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L a B U S E Formalin-Fixed Tissue Cannot Be Processed for Immunofluorescence

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L a B U S E Formalin-Fixed Tissue Cannot Be Processed for Immunofluorescence SPOKANE (509) 892-2700/(888) 814-6277 LAB NUMBER FAX (509) 892-2740 BELLEVUE (425) 646-0922/(877) 288-0922 FAX (425) 646-0925 RICHLAND (509) 392-5920/(833) 369-7268 FAX (509) 866-5020 CHART #/MRN DATE OF COLLECTION SEX M F PATIENT’S NAME (Last Name, First Name, Middle Initial) ADDRESS CITY STATE ZIP PHONE PATIENT SOCIAL SECURITY # PATIENT BIRTHDATE Steps Site(s) _____________ Pathologist Interpretation Slide Prep Only Consultation COPY TO: Please write N/A if SSN is unavailable First Name Last Name Location/Phone INSURED’S NAME (Attach Copy of Insurance Card) RELATIONSHIP TO PATIENT: INSURANCE PLAN NAME OR PROGRAM NAME Self Spouse Bill Office/ Clinic VA Choice Child Other No Insurance Group Health Asuris Molina Aetna POLICY # GROUP # / EMPLOYER Medicare Regence of WA Premera CHPW Tricare United Healthcare Regence of ID First Choice (Group # Req.) _____________________ Cigna (Group # Req.) Blue Cross Medicaid (State) ___________________________ Other ________________________________________________ ICD-10 CODE(S) REQUIRED PLEASE INDICATE DIAGNOSIS CODE(S) PREAUTHORIZATION NUMBER PREVIOUS TISSUE SENT TO OTHER LAB? DATE RECEIVED RELATING TO THE CURRENT PROCEDURE L No Yes (Please attach copy of report) A SPECIMEN SITE BIOPSY TYPE Clinical History/DX (size, color, shape, distribution, duration, history of change, etc.) B BILLING CODES Punch Shave A Excision U Other S Punch Shave E PREP B Excision Other Punch Shave C Excision Other Punch Shave D Excision Other Punch Shave E Excision Other Punch Shave F Excision Other Punch Shave G Excision Other Punch Shave H Excision Other Formalin-fixed tissue cannot be processed for immunofluorescence AFFIX LABEL(S) TO SPECIMEN CONTAINER(S) WITH FULL PATIENT NAME AND SPECIMEN SITE Dermatology Rev 4/2019 ID000086 FREQUENTLY USED DIAGNOSIS CODES DERMATOLOGY DISEASES DUE TO VIRUSES ROSACEA UPPER LIMB, INCLUDING SHOULDER NEOPLASM, SECONDARY MALIGNANCY VIRAL WARTS PERIORAL DERMATITIS L71.0 RIGHT D04.61 LIP D04.0 ANOGENITAL [VENEREAL] A63.0 RHINOPHYMA L71.1 LEFT D04.62 EYELID, INCLUDING CANTHUS PLANTAR WART B07.0 OTHER L71.8 LOWER LIMB, INCLUDING HIP RIGHT EYELID D04.11 OTHER B07.8 UNSPECIFIED L71.9 RIGHT D04.71 LEFT EYELID D04.12 UNSPECIFIED B07.9 SEBORRHEA CAPITIS L21.0 LEFT D04.72 EAR AND EXTERNAL AUDITORY CANAL SEBORRHEIC INFANTILE DERMATITIS L21.1 