Last Reviewed By: Lobaugh, Bruce (Electronic Signature Timestamp: 6/3/2014 3:22:27 PM)

Clinical Laboratories Administrative Documents\Clinical

Reflex Testing (LTR54334)

POLICY NAME:

Reflex Testing

EFFECTIVE DATE:

February 1, 2004

DEFINITION:

Reflex Testing: Testing performed when an initial test result is outside of the normal range and indicates a second related test(s) is medically appropriate. Generally, the primary test result is enhanced by the follow-up reflex test(s), and the reflex test(s) always adds useful diagnostic, prognostic, and/or therapeutic information.

SCOPE:

This policy applies to all DUHS Clinical Laboratories and Pathology Laboratories This document applies to Duke University Health System (DUHS) and Private Diagnostic Clinic (PDC) employees, and the medical staff of Duke University Hospital (DUH), Durham Regional Hospital (DRH), and Duke Raleigh Hospital (DRAH) ordering, testing, charging and/or billing laboratory services.

PURPOSE: Provide a mechanism to ensure laboratory reflex testing is approved by the DUH, DRH, and DRAH Executive Committees of the Medical Staff (hereafter referred to as the ECMS) when required and is in accordance with Medicare, Medicaid, and other payor requirements. POLICY: Reflex testing, as defined by the “Reflex Testing Agreement” (Attachment), must be initially approved by the ECMS and reviewed by the ECMS on an annual basis. This policy addresses only reflex tests that require attending physician approval (Table 1), and does not apply to: 1) confirmatory or adjunctive tests that are universally accepted medical practices, e.g. susceptibilities in microbiology cultures and elucidation of specific antibodies in Transfusion Services; 2) tests that are mandatory under state law and performed automatically e.g. confirmation of a positive HIV and certain serological procedures; or 3) tests defined in Centers for Medicare/Medicaid Services regulations and/or memoranda, e.g. special stains used in Surgical Pathology/Cytopathology (Table 2). PROCESS: Laboratory Directors must:  identify all reflex tests  consult with the appropriate Advisory Committee or Clinical Consultants to determine specific criteria for reflex testing  present all reflex testing initially to the ECMS and on an annual basis thereafter to obtain approval by signature in the form of a “Reflex Testing Agreement”  maintain this documentation for seven (7) years  review and ensure applicable revisions are made to the LIS and billing processes  notify all staff responsible for ordering, testing, charging, or billing laboratory services on the contents of this policy. Disclaimer: Printed copies are not the official document. See on-line version.

Reflex Testing (LTR54334)

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TABLE 2 PROCEDURE: 1. 2.

3.

Laboratories will perform reflex testing only as defined in this policy. Laboratories will perform reflex tests when the following conditions are met: a. ECMS has signed the Reflex Test Agreement; b. The physician orders an “Initial Test” which may prompt reflex testing as defined by the Laboratory Directors; c. The “Initial Test” result meets the “Reflex Criteria” for prompting a reflex test which has been approved by the ECMS. Each laboratory will develop and document reflex testing criteria and reflex tests within laboratory procedures.

CROSS REFERENCE:

1. 2.

APPLICABLE STANDARDS:

1. 2. 3. 4.

Compliance Guidelines for Pathologists; Published by the College of American Pathologists, 1998. Clinical Laboratory Management Association: “Reflex Testing: Do It Right or Not At All”, Vantage Point, 5 (14): 1-2, August 27, 2001. OIG Model Compliance Plan for Clinical Laboratories, Federal Register, 94359441, March 1997. The Office of Inspector General’s (OIG) Compliance Program Guidance for Clinical Laboratories, August 1998. Centers for Medicare and Medicaid Services: National Correct Coding Initiative, Version 8, January 1, 2002. CMS, Medicare Carriers Manual Transmittal 1725: Part III Medicare Carriers Manual, Section 15021, September 27, 2001.

DEVELOPED BY:

Quality Improvement and Compliance Office

POLICY PRIMARY:

Director, DUHS Clinical Laboratories

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Reflex Testing (LTR54334)

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TABLE 2

Attachment Duke University Health System Clinical Laboratories and Duke University Hospital Department of Pathology Laboratories Reflex Testing Agreement Contact Person Bruce Lobaugh, Ph.D., Director, Clinical Pathology Laboratories Facility Duke University Health System Clinical Laboratories and Duke University Hospital Department of Pathology Laboratories Address Box 3631, Durham, North Carolina 27704 Phone 681-6335 Fax 681-7786 E-mail [email protected] 1.

