIABETES (Dx: V77.1) FASTING ( ) RANDOM ( ) TOL 50G-SCREEN TOL 100G-DIAGNOSTIC TOL 75G-NONPREGNANT HCG-QUALITATIVE, SERUM RED HCG-QUALITATIVE, URINE URN HCG-QUANT., BETA RED HDL CHOLESTEROL HELICOBACTER PYLORI, IgG RED HEMOGLOBIN A1C LAV HEPATITIS A ANTIBODY (IGM) RED HEPATITIS B SURFACE AB RED HEPATITIS B SURFACE ANTIGEN (*) RED HEPATITIS B CORE IgM RED HEPATITIS C ANTIBODY RED HIV AG/AB COMBO see back PINK IMMUNOFIX ELECTRO, SERUM RED INTACT PTH LAV IONIZED CALCIUM IRON, TOTAL LDH LIPASE MAGNESIUM MEASLES (RUBEOLA) RED MONO LATEX TEST RED MUMPS-IgG SCREEN RED NEOPLASM SCREEN NON NEOPLASM SCREEN PHOSPHATE POTASSIUM PROGESTERONE RED PROLACTIN GRN PROSTATE SPECIFIC AG SCREEN G0103 RED CODE ALPHABETICAL TESTS CON T PEAK TROUGH RANDOM CARBAMAZEPINE GRN CYCLOSPORINE LAV PROSTATE SPECIFIC AG DIAGNOSTIC RED DIGOXIN GRN PROTEIN ELECTRO, Refl ex, Serum see back RED LITHIUM RED PROTEIN, TOTAL PHENOBARBITAL GRN PHENYTOIN (DILANTIN) GRN PT (PROTIME) BLU TACROLIMUS LAV PTT BLU THEOPHYLLINE GRN RHEUMATOID FACTOR, QUANTITATIVE VALPROIC ACID GRN RPR (*) RED VANCOMYCIN GRN RUBELLA IGG RED SODIUM OTHER DRUG T3, FREE GRN TESTOSTERONE GRN 24 HOUR URINE ( ) TESTOSTERONE, FREE RED START DATE / TIME END DATE / TIME THYROID FUNCTION CASCADE (*) TRIGLYCERIDE, FASTING TSH (THYROTROPIN) CREATININE 24 HR BATTER U THYROXINE (T4), FREE RED CREATININE CLEARANCE (NEED BLOOD & URINE) 24U TOTAL HEMOLYTIC COMP (THC) (CH50) RED PROTEIN 24 HR BATTERY U TYPE & SCREEN (*) see back PNK OTHER TIMED URINE (SPECIFY): UA REFLEX W/CULTURE see back URN UA REFLEX see back URN UA MACROSCOPIC URN MICROBIOLOGY SPECIMEN/SITE: UA MICROSCOPIC URN URIC ACID LOOK FOR: VITAMIN D 25-OH RED TEST CULTURE, AEROBE (ROUTINE) ONLY** SEE BACK STAIN, GRAM CULTURE, FUNGAL (MYCOLOGY) CULTURE, MYCOBACTERIA (AFB)(*) HERPES PCR OVA & PARASITES (O&P) SCREEN SEE BACK STOOL C. DIFFICILE ASSAY STOOL CULTURE, BETA STREP CERVIX CULTURE, BETA STREP VAG/RECTAL CHLAMYDIA/GC AMPLIFIED PROBE SEE BACK THROAT CHLAMYDIA/GC AMPLIFIED PROBE SEE BACK RECTAL SWAB ** SUSCEPTIBILITIES PERFORMED AUTOMATICALLY AS NEEDED CLIA #26DO CONTAINERS RECEIVED SST RED LAV PNK BLU GRN RYB YEL URN 24 U FL OT BACT O & P PROBE URN CUL STERIL FECAL VIRAL SPUN RED LAVENDER 10MLEDTA LT. BLUE GREY DK. GREEN RYL BLU ACD MNT GRN URINE 24 HR URINE FLUID OTHER TRNSPT KIT TRNSPT TRNSPT TRNSPT TRNSPT TRNSPT SPUN TUBE Collection Time: Initials:

2 PATIENT DEMOGRAPHIC INFORMATION: Race: American Indian or Alaska Native AI Asian AS Black or African American BL Native Hawaiian or other Pacific Islander... PI White WH Unknown UN Some other Race SR Ethnicity: Hispanic or Latino Non Hispanic or Latino Unknown TEST COMBINATION / PANEL POLICY Barnes Jewish Hospital Department of Lab policy is to provide physicians, in each instance, with the flexibility to choose appropriate tests to assure that the convenience of ordering test combinations/panels does not distance physicians who wish to order a test combination/panel from making deliberate decisions regarding which tests are truly medically necessary. All the tests offered in test combinations/panels may be ordered individually using the request form. In an effort to keep our clients fully informed of the content, charges and coding of