Patient Name/Date of Birth/Patient ID Number/Patient Location

Roper Hospital 316 Calhoun Street, Charleston, S.C. 29401

Laboratory Test Order Routing Form I Chemistry, Hematology, Coagulation, Immunohematology, Therapeutic Drug Testing, and Toxicology (See Laboratory Test Routing Form II for Laboratory Tests Not Listed Below) ADD-ON (Specimen Already in Lab) DOWNTIME

MUST MARK TEST BOX AND PROVIDE DIAGNOSIS

INSTRUCTIONS: Order only tests that are Medically Necessary for the diagnosis and/or treatment of the patient. *Capitalized tests in BOLD are limited coverage tests, and an ICD-9/diagnosis code must be provided for each limited coverage test. Required Collection Information: Required Order Information: DIAGNOSIS/ 1. ______4. ______Date Collected: Ordering Physician: ICD-9 CODES: Time Collected: Written by: Place corresponding 2. ______5. ______Phleb ID or Employee #: number beside test Routine Stat ordered below. 3. ______6. ______

CPT DX CPT DX CPT DX TEST CODE # TEST CODE # TEST CODE # CHEMISTRY PANELS CHEMISTRY TESTS, continued HEMATOLOGY/COAGULATION

Basic Metabolic Panel (CO2, Cl, 80048 __ *GAMMA GT (GGT) 82977* __ *CBCDIFF ( w/ AUTO DIFF) 85025* __ Creat, Glu, K, Na, BUN, Ca) * 82947* __ *CBC (w/o AUTO DIFF) 85027* __ Comp. Metabolic Panel (Alb, 80053 __ *GLUCOSE – 2 HR PP 82947* __ *HEMOGLOBIN 85018* __

T. Bili, Ca, Cl, Creat, Glu, CO2, Glucose – 1 Hr PG 82950 __ *HEMATOCRIT 85014* __ Alk Phos, K, T. Protein, Na, GLUCOSE TOLERANCE – 2 HR 82947 82950 __ *EOSINOPHIL COUNT 85048* __ SGOT, BUN, SGPT) Glucose Tolerance – 3 Hr 82951 82952 __ *PLATELET COUNT 85049* __

Electrolyte Panel (CO2, Cl, K, Na) 80051 __ *GLYCO. HGB. (A1C) 83036* __ Reticulocyte Count 85045 __ Hemoglobin Electrophoresis 83020 __ Sed Rate (ESR) 85651 or 85652 __ Hepatic Function Panel 80076 __ *HOMOCYSTEINE 83090* __ *WBC COUNT 85048* __ (Alb, T. Bili, D. Bili, Alk Phos, *IRON 83540* __ Sickle Cell Screen 85660 __ SGPT, SGOT, T. Protein) *PLUS IBC 83550* __ D-Dimer 85379 __ *LIPID PANEL 80061* __ Ketone, Serum 82009 __ *PT (Prothrombin Time) 85610* __ (T. Chol., HDL Chol, Trigly.) Lactic acid (Lactate) 83605 __ *PTT (Partial Thombo. Time) 85730* __

Renal Panel (Alb, Ca, CO2, Cl, 80069 __ (LDH) 83615 __ Creat, Glu, Phos, K, Na, BUN) Luteinizing Hormone (LH) 83002 __ CHEMISTRY TESTS Lipase 83690 __ Cardiac Markers __ Magnesium 83735 __ IMMUNOHEMATOLOGY (CPK), Total 82550 __ Phosphorus 84100 __ ‡ MUST USE BLOOD BANK ID BAND Creatine Kinase, MB Fraction 82553 __ Potassium 84132 __ ABO 86900 __ Troponin I 84484 __ Prealbumin 84134 __ Rh Type 86901 __ Albumin 82040 __ Prolactin 84146 __ Antibody Screen 86850 __ 84075 __ Protein, Total 84155 __ ‡ Type & Screen 3 CPT __ Ammonia 82140 __ Protein Electrophoresis 84165 __ (ABO, Rh Type, Antibody Screen) Codes Amylase 82150 __ *PROSTATE SPECIFIC AG (PSA) 84153* __ ‡ Type and X-match, #Units __ 86920 __ *B-TYPE NATRIURETIC PEPTIDE (BNP) 83880* __ *PSA (REFLEXIVE) 84153* __ Note: , Direct 82248 __ Free PSA, if indicated 84154 __ FFP, # Units ______Bilirubin, Total 82247 __ PSA Screen, Annual G0103 __ Platelet Pheresis, #Units______*CA-125 86304* __ Sodium 84295 __ THER. DRUGS & TOXICOLOGY *CA 27.29 86300* __ SGOT (AST) 84450 __ Alcohol (Medical Purposes Only) 82055 __ *CA 19-9 86301* __ SGPT (ALT) 84460 __ Urine Drug Screen w/o Tricyclics (Medical) G0431 __ Calcium 82310 __ *TRIGLYCERIDES 84478* __ Tricyclics Screen, Urine (Medical) G0434 __ *CALCIUM, IONIZED 82330* __ *TSH REFLEX 84443* __ Date/Time of last dose:

Chloride 82435 __ *T4 FREE, if indicated, or 84439* ______

*CHOLESTEROL, TOTAL 82465* __ T3 Total, if indicated 84480 __ Acetaminophen 82003 __ *CHOLESTEROL, HDL 83718* __ *TSH 84443* __ Carbamazepine 80156 __

CO2 82374 __ *T4 FREE 84439* __ *DIGOXIN 80162* __

Creatine Kinase (CPK), Total 82550 __ T3 Total 84480 __ Lithium 80178 __ 82565 __ *T-UPTAKE 84479* __ Phenobarbital 80184 __

Creatinine Clearance 82575 __ T3 Free 84481 __ Phenytoin (Dilantin) 80185 __

C-Reactive Protein (CRP) 86140 __ *T4 TOTAL 84436* __ Theophylline 80198 __ *CRP, HIGH SENSITIVITY (hsCRP) 86141* __ Urea Nitrogen (BUN) 84520 __ Salicylates 80196 __ Folate (Folic Acid) 82746 __ Uric Acid 84550 __ Valproic Acid (Depakene) 80164 __

*FRUCTOSAMINE (Gly. Protein) 82985* __ Vitamin B12 82607 __ Vancomycin 80202 __ Follicle Stim. Hormone (FSH) 83001 __

* = Limited Coverage Test

RH-DT-1&2-060113.R7 *1562*

Patient Name/Date of Birth/Patient ID Number/Patient Location

Roper Hospital 316 Calhoun Street, Charleston, S.C. 29401

Laboratory Test Order Routing Form II Immunology, Microbiology, Urine Analysis, Body Fluid Analysis, Stool Analysis, Miscellaneous, and Additional Tests (See Laboratory Test Routing Form I for Laboratory Tests Not Listed Below) ADD-ON (Specimen Already in Lab) DOWNTIME MISCELLANEOUS TEST ORDER(S)

MUST MARK TEST BOX AND PROVIDE DIAGNOSIS

INSTRUCTIONS: Order only tests that are Medically Necessary for the diagnosis and/or treatment of the patient. *Capitalized tests in BOLD are limited coverage tests, and an ICD-9/diagnosis code must be provided for each limited coverage test. Required Collection Information: Required Order Information: DIAGNOSIS/ 1. ______4. ______Date Collected: Ordering Physician: ICD-9 CODES: Time Collected: Written by: Place corresponding 2. ______5. ______Phleb ID or Employee #: number beside test Routine Stat ordered below. 3. ______6. ______

