TABLE OF CONTENTS Section Subject Page #

Transcription

FLETCHER ALLEN HEALTH CARE
2009 Laboratory Services Directory
TABLE OF CONTENTS
Section
I
Subject
Page #
GENERAL INFORMATION
INTRODUCTION
VISION STATEMENT
MISSION STATEMENT
LICENSURE AND ACCREDITATION
LABORATORY DEPARTMENTS
CONSULTATION SUPPORT STAFF
MEDICARE COMPLIANCE
What will Medicare cover?
Background
Medical Necessity Documentation
Statutorily Excluded Services
Medicare Coverage Limitations
Types of Limitations
Medicare Coverage Decisions Affecting Lab Testing
Medicare Compliance Checking Tool
To Check Compliance
To Perform a Diagnosis Narrative Search
Advance Beneficiary Notice (ABN)
Purpose
When to ask Medicare beneficiaries to sign an ABN
Where to get an ABN Form
Steps to obtaining an ABN
Disclosure of Medicare Regulations
GENETIC TESTING
Informed Consent
LABORATORY ORDERS
Required Patient Information
Outpatient Order: Required Information
Inpatient Order: Required Information
Laboratory Requisitions
Outpatient Laboratory Requisition
Inpatient Laboratory Requisition:
OTHER FORMS
Advanced Beneficiary Notice (ABN)
Informed Consent for Vermont
Informed Consent for New York State
Telephone or Fax Laboratory Order Form
Laboratory Mailing Request Form
Supply Order Form
Lead Demographic Form
ANONYMOUS PATIENT TESTING
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Customer Service 847-5121 or 1-800-991-2799
http://www.fahc.org/pathology
General Information
August 13, 2009
TELEPHONE TEST ORDERS
ADDING A TEST TO AN EXISTING ORDER
STANDING ORDERS
REFLEX TESTING
LABORATORY TESTS SUBJECT TO REFLEX
ANATOMIC PATHOLOGY AND REFLEX TESTING
CUSTOM PROFILES
BILLING INFORMATION
OUTPATIENT BLOOD DRAWING SITES
RESULT REPORTING
Laboratory Report Devices
Cytopathology and Anatomic Pathology Report Print Schedule
Clinical Pathology Report Print Schedule
Client Report Fax
Lab Order Priority Designations
STAT
Call/Fax Result
Routine
Critical Values
COURIER
LABORATORY SUPPLIES
STAT LIST
CRITICAL VALUES LIST
APPENDIX
Informed Consent New York State
Informed Consent Vermont
Laboratory Mailing Request
Supply Order From
Telephone Laboratory Results Form
Telephone/Fax/Standing Order Request Form
II
SPECIMEN HANDLING
III
SPECIMEN REQUIREMENTS
IV
DISEASE MANAGEMENT
V
SPECIAL INSTRUCTIONS
VI
FEES
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General Information
August 13, 2009
INTRODUCTION
Fletcher Allen Health Care was formed on January 1, 1995 as the result of a merger between the
Medical Center Hospital of Vermont, Fanny Allen Hospital, and the University Health Center,
with the University of Vermont as an affiliated partner.
DEPARTMENT OF PATHOLOGY AND LABORATORY MEDICINE
VISION STATEMENT
Pathology and Laboratory Medicine strives to be the best regional, academic Clinical and
Anatomic Pathology Laboratory with areas of national and international prominence in
Laboratory Services, Education, and Research.
MISSION STATEMENT
To deliver excellent pathology and laboratory services that support the patient care mission of
Fletcher Allen and other regional organizations, support clinically relevant research and
education, and provide consultative services within its areas of expertise.
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August 13, 2009
LICENSURE AND ACCREDITATION
Fletcher Allen Health Care Laboratories are accredited by the following agencies.
AABB
ASHI
CAP
CLIA88
TJC
NYS
UNOS
ACC
Laboratory*
001058
03-1-VT-01-1
1182501
47D0660960
5483
3584-LAP34308
01VTMC
Fanny Allen
Laboratory**
Electron Microscopy
Laboratory***
1182801
1182508
*Ambulatory Care Center (ACC) Laboratory is located at the main hospital, East Pavilion 1 and
2, 111 Colchester Avenue, Burlington VT, 05401.
**The Fanny Allen Laboratory is located at the Fanny Allen Campus, 360FA1, 101 College
Parkway, Colchester VT, 05446
***The Electron Microscopy laboratory is located at the University of Vermont, Microscopy
Imaging Center, Health Science Research Facility, Room 204, Burlington VT, 05405.
AABB: American Association of Blood Banks
ASHI: American Society for Histocompatibility & Immunogenetics
CAP: College of American Pathologists
CLIA88: Clinical Laboratory Improvement Amendments’88
TJC: The Joint Commission on Accreditation (formerly JCAHO)
NYS: New York State Department of Health, Clinical Laboratory Permit
UNOS: United Network for Organ Sharing
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General Information
August 13, 2009
LABORATORY DEPARTMENTS
Pathology Laboratory, Ambulatory Care Center East Pavilion-Level 2
Cytopathology
Cytology
Cytotechnology School
Surgical Pathology
Cutting Room
Histology
Autopsy
Clinical Laboratory, Ambulatory Care Center East Pavilion-Level 1
Blood Bank
Compatibility Testing
Donor Center
HLA
Immunohematology
Stem Cell
HLA Testing
General Chemistry
Blood Gases
General Chemistry
HIV-Stat
Mono Test
Pregnancy Test-Urine
Urinalysis
Hematology
Hematopathology
Manual Differentials
Routine Coagulation
Special Hematology
Special Chemistry 1
Atomic Adsorption
Chromatography
ELISA
GLC
Immunoassay
QUAD Marker
Special Coagulation
Cytogenetics
Flow Cytometry
Special Chemistry 2
Electrophoresis
Nephelometry
Microbiology
Bacteriology
Susceptibility Testing
Occult Blood
Special Microbiology 1
Mycology
Mycobacteriology
Parsitology
Virology
Molecular Testing
Antigen Detection
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August 13, 2009
CONSULTATION SUPPORT STAFF
ADMINISTRATION
Edwin G. Bovill, M.D., Director and Chairman
Thomas S. Wadsworth, MBA, MT (ASCP), SBB, Administrative Director
ACC Lab Office, Phone
ACC Lab Office Fax
656-2931
847-3933
847-0241
847-3509
ANATOMIC PATHOLOGY
Kumarasen Cooper, MBChB, Director
Timothy St. John, CT (ASCP), Manager
Karen Brown, Coding and Transcription Supervisor
Anatomic Pathology Office
Anatomic Pathology, Fax
847-9766
847-5134
847-3501
847-3566
847-3509
AUTOPSY SERVICES
Masatoshi Kida, M.D., Director
Jude Carpenter, HT, HTL (ASCP), Supervisor
Autopsy Office
Autopsy Fax
847-9917
847-5134
847-5116
847-3570
847-6443
BLOOD BANK
Mark Fung, M.D., Director
Chuck Powden, CLLSp (H), Manager
Paulette Hammond, MT (ASCP), Supervisor
Sharon Bushor, MT (ASCP), Technical Specialist
847-5145
847-5137
847-5147
847-3523
BUSINESS DEVELOPMENT & OUTREACH
Lynn Bryan, Manager
Eleanor Sinclair, Reimbursement Specialist
Colleen Williams, Senior Marketing Specialist
Valerie Rogers, Client Relations Specialist
Nicole Carney, Client Relations Specialist
Lee Stirling, Client Relations Specialist
Outreach Fax
Billing Fax
847-9540
847-0234
847-9473
847-9472
847-6689
847-7754
847-7418
847-8190
SPECIMEN RECEIVING
Ron Bryant, M.D., Director
Monica Sullivan, MT (ASCP) Manager
Cindy Cruickshank, M (ASCP), Supervisor
Elizabeth Manning, MT (ASCP), Charge Technologist
John Frost, Evening Charge Technologist
Specimen Receiving Fax
847-5139
847-5123
847-5127
847-4763
847-4763
847-2358
CHEMISTRY
Greg Sharp, M.D., Director
Monica Sullivan, MT (ASCP) Manager
Cindy Nelson, MT (ASCP), Supervisor, Special Chemistry
Judy Schwenn, MT (ASCP), Supervisor, High Volume Chemistry
Jocelyne Stocker MT (ASCP), Technical Specialist
Chemistry Fax
847-5115
847-5123
847-5124
847-2714
847-5117
847-6079
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August 13, 2009
CLINICAL PATHOLOGY
Ronald Bryant, M.D., Director
Clinical Pathology Hot Seat
Clinical Pathology Fax
847-5139
847-3795
847-3987
COAGULATION
Edwin Bovill, M.D., Director
Russell Brown, MT (ASCP), Supervisor
656-2931
847-9692
847-1201
COMPLIANCE
Compliance Hot Line
Janet Schroeter, MT (ASCP), Laboratory Compliance Specialist
Kathy Nadeau, MLT (ASCP), Asst. Laboratory Compliance Specialist
Compliance Fax
847-9430
847-9435
847-0930
847-7418
CUSTOMER SERVICE
Lynn Bryan, Manager
Michele Baker, Supervisor
Customer Service
Customer Service Fax, (ACC East Pavilion 1)
847-9540
847-7131
847-5121 or 1-800-991-2799
847-5905
CYTOGENETICS
Mary Tang, M.D., Director
Catherine Buck, MT (ASCP) CLSP (GC), Charge Technologist
Cytogenetics Fax
847-2894
847-5137
847-3565
847-3987
CYTOPATHOLOGY
Gladwyn Leiman, MBBCh, FRCPath, Director
Carol Colasacco, CT (ASCP), Supervisor
Cytopathology Fax
847-5136
847-3921
847-5134
847-6199
847-3632
FANNY ALLEN CAMPUS LAB
John Lunde, M.D., Director
Fanny Allen Lab, Fax
847-5135
847-5137
847-6424
HEMATOLOGY
Hematology Fax
847-5125
847-3683
847-5137
847-1201
847-3509
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HISTOLOGY
Alexandra Kalof, M.D., Director
Histology Fax
847-2712
847-6868
847-5134
847-5116
847-3509
FLOW CYTOMETRY
Danielle Sartini, MT (ASCP), Technical Specialist
847-3683
847-5137
847-1201
847-5373
INFORMATION SERVICES, PATHOLOGY
Information Services Fax
Tania Horton, Lead
847-5614
847-6336
MICROBIOLOGY
Washington Winn, M.D., MBA, Director
Monica Sullivan, MT (ASCP), Manager
Fred Westenfeld, MT (ASCP), SM, Supervisor
Debra Reardon, MT (ASCP), Technical Specialist
Sharon Weisburgh, MT (ASCP), Technical Specialist
Microbiology Fax
847-3554
847-5140
847-5123
847-5141
847-5142
847-6584
847-4806
NIGHTS
Christopher Carpenter, MT (ASCP), Supervisor
847-5137
847-3620
PHLEBOTOMY
Lynn Bryan, Manager
Susan Antell, MT (ASCP), Supervisor, Outpatient Phlebotomy
Michele Baker, MT (ASCP), Supervisor, Inpatient Phlebotomy
847-9540
847-1080
847-7131
SATELLITE LABS – POINT OF CARE TESTING (POCT)
Lynn Bryan, Manager
Sue Antell, MT (ASCP), Supervisor
Marie Beede, MT (ASCP), Technical Specialist
POCT, Fax
847-9540
847-1080
847-8973
847-3509
SURGICAL PATHOLOGY
Donald Weaver, M.D., Director
Hot Seat
Surgical Pathology Fax
847-3566
847-5928
847-5134
847-5116
847-3795
847-4155
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General Information
August 13, 2009
MEDICARE COMPLIANCE
What will Medicare cover?
