Y. Harati, M.D., F.A.C.P. Department of Neurology Professor Neuromuscular Disease Director Neuromuscular Pathology Laboratory

Transcription

1 N EUROMUSCULAR B IOPSY R EGISTRATION F ORM This form must be completed and faxed before the biopsy is sent. Please fax form to (713) Call back number is (713) (Kevin). Arrival Date: Muscle Biopsy [ ] Nerve Biopsy [ ] Referring Physician: NPI #: Phone #: ( ) Fax #: ( ) Patients Name: Home #: ( ) Work #: ( ) Date of Birth: SSN: Insurance Information (Please attach a copy of insurance card) Does patient have Insurance? [ ] YES [ ] NO [ ] SELF PAY will be billed to your institution [ ] HMO [ ] PPO [ ] POS [ ] CPO [ ] Indemnity Plan [ ] Medicare Technical Component will be billed to your institution [ ] Medicaid Texas and Louisiana only Has insurance precertification or authorization been obtained? [ ] YES [ ] NO (Very important we need a precert. or authorization number before specimen arrives!) IF TEST CPT CODES NOT PRECERTIFIED, ORDERING PHYSICIAN WILL BE BILLED. Precertification or Authorization #: Name of Insured: Date of Birth of Insured: Insured SSN/ID #: Ins. Co.: Phone #: ( ) Employer: Group or Policy #: Secondary Insurance: [ ] Supplement [ ] PPO [ ] HMO [ ] Indemnity Plan [ ] POS [ ] EPO Insured SSN/ID #: Ins. Co.: Phone #: ( ) Employer: Group or Policy #:

2 P ATIENT I NFORMATION Patient s Last Name: First Name: Age: DOB: Sex: Race: Hospital Tel. #: Name and Address of Hospital: Date of Biopsy: Site: (circle one) L R Muscle: Quad / Biceps All addresses and phone numbers are needed. Please include all Dr's first names. L R Nerve: Sural L R Other: Referring Physician s Last Name: First Name: NPI #: (Required; Unique physicians identifier number) Tel #: ( ) Work #: ( ) Pathologist s Last Name: First Name: Tel #: ( ) Work #: ( ) Surgeon s Last Name: First Name: Tel #: ( ) Work #: ( ) CLINICAL DIAGNOSIS: (See sheet supplied) For example: (Myopathy) or (Polyneuropathy) or (Motor Neuron Disease) LAB WORK WILL BE BILLED TO YOUR INSTITUTION: Who will be the contact person if there are any questions regarding billing (including phone number)? PLEASE ATTACH CLINICAL HISTORY and print the name and number of the person filling out this sheet. Name: Tel #: ( )

3 P ROCEDURE FOR O UTSIDE B IOPSIES (OUTSIDE CITY LIMITS) FOR MUSCLE BIOPSIES Three muscle samples measuring 1.5 cm x 1.0 x cm 1.0 cm are submitted for histochemical analysis. Carefully blot any excess blood or fluids from the sample. Taking care not to distort the muscle, wrap each specimen with tin foil (one layer). Immerse the specimen directly in liquid nitrogen until bubbling action ceases (approx. 60 seconds). Once frozen, place specimens in a small plastic bag pre-labeled with the patient s name and date of birth and immediately transfer the specimen to a polystyrene container filled with dry ice. Tape polystyrene container shut to slow sublimation of dry ice. Ship to Neuromuscular Pathology Laboratory via Federal Express. If the muscle cannot be shipped immediately, place the frozen specimen in a 70 C freezer. Please fill out provided Patient Information Form and attach billing information. Please notify the lab 24 hours prior to sending biopsies. Laboratory hours are from 9:00 A.M. to 5:00 P.M., Monday through Thursday. Biopsies on Fridays must be approved by lab in advance before the specimen is sent. FOR NERVE BIOPSIES The sample should measure approximately 5 cm. It should be frozen and transported in the same manner as described above. A portion of the specimen measuring 0.5 cm to 0.2 cm should be placed in 3% Glutaraldehyde* in a plastic container. Wrap lid with parafilm and place specimen in a plastic bag. DO NOT PLACE GLUTARALDEHYDE SPECIMEN ON DRY ICE. It may be taped to the outside of the styrofoam container, but must be within the shipping box. Both specimens should be transported to Baylor Neuromuscular Pathology Laboratory in the Department of Neurology. Please fill out the provided Patient Information Form and attach information. Attn: Kevin Blankenship Smith Tower Receiving Dock 6550 Fannin, Suite NB438 Note: If biopsies are not received in the proper condition, the laboratory reserves the right to reject and return specimen(s) to institution of origin. *3% Glutaraldehyde can be obtained from Poly Scientific, 70 Cleveland Ave, Bayshore, NY Catalogue # S