RIGHT D04.21 INFECTIONS OF SKIN AND SUBCUTANEOUS SEBORRHIC DERMATITIS, OTHER L21.8 NEOPLASM, PRIMARY MALIGNANCY LEFT D04.22 TISSUE SEBORRHEIC DERMATITIS, UNSPECIFIED L21.9 LIP FACE ABSCESS XEROSIS CUTIS L85.3 BASAL CELL CARCINOMA C44.01 OTHER PARTS OF FACE D04.30 FACE L02.01 SQUAMOUS CELL CARCINOMA C44.02 UNSPECIFIED PART D04.39 NECK L02.11 OTHER DISEASES OF SKIN AND OTHER SPEC MALIGNANT NEOPLASM C44.09 SCALP AND NECK D04.4 TRUNK SUBCUTANEOUS TISSUE UNSPEC MALIGNANT NEOPLASM C44.00 TRUNK D04.5 ABDOMINAL WALL L02.211 ACTINIC KERATOSIS L57.0 EYELID, INCLUDING CANTHUS UPPER LIMB, INCLUDING SHOULDER BACK , EXCEPT BUTTOCK L02.212 DYSCHROMIA BASAL CELL CARCINOMA RIGHT UPPER LIMB D04.61 BUTTOCK L02.31 DISORDER OF PIGMENTATION, UNSPEC L81.9 RIGHT EYELID C44.112 LEFT UPPER LIMB D04.62 CHEST WALL L02.213 POSTINFLAMMATORY HYPERPIGMENT L81.0 LEFT EYELID C44.119 LOWER LIMB, INCLUDING HIP GROIN L02.214 CHLOASMA L81.1 SQUAMOUS CELL CARCINOMA RIGHT D04.71 PERINEUM L02.215 FRECKLES L81.2 RIGHT EYELID C44.122 LEFT D04.72 UMBILICUS L02.216 CAFE AU LAIT SPOTS L81.3 LEFT EYELID C44.129 UNSPECIFIED LOWER LIMB C44.711 UPPER ARM AND FOREARM OTHER MELANIN HYPERPIGMENTATION L81.4 OTHER SPEC MALIGNANT NEOPLASM SQUAMOUS CELL CARCINOMA AXILLA LEUKODERMA, NEC L81.5 RIGHT EYELID C44.192 RIGHT LOWER LIMB C44.722 RIGHT L02.411 OTHER DISORDERS OF DIMINISHED LEFT EYELID C44.199 LEFT LOWER LIMB C44.729 LEFT L02.412 MELANIN FORMATION L81.6 UNSPECIFIED MALIGNANT NEOPLASM OTHER SPEC MALIGN NEOPLASM UPPER LIMB PIGMENTED PURPURIC DERMATOSIS L81.7 RIGHT EYELID C44.102 RIGHT LOWER LIMB C44.792 RIGHT L02.413 OTHER SPECIFIED DISORDERS OF LEFT EYELID C44.109 LEFT LOWER LIMB C44.799 LEFT L02.414 PIGMENTATION L81.8 EAR AND EXTERNAL AUDITORY CANAL UNSPECIFIED MALIGNANT NEOPLASM HAND, EXCEPT FINGERS LIPOMA BASAL CELL CARCINOMA RIGHT LOWER LIMB C44.702 RIGHT L02.511 SKIN RIGHT C44.212 LEFT LOWER LIMB C44.709 LEFT L02.512 FACE, HEAD, NECK D17.0 LEFT C44.219 LOWER LIMB, EXCEPT FOOT TRUNK D17.1 SQUAMOUS CELL CARCINOMA MELANOMA, PRIMARY MALIGNANCY RIGHT L02.415 LIMB RIGHT C44.222 LIP C43.0 LEFT L02.416 ARM, RIGHT D17.21 LEFT C44.229 EYELID, INCLUDING CANTHUS FOOT, EXCEPT TOES ARM, LEFT D17.22 OTHER SPEC MALIGNANT NEOPLASM RIGHT C43.11 RIGHT L02.611 LEG, RIGHT D17.23 RIGHT C44.292 LEFT C43.12 LEFT L02.612 LEG, LEFT D17.24 LEFT C44.299 EAR AND AUDITORY CANAL PILONDIAL CYST UNSPECIFIED LIMB D17.20 UNSPEC MALIGNANT NEOPLASM RIGHT C43.21 WITH ABSCESS L05.01 OTHER SITES D17.39 RIGHT C44.202 LEFT C43.22 W/O ABSCESS L05.91 UNSPECIFIED SITE D17.30 LEFT C44.209 FACE PILONDIAL SINUS GENITOURINARY