its test combinations/panels when billed to Medicare, we periodically send notices concerning test combinations/panels, as well as information regarding patient fees for all services. We also welcome the opportunity to provide, on request, additional information in connection with our testing services and the manner in which they are billed to physicians, health care plans, and patients. The CPT code(s) listed here are in accordance with the 2010 edition of Physicians Current Procedural Terminology, a publication of the American Medical Association. CPT codes are provided here for the convenience of out clients; however, correct coding often varies from one carrier to another. Consequently, the codes presented here are intended as general guidelines and should not be used without confirming with the appropriate payor that their use is appropriate in each case. All laboratory procedures will be billed to third-party carriers (including Medicare and Medicaid) at fees billed to patients and in accordance with the specific CPT coding required by the intermediary. CPT codes , previously used for automated multichannel testing, have been eliminated as of January 1, New organ or disease panel CPT codes will be used instead, as noted below. Microbiology CPT code(s) for additional procedures such as susceptibility testing, identification, serotyping, etc. will be billed in addition to the primary codes when appropriate. Barnes Jewish Hospital will process the specimen for a Microbiology test based on source. ORGAN or DISEASE ORIENTED PANELS Basic Metabolic Panel Electrolytes Panel Indicates Reflex Testing Refer to Laboratory Test Catalog Comprehensive Metabolic Panel Protein, Total Obstetric Panel Complete Blood Count Hepatitis B surface antigen (HBsAg) Rubella Antibody IgG RPR Type and Screen Lipid Panel Cholesterol Total High Density Cholesterol (HDL) Triglycerides Renal Function Panel Phosphate Acute Hepatitis Panel Hepatitis A AB IGM Hepatitis B Core AB IGM Hepatitis B Surface AG Hepatitis C AB Hepatic Function Panel Bilirubin Direct Protein Total Urine Reflex w/culture Urine Culture (if indicated) Urine Reflex ANA REFLEX (ANTINUCLEAR AB) ds-dna (if appropriate) ANTI ANA QUALITATIVE CBC EXPRESS (No Automated Differential) CHLAMYDIA / GC AMPLIFIED PROBE Probe Amp C. Trachomatis Probe Amp N. Gonorrhoeae COMPLETE BLOOD COUNT (CBC) (With Automated Differential & Platelet Count) Five Part Differential CULTURE, AEROBE (ROUTINE) CPT Code is dependent on specimen type. Routine stool (enteric) culture look for Salmonella and Shigella Routine stool (enteric) culture look for additional pathogens Routine culture (any source except blood, stool, or urine) Routine urine culture (no growth on culture) Routine urine culture (growth on culture) CULTURE, VIRAL Culture, Viral Shell vial ID each 87254x2 DRUG SCREEN PRENATAL Amphetamine/Methamphetamine Barbiturate Benzodiazepines Screen Cannabinoids Screen Cocaine Metabolite Opiates Methadone Phencyclidine ENA SCREEN ENA screen Antibody ID s ( If appropriate) x 4 HEPATITIS B SURFACE ANTIGEN HBsAg Neutralization (if appropriate) HIV/AG COMBO HIV 1-2 Antibody HIV-1 Multi spot HIV-2 Multi spot HIV RNA ( if appropriate) O & P EXAM SCREEN Cryptosporidium Antigen Giardia Antigen Request O&P Complete Microscopic if comprehensive exam is needed. ADDITIONAL CPT CODES O&P Smear & Identification Trichrome Stain PROTEIN ELECTRO, REFLEX, SERUM Protein Electrophoretic fractionation and quantitation Immunoglobulin free light chains (if appropriate) X2 Immunofix electrophoresis (if appropriate) THYROID FUNCTION CASCADE TSH FREE T4 (if appropriate) TYPE AND SCREEN ABO Typing Antibody Screen Rh Typing 86901