2.

Purpose: The purpose of this Reflex Testing Agreement is to ensure the Duke University Hospital (DUH), Durham Regional Hospital (DRH), and Duke Raleigh Hospital (DRAH) Executive Committees of the Medical Staff (hereafter referred to as the ECMS) understand and communicate to providers via Departmental Chairs and Division Chiefs when reflex tests will be performed and how they will be billed to Medicare and Medicaid. Reflex Testing Policy: Reflex testing must be approved by the ECMS initially and on an annual basis thereafter. Duke University Health System (DUHS) Clinical Laboratories and DUH Department of Pathology Laboratories perform reflex testing automatically when all three of the following conditions are met: a. The ECMS has approved and signed this Agreement; b. The physician orders an initial test identified in the “Test Listing Index” (Table: 1), hereafter referred to as the “Index”; c. The Initial Test result meets the criteria listed in the “Index” for prompting a reflex test(s) (“Reflex Criteria”). This policy addresses only reflex tests that require attending physician approval (Table 1), and does not apply to: 1) confirmatory or adjunctive tests that are universally accepted medical practices e.g. susceptibilities in microbiology cultures and elucidation of specific antibodies in Transfusion Services; 2) secondary tests that are mandatory under state law and performed automatically, e.g. confirmation of a positive HIV and certain serological procedures; or 3) tests defined in Centers for Medicare/Medicaid Services regulations and/or memoranda, e.g. special stains used in Surgical Pathology/Cytopathology.

3. 4.

5.

6. 7.

Billing of Reflex Tests: DUHS Clinical Laboratories and DUH Department of Pathology Laboratories bill reflex tests they perform to Medicare and Medicaid. The CPT code used is listed in the “Index” which follows (Table 1). Acknowledgement and Approval: By signing this agreement, the ECMS acknowledges and agrees that whenever Initial Tests ordered meet the Reflex Criteria, the corresponding reflex test listed in the “Index” should be performed, reported, and billed. Option of Ordering Initial Tests Only: Even if the ECMS signs this Agreement, the option to order any Initial Test without the Reflex Test will be available provided the laboratory is notified. Please be advised the laboratory recognizes the Office of the Inspector General of the Department of Health and Human Services takes the position that medically unnecessary tests for which Medicare reimbursement is claimed may be subject to civil penalties. Execution of the Agreement: After the ECMS approves and signs this Agreement, a copy should be maintained for their records and the original should be returned to the contact person listed above. Annual Reapproval and Discontinuation: This Agreement will remain in effect for one year. Thereafter, the ECMS must reapprove the Agreement at least once a year for it to remain in effect. The ECMS may discontinue this Agreement for any reason, at any time upon written notice to the DUHS Clinical Laboratory contact person listed above.

Attachment: Page 1 of 2

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Reflex Testing (LTR54334)

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TABLE 2

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Reflex Testing (LTR54334)

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TABLE 2 Initial Execution: Signature of ECMS

Date

Annual reapprovals: Annual reapproval date

Initials

Annual reapproval date

Initials

Annual reapproval date

Initials

Annual reapproval date

Initials

Date Discontinued

Initials

Attachment: Page 2 of 2

Duke University Health System Clinical Laboratories and Duke University Hospital Department of Pathology Laboratories Reflex Testing Agreement Test Listing Index Laboratory Section: Morris Building Clinical Laboratory Initial Test

Reflex Criteria

Reflex Test(s)

CPT Code for Billing

Serum Protein Electrophoresis

Monoclonal peak present with no previous monoclonal peak identified

Immunofixation electrophoresis

86334

Absence of monoclonal peak with previously identified monoclonal peak

Immunofixation electrophoresis

86334

Immunoglobulin light chains present with no heavy chains

Immunofixation electrophoresis w/IgD, IgE, free kappa, free lambda

86334

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Reflex Testing (LTR54334)

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TABLE 2 Clinical suspicion of monoclonal peak and hypogammaglobulinemia