ORGAN D17.72 FACE OTHER PARTS C43.39 WITH ABSCESS L05.02 SEBACEOUS CYST L72.3 BASAL CELL CARCINOMNA UNSPECIFIED PART C43.30 W/O ABSCESS L05.92 SEBORRHEIC KERATOSIS NOSE C44.311 SCALP AND NECK C43.4 PYOGENIC GRANULOMA L88 INFLAMED L82.0 OTHER PARTS OF FACE C44.319 TRUNK, EXCEPT SCROTUM UNSPECIFIED INFECTION L08.9 OTHER L82.1 SQUAMOUS CELL CARCINOMA ANAL C43.51 NOSE C44.321 BREAST C43.52 OTHER INFLAMMATORY CONDITIONS OF SKIN NEOPLASM, BENIGN OTHER PARTS C44.320 OTHER PART C43.59 ATOPIC DERMATITIS AND RELATED CONDITIONS LIP OTHER SPEC MALIGNANT NEOPLASM UPPER LIMB, INCLUDING SHOULDER BESNIER’S PRURIGO L20.0 MELANOCYTIC D22.0 NOSE C44.391 RIGHT C43.61 ATOPIC NEURODERMATITIS L20.81 OTHER BENIGN NEOPLASM D23.0 OTHER PARTS C44.399 LEFT C43.62 FLEXURAL ECZEMA L20.82 EYELID, INCLUDING CANTHUS UNSPEC MALIGNANT NEOPLASM LOWER LIMB, INCLUDING HIP INFANTILE ECZEMA L20.83 RIGHT NOSE C44.301 RIGHT C43.71 INTRINSIC (ALLERGIC) ECZEMA L20.84 MELANOCYTIC D22.11 OTHER PARTS C44.309 LEFT C43.72 OTHER ATOPIC DERMATITIS L20.89 OTHER BENIGN NEOPLASM D23.11 SCALP AND NECK UNSPECIFIED L20.9 LEFT BASAL CELL CARCINOMA C44.41 MELANOMA IN SITU CONTACT DERMATITIS MELANOCYTIC D22.12 SQUAMOUS CELL CARCINOMA C44.42 LIP D03.0 UNSPECIFIED NATURE L25.9 OTHER BENIGN NEOPLASM D23.12 OTHER SPEC MALIGNANT NEOPLASM C44.49 EYELID, INCLUDING CANTHUS DUE TO COSMETICS L25.0 EAR AND AUDITORY CANAL UNSPEC MALIGNANT NEOPLASM C44.40 RIGHT D03.11 DUE TO DRUGS IN CONTACT W/ SKIN L25.1 RIGHT TRUNK EXCEPT SCROTUM LEFT D03.12 DUE TO DYES L25.2 MELANOCYTIC D22.21 ANAL EAR AND AUDITORY CANAL DUE TO OTHER CHEMICAL PRODUCTS L25.3 OTHER BENIGN NEOPLASM D23.21 BASAL CELL CARCINOMA C44.510 RIGHT D03.21 DUE TO FOOD IN CONTACT W/ SKIN L25.4 LEFT SQUAMOUS CELL CARCINOMA C44.520 LEFT D03.22 DUE TO PLANTS, EXCEPT FOOD L25.5 MELANOCYTIC D22.22 OTHER SPEC MALIGN NEOPLASM C44.590 FACE DUE TO OTHER AGENTS L25.8 OTHER BENIGN NEOPLASM D23.22 UNSPEC MALIGNANT NEOPLASM C44.500 OTHER PARTS D03.39 DERMATITIS,OTHER FACE, OTHER PARTS BREAST UNSPECIFIED PART D03.30 DUE TO SOLAR RADIATION POLYMORPHOUS OTHER PARTS BASAL CELL CARCINOMA C44.511 SCALP AND NECK D03.4 LIGHT ERUPTION L56.4 MELANOCYTIC D22.39 SQUAMOUS CELL CARCINOMA C44.521 TRUNK, EXCEPT SCROTUM OTHER SPECIFIED ACUTE SKIN CHANGES OTHER BENIGN NEOPLASM D23.39 OTHER SPEC MALIGN NEOPLASM C44.591 ANAL D03.51 DUE TO ULTRAVIOLET RADIATION L56.8 SCALP AND NECK UNSPEC MALIGNANT NEOPLASM C44.501 BREAST D03.52 OTHER CHGS DUE TO CHRONIC EXPOSURE MELANOCYTIC D22.4 OTHER PART OF TRUNK OTHER PART D03.59 TO NON IONIZING RADIATION L57.8 OTHER BENIGN NEOPLASM D23.4 