Background
Medicare, like private insurers, makes decision about what services will be covered under their
program. While both Medicare Part A & Part B cover clinical laboratory testing, not every test in
every clinical situation is covered. Services that are generally excluded from coverage include
routine health examinations and services that are not reasonable and necessary for the diagnosis
or treatment of an illness or injury. Some specific types of screening services such as pap smears
for cervical cancer, fecal occult blood for colorectal cancer screening and PSA for prostate
cancer screening are specifically covered by statute, but may be subject to frequency limitations.
Medical Necessity Documentation
Documentation of medical necessity is of utmost importance. Under the Balanced Budget Act of
1997, physicians are required to supply a diagnosis to the laboratory for services provided so the
laboratory can be paid. Medicare requires hospital laboratories to submit all the diagnosis
information, in the form of ICD-9 codes, provided by the referring physician on claims.
Medicare will only pay for testing that meets Medicare’s definition of “medical necessity”.
Therefore, a physician may order a laboratory test that they believe is appropriate for the patient,
however, Medicare will deny payment unless it meets Medicare’s definition of medical
necessity.
To determine the correct ICD-9 code to use, please refer to the current version of the
International Classification of Diseases, 9th Revision, and Clinical Modification (commonly
referred to as the Physician’s ICD-9 CM manual). Please submit the specific diagnosis that
describes the patient’s signs and symptoms pertaining to why the laboratory testing was ordered.
An ICD-9 code is preferable to a narrative diagnosis. We are happy to help you with ICD-9
coding if needed. Please refer to the Compliance contact list for assistance.
Statutorily Excluded Services
Medicare has published a list of ICD-9 diagnosis codes that are statutorily excluded from
coverage regardless of the service. This means that services (including laboratory testing)
submitted to Medicare with only a statutorily excluded diagnosis code will not be covered. A
statutorily excluded ICD-9 code may be the most appropriate diagnosis code to use in some
cases. If a more specific ICD-9 code or sign/symptom is relevant to the requested testing then it
too should be added as diagnosis information on the laboratory requisition. If a statutorily
excluded ICD-9 code is the only appropriate ICD-9 diagnosis code, Medicare requires that we, as
the billing entity, indicate to Medicare on the claim that it is a non-covered service. Advance
Beneficiary Notices (ABN’s) should not be used for services that are statutorily excluded. Please
remind patients in this circumstance that Medicare will not pay and that the beneficiary is
ultimately responsible for the charges.
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Medicare Coverage Limitations
Types of Limitations
Laboratory testing is subject to the following limitations:
1.
Medicare does not cover lab testing considered to be investigational or experimental.
2.
Medicare generally does not pay for any tests ordered for screening purposes (usually
indicated by V-codes). There are exceptions noted below which are specifically
covered by statute, however, the coverage is subject to frequency limits:
•
•
•
•
•
3.
Pap Smear screening for cervical or vaginal cancer
PSA for prostate cancer screening
Fecal Occult Bloods for colorectal cancer screening
Screening for Diabetes Mellitus
Cardiovascular Disease Screening
Coverage Decisions are predicated on what is considered “medically necessary”.
Medicare believes some tests may be over utilized (ex. Urine cultures, CBCs,
Glucose, TSH). Their response to the perceived over utilization was to create the
coverage decisions which define & limit the circumstances under which the test(s)
will be covered. Medicare’s coverage decisions can be at a national or local level.
•
•
National Coverage Decisions (NCD’s)
An NCD is a policy developed at the national level that establishes the
diagnoses (ICD-9 codes) under which a particular procedure/test will be
considered medically necessary and thus reimbursable by Medicare.
Local Coverage Decision (LCD’s)
A local coverage decision is similar in purpose to an NCD except that it is
developed at the local level (ex. VT/NH) either by our Medicare Carrier or
Fiscal Intermediary. A local contractor may only continue to issue an LCD
if there is no national policy or if they wish to supplement an NCD when it
doesn’t address a specific issue, such as frequency.
Medicare Coverage Decisions Affecting Lab Testing with Links to View Policy Online
If a lab test is ordered and will not be considered medically necessary based on one of the
coverage limitations, please obtain an Advance Beneficiary Notice (ABN).
Please visit our website http://www.FAHC.org/Pathology/Services/MedicareCompliance for
more information.
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Medicare Compliance Checking Tool
Fletcher Allen Health Care (FAHC) offers access from the web to the Pathline Medicare Compliance Checker.
Pathline is a software application that includes a tool to help you work out Medicare Compliance rules. This tool is
also useful for looking up ICD-9 codes from a narrative.
In the URL Address box enter: http://pathcc.fahc.org for the direct link to the Medicare Compliance Checking for
VT and NH (database). You do not need a user name and password to use the compliance checker.
To Check Compliance
1. Select Division: From the drop down menu select: LAB
Choices: LAB – Laboratory
CARD – Cardiology
RAD – Radiology
Note: Show NCD/LMRP Tests: This option will show all tests for the division selected that have a local or national
coverage policy.
2. Entering a Test
If you do not know the FAHC test code for the test you are checking on, enter the test name in the box under
Procedure/Tests and hit Search. When you find the test, click on the code and it will populate the search field. You
can add another test in the Procedure /Test box and hit search to look for another test or enter the test code and
press Add.
NOTE: If only one test is added to the list box you can press Display Covering Diagnosis and view all ICD-9
codes that are covered for that test.
3. Entering a Diagnosis
You can add a narrative to the Diagnosis box and press Search to find the correct ICD-9 code or if you know the
correct code, you can enter the code and press Add.
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To Perform a Diagnosis Narrative Search
In the Diagnosis search box add the word or words you need the ICD-9 code for. Press Search. The search result
will return a list of all possible ICD-9 code matches. Here is a search result for Hypothyroidism.
ICD Search
Search For (7 Matches)
Code
243
244.0
244.1
244.2
244.3
244.8
244.9
Desc
Congenital hypothyroidism
Postsurgical hypothyroidism
Other postablative hypothyroidism
Iodine hypothyroidism
Other iatrogenic hypothyroidism
Other specified acquired hypothyroidism
Unspecified hypothyroidism
Select the most appropriate code by clicking on the underlined code number.
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You can also look up a diagnosis by entering the ICD-9 code or partial code into the Diagnosis search box and
pressing Search. The search result will return all entries with the diagnosis entered. Here is a search result for the
partial code V52.
ICD Search
Search For (7 Matches)
Code
V52.0
V52.1
V52.2
V52.3
V52.4
V52.8
V52.9
Desc
Fitting and adjustment of artificial arm (complete) (partial)
Fitting and adjustment of artificial leg (complete) (partial)
Fitting and adjustment of artificial eye
Fitting and adjustment of dental prosthetic device
Fitting and adjustment of breast prosthesis and implant
Fitting and adjustment of other specified prosthetic device
Fitting and adjustment of unspecified prosthetic device
Select the most appropriate code by clicking on the underlined code number.
NOTE: If you press the Search button without a code in the search box you will get a listing of all ICD-9 codes in
numerical order.
4. When all the tests and codes are entered press Check Compliance.
Checker Results
Test (CPT) Diagnosis
244.3,
TSH(84443)
250.00
244.3,
√ LPR(80061)
250.00
PSA(84153)
Reason
Medically necessary according to NCD-Thyroid titled THYROID TESTING and
dated 07/01/2008
Medically necessary according to NCD-Lipids titled LIPIDS and dated 10/01/2006
Medicare does not pay for these items/services for your condition.
The following options will display as per Medicare rules based on tests/diagnoses entered:
1. (Green
2.
3.
4.
5.
) a This CPT code is not subject to Medicare coverage policy.
b. Medically necessary according to (LCD/NCD titled …..)
(Yellow
) Medically necessary according to frequency rules titled…..
(Red
) Medicare does not pay for these items/services for your condition.
(Yellow/green
) Some test have frequency limitations, if they are not met a message will display stating the
frequency limitation. Ex. Fecal Occult Screening covered once a year for persons over 50.
(Black -- ) NA – not applicable.
If the Compliance Checker labels a test with an X of any color, an ABN must be obtained.
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66.91
Advance Beneficiary Notice (ABN)
Purpose:
An Advance Beneficiary Notice (ABN) is a written document used to notify a Medicare patient
of the likelihood that Medicare will deny payment for the ordered tests(s) and to indicate the
patient’s agreement to accept responsibility for payment if the service is not covered by
Medicare. An ABN allows beneficiaries to make informed consumer decisions about receiving
items or services for which they may have to pay out-of-pocket and to be more active
participants in their own health care treatment decisions.
When to ask Medicare beneficiaries to sign an ABN:
1. When ordering any procedure or test that is subject to a National Coverage Decision (NCD)
or a Local Coverage Decision (LCD), where the ICD-9 code provided by the physician is not
covered as part of the policy.
2. When ordering a screening test that is subject to a frequency limit and the frequency limit is
not met. In the lab, the tests included are:
• Pap smear for cervical cancer screening
• PSA for prostate cancer screening
• Fecal occult blood for colorectal cancer screening
• Glucose testing as a screen for diabetes
• Lipid testing as a screening for cardiovascular disease
3. When ordering a test which is considered experimental or investigational.
Where to get an ABN Form:
Contact Laboratory Customer Service at (802)847-5121
Steps to obtaining an ABN:
1.
The following information must be completed on the ABN form before you present it to the
patient to sign:
•
Patient’s name
•
Date of Birth
•
Medical record number
•
The specific procedure/test(s) you believe is/are likely to be denied by Medicare.
•
The reason you believe Medicare is likely to deny coverage. Check the
most appropriate reason. If multiple tests and reasons are listed, please indicate which
reason applies to which test.
•
Estimated cost
2. Present the ABN to the beneficiary or authorized representative* for review.
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3. When the beneficiary has read the ABN, ask them to choose an option by checking the appropriate
box on the form.
Option 1: I want the items and services listed above. You may ask to be paid now, but I
also want Medicare billed for an official decision on payment which is sent to me
on a Medicare Summary Notice (MSN).
Option 2: I want the items or services listed above, but do not bill Medicare. You may ask
to be paid now as I am responsible for payment. I cannot appeal if Medicare is
not billed.
Option 3: I don’t want the items or services listed above. I understand with this choice I
am not responsible for payment, and I cannot appeal to see if Medicare would
pay.
4.
5.
Ask the beneficiary or authorized representative* to sign and date the form.
If the beneficiary refuses to sign either option but demands the service, the provider should annotate
the ABN, and have the annotation witnessed by a fellow staff member, indicating the circumstances
and persons involved. The signature line can be used for the annotation.
6. The ABN is a 3 part form and must be distributed as follows:
• Copy given to patient
• Copy filed in physician’s office
• Copy attached to appropriate clinical requisition
Please Note:
1.
Do not routinely ask all Medicare patients to sign ABNs. This is considered a “blanket ABN” and is
not an acceptable practice. Use the ABN only when you believe Medicare will deny payment for an
ordered test for one of the reasons listed on the ABN.
Exception: In the case when a service/test provided is subject to a frequency limitation, the
physician or supplier may routinely give ABNs to beneficiaries because the physician may not know
when or where the patient last had the test performed (i.e. may have been ordered by another
physician in a different location).
2.
The ABN must be presented before the service is provided or before testing of specimen begins.
3.
The beneficiary must be provided with an estimated cost to help them make an informed decision.
1.
2.
3.
4.
5.
6.
***Reminder: A valid ABN must:
Be on an approved CMS-R-131 (03/08) form.
Clearly identify the test or service.
Give the reason why denial is likely to occur.