3 Date } ACCOUNT INFORMATION NAME ADDRESS PHONE ORDERING PHYSICIAN BILL TO: ACCOUNT PATIENT/INSURANCE ALTERNATE PATIENT DEPARTMENT OF LABORATORIES St. Louis, Missouri PHONE: (314) FAX: (314) PATIENT S NAME (LAST) (FIRST) (MI) SEX DATE OF BIRTH PATIENT S SS # RACE (SEE BACK) ETHNICITY (SEE BACK) DIAGNOSIS CODE PATIENT S ADDRESS PHONE PATIENT S RELATIONSHIP TO RESPONSIBLE PARTY 1-SELF 2-SPOUSE 3-CHILD 4-OTHER NAME OF RESPONSIBLE PARTY (IF DIFFERENT FROM PATIENT) SOCIAL SECURITY (INSURED SS#): ADDRESS OF RESPONSIBLE PARTY APT # DATE OF BIRTH MEDICAID # STATE MEDICARE # (INCLUDE PREFIX/SUFFIX) PRIMARY MEDICARE RETIREMENT OR DISABILITY SECONDARY DATE: STAT FAX REPORT TO: COLLECTION TIME FASTING AM : PM YES NO BJH REGISTRATION # CALL RESULTS TO: (# ) COLLECTION DATE COMPLETE AND ATTACH STAT FLYER URINE hrs/vol hrs vol INSURANCE COMPANY NAME PLAN CARRIER CODE SUBSCRIBER / MEMBER # LOCATION GROUP # INSURANCE ADDRESS PHYSICIAN S PROVIDER # FORM NO (4/02/15) REGISTERED EMPLOYER S NAME OR NUMBER WORKER S COMP BY YES NO NOTE TO PHYSICIAN: When seeking payment from Medicare or Medicaid, Physicians should only order tests that are medically necessary for the diagnosis or treatment of the patient, for instance, Medicare does not cover routine screening, testing that is investigative or research use only, testing with quantity limits. Components of the organ or disease panels/combinations printed below are shown on the reverse side and may also be ordered individually below. Components may be billed separately if allowed by the payer. ORGAN OR DISEASE PANELS CODE (See Reverse for Components) Electrolyte Panel Basic Metabolic Panel Comprehensive Metabolic Panel Hepatic Function Panel Renal Function Panel Acute Hepatitis Panel RED Lipid Panel (*) Obstetric Panel ALPHABETICAL/COMBINATION TESTS SST ACID PHOSPHATASE, PROSTATIC ICE 2LAV/ 2RED ALBUMIN ALKALINE PHOSPHATASE ALPHA FETOPROTEIN (AFP) (Tumor Marker) RED AMYLASE ANA Refl ex (Antinuclear Ab)* see back RED ANA Qualitative (Antinuclear Ab) see back RED ANTI-DS-DNA ANTIBODY RED BILIRUBIN, DIRECT BILIRUBIN, TOTAL BUN C3, COMPLEMENT RED C4, COMPLEMENT RED CALCIUM CARCINOEMBRYONIC ANTIGEN (CEA) RED CBC w DIFF w PLT (see back) LAV CBC EXPRESS (see back) LAV CHLORIDE CHOLESTEROL CK (CPK) TOTAL CMV, IgG RED CORTISOL GRN C-PEPTIDE RED CREATININE DRUG SCREEN PRENATAL see back URN ENA SCREEN (*) RED ESR (SEDIMENTATION RATE) LAV ESTRADIOL RED FERRITIN RED FOLATE GRN FSH, BLOOD GRN GAMMA-GT FASTING RANDOM TOL 50G-SCREEN TOL 100G-DIAGNOSTIC TOL 75G-NONPREGNANT PREDIABETES (Dx: V77.1) FASTING ( ) RANDOM ( ) TOL 50G-SCREEN TOL 100G-DIAGNOSTIC TOL 75G-NONPREGNANT HCG-QUALITATIVE, SERUM RED HCG-QUALITATIVE, URINE URN HCG-QUANT., BETA RED HDL CHOLESTEROL HELICOBACTER PYLORI, IgG RED HEMOGLOBIN