BASAL CELL CARCINOMA C44.519 UPPER LIMB, INCLUDING SHOULDER DERMATITIS, UNSPECIFIED L30.9 TRUNK, EXCEPT SCROTUM SQUAMOUS CELL CARCINOMA C44.529 RIGHT D03.61 FOLLICULITIS MELANOCYTIC D22.5 OTHER SPEC MALIGN NEOPLASM C44.599 LEFT D03.62 BOCKHART’S IMPETIGO L01.02 OTHER BENIGN NEOPLASM D23.5 UNSPEC MALIGNANT NEOPLASM C44.509 LOWER LIMB, INCLUDING HIP PERIFOLLICULITIS CAPITIS ABSCEDENS L66.3 UPPER LIMB, INCLUDING SHOULDER UPPER LIMB, INCLUDING SHOULDER RIGHT D03.71 OTHER SPEC FOLLICULAR DISORDERS L73.8 RIGHT BASAL CELL CARCINOMA LEFT D03.72 LICHEN MELANOCYTIC D22.61 RIGHT UPPER LIMB C44.612 PLANOPILARIS L66.1 OTHER BENIGN NEOPLASM D23.61 LEFT UPPER LIMB C44.619 NEOPLASM, UNCERTAIN BEHAVIOR HYPERTROPHIC LICHEN PLANUS L43.0 LEFT SQUAMOUS CELL CARCINOMA SKIN D48.5 BULLOUS LICHEN PLANUS L43.1 MELANOCYTIC D22.62 RIGHT UPPER LIMB C44.622 LICHENOID DRUG REACTION L43.2 OTHER BENIGN NEOPLASM D23.62 LEFT UPPER LIMB C44.629 NEOPLASM OF UNSPECIFIED NATURE SUBACUTE (ACTIVE) LICHEN PLANUS L43.3 LOWER LIMB, INCLUDING HIP OTHER SPEC MALIGNANT NEOPLASM SKIN, SOFT TISSUE, BONE D49.2 OTHER LICHEN PLANUS L43.8 RIGHT RIGHT UPPER LIMB C44.692 LICHEN PLANUS, UNSPECIFIED L43.9 MELANOCYTIC D22.71 LEFT UPPER LIMB C44.699 PERSONAL HISTORY OF OTHER MALIGNANT LICHEN SIMPLEX CHRONICUS L28.0 OTHER BENIGN NEOPLASM D23.71 UNSPEC MALIGNANT NEOPLASM NEOPLASM PRURIGO NODULARIS L28.1 LEFT RIGHT UPPER LIMB C44.602 MALIGNANT MELANOMA Z85.820 PSORIASIS MELANOCYTIC D22.762 LEFT UPPER LIMB C44.609 MERKEL CELL CARCINOMA Z85.821 OTHER L40.8 OTHER BENIGN NEOPLASM D23.72 LOWER LIMB, INCLUDING HIP OTHER MALIGNANT NEOPLASM Z85.828 VULGARIS L40.0 BASAL CELL CARCINOMA GENERALIZED PUSTULAR L40.1 CARCINOMA IN SITU RIGHT LOWER LIMB C44.712 ACRODERMATITIS CONTINUA L40.2 LIP D04.0 LEFT LOWER LIMB C44.719 PUSTULOSIS PALMARIS ET PLANTARIS L40.3 EYELID, INCLUDING CANTHUS SQUAMOUS CELL CARCINOMA GUTTATE L40.4 RIGHT D04.11 RIGHT LOWER LIMB C44.722 ARTHROPATHIC, UNSPECIFIED L40.50 LEFT D04.12 LEFT LOWER LIMB C44.729 DISTAL INTERPHALANGEAL PSORIATIC EAR AND AUDITORY CANAL OTHER SPEC MALIGN NEOPLASM ARTHROPATHY L40.51 RIGHT D04.21 RIGHT LOWER LIMB C44.792 PSORIATIC ARTHRITIS MUTILANS L40.52 LEFT D04.22 LEFT LOWER LIMB C44.799 PSORIATIC SPONDYLITIS L40.53 FACE UNSPECIFIED MALIGNANT NEOPLASM PSORIATIC JUVENILE ARTHROPATHY L40.54 OTHER PARTS D04.30 RIGHT LOWER LIMB C44.702 OTHER PSORIATIC ARTHROPATHY L40.59 UNSPECIFIED PART D04.39 LEFT LOWER LIMB C44.709 SCALP AND NECK D04.4 TRUNK, EXCEPT SCROTUM C04.5 Frequently used diagnosis codes for Dermatology.
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