Indicate the option chosen by the beneficiary.
Be dated & signed by the beneficiary or authorized representative*.
Provide the cost of test/service not meeting medical necessity rules.
* An authorized representative is a person who is acting on the beneficiary’s behalf when the
beneficiary is temporarily or permanently unable to act for himself/ herself. The authorized
person is acting in the beneficiary’s best interests and does not have a conflict of interest
with the beneficiary. Examples: spouse, adult child, adult sibling, close adult friend, and
public guardian.
A representation of the ABN form is located at the back of this section.
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Disclosure of Medicare Regulations
In an effort to keep our physician clients informed of Medicare regulations as they pertain to the laboratory, we
provide the following notice on an annual basis to all physician clients.
Please note that Medicare will only pay for tests that meet the Medicare coverage criteria
and are reasonable and necessary to treat or diagnose an individual patient. Section
1862(a)(1)(A) of the Social Security Act states, “no payment may be made under Medicare
Part A or Part B for any expenses incurred for items or services which are not reasonable
and necessary for the diagnosis or treatment of an illness or injury or to improve the
functioning of a malformed body member.” In addition, Medicare has developed coverage
policies at both the national and local level. These policies limit and define the diagnosis
(ICD-9) codes that will support medical necessity for a particular laboratory test.
Medicare can issue or update coverage policies at any time. As we receive these policies
we will continue to pass them on to our clients. The importance of an accurate diagnosis
being submitted with each laboratory test request cannot be overstated as this is the means
by which Medicare justifies medical necessity.
Our laboratory offers the organ or disease oriented panels listed: Basic Metabolic Panel,
Comprehensive Metabolic Panel, Electrolyte Panel, Lipid Panel, Liver (Hepatic Function)
Panel, and Prenatal Panel. On the back of our laboratory requisition we have provided a
list of tests included in each panel with the CPT code used for billing. The Specimen
Requirements section of our Lab Services Directory also describes what is included in
each panel. These panels should only be ordered when all the tests in the panel are
medically necessary. Our laboratory requisition provides the option to order as a panel or
individually as needed.
We are happy to provide the Medicare reimbursement schedule for any clinical laboratory
procedure upon request. If this information is desired, please contact a Laboratory
Compliance Specialist at (802)847-5121. Please note that Medicaid reimbursement will be
equal to or less than the amount of Medicare reimbursement.
A complete list of clinical consultants is available (see Telephone Number listing earlier in
this section) should any questions arise regarding laboratory test ordering or
interpretation of results.
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GENETIC TESTING
As defined by Vermont law, genetic testing means a test, examination or analysis that is diagnostic or predictive of
a particular heritable disease or disorder and is of a human chromosome or gene; human DNA or RNA; or a human
genetically encoded protein.
Genetic testing does not include a test, examination or analysis of a human chromosome or gene, of human DNA or
RNA, or of a human genetically encoded protein that is diagnostic or predictive of a particular heritable disease or
disorder, if, in accordance with generally accepted standards in the medical community, the potential presence or
absence of a mutation, alteration or deletion of a gene or chromosome has already manifested itself by causing a
disease, disorder or medical condition or by symptoms highly predictive of the disease, disorder or medical
condition.
State regulations define what is considered genetic testing. Regulations are applied by where the sample is
obtained, not the residence of the patient.
Examples of Genetic Testing
Carrier Identification includes genetic tests used by families with a history of recessive genetic disorders and who
are considering having children. Three common tests include those for Cystic Fibrosis, Tay-Sachs disease, and
sickle cell trait.
Late-onset Disorders include adult diseases such as cancer and heart disease. Genetic tests may indicate a
susceptibility or predisposition for these diseases. Examples include Huntington’s disease, Myotonic Dystrophy and
other DNA mutations analyses for single gene disorders.
Prenatal Screening (Including QUAD Markers)
Information from genetic testing can affect the lives of individuals and their families. In addition to personal and
family issues, genetic disease or susceptibility may have implications for employment and insurance. Vermont and
New York State require an Informed Consent from the patient prior to testing. It is the physician’s
responsibility to obtain Informed Consent when ordering Genetic Testing.
Guidelines for Informed Consent for Genetic Testing
1. Obtaining Informed Consent is the responsibility of the ordering physician.
2. Informed Consent is not necessary for genetic testing used for diagnosis in a symptomatic patient.
3. Informed Consent is necessary for genetic testing used to determine predisposition to a genetic disorder,
carrier status, and screening of asymptomatic patients or family members.
4. We recommend: When in doubt, fill it out.
5. An Informed Consent should include the following information:
i.
Information about the sensitivity and specificity of the test has been reviewed
ii.
Test results may become part of the patient’s permanent medical record
iii.
Test results may impact the patient’s ability to obtain certain insurance benefits
iv.
Results are reported only to the ordering physician unless written authorization is obtained.
6. Informed Consent should be documented in the patient chart.
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August 13, 2009
Informed Consent
An Informed Consent form for samples drawn in Vermont can be obtained at the Fletcher Allen Health
Care Laboratory web-site http://www.fahc.org/pathology/ go to Services, Information for Health Care
Professionals, Forms or by calling Customer Service at (802)847-5121. A representation of the form is
located in the back of this section.
Fletcher Allen Health Care Laboratory requisitions include the following reminder with regard to Genetic
testing:
Informed Consent Certification required for all genetic testing. Submission of an order for any
laboratory test constitutes certification to Fletcher Allen Health Care that:
1. The Ordering Provider has obtained the “Informed Consent” of the patient as required by any
applicable state or federal laws with respect to each test ordered; and
2. The Ordering Provider has obtained from the patient authorization permitting Fletcher Allen
Health Care to report results of each test ordered directly to the ordering physician.
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August 13, 2009
LABORATORY ORDERS
Required Patient Information
1. We strongly discourage the use of prescription pads for laboratory test orders as the laboratory does
not usually receive all the required information when orders are requested by this format.
2. In order for the Fletcher Allen Health Care Laboratory to perform the test requested by the physician
and bill appropriately for that test, it is essential that the laboratory order be filled out correctly.
3. If you need forms for ordering laboratory testing, please call Customer Service (802)847-5121.
Outpatient Order: Required Information
1.
2.
3.
4.
5.
Patient’s full name (first and last name)
Patient’s date of birth
Sex of patient
Billing provider (first and last name)
If ordering provider different than billing provider, add ordering provider under [Additional Copy To]
section (first and last name required).
6. Who should be billed: Electronic billing rules required that we submit the subscriber’s date of birth
with each claim.
a. If patient’s insurance, fill in lines 1-6 of billing section.
b. If patient has no insurance, fill in lines 1 and 2 of billing section.
c. To bill your office, supply correct 96 or 97 account number for billing.
7. ICD-9 code/diagnosis information
8. Specimen collection date and time
9. Specimen Type
10. The test(s) requested to be performed.
11. If Pap Smear requested on Medicare patient, whether physician considers it is
screening (low or high risk) or diagnostic. See Pap smear guidelines in Section V, Special
Instructions.
Inpatient Order: Required Information
1.
2.
3.
4.
5.
6.
7.
8.
Patient’s full name (first and last name).
Patient’s MRN.
Ordering Provider (first and last name).
Specimen collection date and time.
Specimen Type.
The test(s) requested to be performed.
For Cytology and Surgical Pathology, we need clinical diagnosis, pertinent history, previous lab data.
Phone or beeper number for questions (optional but extremely helpful when there are specimen
questions or critical lab values).
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August 13, 2009
Laboratory Requisitions
The following is a summary of the laboratory order forms that we supply to outside clients. We
customize the Account Information area with your practice name and phone number. Below are common
fields on all forms.
Please be sure to write legibly. We try to customize as much of the form as possible. If there are tests
that you need to write in frequently, we can add these tests to your form.
Account information: We customize this area with the following:
Report Code/Location Code (Code set-up by Lab unique to your practice)
Practice Name
Phone Number (for patient or sample questions)
Provider: In most cases the billing and ordering provider will be the same but in cases where
they are different we require both. Please supply the provider(s) first and last name.
Patient Information: This area is located on the top right of the form. We will need the
patient’s full name along with two identifiers. The date of birth as well as the sex of the patient
is required. Please provide the patients FAHC Medical Record Number if available, if not
please provide the patient Social Security Number.
Client ID: If you have an internal identifier (medical record number or protocol number) that
you would like to have associated with this patient you would enter that information here. This
identifier will print on the report.
Additional Copy to: If you would like us to send another provider a copy of the report, please
fill in the Additional Copy to area with the providers first and last name. If the provider is not
local, please provide additional information, address and or fax number for report.
Billing Information: Billing information is required on outpatients, if you are using this form
on an inpatient you can ignore this area. Please let us know who should be billed. If we are to
bill an insurance company or Medicare or Medicaid we will need subscriber’s date of birth with
each claim, please fill in lines 1-6 in the billing area. If patient has no insurance, we require the
name, address, and phone number of the person responsible for payment (lines 1 and 2 of
billing section). If your office has an account number and you would like to charge the testing
to your office please supply your billing number.
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Outpatient Laboratory Requisition:
This is the form used to order clinical laboratory testing for Chemistry, Hematology, Microbiology and therapeutic
drug levels. You can also order PAP Smears on this form. The form is dark green and white and the form number
is 23-014951.
Test(s) Requested: This area is located on the bottom half of the form. Tests included are the most commonly
ordered tests listed by laboratory department.
• Tests shaded green are subject to Medicare coverage policies (See Medicare Compliance in this section).
• Tests that have a check (√) mark to the right of the test name are subject to Reflex (See Reflex Testing in this
section).
• Tests in Italics are available stat.
• Specimen codes are listed to the right of the test name, B-blue top, Gn-green top, L-lavender top, S-red top
(serum), T-serum separator (sst), U-urine, and X-See Laboratory Services Directory.
Other Area: This area is for tests that are not already included on this form but that your office orders
frequently.
Cytogenetics /Flow/Bone Marrow Exam Lab Requisition: This form should be used for ordering Cytogenetics,
Flow Cytometry or when you are requesting a Bone Marrow Exam All relevant diagnosis information should be
documented in the Clinical Diagnosis/Pertinent History/Lab Data area located in the middle of this form. This
form is maroon and white and the form number is 23-033734.
Surgical Pathology/Non GYN-Cytology Requisition: This form is used for submitting tissue and cytology
samples. The form is blue and white and the form number is 23-017154. All relevant diagnosis information
should be documented in the Clinical Diagnosis/Pertinent History/Lab Data area located in the middle of this form.
Genetic & Prenatal Laboratory Requisition: This form is used for submitting QUAD Markers and other prenatal
and genetic screening. The form is purple and white and the form number is 23-017153. All relevant diagnosis
information should be documented in the Diagnosis Information area located in the middle of this form. The
prenatal screening questions must be filled in for result interpretation. Tests shaded are subject to Medicare
coverage policies (See Medicare Compliance in this section).
Inpatient Laboratory Requisition: Most laboratory orders should be sent through PRISM during computer
downtime.
Emergency Department Laboratory Requisition: This is the form used by the Emergency Department to order
clinical laboratory testing for Chemistry, Hematology, Microbiology and therapeutic drug levels when Pathline is
down. The form is black, white, and red and the form number is 23-014591.
In-Patient Back-up Requisition: This form is used only on inpatients and only when HISPROD is down. This is
the form used to order clinical laboratory testing for Chemistry, Hematology, Microbiology and therapeutic drug
levels. This form is black, white, and green and the form number is 23-014667.
Surgical Pathology / Non GYN-Cytology Order: This form is used for submitting tissue and cytology samples.