Immunofixation electrophoresis

86334

Presence of asymmetric peaks and hypogammaglobulinemia

Immunofixation Electrophoresis

86334

Pediatric Bone Marrow transplant patients that are currently negative but have a history of monoclonal peaks. Monoclonal peak present with no previous monoclonal peak identified

Immunofixation Electrophoresis

86334

Immunofixation electrophoresis

86334

Absence of monoclonal peak with previously identified monoclonal peak

Immunofixation electrophoresis

86334

Mixed proteinuria with suspect light chains

Immunofixation electrophoresis

86334

Initial Test

Reflex Criteria

Reflex Test(s)

CPT Code for Billing

Cryoglobulin Screen

Positive

Cryocrit

82595

Cryocrit

>5%

Cryoglobulin identification by immunofixation electrophoresis

86334

Hemoglobin Electrophoresis

MCV 4.0 % All hemoglobin variants migrating in “non A, nonS” positions where clinically and technically appropriate Hemoglobin variant migrates in the S position and solubility testing is

A2 quantitative

83021

Further defined with an acid pH electrophoresis method

83020

Urine Protein Electrophoresis

Further defined with an acid pH electrophoresis method

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Reflex Testing (LTR54334)

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TABLE 2 negative

Sickle Screen (Prep)

Hgb migrates in S position, initial test only Hgb only and solubility testing is positive Any fast or slow migrating hemoglobin variant For detecting Hgb S in emergent clinical situations, only with prior approval of hematology consult service:  It cannot detect low levels of Hgb S, particularly in transfused patients or neonates;  It cannot detect other clinically relevant hemoglobinopathies such as hemoglobin E, C, beta thalessemia;  It cannot distinguish between heterozygous (AS) and homozygous (SS) individuals;  There is a high frequency of false positive and false negative results.

Solubility testing

85660

Further defined with acid electrophoresis Further defined with acid electrophoresis Without hematology consult 83020 approval Sickle Screens will be analyzed electively by hemoglobin electrophoresis alone

Laboratory Section: Laboratories (Roxboro Road Lab, Pickens Lab, Pickett Road Lab, Fayetteville Road Lab) Initial Test

Reflex Criteria

Reflex Test(s)

CPT Code for Billing

Strep A, Rapid Test

Negative

Culture Group A Strep

87081

Laboratory Section: Clinical Coagulation Laboratory Initial Test

Reflex Criteria

Reflex Test(s)

CPT Code for Billing

Lupus Anticoagulant Panel

PT>normal range

Prothrombin mix

85611

DRVVT>1.2

DRVVT confirm/mix

85730 x 4, 85613

Thrombosis Panel/Protein S (functional)

Protein S (functional) 400, a direct LDL is performed

Urinalysis w/ microscopic

81003, 81001

Direct LDL

82465 (Chol), 83718(HDL), 84478 (Trig), 83721 (DLDL)

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Reflex Testing (LTR54334)

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TABLE 2

Laboratory Section: Clinical Microbiology Laboratory Initial Test

Reflex Criteria

Reflex Test(s)

CPT Code for Billing

Culture Bacteria Body Fluid Or Culture Bacteria Tissue

Physician orders original test on Pericardial Tissue/Fluid or joint fluids and Gram stain results show 2+ WBC and no bacteria. Physician orders original test on amniotic fluid. Physician orders original test on immuno-compromised patient and appropriate source Physician orders original test on appropriate respiratory secretions. Physician orders original test on appropriate respiratory secretions and patient is immuno-compromised

Culture mycoplasma/ureaplasma

87109

Culture Cytomegalovirus Isolation

87254

Resp Viral PCR BasicFluAB&RSV (includes PCR for 3-5 viruses) Resp Viral PCR, Extend PNL 6-11 (includes PCRs for 6-11 viruses including Adenovirus, Influenza A, Influenza B, hMetapneumo Virus, Parainfluenza 1, Parainfluenza 2, Parainfluenza 3, and RSV) PCR on appropriate sources

87631

Culture Virus

Culture HSV

Physician orders original test.