A1C LAV HEPATITIS A ANTIBODY (IGM) RED HEPATITIS B SURFACE AB RED HEPATITIS B SURFACE ANTIGEN (*) RED HEPATITIS B CORE IgM RED HEPATITIS C ANTIBODY RED HIV AG/AB COMBO see back PINK IMMUNOFIX ELECTRO, SERUM RED INTACT PTH LAV IONIZED CALCIUM IRON, TOTAL LDH LIPASE MAGNESIUM MEASLES (RUBEOLA) RED MONO LATEX TEST RED MUMPS-IgG SCREEN RED NEOPLASM SCREEN NON NEOPLASM SCREEN PHOSPHATE POTASSIUM PROGESTERONE RED PROLACTIN GRN PROSTATE SPECIFIC AG SCREEN G0103 RED CODE ALPHABETICAL TESTS CON T PEAK TROUGH RANDOM CARBAMAZEPINE GRN CYCLOSPORINE LAV PROSTATE SPECIFIC AG DIAGNOSTIC RED DIGOXIN GRN PROTEIN ELECTRO, Refl ex, Serum see back RED LITHIUM RED PROTEIN, TOTAL PHENOBARBITAL GRN PHENYTOIN (DILANTIN) GRN PT (PROTIME) BLU TACROLIMUS LAV PTT BLU THEOPHYLLINE GRN RHEUMATOID FACTOR, QUANTITATIVE VALPROIC ACID GRN RPR (*) RED VANCOMYCIN GRN RUBELLA IGG RED SODIUM OTHER DRUG T3, FREE GRN TESTOSTERONE GRN 24 HOUR URINE ( ) TESTOSTERONE, FREE RED START DATE / TIME END DATE / TIME THYROID FUNCTION CASCADE (*) TRIGLYCERIDE, FASTING TSH (THYROTROPIN) CREATININE 24 HR BATTER U THYROXINE (T4), FREE RED CREATININE CLEARANCE (NEED BLOOD & URINE) 24U TOTAL HEMOLYTIC COMP (THC) (CH50) RED PROTEIN 24 HR BATTERY U TYPE & SCREEN (*) see back PNK OTHER TIMED URINE (SPECIFY): UA REFLEX W/CULTURE see back URN UA REFLEX see back URN UA MACROSCOPIC URN MICROBIOLOGY SPECIMEN/SITE: UA MICROSCOPIC URN URIC ACID LOOK FOR: VITAMIN D 25-OH RED TEST CULTURE, AEROBE (ROUTINE) ONLY** SEE BACK STAIN, GRAM CULTURE, FUNGAL (MYCOLOGY) CULTURE, MYCOBACTERIA (AFB)(*) HERPES PCR OVA & PARASITES (O&P) SCREEN SEE BACK STOOL C. DIFFICILE ASSAY STOOL CULTURE, BETA STREP CERVIX CULTURE, BETA STREP VAG/RECTAL CHLAMYDIA/GC AMPLIFIED PROBE SEE BACK THROAT CHLAMYDIA/GC AMPLIFIED PROBE SEE BACK RECTAL SWAB ** SUSCEPTIBILITIES PERFORMED AUTOMATICALLY AS NEEDED CLIA #26DO CONTAINERS RECEIVED SST RED LAV PNK BLU GRN RYB YEL URN 24 U FL OT BACT O & P PROBE URN CUL STERIL FECAL VIRAL SPUN RED LAVENDER 10MLEDTA LT. BLUE GREY DK. GREEN RYL BLU ACD MNT GRN URINE 24 HR URINE FLUID OTHER TRNSPT KIT TRNSPT TRNSPT TRNSPT TRNSPT TRNSPT SPUN TUBE Collection Time: Initials:

4 PATIENT DEMOGRAPHIC INFORMATION: Race: American Indian or Alaska Native AI Asian AS Black or African American BL Native Hawaiian or other Pacific Islander... PI White WH Unknown UN Some other Race SR Ethnicity: Hispanic or Latino Non Hispanic or Latino Unknown TEST COMBINATION / PANEL POLICY Barnes Jewish Hospital Department of Lab policy is to provide physicians, in each instance, with the flexibility to choose appropriate tests to assure that the convenience of ordering test combinations/panels does not distance physicians who wish to order a test combination/panel from making deliberate decisions regarding which tests are truly medically necessary. All the tests offered in test combinations/panels may be ordered individually using the request form. In an effort to keep our clients fully informed of the content, charges and coding of its test combinations/panels when billed to Medicare, we periodically send notices concerning test combinations/panels, as well as information regarding patient fees for all services. We also welcome the opportunity to provide, on