The form is Blue and White and the form number is 23-036550. The top copy is the physicians order and is meant
to be a part of the patient’s medical record. The back copy follows the sample to the lab. All relevant diagnosis
information should be documented in the Clinical Diagnosis/Pertinent History/Lab Data area located in the middle
of this form.
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August 13, 2009
OTHER FORMS
These forms are available in the Appendix to this section
An ABN is a form that when used properly allows physicians and clinics to bill Medicare patients for
services that Medicare deems not “medically necessary.” (See “Medicare Compliance” beginning on page
10) The ABN allows the Medicare beneficiary to make an informed decision about whether to receive a
service that may not be deemed medically necessary, or a service that is governed by frequency
limitations.
Informed Consent for Vermont
Informed Consent Certification is required for all genetic testing. Please See “Genetic Testing” beginning
on page 18.
Informed Consent for New York State
Informed Consent Certification is required for all genetic testing. Please See “Genetic Testing” beginning
on page 18.
Telephone or Fax Laboratory Order Form
This form should be used for call-in orders and for standing orders. Other laboratory requisitions do not
fax well.
Laboratory Mailing Request Form
This form is required when you have a request for testing to be performed by a lab other than one we
would normally send testing to.
Supply Order Form
This form lists all the supplies that we will provide for our clients use.
Vermont Department of Health collects patient demographic information on all lead testing. This form
lists the required information.
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August 13, 2009
ANONYMOUS PATIENT TESTING
The laboratories at Fletcher Allen Health Care are committed to serving clients who need anonymous
patient testing. Guidelines have been established to create a system in which this type of sample can flow.
1) The client must complete a Fletcher Allen Laboratory requisition with the following:
a)
b)
c)
d)
e)
Anonymous Name – 7 characters (to be supplied by client)
Billing Provider
Client location code
96 billing number
Testing requested
2) The anonymous name needs to be assigned by the client office. The name is limited to 7
alphanumeric characters. The lab will add ANON,T to the code assigned by the office so the name
will appear on the report as ANON,T * (* represents coded name assigned by your office). When the
results arrive at the client office the correct person can decode the name and forward the result to the
provider.
3) The testing must be billed to a 96 account number, which bills the client office. Since the testing is
being done anonymously we cannot submit a bill to the patient’s insurance because we do not know
the identity of the patient.
4) The client office will receive a bill for this testing and is responsible for collecting the money from the
patient and paying Fletcher Allen Health Care for the testing.
5) If the patient is to be drawn in one of our outpatient drawing centers, all appropriate paperwork must
accompany the patient.
6) If some testing will be done anonymously and some done under the patient’s name then two
requisitions must accompany the sample and/or the patient. One will list the testing to be done
anonymously and all appropriate information (see #1 above) and the other will have the patient’s
name and billing information. Please submit a different sample(s) for each requisition, with the
appropriate name on the tube.
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General Information
August 13, 2009
TELEPHONE TEST ORDERS
Although we prefer patients to present for laboratory testing with an outpatient requisition, Fletcher Allen
Health Care Laboratory will accept telephone test orders.
There are two types of telephone test orders, those taken as a new test order and those taken as an
additional test for an existing order. New test orders can be called to Laboratory Customer Service at
(802)847-5121. We will fax you a Telephone or Fax Laboratory Order Form for someone in your office
to review, sign and fax back to (802)847-5905.
The laboratory will require that a diagnosis be provided for all telephone orders. In addition, as telephone
orders are taken, the laboratory staff will ask, “Is the order documented in the patient’s chart?” It is the
physician’s responsibility to ensure the test order is documented in the patient’s chart.
Federal law states that laboratories must request written documentation as a follow-up to any telephone
orders received. You will be asked to verify telephone orders (both new and add-ons to an existing order)
with written confirmation. For new orders, a form, the Telephone or Faxed Laboratory Order Form, will
be faxed to you for this purpose. For add-ons to an existing order, the lab compliance staff will send you a
list of telephone orders received on a biweekly basis. Please verify the information on the form or list is
complete and accurate. Confirm your review by providing an authorized signature on the form and fax or
mail it back to Fletcher Allen Health Care Laboratory
ADDING A TEST TO AN EXISTING ORDER
If you would like to add a test to an existing order, call Laboratory Customer Service at (802)847-5121 or
1-800-991-2799. Depending upon sample type we may be able to add testing on to samples previously
sent to the lab. Samples are discarded after 5 days.
Fax: (802)847-5905
Mail:
Fletcher Allen Health Care
Pathology and Laboratory Medicine
Compliance Office, MP1-107
111 Colchester Avenue
Burlington VT 05401
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General Information
August 13, 2009
STANDING ORDERS
When initiating a standing order, please fill out a Fletcher Allen Health Care Telephone or Faxed
Laboratory Order Form. We will provide these forms to all our clients so that they may be used when a
standing order is initiated.
If a standing order is phoned into our lab, Customer Service will fill out the Telephone or Faxed
Laboratory Order Form with the information we received. All Telephone orders must be followed by
written confirmation. See Telephone Orders for information on that process.
It is Fletcher Allen Health Care laboratory policy that standing orders be reviewed on at least an annual
basis. Standing orders expire at the end of duration stated on original request and/or automatically expire
1 year from date of original request. The lab will send a reminder notice (Standing Order Confirmation)
to the ordering physician asking for renewal, revision or cancellation of current standing order on all
standing orders with an original duration of one year.
The standing order will automatically be cancelled as of the expiration date, either at the expiration date
stated on the original order or one year from original order date.
We will only accept Standing Orders with a frequency of 4 months or less. A Standing Order for a test
requested every 6 months for one year would be treated as a 1 time order six months in the future.
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General Information
August 13, 2009
REFLEX TESTING
Reflex testing occurs when initial test results are positive or outside normal parameters indicating that a
second related test is medically appropriate for patient care.
The Fletcher Allen Health Care Laboratory offers reflex testing in accordance with the Office of Inspector
General’s Compliance Program Guidelines for Clinical Laboratories. It is the policy of Fletcher Allen
Health Care Laboratory to list tests subject to reflex on the laboratory requisitions and to allow physicians
the opportunity to decline the reflex testing if they believe it is not medically necessary. Fletcher Allen
Health Care Laboratory will perform reflex tests automatically when the following conditions are met:
Physician orders a test listed below and:
1. The initial test result meets the criteria listed below for prompting a reflex test or:
2. The specimen was sent to anatomic pathology and additional studies are needed to complete the
evaluation of the case. Please refer to Anatomic Pathology and Reflex Testing on following pages.
The physician has the option of declining reflex testing by writing in the name of the test in the box on the
front of the laboratory requisition.
All reflex testing is reviewed and approved by the laboratory pathologists or their designee on an annual
basis. All Fletcher Allen Health Care Laboratory clients will be notified of changes to the reflex policy.
Fletcher Allen Health Care bills for the reflex tests it performs using the CPT code listed in the chart.
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August 13, 2009
LABORATORY TESTS SUBJECT TO REFLEX
Initial
Test
Reflex
criteria
Reflex
Test(s)
Additional
CPT billed
Amphetamine screen,
positive result
Amphetamine confirmation
82145
urine
______________________________________________________________________________________
Antibody screen
positive
Antibody ID panel
86870*
RBC Antigens
86905*
Pretreatment serum
86975
*number of additional charges will vary depending on the # of antibodies and the extent of the work-up.
______________________________________________________________________________________
Anti neutrophil
positive at screening dilution
Anti neutrophil
86256
Cytoplasmic Ab
Cytoplasmic Ab titer
______________________________________________________________________________________
Anti neutrophil
positive perinuclear pattern
Myeloperoxidase Ab
83520
Cytoplasmic Ab
______________________________________________________________________________________
Antinuclear Ab
ANA positive at screening dilution Antinuclear Ab titer
86039
______________________________________________________________________________________
Centromere Ab
Centromere titer
86256
______________________________________________________________________________________
Direct Antiglobulin Test positive
DAT IgG
86880
(DAT)
DAT complement
86880
______________________________________________________________________________________
Dilute Russell
Result above normal range
LA Confirm test
85613
Viper Venom
______________________________________________________________________________________
Electrophoresis
suspicious band not
Immunofixation
86334
Protein, Serum
previously identified
______________________________________________________________________________________
Electrophoresis
suspicious band not
Immunofixation
86335
Protein, Urine
previously identified
______________________________________________________________________________________
Fluid cell count
any wbc’s present
Differential
89051
______________________________________________________________________________________
Hemagram &
See Lab Services
Pathologist’s smear review
85060
Differential
Directory
& written interpretation
______________________________________________________________________________________
Hepatitis A Antibody
positive result
Hepatitis A -IgM
86709
Antibody confirmation
______________________________________________________________________________________
Hepatitis C Antibody
low level reactivity
Hepatitis c RIBA
86804
______________________________________________________________________________________
Lupus work-up
Abnormal PTT
PTT 50/50 mix
85732
______________________________________________________________________________________
Lyme Ab
Lyme ELISA of
Lyme western Blot
86617
>1.10
Mitochondrial Ab
Mitochondrial Ab titer
86256
______________________________________________________________________________________
Parietal Ab
Parietal Ab titer
86256
______________________________________________________________________________________
Platelet Function
Above normal limit
COL/ADD cartridge
85576
Analysis
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August 13, 2009
Initial
Reflex
Reflex
Additional
Test
Criteria
Test(s)
CPT billed
Prenatal Panel
Ab screen positive
Antibody ID panel
86870
(up to 3x)
Antigen typing
86905
Ig subclass
86975
Ab titer
86886
______________________________________________________________________________________
PTT 50/50 mix
PTT done first, if PTT
PTT
85730
nd
is abnormal and patient is on
PTT (2 )
85730
heparin-heparin is neutralized
Heparin neutralization
85525
and a 2nd PTT is done
______________________________________________________________________________________
RPR
RPR titer
86593
______________________________________________________________________________________
RPR Titer
reactive RPR at any dilution
FTA abs
86781
______________________________________________________________________________________
Sickledex
positive result
Hg electrophoresis
83020
______________________________________________________________________________________
Smooth muscle Ab
Smooth Muscle Ab titer
86256
______________________________________________________________________________________
Urinalysis, routine
when protein 1+ or
Urine microscopic
81001
blood positive or
leukocyte esterase positive
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August 13, 2009
ANATOMIC PATHOLOGY AND REFLEX TESTING
In Anatomic Pathology, a specimen is sent to the laboratory with the intent that the pathologist will
evaluate the specimen thoroughly enough to make a diagnosis. To this end the pathologist uses their
medical judgment in ordering and interpreting additional studies on the material which they feel are
necessary to fully evaluate the specimen. In this regard the pathologist is acting as a consultant in the care
of the patient. The additional studies are charged only when deemed medically necessary by the
pathologist. Such cases would include, but is not limited to, ordering special stains, decalcification of the
tissue, immunoperoxidase stains, microbiology cultures on fresh tissue, flow cytometry on certain tumors
or products of conception, and electron microscopy as indicated.
Providers can also request additional studies on Anatomic Pathology cases, usually following discussion
of the case with the pathologist.
There are some tests which are often useful for prognosis and diagnosis which are not yet considered
routine or standard of care. For these tests, reflex testing procedures have been made so that if a
specimen/process meets the reflex criteria then the additional testing will be performed.
Providers may decline the reflex
testing by completing this box on
the Surgical Pathology
requisition.
The department of Anatomical Pathology will automatically perform reflex testing as outlined in the
following page.