87632

87529 – HSV PCR

Culture CMV

87497 – CMV PCR

Culture Virus

Parasite screen Giardia/Crypto AG

87798 – Enterovirus PCR, 87798 –Varicella zoster PCR 87632 – Resp Viral PCR, Extend Pnl-611 87328 87329

Culture Group A Strep

87081

Parasite Complete Exam

Rapid Strep Test On Throat

Physician orders original test and no prior parasite screen for Giardia/Cryptosporidium Antigen performed within past 7 days Rapid strep test is negative and 2 swabs received

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TABLE 2

Laboratory Section: Clinical Pediatric Laboratory Initial Test

Reflex Criteria

Reflex Test(s)

CPT Code for Billing

Strep A, Rapid Test

Negative and 2 swabs received Any urine that is not clear Any urine that is not straw/yellow Positive Leukocyte Esterase Positive Blood Positive Protein Positive Nitrate

Culture Group A Strep

use 87081

Urinalysis w/ microscopic

81003, 81001

Chemical Urinalysis w/o microscopic

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Reflex Testing (LTR54334)

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TABLE 2

Laboratory Section: Image Cytometry Laboratory *

Image cytometry tests are reflex tests that are tailored to the clinical practice of each physician and the type of tumor. Prognostic tests are being developed continually; when a new test becomes available then physicians are given the opportunity to add this to their “panel”. The reflex tests listed below are representative of these being offered as of January 1, 2005.

Initial Test

Reflex Criteria

Reflex Test(s)

CPT Code for Billing

HER2/neu immunoperoxidase

If the result is a 2+, then reflex to HER2/neu FISH. This test is ordered according to the physician’s choice. If the result is invasive breast carcinoma, then reflex to any test(s) included in the breast panel in Image Cytometry Laboratory. These tests are ordered according to the physician’s choice. Therefore, not all tests must be ordered.

HER2/neu fluorescence in situ hybridization (FISH)

88367 x2

Estrogen receptor Progesterone receptor HER2/neu immunoperoxidase DNA ploidy Proliferation index HER2/neu FISH Epidermal growth factor receptor immunoperoxidase Epidermal growth factor receptor FISH DNA ploidy Proliferation index PTEN Immunohistochemistry AKT Immunohistochemistry

88361 88361 88342 88358 88361 88367 x2 88342

HER2/neu immunoperoxidase DNA ploidy Proliferation index HER2/neu FISH Epidermal growth factor receptor immunoperoxidase Epidermal growth factor receptor FISH P53 DNA ploidy Proliferation index Epidermal growth factor receptor immunoperoxidase

88342 88358 88361 88367 x2 88342

Surgical Pathology

Surgical Pathology

If the result is prostate carcinoma, then reflex to any test(s) included in the prostate panel in Image Cytometry Laboratory. These tests are ordered according to the physician’s choice. Therefore, not all tests must be ordered. If the result is bladder carcinoma, then reflex to any test(s) included in the bladder panel in Image Cytometry Laboratory. These tests are ordered according to the physician’s choice. Therefore, not all tests must be ordered. If the result is renal carcinoma, then reflex to any test(s) included in the renal panel in Image Cytometry

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88367 x2 88358 88361 88342 88342

88367 x2 88342 88358 88361 88342

Reflex Testing (LTR54334)

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TABLE 2

Epidermal Growth Factor Receptor immunoperoxidase

Laboratory. These tests are ordered per the physician’s choice. Therefore, not all tests must be ordered. If the result is a 2+, then reflex to epidermal growth factor receptor FISH. This test is ordered according to the physician’s choice.

Epidermal growth factor receptor FISH

88367 x2

Laboratory Section: Image Cytometry Laboratory (continued) Initial Test

Reflex Criteria

Reflex Test(s)

CPT Code for Billing

Surgical Pathology

If the result is endometrial carcinoma, then reflex to any test(s) included in the endometrial panel in Image Cytometry Laboratory. These tests are ordered according to the physician’s choice. Therefore, not all tests must be ordered. If the result is ovarian carcinoma, then reflex to any test(s) included in the ovarian panel in Image Cytometry Laboratory. These tests are ordered according to the physician’s choice. Therefore, not all tests must be ordered. If the result is lung carcinoma, then reflex to any test(s) included in the lung panel in Image Cytometry Laboratory. These tests are ordered according to the physician’s choice. Therefore, not all tests must be ordered. If the result is sarcoma, then reflex to any test(s) included in the sarcoma panel in Image Cytometry Laboratory. These tests are ordered according to the physician’s choice. Therefore, not all tests must be ordered.