request, additional information in connection with our testing services and the manner in which they are billed to physicians, health care plans, and patients. The CPT code(s) listed here are in accordance with the 2010 edition of Physicians Current Procedural Terminology, a publication of the American Medical Association. CPT codes are provided here for the convenience of out clients; however, correct coding often varies from one carrier to another. Consequently, the codes presented here are intended as general guidelines and should not be used without confirming with the appropriate payor that their use is appropriate in each case. All laboratory procedures will be billed to third-party carriers (including Medicare and Medicaid) at fees billed to patients and in accordance with the specific CPT coding required by the intermediary. CPT codes , previously used for automated multichannel testing, have been eliminated as of January 1, New organ or disease panel CPT codes will be used instead, as noted below. Microbiology CPT code(s) for additional procedures such as susceptibility testing, identification, serotyping, etc. will be billed in addition to the primary codes when appropriate. Barnes Jewish Hospital will process the specimen for a Microbiology test based on source. ORGAN or DISEASE ORIENTED PANELS Basic Metabolic Panel Electrolytes Panel Indicates Reflex Testing Refer to Laboratory Test Catalog Comprehensive Metabolic Panel Protein, Total Obstetric Panel Complete Blood Count Hepatitis B surface antigen (HBsAg) Rubella Antibody IgG RPR Type and Screen Lipid Panel Cholesterol Total High Density Cholesterol (HDL) Triglycerides Renal Function Panel Phosphate Acute Hepatitis Panel Hepatitis A AB IGM Hepatitis B Core AB IGM Hepatitis B Surface AG Hepatitis C AB Hepatic Function Panel Bilirubin Direct Protein Total Urine Reflex w/culture Urine Culture (if indicated) Urine Reflex ANA REFLEX (ANTINUCLEAR AB) ds-dna (if appropriate) ANTI ANA QUALITATIVE CBC EXPRESS (No Automated Differential) CHLAMYDIA / GC AMPLIFIED PROBE Probe Amp C. Trachomatis Probe Amp N. Gonorrhoeae COMPLETE BLOOD COUNT (CBC) (With Automated Differential & Platelet Count) Five Part Differential CULTURE, AEROBE (ROUTINE) CPT Code is dependent on specimen type. Routine stool (enteric) culture look for Salmonella and Shigella Routine stool (enteric) culture look for additional pathogens Routine culture (any source except blood, stool, or urine) Routine urine culture (no growth on culture) Routine urine culture (growth on culture) CULTURE, VIRAL Culture, Viral Shell vial ID each 87254x2 DRUG SCREEN PRENATAL Amphetamine/Methamphetamine Barbiturate Benzodiazepines Screen Cannabinoids Screen Cocaine Metabolite Opiates Methadone Phencyclidine ENA SCREEN ENA screen Antibody ID s ( If appropriate) x 4 HEPATITIS B SURFACE ANTIGEN HBsAg Neutralization (if appropriate) HIV/AG COMBO HIV 1-2 Antibody HIV-1 Multi spot HIV-2 Multi spot HIV RNA ( if appropriate) O & P EXAM SCREEN Cryptosporidium Antigen Giardia Antigen Request O&P Complete Microscopic if comprehensive exam is needed. ADDITIONAL CPT CODES O&P Smear & Identification Trichrome Stain PROTEIN ELECTRO, REFLEX, SERUM Protein Electrophoretic fractionation and quantitation Immunoglobulin free light chains (if appropriate) X2 Immunofix electrophoresis (if appropriate) THYROID FUNCTION CASCADE TSH FREE T4 (if appropriate) TYPE AND SCREEN ABO Typing Antibody Screen Rh Typing 86901