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General Information
August 13, 2009
ANATOMIC PATHOLOGY SPECIMENS SUBJECT TO REFLEX
_____________________________________________________________________________________
Initial
Reflex
Reflex
Additional
Specimen
criteria
Test(s)
CPT billed
Breast excision
All invasive adenoncarcinomas
HercepTest®
88360
for carcinoma
_____________________________________________________________________________________
Breast excision
HercepTest® with
FISH
2x 88271
for carcinoma
an indeterminate result (2+)
88274
88291
_____________________________________________________________________________________
Breast biopsy
1st incidence of
ER/PR receptor testing
2x 88360
DCIS.
2x 88360.26
_____________________________________________________________________________________
Fatty tumor excision
>5 cm
Cytogenetics
88233
88264
Renal tumor excision
enough tumor to sample.
88291
_____________________________________________________________________________________
Bone tumor excision
enough tumor to sample
Cytogenetics
88239
88264
Soft tissue excision
enough tumor to sample
88291
Additional reflex information:
HercepTest® (C-erb-B2 immunoperoxidase stain) Reflex Testing on Breast Cancers
C-erb-B2 (Her2/neu) analysis by the Herceptest® will also be performed routinely on all invasive breast
carcinomas at the time of the definitive excision with the exception of well-differentiated tumors, which
are lymph node negative.
The HercepTest® is a FDA approved standardized immunohistochemical assay, which measures the
HER2 protein overexpression in tumors. The HercepTest is an excellent first line HER2 assay that is
scored as 0-3+ with 0 and 1+ considered a negative result for protein overexpression and 3+ considered as
positive for protein overexpression. A 2+ result is considered indeterminate and as such we automatically
have Fluorescence in situ hybridization (FISH) performed on these cases to measure whether there is
Her2 gene amplification in the tumor.
The Division of Surgical Pathology will automatically perform the HercepTest® on invasive breast
adenocarcinomas which meet certain reflex testing criteria outlined below.
Criteria for reflex performance of the HercepTest® on Breast carcinomas:
1. Tumor present in a resection specimen so that the grade of the tumor can be accurately established
(this test will not be performed automatically on core biopsies, unless there is no residual tumor in
the resection specimen).
2. All invasive adenocarcinomas are included except well-differentiated tumors (total histologic
grading score of 3,4, or 5) that are less than 1 cm (pT1a and pT1b).
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August 13, 2009
Estrogen and Progesterone receptor testing on breast biopsies with ductal carcinoma in situ (DCIS)
Recent studies have shown a therapeutic benefit in treating patients with DCIS with tamoxifen. Allred et
al.1 presented data at two meetings, which have shown that women with estrogen receptor (ER) positive
DCIS treated with tamoxifen have significant reductions in the incidence of ipsilateral and contralateral
breast cancer. Their subsequent data showed no benefit for tamoxifen therapy in women with ER negative
DCIS. Performance of the PR assay provides additional information on the integrity of the ER receptor
axis.
As a result of this new data, we now perform reflex testing on breast core biopsies with DCIS alone for
estrogen and progesterone receptors.
Guidelines for the testing include:
1. All DCIS cases will be tested unless the reflex testing is declined by the provider ordering the test or
there is insufficient tissue present for testing;
2. The reflex testing will be performed on the first incidence of DCIS (typically the core biopsy);
3. If invasive tumor is also present in the tissue being tested, the report will reflect the ER/PR results of
the invasive tumor only unless the DCIS pattern is significantly different from the invasive tumor;
4. ER/PR testing will be repeated on a subsequent biopsy/ excision which contains an invasive tumor
when the original biopsy showed only DCIS.
1
Allred DC, et al. Estrogen receptor status as a predicative marker of the effectiveness of tamoxifen in
DCIS: Findings from NSABP Protocol B-24. (Abstract 80) Modern Pathol 2003; 16:21A.
Reflex cytogenetic testing on adult renal tumors:
Although histologic analysis is the mainstay to the diagnosis of adult renal neoplasms, cytogenetic
analysis can provide supportive diagnostic information in many cases. For this reason, Fletcher Allen
Health Care has initiated sending portions of renal neoplasms for cytogenetic analysis when we receive a
fresh resection specimen, which has enough tumor to sample for cytogenetics. Conventional renal cell
carcinomas typically have loss of the genetic material in the long arm of chromosome 3 and chromophobe
carcinomas are typically characterized by monosomy of multiple chromosomes and hypodiploidy.
Papillary renal cell carcinomas, in contrast, often have a better prognosis than conventional renal cell
carcinomas and typically have a distinct cytogenetic profile with trisomy of chromosomes 7, 16 and 17 as
well as additional genetic abnormalities. The histomorphologic features of these tumors may overlap in
certain cases and thus cytogenetic analysis is felt to be useful in many cases.
Reflex cytogenetic testing on fatty tumors:
Fatty tumors similarly may be difficult at times to classify on morphologic basis alone and cytogenetics
on lesions greater than 5 cm can add additional diagnostic information. Solitary lipomas have been shown
to have translocations involving 12q13-15 as well as chromosomal rearrangements of 13q or 6p21-33.
Atypical lipomatous tumor/well differentiated liposarcomas, on the other hand, commonly show ring
chromosomes and long marker chromosomes from 12q13-15. Dedifferentiated liposarcomas may have
additional complex aberrations. Finding specific cytogenetic changes can therefore support the histologic
findings.
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August 13, 2009
Reflex cytogenetic testing on soft tissue and bone tumors.
In addition to the current reflex policy in surgical pathology for submitting Cytogenetics on renal tumors
and fatty tumors, soft tissue tumors and bone tumors including certain pediatric tumors will routinely be
submitted for Cytogenetics. More data has emerged on the utility of Cytogenetics as an adjunct to
traditional diagnostic methods such as histologic examination with H&E stains as well as
immunohistochemical stains. Cytogenetics is considered integral to the diagnosis of some soft tissue and
bone tumors, especially in cases which pose histologic challenge. Soft tissue and bone tumors with well
known chromosomal translocations and gene rearrangements include Ewing sarcoma/PNET, desmoplastic
small round cell tumor, extraskeletal myxoid chrondrosarcoma, synovial sarcoma, alveolar
rhabdomyosarcoma, low grade fibromyxoid sarcoma and inflammatory myofibroblastic tumor, to name a
few. As with all reflex testing, the ordering provider can choose to decline the reflex testing by checking
the selection on the surgical pathology requisition.
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General Information
August 13, 2009
CUSTOM PROFILES
Custom profiles permit physicians to establish their own profile consisting of a particular group of tests
that they order together frequently. Physicians in certain specialties request such groupings for particular
clinical situations. The government recognizes the need to permit custom panels; however, the
government expects laboratories that construct custom profiles in response to a physician’s request to
provide a disclosure notice to physicians who use the custom panel. This disclosure is called a Physician
Acknowledgement of Customized Profile.
Our Laboratory will work with physician clients to construct custom profiles to meet specific testing
needs. At the time of implementation of any custom profile, and annually thereafter, the physician will be
requested to sign a Physician Acknowledgment form.
Please contact Laboratory Customer Service (847-5121) and ask to speak to an Outreach Specialist if you
would like more information about custom profiles.
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General Information
August 13, 2009
BILLING INFORMATION
Fletcher Allen Health Care can bill:
•
•
•
•
•
Your patient
Medicare
Medicaid
Most commercial insurance companies
Your office*
*A volume discount may be available if we bill your office.
Contact Customer Service at (802)847-5121, ask for a
Laboratory Outreach Specialist to set up your "96" account.
Current legislation requires hospital laboratories to bill Medicare and Medicaid directly for clinical laboratory tests
performed for physicians and clinics.
Fletcher Allen will submit separate bills for pathologist interpretation of certain tests (e.g. Cytology, Cytogenetics,
and Surgical Pathology). This is a federal regulation. These tests are noted on the fee schedule with a "Part B"
component. All test orders must be accompanied with up to date billing information. The lab requisition billing
information section must be completely filled out.
QUESTIONS ABOUT LABORATORY BILLS?
Call:
96 Account Billing (Client Billing) ...Lab Reimbursement Specialist: (802)847-0234
Long distance toll free calls: (800) 991-2799
or email: LabMarketing@vtmednet.org
Patient Billing (Part A & Part B)……..….Patient Financial Services (PFS)
Main Office
ACC Building, Main Pavilion, Third Floor
Burlington, VT 05401
Email CustomerService@vtmednet.org
PFS Customer Service Line: (802)847-8000
And Long distance toll free calls: (800)639-2719
Telephone Lines Are Open ................. Monday through Friday, 8:30 a.m. – 4:30 p.m.
Office Hours......................................... Monday through Friday, 8:00 a.m. – 4:30 p.m.
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General Information
August 13, 2009
OUTPATIENT BLOOD DRAWING SITES
Lactose and glucose tolerance tests must be scheduled in advance by calling laboratory Customer Service
((802)847-5121). For all other testing, no appointment is necessary at any of the phlebotomy areas.
Patients are seen in the order in which they arrive. Patients with stat testing, timed tests or patients with
special needs will be expedited.
Please call Laboratory Customer Service for hours and directions.
Medical Center Campus
Ambulatory Care Center (ACC)
Laboratory Services
Level 2 (Orange), Main Pavilion
Burlington, VT 05401
The primary care site – with four collection stations.
Fanny Allen Campus Laboratory
790 College Parkway
Colchester, VT 05446
This site has two collection stations.
Please plan to stop in the patient registration area
before proceeding to the Laboratory
OFF-HOURS INFORMATION
Routine blood drawing is available Monday through Friday and Saturday morning. If a patient needs to have
blood drawn immediately, or if the testing required is a timed draw & not during routine hours, you should
instruct the patient to come to the Ambulatory Care Center information desk inside the front entrance on
Level 3 (street level) for instructions. After going to registration, a phlebotomist will be paged.
35
General Information
August 13, 2009
RESULT REPORTING
Individual patient reports are printed every night and distributed by courier or mail the following day. For
clients that have Laboratory report devices (fax or printer) in their office, reports print at the same time
each day according to a schedule set up when the printer was installed.
Each patient report includes the patient's name, date of birth, sex, Fletcher Allen medical record number,
laboratory location code, clinician and the date the report was printed in the header. With each test the
date/time collected and date/time received will print along with the normal ranges for the tests requested.
Any test result that is outside the normal range will be flagged with an "H" for above normal results or
"L" for results below normal. Critical values are flagged with a "*".
Laboratory Report Devices
Types of Report Printers
DEVICE
CARTRIDGE
KIT Printer 6000 (AP, CP & General Lab reports)
Brother Fax 2820 (AP, CP & General Lab reports)
Toner 12LM-69G8256
Toner 13T0101 or 13T0301
Toner 12LM-4K00198 or 12LM-4K00199
Toner TN-350, Drum DR-350
Cytopathology and Anatomic Pathology Report Print Schedule
Reports print in the very early hours of the morning either in your office or at the laboratory and we will forward
them to your office.
Clinical Pathology Report Print Schedule
We provide a written report to the ordering physician and any additional copy to physicians indicated on the order.
Laboratory reports will print on a prearranged schedule. Some supplementary reports will be mailed or sent by
courier when completed. You will not be called unless a result is a critical value or you have requested that the
result be called or faxed.
36
General Information
August 13, 2009
Report Print Options
There are 4 options for printing.
Definitions
Test: single assay i.e. glucose
Battery: A group of assay’s i.e. electrolytes
Accession: Test(s) and /or battery(s) that are ordered at the same time.
This will vary sometimes with specimen type.
Reports are printed by accession.
You will get a final report with all test(s) ordered under that accession on a single report.
Completed This option allows tests and
Accessions batteries to qualify for a report
only when an entire accession is
Option #1 completed. All accessions that
are complete at the scheduled
print time will print for any
location defined with option #1.
Pending
Accession
Option #2
This option allows tests and batteries to
qualify for a printed report when there is
any activity on an accession, the entire
accession prints each time.