Estrogen receptor Progesterone receptor

88361 88361

HER2/neu immunoperoxidase

88342

HER2/neu immunoperoxidase DNA ploidy Proliferation index HER2/neu FISH Epidermal growth factor receptor immunoperoxidase Epidermal growth factor receptor FISH LAVysion FISH DNA ploidy Proliferation index Synovial Sarcoma FISH Ewing Sarcoma FISH

88342 88358 88361 88367 x2 88342

Surgical Pathology

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88367 x2 88367 x4 88358 88361 88367 88367

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TABLE 2 If the result is colon or colorectal carcinoma, then reflex to any test(s) included in the colon panel in Image Cytometry Laboratory. These tests are ordered according to the physician’s choice. Therefore, not all tests must be ordered. If the result is glioblastoma, anaplastic cytoma, oligodendroglioma, or astrocytoma, then reflex to any test(s) included in the brain panel in Image Cytometry Laboratory. These tests are ordered according to the physician’s choice. Therefore, not all tests must be ordered.

DNA ploidy Proliferation index Epidermal growth factor receptor immunoperoxidase Epidermal growth factor receptor FISH

88358 88358 88342

Epidermal growth factor receptor immunoperoxidase PTEN/cep 10/cep 2 FISH Epidermal growth factor receptor FISH MGMT (O6methylguanine-DNA methyltransferase) PTEN Immunohistochemistry AKT Immunohistochemistry PS6 Immunohistochemistry EGFR VIII Immunohistochemistry MAPK Immunohistochemistry IP/19Q FISH IDH1/2 Immunohistochemistry IDH1/2 Mutation Analysis

88342

88367 x2

88367 x3 88367 x2 88342 88342 88342 88342 88342 88342 88367 x6

88342 81403x2 G0452

Laboratory Section: Flow Cytometry Laboratory Initial Test

Reflex Criteria

Reflex Test(s)

CPT Code for Billing

Leukemia Immunophenotyping

Chronic lymphoma Monoclonal B-cells positive for CD5, CD19, and CD23

ZAP-70 and CD38 phenotyping

88187 x2

Laboratory Section: Cytopathology Laboratory Initial Test

Reflex Criteria

Reflex Test(s)

CPT Code for Billing

CPT 88142, P3000 & G0123-Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation

Atypical squamous cells found on routine PAP test or thin layer prep of vaginal or cervical slides

Human Papilloma Virus(HPV) DNA-HR

87621

CPT 88112-

Initial urine cytology

UroVysion FISH assay

88271 x 4

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TABLE 2 Cytopathology-liquidbased slide prep technique, smears and interpretation

specimen interpretation has a diagnosis of atypical/inconclusive or suspicious for malignancy.

88291 88274

(Pertains to bladder washing, voided urine, catherized urine, upper urinary tract washings and brushing specimens only)

Laboratory Section: Duke Raleigh Hospital Laboratory Initial Test

Reflex Criteria

Reflex Test(s)

CPT Code for Billing

TSH

Free T4

84433

Urinalysis w/ microscopic

81003, 81001

Manual differential

85007

CSF Cell Count

Outside of the normal reference range Positive blood Cloudy Urine Positive Protein Positive Nitrite Positive Leukocyte Poor scatterplot discrimination. Incomplete computation messages for differential results. WBC or differential region flags Instrument suspect messages. Instrument definitive message. RBC > 50

CSF RBC count

89051

Fetal Blood Screen

Test is positive

Kleihauer Betke

85460

Antibody Screen

Test is positive

Antibody Identification

86870

Urinalysis w/o microscopic

Automated differential

Laboratory Section: Durham Regional Hospital Laboratory Initial Test

Reflex Criteria

Reflex Test(s)

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CPT Code for Billing

Reflex Testing (LTR54334)

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TABLE 2 Rapid Strep

Negative and two swabs

Culture Strep Only

87081

Cell Count, CFS w/o Differential Cell Count, Misc, Body Fluid w/o Differential CBC w/ Auto Differential