5 Date } ACCOUNT INFORMATION NAME ADDRESS PHONE ORDERING PHYSICIAN BILL TO: ACCOUNT PATIENT/INSURANCE ALTERNATE PATIENT DEPARTMENT OF LABORATORIES St. Louis, Missouri PHONE: (314) FAX: (314) PATIENT S NAME (LAST) (FIRST) (MI) SEX DATE OF BIRTH PATIENT S SS # RACE (SEE BACK) ETHNICITY (SEE BACK) DIAGNOSIS CODE PATIENT S ADDRESS PHONE PATIENT S RELATIONSHIP TO RESPONSIBLE PARTY 1-SELF 2-SPOUSE 3-CHILD 4-OTHER NAME OF RESPONSIBLE PARTY (IF DIFFERENT FROM PATIENT) SOCIAL SECURITY (INSURED SS#): ADDRESS OF RESPONSIBLE PARTY APT # DATE OF BIRTH MEDICAID # STATE MEDICARE # (INCLUDE PREFIX/SUFFIX) PRIMARY MEDICARE RETIREMENT OR DISABILITY SECONDARY DATE: STAT FAX REPORT TO: COLLECTION TIME FASTING AM : PM YES NO BJH REGISTRATION # CALL RESULTS TO: (# ) COLLECTION DATE COMPLETE AND ATTACH STAT FLYER URINE hrs/vol hrs vol INSURANCE COMPANY NAME PLAN CARRIER CODE SUBSCRIBER / MEMBER # LOCATION GROUP # INSURANCE ADDRESS PHYSICIAN S PROVIDER # FORM NO (4/02/15) REGISTERED EMPLOYER S NAME OR NUMBER WORKER S COMP BY YES NO NOTE TO PHYSICIAN: When seeking payment from Medicare or Medicaid, Physicians should only order tests that are medically necessary for the diagnosis or treatment of the patient, for instance, Medicare does not cover routine screening, testing that is investigative or research use only, testing with quantity limits. Components of the organ or disease panels/combinations printed below are shown on the reverse side and may also be ordered individually below. Components may be billed separately if allowed by the payer. ORGAN OR DISEASE PANELS CODE (See Reverse for Components) Electrolyte Panel Basic Metabolic Panel Comprehensive Metabolic Panel Hepatic Function Panel Renal Function Panel Acute Hepatitis Panel RED Lipid Panel (*) Obstetric Panel ALPHABETICAL/COMBINATION TESTS SST ACID PHOSPHATASE, PROSTATIC ICE 2LAV/ 2RED ALBUMIN ALKALINE PHOSPHATASE ALPHA FETOPROTEIN (AFP) (Tumor Marker) RED AMYLASE ANA Refl ex (Antinuclear Ab)* see back RED ANA Qualitative (Antinuclear Ab) see back RED ANTI-DS-DNA ANTIBODY RED BILIRUBIN, DIRECT BILIRUBIN, TOTAL BUN C3, COMPLEMENT RED C4, COMPLEMENT RED CALCIUM CARCINOEMBRYONIC ANTIGEN (CEA) RED CBC w DIFF w PLT (see back) LAV CBC EXPRESS (see back) LAV CHLORIDE CHOLESTEROL CK (CPK) TOTAL CMV, IgG RED CORTISOL GRN C-PEPTIDE RED CREATININE DRUG SCREEN PRENATAL see back URN ENA SCREEN (*) RED ESR (SEDIMENTATION RATE) LAV ESTRADIOL RED FERRITIN RED FOLATE GRN FSH, BLOOD GRN GAMMA-GT FASTING RANDOM TOL 50G-SCREEN TOL 100G-DIAGNOSTIC TOL 75G-NONPREGNANT PREDIABETES (Dx: V77.1) FASTING ( ) RANDOM ( ) TOL 50G-SCREEN TOL 100G-DIAGNOSTIC TOL 75G-NONPREGNANT HCG-QUALITATIVE, SERUM RED HCG-QUALITATIVE, URINE URN HCG-QUANT., BETA RED HDL CHOLESTEROL HELICOBACTER PYLORI, IgG RED HEMOGLOBIN A1C LAV HEPATITIS A ANTIBODY (IGM) RED HEPATITIS B SURFACE AB RED HEPATITIS B SURFACE ANTIGEN (*) RED HEPATITIS B CORE IgM RED HEPATITIS C ANTIBODY RED HIV AG/AB COMBO see back PINK IMMUNOFIX ELECTRO, SERUM RED INTACT PTH LAV IONIZED