Any pending tests or batteries will print as
“Pending”. When all tests are complete a
report with all the tests ordered for that
accession will print completed.
Summary - If you order a test
that takes longer to report with
tests that are usually completed
on the same day as received you
will not receive a report until
the test that takes longer is
finalized.
Summary - If you order a test that takes
longer to complete with tests that are
usually completed on the same day you
will receive a report at the scheduled print
time with the test result that was
completed on the same day resulted and
the incomplete test reported as “pending”.
NOTE: Gram stains that are
ordered with a culture will not
print until the culture has been
resulted.
NOTE: Gram stains that are ordered with
a culture will print with the next
scheduled print after they are completed
and the culture will print as pending.
37
General Information
August 13, 2009
Reports are printed by individual test
You may not receive a final report with all tests resulted on a single report.
Completed
Test &
Batteries
Option #3
This option qualifies tests and
batteries for a printed report when
the battery or test is completed. Any
battery or test that is complete at the
scheduled print time will print. Test
and batteries will print only once and
you will not see any pending tests or
batteries. You will have a printed
report for each test and battery but
you may not receive a report with the
entire accession completed on the
same report.
Pending
Test &
Batteries
Option #4
This option qualifies tests and batteries for a
printed report when there is any activity.
Only those tests or batteries that have activity
will print. Once a test or battery has printed
it will not print again. You will have a
printed report for each test and battery but
you may not receive a report with the
entire order completed on the same report.
Summary - If you order a test that takes
longer to report with tests that are usually
completed on the same day you will receive a
report at the scheduled print time with the
test result that was completed on the same
day resulted, and the test that takes longer as
“pending”.
Summary - If you order a test that
takes longer to result with tests that
are usually completed on the same
day, you will receive a report at the
scheduled print time for tests that are
completed, and when a test that takes
longer to result is complete you will
receive another report for those tests.
Previously reported results will not
reprint.
If there is any new activity on this order a
new report will print. New activity could be
a pending result, a completed result a
corrected result or it could be an updated
date/time or something else.
NOTE: Gram stains that are ordered with a
culture will print with the next scheduled
print after they are completed and the culture
will print as pending.
NOTE: Gram stains that are ordered
with a culture will not print until the
culture has been resulted.
38
General Information
August 13, 2009
Client Report Fax
For clients that have a report fax in their office please review the following information.
Paper
Use plain paper only. To avoid paper jams DO NOT USE pre-punched paper or recycled paper
or paper with rough or heavily textured surfaces, coated, preprinted, synthetic or thermal paper.
The laboratory will supply paper for these report devices.
Moving a Device
Please contact Fletcher Allen Health Care Lab Customer Service before moving your printer.
Index Reports
•
•
•
•
•
Index reports print at the end of each report batch and should be saved for two months.
For Pathology Reports, this is a single page detailing the location, ordering physicians, specimen
number, report status and patient name in the report batch.
For Clinical General Lab Reports, two index reports print, Index of New Activity Event Report
Summary By Patient Name and Index of New Activity Event Report Summary By Hospital Number.
Always wait until the end of the print to remove the Index Reports from the printer.
If the Index Report does not print, call Lab Customer Service at (802)847-5121.
Format Errors
• Reports should print with a header and footer.
• The footer will print approximately 1.5 inches from the bottom of the report.
• If the footer prints any further from the bottom of the page, do not use results on any of the reports
that have printed in this batch. Call Lab Customer Service at (802)847-5121 to report the problem.
Unexpected End of Transmission Error
• When did the error occur? This error is normal and expected for KIT 8100, if it occurs after index
prints.
• For all other printer/fax models, if error occurred before index reports printed – there was an
interruption in the transmission. DO NOT use any of the reports that have printed in this batch.
• Contact Lab Customer Service at (802)847-5121 to request retransmission of report batch.
No Dial Tone Detected:
• Check the phone line. Make sure it is securely connected to the wall jack and the printer LINE IN (NOT
the FAX OUT) jack. If you reinsert the cable into the printer/fax, turn it off and then back on prior to
receiving data.
• Plug a standard, single-line phone into the wall jack and listen for a dial tone. If you don't hear a dial
tone, the line will need to be tested. Contact Lab Customer Service at (802)847-5121
No Reports Printed
Please verify the following:
• Printer/fax has power.
• Fax box, if applicable has power. (Is the light on?)
• Paper is loaded.
• No error messages are displayed (on-line/ready status.)
**DO NOT turn off the printer unless you are instructed to do so.**
39
General Information
August 13, 2009
Lab Order Priority Designations
To efficiently manage patient care, the following order status designations are offered.
DESIGNATION
AVAILABILITY
TESTING
REPORTING
Immediately Upon
STAT
Limited
Phone Results
Receipt
Call Results
All Tests
Routine
Phone Results
Routine or ASAP
All Tests
Routine
Phone critical results
only
STAT
Stat testing is defined as laboratory testing required in order to
immediately treat a patient. The inappropriate use of requesting Stat
testing affects the care of critically ill patients by delaying the turnaround
time for Stat testing required to immediately treat them.
All tests on the Stat list are completed on the same day the samples are
received. Some laboratory testing cannot be offered Stat due to the
amount of time it takes to process the sample. Examples are:
microbiology cultures, cytogenetics testing, and tests sent out to reference
laboratories.
STAT requests are given the highest priority at all stages of specimen
handling, including collection, processing, testing and reporting. Most
STAT tests are reported within sixty minutes of being received in the lab.
If you need a test done STAT write STAT on the lab requisition next to
the test you want STAT, along with a phone number or beeper number
where you can be reached. Also call Customer Service at 847-5121 to let
us know a STAT is coming. The STAT result will be called as soon as
testing is complete. We perform a limited number of tests STAT. Please
see STAT list in this section. Tests not on the STAT list must be approved
by a pathologist before testing will be performed.
Call/Fax Result
Requests for tests to be called or faxed will be treated as routine. Results
will be called as soon as they are available. If results are complete after
your office hours, we will call the provider on call.
Any critical results (see list in this section) will be called immediately.
For anatomic and cytopathology, we call all new cancer diagnosis,
unexpected malignancy or malignancy in an unusual location, a significant
change between a rapid and a final diagnosis, identification of a significant
infectious organism, and any case that a pathologists flags.
If you need results called or faxed to your office, please fill in the
appropriate box on the requisition and supply the phone/fax number.
These results will be called or faxed to your office as soon as possible
after the completion of the testing.
40
General Information
August 13, 2009
Routine
Critical Values
Individual patient reports are printed every night and distributed by
printer, courier or mail the following day. Most testing is done within 8
hours of being received in the laboratory. Cultures and some esoteric tests
will take longer than 24-hours. Any critical results (see list in this section)
will be called immediately. Tests ordered ASAP will be tested as routine.
See Lab Services Directory, Section III, Sample Requirements for
information on analytical time for specific testing.
Critical values will be called to the ordering physician as soon as the
results are available. (See the Critical Values list located in this section).
A laboratory representative will call and clearly state that the value is
critical and requires immediate attention.
The laboratory representative will ask the individual who received the
result to repeat back the result for confirmation. The call will be recorded
in the laboratory information system.
The following information must be documented:
• Time and date the call was made;
• Full name of the individual who received the results;
• Name of the individual in the laboratory who communicated the
results.
Repeat Testing
Specimens are generally held for 5 days after test completion. If
laboratory results do not match clinical conditions, please call Customer
Service 847-5121 to arrange repeat testing.
41
General Information
August 13, 2009
COURIER
The laboratory operates several courier routes throughout the state of Vermont. For clients
outside of our courier area we have various mechanisms in place to handle your specimens.
Please contact Laboratory Customer Service, (802) 847-5121, to assist you with this process.
STAT Courier Pickups
Pickups provided outside the courier’s regular schedule and requiring immediate
processing are considered STAT. We are able to provide this service to clients within
Chittenden County. Arrangements can be made by calling Customer Service at 8475121. Fletcher Allen Health Care will NOT pay courier pick-up fees for samples brought
to the lab by a courier that has not been arranged for by the laboratory.
LABORATORY SUPPLIES
Collection supplies necessary to forward specimens to our laboratory such as requisitions,
transport media, sterile containers, specimen preservatives, needles and vacuum tubes are
furnished at no extra charge. Please use the supply order form to order supplies.
42
General Information
August 13, 2009
STAT LIST
STAT Tests not requiring pathologists approval
Blood Bank
Blood Group (ABO and Rh Type)
Cord Blood Routine
Crossmatch of units
Transfusion Reaction Workup
Type and screen (with or without crossmatch)
Chemistry
Acetaminophen
Acetone
Albumin
Alkaline Phosphatase
Amikacin
Ammonia
Amylase
ALT
AST
B-type Natiuretic Peptide (BNP)
Bilirubin
BNP
Calcium
Calcium, ionized
Carbamazepine (Tegretol)
Carbon Dioxide
Carboxy Hemoglobin
Chloride
Cholesterol
CK
CKMB
Cortisol (M3, M4, and the ER)
Creatinine
CRP
Creatinine Clearance
Digoxin
Drug Screen-6
Drug Screen-7
Drug Screen-Agitated
Drug Screen-Sedated
Electrolytes (Na, K, Cl)
Estradiol – In vitro Fertilization Samples (UIVF)
Ethanol
Ethylene Glycol
Fetal Fibronectin
Fetal Lung Maturity
GGT
Gases - PH, PO2, PCO2
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General Information
August 13, 2009
STAT Tests not requiring pathologists approval
Gentamicin
Glucose
HCG
Hemoglobin, Plasma
HIV-Rapid (7 a.m. to 10 p.m. daily)
Iron
Iron Binding Capacity
Isopropanol - See Volatile Screen
Lactic Acid
LDH
Lipase
Lithium
Magnesium
Methanol - See Volatile Screen
Methemoglobin
Methotrexate
Monospot
Osmolality
Oxygen Saturation
Phenobarbital
Phenytoin (Dilantin)
Phosphorus
Potassium
Pregnancy Test, Urine
Progesterone – In Vitro Fertilization Samples (UIVF)
Protein, Total
Salicylate
Sodium
Theophylline
Tobramycin
Tricyclic Screen
Triglycerides
Troponin
TSH – ED and Nuclear Medicine Only
Urea Nitrogen
Uric Acid
Urinalysis
Urine pH
Valproate
Vancomycin
Volatiles Screen (includes Ethanol, Methanol, and Isopropanol)
44
General Information
August 13, 2009
Hematology and Coagulation
Body Fluid Cell Count
Crystals, Joint
CSF Cell Count
D-Dimer
Fibrinogen, plasma
Hemagram (CBC)
Hemagram and Differential (or any part-WBC HGB, HCT, Platelet)
Heparin Level (unfrationated, low molecular weight, fondaparinux)
Kleihauer-Betke (approval needed when ordered on evenings, nights and weekend shifts)
Partial Thromboplastin Time (PTT)
PFA-100 (Platelet Function Analysis)
Prothrombin Time
Sedimentation Rate
Histology
Pneumocystis Stain (Pathologist on call must approve before Histology is called in.)
Microbiology
AFB Smear
Fungal Smears (Day only)
Gram Smears (on Evening/Night preparation & staining only)
Inoculation of bacterial cultures
Malarial Smears
Parasite Exam, Blood
Wet Preps
45
General Information
August 13, 2009
CRITICAL VALUES LIST
The following is a list of laboratory results that are considered critical values. These results will be called
immediately to the ordering provider.