WBC >10

Cell Count, CFS w/ Differential Cell Count Misc, Body Fluid w/ Differential CBC w/ Manual Differential

89050, 89051

Urinalysis w/ microscopic

81003, 81001

Urinalysis w/o microscopic

WBC >10 < 5 yr old Auto diff absent or incomplete > 10% Bands > 5% Atypical lymphocytes > 2% Plasmacytoid lymphocytes Positive WBC Positive RBC Cloudy Urine Positive Protein Positive Nitrite < 1 yr old child

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89050, 89051 85025, 85023

Reflex Testing (LTR54334)

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TABLE 2

Laboratory Section: Immunology Laboratory Initial Test

Reflex Criteria

Reflex Test(s)

CPT Code for Billing

Anti-Nuclear Antibody Screen

Anti-nuclear antibody screen has a fluorescence intensity of > 1+ at the 1:40 dilution

Anti-nuclear antibody titer

86039

Anti-Neutrophil Antibody

Anti-neutrophil antibody screen has a fluorescence intensity of > 1+ at the 1:20 dilution

Anti-neutrophil antibody titer

86256

Anti-neutrophil antibody screen has a positive cytoplasmic pattern

Anti-proteinase 3 antibody

83520

Anti-neutrophil antibody screen has a positive perinuclear pattern

Anti-myeloperoxidase antibody

83520

Anti-Smooth Muscle Antibody

Anti-smooth muscle antibody screen has a fluorescence intensity of > 1+ at the 1:20 dilution

Anti-smooth muscle antibody titer

86256

Anti-Mitochondrial Antibody Screen

Anti-mitochondrial antibody screen has a fluorescence intensity of > 1+ at the 1:20 dilution

Anti-mitochondrial antibody titer

86256

Lyme Disease Total IG

Lyme disease Western blot confirmation

86617

IgA

Lyme disease total IG screen has an absorbance value > to the cutoff < 10 mg/dl

IgA low level assay

86329

IgM

< 10 mg/dl

IgM low level assay

86329

Laboratory Section: Immunology Laboratory Panel

Panel Components

CPT Code for Billing

1. Anti-Cardiolipin (IgG, IgM, IgA)

Anti-Cardiolipin IgG Anti-Cardiolipin IgM Anti-Cardiolipin IgA Anti-Beta-2 Glycoprotein1IgG Anti-Beta-2 Glycoprotein1IgM Anti-Beta-2 Glycoprotein1IgA

86147 (X 3)

2. Anti-Beta-2 Glycoprotein 1

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86146 (X 3)

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TABLE 2 3. Streptococcal Antibody 4. Immunoglobulin Profile

5. Humoral Immunocompetance Profile

6. Immunoglobulins

7. Antibodies - Sm, RNP, Ro, La

8. Epstein Barr Virus Antibody

9. Lymphocyte Enumeration 10. Complement Profile (C3/C4) 11. Cellular Immunocompetence Profile

12. Isohemagglutinin Antibodies 13. IG Free Light Chains Serum 14. Celiac Disease Panel 15. Inflammatory Bowel Disease (Duke)

Anti-Streptolysin O Anti-DNase B Immunoglobulin A Immunoglobulin M Immunoglobulin G Immunoglobulin E Diphtheria Toxoid IgG Ab Tetanus Toxoid IgG Ab Immunoglobulin A Immunoglobulin M Immunoglobulin G Immunoglobulin E Anti-A Anti-B Immunoglobulin A Immunoglobulin M Immunoglobulin G Sm Antibodies RNP Antibodies Ro Antibodies La Antibodies EBV IgG Antibodies EBV IgM Antibodies EBV EBNA Antibodies EBV EA Antibodies Various CD markers C3 Complement C4 Complement PHA Con A PWM Tetanus Candida Anti-A Anti-B IG Kappa IG Lambda Immunoglobulin A TissueTransglutaminase IgA Neutrophil Cytoplasmic Ab ASCA IgA ASCA IgG Anti-Omp C

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86060 86215 82784 82784 82784 82785 86648 86774 82784 82784 82784 82785 86406 86406 82784 82784 82784 86235 (X 4)

86665 86665 86664 86663 88184 (initial) 88185 (additional) 86160 86160 86353 (X 5)