CALCIUM IRON, TOTAL LDH LIPASE MAGNESIUM MEASLES (RUBEOLA) RED MONO LATEX TEST RED MUMPS-IgG SCREEN RED NEOPLASM SCREEN NON NEOPLASM SCREEN PHOSPHATE POTASSIUM PROGESTERONE RED PROLACTIN GRN PROSTATE SPECIFIC AG SCREEN G0103 RED CODE ALPHABETICAL TESTS CON T PEAK TROUGH RANDOM CARBAMAZEPINE GRN CYCLOSPORINE LAV PROSTATE SPECIFIC AG DIAGNOSTIC RED DIGOXIN GRN PROTEIN ELECTRO, Refl ex, Serum see back RED LITHIUM RED PROTEIN, TOTAL PHENOBARBITAL GRN PHENYTOIN (DILANTIN) GRN PT (PROTIME) BLU TACROLIMUS LAV PTT BLU THEOPHYLLINE GRN RHEUMATOID FACTOR, QUANTITATIVE VALPROIC ACID GRN RPR (*) RED VANCOMYCIN GRN RUBELLA IGG RED SODIUM OTHER DRUG T3, FREE GRN TESTOSTERONE GRN 24 HOUR URINE ( ) TESTOSTERONE, FREE RED START DATE / TIME END DATE / TIME THYROID FUNCTION CASCADE (*) TRIGLYCERIDE, FASTING TSH (THYROTROPIN) CREATININE 24 HR BATTER U THYROXINE (T4), FREE RED CREATININE CLEARANCE (NEED BLOOD & URINE) 24U TOTAL HEMOLYTIC COMP (THC) (CH50) RED PROTEIN 24 HR BATTERY U TYPE & SCREEN (*) see back PNK OTHER TIMED URINE (SPECIFY): UA REFLEX W/CULTURE see back URN UA REFLEX see back URN UA MACROSCOPIC URN MICROBIOLOGY SPECIMEN/SITE: UA MICROSCOPIC URN URIC ACID LOOK FOR: VITAMIN D 25-OH RED TEST CULTURE, AEROBE (ROUTINE) ONLY** SEE BACK STAIN, GRAM CULTURE, FUNGAL (MYCOLOGY) CULTURE, MYCOBACTERIA (AFB)(*) HERPES PCR OVA & PARASITES (O&P) SCREEN SEE BACK STOOL C. DIFFICILE ASSAY STOOL CULTURE, BETA STREP CERVIX CULTURE, BETA STREP VAG/RECTAL CHLAMYDIA/GC AMPLIFIED PROBE SEE BACK THROAT CHLAMYDIA/GC AMPLIFIED PROBE SEE BACK RECTAL SWAB ** SUSCEPTIBILITIES PERFORMED AUTOMATICALLY AS NEEDED CLIA #26DO CONTAINERS RECEIVED SST RED LAV PNK BLU GRN RYB YEL URN 24 U FL OT BACT O & P PROBE URN CUL STERIL FECAL VIRAL SPUN RED LAVENDER 10MLEDTA LT. BLUE GREY DK. GREEN RYL BLU ACD MNT GRN URINE 24 HR URINE FLUID OTHER TRNSPT KIT TRNSPT TRNSPT TRNSPT TRNSPT TRNSPT SPUN TUBE Collection Time: Initials:

6 PATIENT DEMOGRAPHIC INFORMATION: Race: American Indian or Alaska Native AI Asian AS Black or African American BL Native Hawaiian or other Pacific Islander... PI White WH Unknown UN Some other Race SR Ethnicity: Hispanic or Latino Non Hispanic or Latino Unknown TEST COMBINATION / PANEL POLICY Barnes Jewish Hospital Department of Lab policy is to provide physicians, in each instance, with the flexibility to choose appropriate tests to assure that the convenience of ordering test combinations/panels does not distance physicians who wish to order a test combination/panel from making deliberate decisions regarding which tests are truly medically necessary. All the tests offered in test combinations/panels may be ordered individually using the request form. In an effort to keep our clients fully informed of the content, charges and coding of its test combinations/panels when billed to Medicare, we periodically send notices concerning test combinations/panels, as well as information regarding patient fees for all services. We also welcome the opportunity to provide, on request, additional information in connection with our testing services and the manner in which they are billed to physicians, health care plans, and patients. The CPT code(s) listed here are in accordance with the 2010 edition