Hematology
Test
Differential Cell Count
Hematocrit
Hemoglobin
Leukocyte Count
Critical Value
Blast cells greater than 20%
Less than 21%
Less than 7.0g/dL
Less than 1000/µl OR
Absolute Neutrophil count <500/µl OR
Greater than 50,000/µl
Less than 2,000/µl
INR greater than 3.8
Over 100 seconds
less than 90 mg/dL
All Results
Greater than 1.5mg/L
Greater than 2.0 IU/mL
Greater than 1.0 IU/mL
Platelet Count
Prothrombin Time
Partial Thromboplastin Time
Fibrinogen
Heparin Platelet Ab PF4 ELISA
Heparin Level, Fondaparinux
Heparin Level, Low Molecular weight
Heparin Level, Unfractionated
Chemistry
Dialysis: The only critical values that must be confirmed and called on samples clearly labeled
PreDialysis or PostDialysis are listed below. Use standard call values otherwise:
Test
Calcium
Potassium
<6.5
<3. 0
Standard Critical Values
Test
Acetaminophen
Acetone
Amikacin
Critical Value
>14.0 mg/dL
>7.0 Meq/L
Critical Value
>100 ug/mL
Any positive result
Peak:
>36 ug/mL
Trough:
>6 ug/mL
>15 mg/dL
<6.5 or
>11.5 mg/dL
<6.5 or
>12.0mg/dL
>15 ug/mL
>15%
>15 mg/dL
>5.0 mg/dL with no previous OR
3 times higher than the previous OR
>4.0 mg/dL and is more than 2.5 mg/dL higher
than previous value
>2.0 ng/dL
Positive
Bilirubin (Children and Adults)
Calcium
Calcium, (patients 0-28 days old)
Carbamazepine (Tegretol)
Carboxyhgb
Creatinine
Delta Creatinine
Digoxin
Fetal Fibronectin
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General Information
August 13, 2009
Test
Critical Value
Gentamicin
Peak:
Trough:
<50
or
<40
or
Glucose
Glucose (Neonate <1 day)
HCG-on Accutane
Ionized Calcium
Ketones, Urine
Lead
Lead
Lithium
Magnesium
Methotrexate
PH (blood gas)
Phenobarbital
Phenytoin (Dilantin)
Potassium
Salicylate
Sodium
Theophylline
Tobramycin
<0.8
or
0-18 years
Adult
<1.0
or
<7.00 or
<3.0
or
<125
or
Peak:
Trough:
Tricyclic screen
Valproate
Vancomycin
Peak:
Trough:
>12 ug/mL
>1.5 ug/mL
>500 mg/dL
>180 mg/dL
>4 mIU/mL
>1.60 mmol/L
Large
>20 ug/dL
>40 ug/dL
>1.5 mEq/L
>4.8 mEq/L
>1000 uM/L
>7.60
>45 ug/mL
>22 ug/mL
>6.0. mEq/L
>30 mg/dL
>155 mEq/L
>20 ug/mL
>12 ug/mL
>1.5 ug/mL
>500 ng/mL
>150 ug/mL
>40 ug/mL
>20 ug/mL
Microbiology
Test
Blood cultures
CSF specimens
Acid-fast bacilli
Plasmodium species
Group A streptococci - from other than throat
Critical Value
positive result
positive result
positive result
positive result
positive result
47
General Information
August 13, 2009
Appendix
Informed Consent Vermont
Informed Consent New York State
Telephone/Fax/Standing Order Request Form
Special Send-Out Laboratory Mailing Request Form
Laboratory Supply Order Form
General Information
February 16, 2009
FAHC MRN:
NAME:
DOB:
VERMONT STATE
INFORMED CONSENT FOR GENETIC TESTING
Addressograph
Genetic Testing has been recommended for me (or my child). I understand that the genetic testing requires
analysis of the chromosomes, Deoxyribonucleic acid (DNA), Ribonucleic acid (RNA), or protein obtained
from a sample of blood, skin, cheek brushings or other body tissues. I understand that no other tests than those
authorized will be performed and that my biological sample will not be saved without my authorization.
I understand the specific test that I (or my child) is having and its accuracy. I understand that the results of this
test may be inconclusive or uninformative (not tell me anything). I understand that incorrect information about
family relationships may affect the test result. I understand that this test may reveal private information such as
non-paternity (someone’s father not being who they think they are) or adoption. I understand that such
information, if obtained through this test, will NOT be revealed to me, my child, or to anyone else, under any
circumstances.
I understand that I am responsible for the costs of genetic testing. If I choose to have my (or my child’s) insurance
company pay for the testing, it is my responsibility to contact the company to determine that they cover such
testing. I know that if the insurance company pays for the testing they may have a right to learn the test results. I
can choose not to have the insurance company pay for the testing, in which case I will pay for the test myself. I
understand that in some cases payment is required before the genetic testing is performed.
Whether it is the insurance company or me that pays for the testing, the results may become part of my (or my
child’s) permanent medical record. Having this information in the medical record may make it more difficult for
me (or my child) to get health, disability, long-term care or life insurance. I have also considered the possible
financial impact of the test result.
I understand that Vermont law gives me certain protections from misuse of genetic information, including the
right to sue if such misuse occurs.
I have explained to ________________________________ the possible risks, benefits and limitations of
the genetic test _________________________________________________________ (name of the test).
Provider Signature: ___________________________________________Date:____________________
Institution: _______________________________________Phone number: _______________________
I have read (or had read to me) the above information and received a copy of this page. All of my questions and
concerns about genetic testing have been addressed. I know that I can contact the person above if I have additional
questions.
Patient ______________________________________________
Date: ________________
If patient is a minor:
Parent or guardian: _______________________________________
Date: ________________
Witness: _______________________________________________
Form# 036431P
Retain in Patient’s Chart
03/2006
Consent Section
Date: ________________
Page 1 of 1
FAHC MRN:
NAME:
DOB:
NEW YORK STATE
INFORMED CONSENT FOR GENETIC TESTING
Addressograph
The purpose of this form is to allow you to make an informed decision in regard to whether or not you
wish to undergo genetic testing. You may wish to obtain professional genetic counseling before you sign
this form. If you do not sign this form, no genetic tests will be performed on your behalf.
I understand that the purpose of this test, and its potential benefit, is to obtain the possible diagnosis of an
inherited metabolic disease. It may also determine which of my family members may be carriers of the
disease. For prenatal diagnosis, it may determine the genetic status of the fetus.
I understand that a positive test result is an indication that I (or my child) may be predisposed to or have
the specific disease or condition tested for. If I (or my child) receive a positive test result, I understand
that I (or my child) may benefit from further independent testing, consultation from my physician, or
pursuing genetic counseling.
I understand that genetic testing has been recommended for me (or my child). I understand that the
genetic testing requires analysis of the chromosomes, Deoxyribonucleic acid (DNA), Ribonucleic acid
(RNA), or protein obtained from a sample of blood, skin, cheek brushings or other body tissues. I
understand that no other tests than those authorized will be performed and that my biological sample will
not be saved without my authorization.
I understand that the following diseases or conditions will be tested for:
__________________________________ _______________________________________
__________________________________
_______________________________________
I understand that a positive test result for _________________________ disease or condition serves as a
___________ percentage predictor of such disease. Or, in the alternative, as explained to me, no level of
certainty has been established for the disease or condition which I am being tested for.
I understand the specific test that I (or my child) is having and its accuracy. I understand that the results of
this test may be inconclusive or uninformative (not tell me anything).
I understand that incorrect information about family relationships may affect the test result.
I understand that this test may reveal private information such as non-paternity (someone’s father not
being who they think they are) or adoption. I understand that such information, if obtained through this
test, will NOT be revealed to me, my child, or to anyone else, under any circumstances.
I understand that I am responsible for the costs of genetic testing. If I choose to have my (or my child’s)
insurance company pay for the testing, it is my responsibility to contact the company to determine that
they cover such testing. I understand that if the insurance company pays for the testing they may have a
right to learn the test results. I understand that I can choose not to have the insurance company pay for the
testing, in which case I will pay for the test myself. I understand that in some cases payment is required
before the genetic testing is performed.
Form# 036432P
03/2006
Consent Section
Page 1 of 2
I understand that whether it is the insurance company or me that pays for the testing, the results may
become part of my (or my child’s) permanent medical record. I understand that having this information in
the medical record may make it more difficult for me (or my child) to get health, disability, long-term
care or life insurance. I have also considered the possible financial impact of the test result.
I understand that my genetic sample will be destroyed at the end of the testing process or not more than
sixty days after my sample was taken, unless I authorize a longer period of retention.
I authorize the results of this test to be disclosed to the following persons/organizations:
________________________________ _________________________________________
________________________________ _________________________________________
I have explained to _________________________________________________ the possible risks,
benefits and limitations of the genetic test ___________________________________ (name of the test).
Provider Signature: _____________________________________________Date: __________________
Institution: _____________________________________Phone number: _______________________
I have read (or had read to me) the above information and received a copy of this form. All of my
questions and concerns about genetic testing have been addressed. I understand that I can contact the
person listed above if I have additional questions.
Patient ______________________________________________
Date: ________________
Date: ________________
Witness: _______________________________________________
Date: ________________
I hereby authorize my genetic sample to be retained by the testing organization for a length of time as
they see fit, in order that they may use my sample for anonymous research. I understand that this is
entirely optional and that my refusal to allow my sample to be used for anonymous research will in no
way affect my ability to have my genetic test performed. By signing below, I understand that my sample
may be held longer than the sixty day period stated above.
Patient ______________________________________________
Date: ________________
Date: ________________
Witness: _______________________________________________
Date: ________________
Form# 036432P
03/2006
Consent Section
Page 2 of 2
Department of Pathology and Laboratory Medicine
111 Colchester Ave., Burlington, Vermont 05401
Phone: 802-847-5121 or 800-991-2799
TELEPHONE/FAXED LABORATORY ORDER FORM
This material is intended for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential and
exempt from disclosure by applicable law. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination,
distribution, or copying of this communication is strictly prohibited. If you received this communication in error, please notify the sender immediately by
telephone (collect) and return the original message to the sender listed above.
FAX To:
Physician
fax# __________________________Physician
phone
_________________________
Outpatient
Laboratory Request for Verbal
or #Standing
Orders
Attention _______________________________________________________________________
This form is to be used as follows:
1. For providers who wish to fax in either a one-time or a standing order to the laboratory or
2. By the laboratory for documenting a one time or a standing order received by telephone.
If you are faxing in an order, please complete all the information and print legibly.
If this form has been faxed to you, please review the telephone order below for completeness and accuracy and confirm this
review by providing an authorized signature* below.
Fax this form to us at 802-847-5905 or mail it to us at the above address, attention Customer Service. Please return this
form to us as promptly as possible. Thank you.
➨Authorized Signature: _________________________________________________________
*An authorized signature is the ordering physician or an authorized person on the physician’s staff.
One time Order:
Date to be drawn ___________
Standing Order:
Frequency ________________________
Duration __________________________
Date Order Requested ____/____/____ Who called? ____________________ Loc Code _________________
Patient Full Name__________________________________________ Date of Birth_____________________
FAHC MRN# or SS#_______________________ Ordering Provider_________________________________
Copy to another physician? Y/N Name_____________________________ Loc Code___________________
Testing Requested _______________________________ ICD-9 Diagnosis Code_______________________
_______________________________
________________________
_______________________________
________________________
Order is documented in chart?
Y/N
Is this a Medicare Patient? Y/N
If Medicare: ABN not required_____
Diagnosis not covered, ABN attached_____
Internal Use Only
Telephone Order Statement: All Telephone Orders must be followed with written documentation of the Telephone Order
within 30 days of the request to comply with federal regulations. The Laboratory has faxed you this form with the
telephone order we received and ask that you review the order for completeness and accuracy. We also remind you that the
order should be documented in the patient’s chart.