CPT DX CPT DX CPT DX TEST CODE # TEST CODE # TEST CODE # IMMUNOLOGY MICROBIOLOGY BODY FLUID ANALYSIS *ALPHA-FETOPROTEIN (AFP) 82105* __ SOURCE REQUIRED: For : *AFP TUMOR MARKER 82105* ______CSF Cell Count (Tube #:____) 89051 __ ANA Fluorescent 86038 __ Collection date:______CSF Glucose (Tube #:____) 82945 __ ANA Latex 86038 __ Gram Stain Only 87205 __ CSF Protein (Tube #:____) 84157 __ Anti - DNA 86225 __ KOH Prep 87220 __ ASO (Streptozyme) 86063 __ Wet Prep 87210 __ For Other Body Fluid Specimens: *BHCG TUMOR MARKER 84702* __ Culture, Aerobic & Stain 87070 87205 __ Specify Type:______*CARCINOEMBRYONIC AG (CEA) 82378* __ Culture, Aerobic, Anaerobic, & Stain 87205 __ (CPT Codes may differ for Urine) *FERRITIN 82728* __ 87070 87075 __ Cell Count, Body Fluid 89051 Hepatitis B Surface Ag (HBsAg) 87340 __ Culture, AFB & Stain 87116 87206 __ Crystal Identification, Body Fluid 89060 __ Hepatitis B Surface Ab (HBsAb) 86706 __ Culture, Beta-Strep 87081 __ Albumin, Body Fluid 82042 __ Hepatitis A Ab (HAAb), Total 86708 __ Culture, Blood X _____ 87040 __ Amylase, Body Fluid 82150 __ Hepatitis A Ab (HAAb), IgM 86709 __ Site ______Emp # ______Calcium, Body Fluid 82310 __ Hepatitis C Ab 86803 __ Culture, Fungus Dermatophyte 87101 __ Chloride, Body Fluid 82438 __ Hepatitis B Core Ab (HBcAb), Total 86704 __ Culture, Fungus Non-blood & Smear 87102 __ Creatinine, Body Fluid 82570 __ Hepatitis B Core Ab (HBcAb), IgM 86705 __ 87210 Glucose, Body Fluid 82945 __ *HIV AG/AB COMBO 87389* __ Culture, Herpes 87252, 87254 87015 __ Protein, Body Fluid 84157 __ IgA 82784 __ MRSA Screen/Site______87081 __ Uric Acid, Body Fluid 84560 __ IgG 82784 __ VRE Screen/Site______87081 __ IgM 82784 __ Bordetella, DNA PCR 87798x2 __ IgE 82785 __ Chlamydia Amplified Probe 87491 __ Infectious Mononucleosis Test 86308 __ GC Amplified Probe 87591 __ Preg. Test - Urine Qualitative 81025 __ Influenzae A Antigen, Rapid 87804 __ MISCELLANEOUS Preg. Test - Serum Qualitative 84703 __ Influenzae B Antigen, Rapid 87804 __ *HIV RNA QUANT. PCR 87536* __ *PREG TEST-SERUM HCG, QUANT 84702* __ Rapid Resp Syncytial (RSV) 87420 __ CD4 Absolute T-Cells 86361 __ Rheumatoid Factor (RA), Quantitative 86431 __ Rapid Strep A Screen (Throat) 87430 __ CD4/CD8 86360 __ RPR, Qualitative 86592 __ Culture, Chlamydia 87110 87140 __ Therapeutic Phlebotomy 99195 __ RPR Titer 86593 __ T-Mycoplasma/Ureaplasma, PCR 87801 __ FTA 86781 __ Culture, Viral R/O______87252 __ STOOL ANALYSIS Rubella Antibody 86762 __ Collection Date:______*TRANSFERRIN 84466* __ Stool, Culture (SSC) 87045 87046 __ Aer/Ples Vibrio Yersinia 87046 ea __ Stool, Shiga Toxin 87899x2 __ Stool, C. difficile PCR 87493 __ Stool, Helicobacter Stool Ag 87338 __ ADDITIONAL TESTS URINE ANALYSIS Stool, Rotavirus Ag Detection 87425 __ __ *CULTURE, URINE-Must Specify 87086* __ *STOOL, OCCULT BLOOD 82272* __ __ Urine Culture Source: Stool, Giardia EIA 87329 __ __ Clean Catch Cath Indwelling Cath Stool, Cryptosporidium EIA 87328 __ __ Emp # ______Stool, O & P Conc/ID 87177 87209 __ __ Urinalysis 81003 __ Stool, Cyclospora Stain 87206 87015 __ __ Must Specify Urinalysis Source: Stool , Fat Stain 82705 __ __ Rt. Void Clean Catch Cath Stool, Lactoferrin (WBC) 83630 __ Stool, WBC Smear (breast-fed infants only) 89055 __

* = Limited Coverage Test

RH-DT-1&2-060113.R7 *1562*