of Physicians Current Procedural Terminology, a publication of the American Medical Association. CPT codes are provided here for the convenience of out clients; however, correct coding often varies from one carrier to another. Consequently, the codes presented here are intended as general guidelines and should not be used without confirming with the appropriate payor that their use is appropriate in each case. All laboratory procedures will be billed to third-party carriers (including Medicare and Medicaid) at fees billed to patients and in accordance with the specific CPT coding required by the intermediary. CPT codes , previously used for automated multichannel testing, have been eliminated as of January 1, New organ or disease panel CPT codes will be used instead, as noted below. Microbiology CPT code(s) for additional procedures such as susceptibility testing, identification, serotyping, etc. will be billed in addition to the primary codes when appropriate. Barnes Jewish Hospital will process the specimen for a Microbiology test based on source. ORGAN or DISEASE ORIENTED PANELS Basic Metabolic Panel Electrolytes Panel Indicates Reflex Testing Refer to Laboratory Test Catalog Comprehensive Metabolic Panel Protein, Total Obstetric Panel Complete Blood Count Hepatitis B surface antigen (HBsAg) Rubella Antibody IgG RPR Type and Screen Lipid Panel Cholesterol Total High Density Cholesterol (HDL) Triglycerides Renal Function Panel Phosphate Acute Hepatitis Panel Hepatitis A AB IGM Hepatitis B Core AB IGM Hepatitis B Surface AG Hepatitis C AB Hepatic Function Panel Bilirubin Direct Protein Total Urine Reflex w/culture Urine Culture (if indicated) Urine Reflex ANA REFLEX (ANTINUCLEAR AB) ds-dna (if appropriate) ANTI ANA QUALITATIVE CBC EXPRESS (No Automated Differential) CHLAMYDIA / GC AMPLIFIED PROBE Probe Amp C. Trachomatis Probe Amp N. Gonorrhoeae COMPLETE BLOOD COUNT (CBC) (With Automated Differential & Platelet Count) Five Part Differential CULTURE, AEROBE (ROUTINE) CPT Code is dependent on specimen type. Routine stool (enteric) culture look for Salmonella and Shigella Routine stool (enteric) culture look for additional pathogens Routine culture (any source except blood, stool, or urine) Routine urine culture (no growth on culture) Routine urine culture (growth on culture) CULTURE, VIRAL Culture, Viral Shell vial ID each 87254x2 DRUG SCREEN PRENATAL Amphetamine/Methamphetamine Barbiturate Benzodiazepines Screen Cannabinoids Screen Cocaine Metabolite Opiates Methadone Phencyclidine ENA SCREEN ENA screen Antibody ID s ( If appropriate) x 4 HEPATITIS B SURFACE ANTIGEN HBsAg Neutralization (if appropriate) HIV/AG COMBO HIV 1-2 Antibody HIV-1 Multi spot HIV-2 Multi spot HIV RNA ( if appropriate) O & P EXAM SCREEN Cryptosporidium Antigen Giardia Antigen Request O&P Complete Microscopic if comprehensive exam is needed. ADDITIONAL CPT CODES O&P Smear & Identification Trichrome Stain PROTEIN ELECTRO, REFLEX, SERUM Protein Electrophoretic fractionation and quantitation Immunoglobulin free light chains (if appropriate) X2 Immunofix electrophoresis (if appropriate) THYROID FUNCTION CASCADE TSH FREE T4 (if appropriate) TYPE AND SCREEN ABO Typing Antibody Screen Rh Typing 86901