Person receiving order _______________
Form # 029402
Database Date/Initials____________
Date faxed _______________
SPECIAL SEND-OUT
LABORATORY TEST REQUEST FORM
• This form MUST be completed and submitted to Specimen Receiving when the FAHC laboratory is asked to ship any type of specimen to a
laboratory that we do not routinely send to (Labs we routinely send-to include: Mayo Medical Laboratory and VT State Lab).
• Fax form to 847-2358 and call 847-4763 for confirmation from Specimen receiving Supervisor.
• This form MUST accompany a completed laboratory requisition from the performing lab (not an FAHC laboratory requisition).
PATIENT INFORMATION
Date to be drawn:___________________________ Where patient will be drawn:______________________________________
Patient
Full Name:_______________________________________________DOB:_______________ MRN:_________________________
Diagnosis Code(s):__________________________________________________________________________________________
□ Bill Provider: Please provide account number (9____--___________ ) or call 847-5121 to speak to a Marketing Rep.
□ Bill Patient or Patient Insurance (Please include insurance information):
□ Performing lab listed to bill patient (Include copy of patients insurance card, back and front).
Responsible Party Name: _________________________________________________Phone Number: _____________________
Address (Street, Town, State, Zip Code):
__________________________________________________________________________________________________________
Medicare No.______________Medicaid No. ______________Managed Care Medicaid No:_________________State:_________
Insurance Name: _____________________________Cert. No. ________________________Group _________________________
Subscriber Name:_______________________________________________DOB______________Relationship________________
Employer__________________________________________________________________________________________________________
YOUR PRACTICE INFORMATION
Person Filling Out Form:______________________________________Telephone Number:_________________________
Practice
Name:___________________________________________________________________________________________
Address:__________________________________________________________________________________________
Ordering
Provider: ___________________________________________Additional Copy To:_______________________________
Physician
Signature:_________________________________________________________________________________________
PERFORMING LABORATORY & TESTING INFORMATION
You must send Specimen Receiving a completed laboratory requisition from the performing laboratory
Specimen Type: ____________________Volume Required:_________________Shipping Temperature:_____________________
Test Name: _____________________________________________________________Test CPT: _____________Test Price: ___________
Performing Lab:_________________________________________________________ CLIA License No:____________________
Lab Address (Street, Town, State, Zip
____________________________________________________________________________________________________________
Lab Phone:______________________________CLIA REQUIRES THAT A COPY OF RESULTS BE SENT TO FAHC LABORATORY
In the event that your insurance does not cover these services you will be responsible for the charges.
Print name:_____________________________________Signature:____________________________________________________Date:_________________________
Date: _____/_____/_____ Account. Name: __________________________________________________________________
LABORATORY SUPPLY ORDER FORM
Phone Orders: 847-5121 or 1-800-991-2799
Fax Orders: 802-847-5905
Your Name: ______________________________________ Location Code:___________________Phone #:_____________
Items supplied are intended to be used solely for specimens sent to FAHC laboratory. The number of items provided will be monitored to
ensure they correlate with the number of tests sent to the lab for processing.
Where quantities are listed, we assume you are ordering that number of the quantity
listed. For instance, if _3_ Serum separator (SST), 8 ml (box of 50) are ordered we
will send you 3 boxes or 150 tubes. Please do not order more items than you will use in
30 days. Items transported and stored at room temperature unless otherwise stated.
®Items transported and stored at 2-8˚c, F items transported 0˚c.
TUBES
_____ Serum separator(SST), 8 ml (Tray of 50)(031972)
_____ Lavender, 4 ml (box of 50)
(031974)
_____ Lt. Blue, 3.5 ml (box of 50)
(031975)
_____ Green, 6 ml, (box of 50)
(031977)
_____ Grey, 4 ml (box of 50)
(031978)
_____ Yellow, 6 ml (box of 100)
(031980)
_____ Red, Plain (Serum), 10 ml (box of 100) (031973)
PEDI TUBES (Box of 50 or Specify Quantity)
_____ Serum separator, Pedi, 4 ml
(031982)
_____ Lt. Blue, Pedi, 2.0 ml
(031981)
_____ Green, Pedi, 3 ml
(031979)
_____ Grey, Pedi, 2 ml
(031976)
MICROTAINER TUBES (Bag of 50)
_____ Gold (serum microtainer)
_____ Lavender
_____ Green
NEEDLES (Box of 100)
_____ 21 GA-1 ¼ in.
_____ 22 GA-1 ¼ in.
(031983)
(031984)
(031985)
(031986)
(031988)
SPECIMEN COLLECTION & TRANSPORT
_____ Special Jumbo Bag (pkg. of 100)
(031989)
_____ Special Yellow Frozen Bag Sm(Pkg of 50) (035194)
_____ Special Pink Refrig Bag Sm (Pkg of 50) (035195)
_____ Special White RT Bag Sm (Pkg of 50) (035196)
_____ Transport bag (pkg. of 100)
(031990)
_____ Needle Holder Puncture Guard (BG of 250)
(031993)
_____ Tourniquet (1 roll) (031997)
_____ Coag transfer tube (2 ml, 25 w/caps) (035182)
_____ Pour off Tube (pkg of 100)
(031994)
_____ Transfer Pipet (box of 500)
(031995)
_____ Container Sterile 100 ml (pkg of 75) (031996)
_____ Towelette
(031998)
_____ Container w/lid, 250 ml
(031999)
_____ 24 hr. Urine Container Jug #_____ (032000)
_____ 24 Hr. Stool Culture Container
(032002)
_____ Mailing Container Kit, 3 Tube
(59182)
_____ Mailing Container Kit, 8 Tube
(035183)
RETURNS: If you return any laboratory supplies please tag the item
with a copy of this sheet or add a note explaining where they are being
returned from and why so that we can update your location compliance
log.
Thank you
CYTOLOGY/PAP SMEAR SUPPLIES
Conventional Pap Supplies
_____ Kit(trays of 36 Slides, brushes, scrapers,
Sprayfix)
(032003)
Thin Prep Pap Supplies
_____ Vial ( box of 25)
(032004)
_____ Broom (box of 25)
(032005)
_____ Brush (box of 25)
(034397)
_____ Spatula (box of 25)
(034399)
_____ Brush + Spatula ( box of 25 each)
Non-Gyn/Fine Needle Aspiration
(032006)
_____ CytoLyt Tubes (20 per tray)
(034401)
SURG PATH/HISTOLOGY
_____Formalin, 20ml vial/10ml formalin
_____Formalin, 60ml vial/30ml formalin
_____Formalin, 120 mL vial/60ml formalin
_____Hollandes Filled Cont.,40 ml 24/pk
_____Biopsy Filter Paper Circle
_____Michel’s Fixative
(032026)
(032027)
(032029)
(032028)
(032030)
(032031)
MICROBIOLOGY
_____ Blood Culture set, Adult
(032033)
_____ Blood Culture Set Pedi
(032034)
_____ Blood Culture Tube, Fungal(Isolator) (59185)
_____ Blood Culture Tube, Fungal (Pedi) (59186)
_____ Blood Culture Prep Kit II
(032149)
_____ Blood Culture Chloraprep One-Step (59183)
_____ Bone Marrow Tube (SPS)
(58852)
_____ Anaerobic Transport Vial
(032036)
® _____ VCT Transport Media
(032037)
_____ Genprobe, Unisex (box of 50)
(032039)
_____ Genprobe, Urine (box of 50)
(032038)
_____ Ova & Parasite fixative (case of 100) (032040)
_____ Stool Culture Vial (box of 20)
(032041)
_____ Swab (each) (Copan)
(59184)
F _____ Mycoplasma Transport Media
(032042)
®_____ Regan-Lowe
(032043)
®_____ Potato Flakes (Mycosel)
(032044)
®_____ Jembec Plates
(032045)
_____ Autoclave Check
(032046)
CYTOGENETICS
®_____ Bone Marrow Tube (RPMI)
(032047)
_____ Hanks Solution, Tissue
(032048)
_____ Sodium HeparinTube,Blood 4ml
(green top)
(032049)
_____ Sodium Heparin Tube, Blood 6ml
(green top)
(032050)
REQUISITIONS/FORMS/OFFICE
_____ Outpt Lab Requisition
(032007)
_____ Genetic & Prenatal Req.
(034626)
_____ Cytogenetics/Flow Cytometry/ Bone
Marrow Exam Req.
(032014)
_____ Surg Path Non GYN Req.
(032013)
_____ Lead Demographic Form (25-bound)
(Print Shop)
(58914)
_____ Vet Requisition
(032008)
_____ Supply Order Form (max 25)
(032009)
_____ Call Report Form Pad
(032016)
_____ Advance Beneficiary Notice(ABN)
(Max 25)
(032022)
_____ Telephone/Fax Lab Order Form (032021)
PHLEBOTOMY DRAW SITE CARD
_____ ACC Cards (50 cards)
(032025)
_____ Fanny Allen Cards (50 Cards)
(56472)
_____Acc Card Holder
(58853)
_____ Fanny Allen Card Holder
(58854)
PRINTER/FAX LAB REPORT
_____ Paper (max 2 reams)
(032012)
_____Cartridge: Devise Model#______________
Brother Fax 2128
(58856)
Kit 6000
(032018)
Kit 6100
(032019)
Kit 8100
(032020)
_____Drum Kit Brother Fax 2128,
Every 5th cartridge
(58855)
_____ Addressograph Cartridge Large (034445)
_____ Addressograph Cartridge Small (034446)
_____ Labels, Addressograph
(032024)
_____ Labels, Lab printer
(034311)
_____ Labels, STAT/Red Hot
(034573)
FLOW CYTOMETRY/ TISSUE
TYPING
®_____ Special Heparin
(032051)
®_____ RPMI (For Lymph Nodes)
(042119)
MISCELLANEOUS SUPPLIES
_____ ACD Tube, Sol A
(58757)
®_____ Catecholamine Tube
(032053)
_____ Centrifuge Rubber
Cushions (58857)
Slide Holders
_____ Plastic
_____ Cardboard
(58913)
(032052)
Glucose Tolerance Beverage
_____ Flavored 75 gr
(032055)
_____ Flavored 100 gr
(032056)
_____ Orange 75 gr
(032057)
_____ Orange 100 gr
(032058)
LAB SUPPORT USE
□ Priority-Scheduled
□ Priority-on call
□ GMM- Scheduled
□ GMM-on call
□ U.S. Mail
□ ACC □ FAH □ UHC
Date
Tech Code
Order
Received: ________________
Order
Filled:____________________
#015720B (Rev. 4/24/09) Client
LEAD DEMOGRAPHIC FORM
Please submit this form when ordering Lead Testing.
This form must accompany a laboratory test
requisition.
PLEASE PRINT CLEARLY
Patient
Full Name:
Street /PO Box
City
State
Guardian
Zip Code
Full Name:
Home Phone:
Sample
Venous
Capillary
Check one
Date of Collection
Race:
White (Non-Hispanic)
Black (Non-Hispanic)
Hispanic
Asian/Pacific Islander
American Indian/Alaskan Native
Other
Unknown
Check one
Insurance:
Ordering
Provider:
Submit to:
Private Insurer
Medicaid
No insurance
Unknown
Full Name:
Practice Name:
Street /PO Box
City
Zip Code
Pathology & Laboratory Medicine EP1-100
Burlington VT 05401
Phone: 847-5121 or 1-800-991-2799 Fax 1-802-847-6079
Form #036447P (Revised 09/01/2006)
…Office MCHV/Requisitions/Lead Demographic Form

TABLE OF CONTENTS Section Subject Page #

Transcription

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