Patient Name/Patient ID Number/Patient Location
Roper Emergency Services Northwoods 2233 Northwoods Boulevard, Charleston, SC 29406
Laboratory Test Order Form I
Chemistry, Hematology, Coagulation, Urinalysis, Immunohematology,
Therapeutic Drug Testing, and Toxicology
(See Laboratory Test Order 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. DIAGNOSIS/ 1.______4.______Required Order Information: Required Collection Information: ICD-9 CODES: Ordering Physician:______Date Collected:______Place corresponding 2.______5.______Written by:______Time Collected:______number beside test Nurse/Phleb ID:______ordered below. 3.______6.______Routine Stat
CPT DX CPT DX CPT DX TEST CODE # TEST CODE # TEST CODE # CHEMISTRY PANELS CHEMISTRY TESTS, continued HEMATOLOGY/COAG/URINALYSIS
Basic Metabolic Panel (CO2, Cl, 80048 __ *FRUCTOSAMINE (Gly. Protein) 82985* __ *CBCDIFF (W/ AUTO DIFF) 85025* __ Creat, Glu, K, Na, BUN, Ca) Follicle Stim. Hormone (FSH) 83001 __ *CBC (W/O AUTO DIFF) 85027* __ Comp. Metabolic Panel (Alb, 80053 __ *GAMMA GT (GGT) 82977* __ *HEMOGLOBIN 85018* __
T. Bili, Ca, Cl, Creat, Glu, CO2, *GLUCOSE 82947* __ *HEMATOCRIT 85014* __ Alk Phos, K, T. Protein, Na, *GLUCOSE – 2 HR PP 82947* __ *EOSINOPHIL COUNT 85048* __ SGOT, BUN, SGPT) Glucose – 1 Hr PG 82950 __ *PLATELET COUNT 85049* __ ELECTROLYTE PANEL 80051* __ Glucose – 2 Hr PG 82950 __ Reticulocyte Count 85045 __ (CO2, Cl, K, Na) Glucose Tolerance – 3 Hr 82951 __ *SED RATE (ESR) 85651* __
*HEPATIC FUNCTION PANEL 80076* __ *GLYCO. HGB. (A1C) 83036* __ *WBC COUNT 85048* __ (Alb, T. Bili, D. Bili, Alk Phos, Hemoglobin Electrophoresis 83020 __ Sickle Cell Screen 85660 __ SGPT, SGOT, T. Protein) Homocysteine 83090 __ D-Dimer 85380 __ *LIPID PANEL 80061* __ *IRON 83540* __ *PT (Prothrombin Time) 85610* __ (T. Chol., HDL Chol, Trigly.) *PLUS IBC 83550* __ *PTT (Partial Thombo. Time) 85730* __
*RENAL PANEL (Alb, Ca, CO2, Cl 80069* __ Ketone, Serum 82010 __ *URINALYSIS 81003* __ (Creat, Glu, Phos, K, Na, BUN) Lactate Dehydrogenase (LDH) 83615 __ Specify Specimen Type: CHEMISTRY TESTS Luteinizing Hormone (LH) 83002 __ Rt. Void Clean Catch Cath Cardiac Markers __ Lipase 83690 __ IMMUNOHEMATOLOGY Creatine Kinase (CPK) 82550 __ *MAGNESIUM 83735* __ ‡ MUST USE BLOOD BANK ID BAND Creatine Kinase, MB Fraction 82553 __ *PHOSPHORUS 84100* __ ABO 86900 __ *TROPONIN I 84484* __ *POTASSIUM 84132* __ Rh Type 86901 __ Albumin 82040 __ Prealbumin 84134 __ Antibody Screen 86850 __ Alkaline Phosphatase 84075 __ Prolactin 84146 __ ‡ Type & Screen 3 CPT __ Ammonia 82140 __ *PROTEIN, TOTAL 84155* __ (ABO, Rh, Type, Antibody Screen) Codes Amylase 82150 __ *PROTEIN ELECTROPHORESIS 84165* __ ‡ Type