86406 86406 83883 (X 2) 82784 83520 86255 83520 83520 83520

Reflex Testing (LTR54334)

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TABLE 2 IgE Ab Allergen Boxelder Maple IgE Ab Allergen Cottonwood Tree IgE Ab Allergen Elm Tree IgE Ab Allergen Oak Tree IgE Ab Allergen Pine Tree IgE Ab Allergen Silver Birch IgE Ab Allergen Walnut IgE Ab Allergen Willow Tree 17. IgE Ab Allergen Epith IgE Ab Allergen Cat Epithelium IgE Ab Allergen Dog Epithelium Panel 1 IgE Ab Allergen Cow Epithelium IgE Ab Allergen Horse Epithelium 18. IgE Ab Allergen Epith IgE Ab Allergen Guinea Pig Epithelium Panel 2 IgE Ab Allergen Hamster Epithelium IgE Ab Allergen Rabbit Epithelium IgE Ab Allergen Mouse Epithelium IgE Ab Allergen Rat Epithelium 19. IgE Ab Allergen Food IgE Ab Allergen Cod Fish IgE Ab Allergen Egg White Panel IgE Ab Allergen Milk Cow IgE Ab Allergen Peanut IgE Ab Allergen Soybean IgE Ab Allergen Wheat IgE Ab Allergen Barley Grass 20. IgE Ab Allergen IgE Ab Allergen Rye Grain Panel IgE Ab Allergen Wheat IgE Ab Allergen Rice Grain 21. IgE Ab Allergen Grass IgE Ab Allergen Bermuda Grass IgE Ab Allergen Johnson Grass Panel 1 IgE Ab Allergen KY Blue Grass IgE Ab Allergen Meadow Fescue IgE Ab Allergen Orchard Grass IgE Ab Allergen Rye Grass IgE Ab Allergen Timothy Grass 22. IgE Ab Allergen Grass IgE Ab Allergen Bahia Grass IgE Ab Allergen Rye Grass Panel 2 IgE Ab Allergen Vernal Grass IgE Ab Allergen Velvet Grass IgE Ab Allergen Cockroach Body 23. IgE Ab Allergen IgE Ab Allergen Dust Mite, D. FRN House Dust Panel 1 IgE Ab Allergen Dust Mite, D. PTR IgE Ab Allergen House Dust HSR 16. IgE Ab Allergen Tree Panel

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86003 (X 8)

86003 (X 4)

86003 (X 5)

86003 (X 6)

86003 (X 4)

86003 (X 7)

86003 (X 4)

86003 (X 4)

Reflex Testing (LTR54334)

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TABLE 2 24. IgE Ab Allergen Mold Panel

25. IgE Ab Allergen Nut Panel

26. IgE Ab Allergen Ragweed Panel

27. IgE Ab Allergen Seafood Panel

28. IgE Ab Allergen Tree Panel

29. IgE Ab Allergen Indoor Inhalant Screen

30.

IgE Ab Outdoor Inhalant Screen

IgE Ab Asp Fumigatus IgE Ab Allergen Alternaria IgE Ab Allergen Candida Albicans IgE Ab Allergen Cladosporium IgE Ab Allergen Helminthospore IgE Ab Allergen Penicillium IgE Ab Allergen Hazel Nut IgE Ab Allergen Almond Nut IgE Ab Allergen Brazil Nut IgE Ab Allergen Cashew Nut IgE Ab Allergen Peanut IgE Ab Allergen Pecan IgE Ab Allergen Pistachio IgE Ab Allergen Walnut IgE Ab Allergen Coconut (fruit) IgE Ab Allergen Short Ragweed IgE Ab Allergen Ragweed, False IgE Ab Allergen Ragweed, Giant IgE Ab Allergen Ragweed, Western IgE Ab Allergen Cod Fish IgE Ab Allergen Salmon IgE Ab Allergen Shrimp IgE Ab Allergen Tuna IgE Ab Allergen Blue Mussel IgE Ab Allergen Boxelder Maple IgE Ab Allergen Cottonwood Tree IgE Ab Allergen Elm Tree IgE Ab Allergen Oak Tree IgE Ab Allergen Pine Tree IgE Ab Allergen Silver Birch IgE Ab Allergen Walnut Tree IgE Ab Allergen Willow Tree IgE Ab Allergen Cat Epithelium IgE Ab Allergen Cockroach Body IgE Ab Allergen Dust Mite, D. FRN IgE Ab Allergen Dust Mite, D. PTR IgE Ab Allergen Dog Dander IgE Ab Allergen Asp Fumigatus IgE Ab Allergen Alternaria IgE Ab Allergen Bermuda Grass IgE Ab Allergen Hickory Tree IgE Ab Allergen Meadow Fescue IgE Ab Allergen Oak Tree IgE Ab Allergen Short Ragweed