4 P ROCEDURE FOR O UTSIDE B IOPSIES (OUTSIDE CITY LIMITS WITHOUT LIQUID NITROGEN) FOR MUSCLE BIOPSIES Three muscle samples measuring 1.5 cm x 1.0 x cm 1.0 cm are submitted for histochemical analysis. IMPORTANT: PLACE SPECIMEN BETWEEN TWO GAUZE SPONGES THAT HAVE BEEN LIGHTLY MOISTENED WITH NORMAL SALINE (SQUEEZE OUT ANY EXCESS SALINE BEFORE PLACING SPECIMEN). Do not saturate in saline solution. Specimen is then placed in a well-sealed container, which can be chilled with blue ice, within a larger container. (It is very important that the specimen not come into direct contact with water or ice during transport. Therefore place a towel between specimens and blue ice.) Please fill out provided Patient Information Form and attach billing information. Ship to Neuromuscular Pathology Laboratory using the courier of your choice. Please notify the lab 24 hours prior to sending biopsies. Laboratory hours are from 9:00 A.M. to 5:00 P.M., Monday through Thursday. Biopsies on Fridays must be approved by lab in advance before the specimen is sent. FOR NERVE BIOPSIES The sample should measure approximately 5 cm. Before freezing, a 0.5 cm piece should be submitted in glutaraldehyde for semithin sectioning. It should be shipped outside dry ice container. The remainder should be covered with aluminum foil, snap frozen (dry ice slurry or colder) and shipped on dry ice. The specimen(s) should be transported to Baylor Neuromuscular Pathology Laboratory in the. Attn: Kevin Blankenship Smith Tower Receiving Dock 6550 Fannin, NB438 Note: If biopsies are not received in the proper condition, the laboratory reserves the right to reject and return specimen(s) to institution of origin.

5 P ROCEDURE FOR O UTSIDE B IOPSIES (WITHIN CITY LIMITS) FOR MUSCLE BIOPSIES Three muscle samples measuring 1.5 cm x 1.0 cm x 1.0 cm are submitted for histochemical analysis. IMPORTANT: PLACE SPECIMEN BETWEEN TWO GAUZE SPONGES THAT HAVE BEEN LIGHTLY MOISTENED WITH NORMAL SALINE (SQUEEZE OUT ANY EXCESS SALINE BEFORE PLACING SPECIMEN). Do not saturate in saline solution. Specimen is then placed in a well-sealed container, which can be chilled with ice, within a larger container (it is very important that the specimen not come into direct contact with water or ice during transport. Please fill out provided Patient Information Form and attach billing information. Ship to Neuromuscular Pathology Laboratory courier of your choice. For Biochemical Studies, our laboratory should receive specimen within one hour of excision. Please notify the lab 24 hours prior to sending biopsies. Laboratory hours are from 9:00 A.M. to 5:00 P.M., Monday through Thursday. Biopsies on Fridays must be approved by lab in advance before the specimen is sent. FOR NERVE BIOPSIES The sample should measure approximately 5 cm. It should be handled in the same manner as described above. The specimen(s) should be transported to Baylor Neuromuscular Pathology Laboratory in the. Attn: Kevin Blankenship Jones Tower 6501 Fannin, NB438 Note: If biopsies are not received in the proper condition, the laboratory reserves the right to reject and return specimen(s) to institution of origin.

6 CPT AND ICD- 9 C ODING If insurance is to be billed, the following test needs to be pre-approved by the requesting physician before specimen is processed. Medicare cases require that the Technical Component be billed to your institution. MUSCLE BIOPSIES consist of the following CPT codes: NERVE BIOPSIES consist of the following CPT codes: Appropriate ICD-9 Codes should also be provided Amyotrophic Lateral Sclerosis Motor Neuron Disease Neurogenic Atrophy Mononeuropathy Muscular Dystrophy Myalgia Myopathies, Other Myopathy Myotonic Dystrophy Neuralgia-Neuritis PN, Toxic Polyneuropathy PN, Idiopathic, Progressive PN, Other Polymyositis Peripheral Neuropathy-Hereditary PN, NOS Idiopathic Peripheral Neuropathy APIN, G-B Syndrome PN, Vasculitis PN, Diabetes Best regards, Yadollah Harati, M.D., F.A.C.P. Professor Neuromuscular Diseases Director, Neuromuscular Pathology Laboratory

7 I NSTRUCTIONS FOR THE S URGEON To: Surgeon obtaining neuromuscular biopsy specimens. via FACSIMILE or INTERNET Subject: Size and quality of specimens sent to our lab for neuromuscular pathology analysis. Specimen size is very important for the study of neuromuscular disorders. Inadequate specimens limit the quality of results obtained in the study of biopsies and may necessitate repeat procedures. Nerves should be submitted intact and approximately 5 cm in length to allow for adequate fiber teasing, frozen longitudinal and cross-sections. All of these tests are necessary for a complete nerve study. The specimen should be visually inspected for the presence of white glistening fascicles in bundles. The specimen should include epineurium, perineurium, and endoneurium. Muscle biopsies should contain at least three 1.5 cm x 1.0 cm x 1.0 cm specimens to provide a representative sample and enough tissue for quantitative studies if necessary. Single samples should be avoided if possible. Specimens removed from the Quadriceps or Biceps yield superior results and Gastrocnemius muscle should be avoided. Cautery destroys enzymes in muscle specimens, therefore surgical specimens should not be obtained using laser or electrocautery devices. Specimens should not be exposed to saline due to ice crystal formation during freezing. Never place specimens in formalin, resubmit fresh tissue before sending the specimen to Baylor Neurology. Respectfully yours, F. Kevin Blankenship Manager, Neuromuscular Pathology Laboratory FKB