and X-match #Units __ 86920 __ B-type Natriuretic Peptide (BNP) 83880 __ Prostatic Acid Phosphatase 84066 __ ___ Autologous ___ Directed Bilirubin, Direct 82248 __ *PROSTATE SPECIFIC AG (PSA) 84153* __ FFP, # Units ______Bilirubin, Total 82247 __ *PSA (REFLEXIVE) 84153* __ Platelet Pheresis, #Units______Bilirubin, Neonatal 82247 __ Free PSA, if indicated 84154 __ THER. DRUGS & TOXICOLOGY *CA-125 86304* __ PSA Screen, Annual G0103 __ Alcohol (Medical Purposes Only) 82055 __ *CA 27.29 86300* __ Sodium 84295 __ Urine Drug Screen (Medical 80100 __ *CA 19-9 86301* __ SGOT (AST) 84450 __ Purposes Only) Calcium 82310 __ SGPT (ALT) 84460 __ Date/Time of last dose: *CALCIUM, IONIZED 82330* __ *TRIGLYCERIDES 84478* ______Chloride 82435 __ *T-UPTAKE 84479* __ Acetaminophen 82003 __
*CHOLESTEROL, TOTAL 82465* __ T3 Total 84480 __ Carbamazepine 80156 __
*CHOLESTEROL, HDL 83718* __ T3 Free 84481 __ *DIGOXIN 80162* __
CO2 82374 __ *T4 FREE 84439* __ Lithium 80178 __
Creatine Kinase (CPK), Total 82550 __ *T4 TOTAL 84436* __ Phenobarbital 80184 __ Creatinine 82565 __ *THYROID STIM. HORMONE (TSH) 84443* __ Phenytoin (Dilantin) 80185 __ Creatinine Clearance 82575 __ Urea Nitrogen (BUN) 84520 __ Theophylline 80198 __ C-Reactive Protein (CRP) 86140 __ Uric Acid 84550 __ Salicylates 80196 __
hs C-Reactive Protein (hsCRP) 86141 __ Vitamin B12 82607 __ Valproic Acid (Depakene) 80164 __ Folate 82746 __ Vancomycin 80202 __
= Limited Coverage Test
Origin: 07/99 Revision: 03/04 08/04 06/05 09/05 07/06 03/07 *1564* NW-DT- 1&2
Patient Name/Patient ID Number/Patient Location
Roper Emergency Services Northwoods 2233 Northwoods Boulevard, Charleston, SC 29406
Laboratory Test Order Form II Serology, Parasitology, Microbiology, Body Fluid Analysis, Miscellaneous, and Additional Tests (See Laboratory Test Order 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. DIAGNOSIS/ 1.______4.______Required Order Information: Required Collection Information: ICD-9 CODES: Ordering Physician:______Date Collected:______Place corresponding 2.______5.______Written by:______Time Collected:______number beside test Nurse/Phleb ID:______ordered below. 3.______6.______Routine Stat
CPT DX CPT DX CPT DX TEST CODE # TEST CODE # TEST CODE # SEROLOGY MICROBIOLOGY BODY FLUID ANALYSIS *ALPHA-FETOPROTEIN (AFP) 82105* __ SOURCE REQUIRED: For Cerebrospinal Fluid: *AFP TUMOR MARKER 82105* ______CSF Cell Count (Tube #:____) 89051 __ ANA Fluorescent 86038 __ Gram Stain Only 87205 __ CSF Glucose (Tube #:____) 82945 __ ANA Latex 86038 __ India Ink Only (CSF Only) 87210 __ 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 __ Specify Type:______*CARCINOEMBRYONIC AG (CEA) 82378* __ Culture, AFB & Stain 87116 __ (CPT Codes may differ for Urine) *FERRITIN 82728* __ Culture, Anaerobic 87075 __ Crystals, Body Fluid 89060 __ Hep B Surface Ag (HBsAg) 87340 __ Culture, Beta-Strep 87081 __ Amylase, Body Fluid 82150 __ Hep B Surface Ab (HBsAb) 86706 __ Culture, Blood X _____ 87040 __ Calcium, Body Fluid 82310 __ Hep A Ab (HAAb), Total 86708 __ Site ______Emp # ______Chloride, Body Fluid 82438 __ Hep A Ab (HAAb), IgM 86709 __ Culture, Fungus & Smear 87102 __ Creatinine, Body Fluid 82570 __ Hep C Ab 86803 __ Culture, Herpes Simplex & FA 87253 __ Glucose, Body Fluid 82945 __ Hep B Core Ab (HBcAb), Total 86704 __ *CULTURE, URINE-Specify Source 87086* __ Protein, Body Fluid 84157 __ Hep B Core Ab (HBcAb), IgM 86705 __ Rt. Void Clean Catch Cath Sodium, Body Fluid 84302 __ *HIV AB 86703* __ DNA Probe, Chlamydia 87490 __ Uric Acid, Body Fluid 84560 __ IgA 82784 __ DNA Probe, GC 87590 __ IgG 82784 __ MRSA Screen/Site______87081 __ IgM 82784 __ VRE Screen/Site______87081 __ MISCELLANEOUS IgE 82785 __ Rapid Influenzae A & B 2 CPT 87400 __ *HIV RNA QUANT. PCR 87536* __ Infectious Mononucleosis Test 86308 __ Rapid Resp Syncytial (RSV) 87420 __ CD4 Absolute, T-Cells 86361 __ Preg. Test - Urine Qualitative 81025 __ Rapid Strep A Screen (Throat) 87430 __ Therapeutic Phlebotomy 99195 __ Preg. Test - Serum Qualitative 84703 __ Culture, Bordetella 87081 __ *PREG TEST-SERUM HCG-QUANT 84702* __ Bordetella Smear (DFA) 87265 __ BLOOD GAS PANEL *RHEUMATOID FACTOR (RA) 86431* __ Culture, Chlamydia 87110 __ Arterial Blood Gas (Comp.) 82803 __ *RPR 86592* __ Culture, T-Myco/Ureaplasma 87109 __ PATIENT DATA: *RPR TITER 86593* __ Culture, Viral R/O______87252 __ Temp: ______C F *FTA 86781* __ PARASITOLOGY & STOOL EXAM Puncture Site: ______Rubella 86762 __ *STOOL, OCCULT BLOOD 82270* ___ Allen’s Test Pos Neg *TRANSFERRIN 84466* __ Stool, O & P Screen Inspired O2: FIO2 ______Stool, Giardia EIA 87329 ___ Device: ______MICROBIOLOGY STOOL EXAM Stool, Cryptosporidium EIA 87328 ___ Liter Flow: ______Stool, O & P, Screen Date/Time Received in Lab Culture, Stool (SSC) 87045, 87046 __ Stool, Giardia EIA 87329 ___ Date: ______Time: ______EC 0157 Aer/Ples __ Stool, Cryptosporidium EIA 87328 ___ Tech: ______Vibrio Yersinia 87046 __ Stool, O & P Conc/ID 87209 ___ ADDITIONAL TESTS Stool – C. difficile Toxin A & B 87324 __ Stool – C. Diff Toxin A & B 87324 ______Stool – Helicobacter Stool Ag 87338 __ Stool – Cryptosporidia Stain 87206 ___ Stool – Rotavirus Ag Detection 87425 __ Stool – Cyclospora Stain 87206 ______Stool – Fat Stain 89125 ___ Stool – WBC 89055 ______
* = Limited Coverage Test
Origin: 07/99 Revision: 03/04 08/04 06/05 09/05 07/06 03/07 NW-DT- 1&2 *1564*