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86003 (X 6)

86003 (X 9)

86003 (X 4)

86003 (X 5)

86003 (X 8)

86003 (X 5)

86003 (X 7)

Reflex Testing (LTR54334)

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TABLE 2 31. IgE Childhood Allergy March Profile

Immunoglobulin E IgE Ab Allergen Alternaria IgE Ab Allergen Cat Epithelium IgE Ab Allergen Cockroach Body IgE Ab Allergen Cod Fish IgE Ab Allergen Egg White IgE Ab Allergen Milk, Cow IgE Ab Allergen Peanut IgE Ab Allergen Soybean IgE Ab Allergen Wheat IgE Ab Allergen Dust Mite, D. FRN IgE Ab Allergen Dog Dander

86003 (X 12)

32. IgE Region II Respiratory Profile

Immunoglobulin E IgE Ab Asp Fumigatus IgE Ab Allergen Alternaria IgE Ab Allergen Bermuda Grass IgE Ab Allergen Boxelder Maple IgE Ab Allergen Cat Epithelium IgE Ab Allergen Cladosporium IgE Ab Allergen Cockroach Body IgE Ab Allergen Cottonwood Tree IgE Ab Allergen Elm Tree IgE Ab Allergen Hickory Tree IgE Ab Allergen Johnson Grass IgE Ab Allergen Juniper Tree IgE Ab Allergen Oak Tree IgE Ab Allergen Short Ragweed IgE Ab Allergen Silver Birch IgE Ab Allergen Timothy Grass IgE Ab Allergen Dust Mite, D. FRN IgE Ab Allergen Dust Mite, D. PTR IgE Ab Allergen Sheep Sorrell IgE Ab Allergen Dog Dander IgE Ab Allergen Penicillium IgE Ab Allergen Pigweed, Rough IgE Ab Allergen Mulberry

86003 (X 24)

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Reflex Testing (LTR54334)

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TABLE 2 33.

IgE Ab Allergen Zone 2 Panel

IgE Ab Asp Fumigatus IgE Ab Allergen Alternaria IgE Allergen Bahia Grass IgE Ab Allergen Bermuda Grass IgE Ab Allergen Cat Epithelieum IgE Ab Allergen Cedar Tree IgE Ab Allergen Cladosporium IgE Ab Allergen Cockroach Body IgE Ab Allergen Dog Epithelium IgE Ab Allergen Elm Tree IgE Ab Allergen Johnson Grass IgE Ab Allergen Oak Tree IgE Ab Allergen Short Ragweed IgE Ab Allergen Silver Birch IgE Ab Allergen Sweet Gum Tree IgE Ab Allergen Sycamore Tree IgE Ab Allergen Timothy Grass IgE Ab Allergen Dust Mite, D. FRN IgE Ab Allergen Dust Mite, D. PTR IgE Ab Allergen Plantain Weed IgE Ab Allergen Mugwort Weed IgE Ab Allergen Nettle Weed IgE Ab Allergen Sheep Sorrell IgE Ab Allergen Penicillium IgE Ab Allergen Pigweed, Rough IgE Ab Allergen White Hickory IgE Ab Allergen Mucor Racemosus IgE Ab Allergen Mulberry IgE Ab Allergen Stemphylium

86003 (X 29)

Laboratory Section: Molecular Diagnostics Initial Test

Reflex Criteria

Surgical Pathology

If the result is colon adenocarcinoma MSI DNA Screen for HNPCC 81301 Physician Interpretation G0452

ABL1 Kinase Domain Mutation Analysis AGL Sequencing (full gene, single exon and two exon) for GSDIII B Cell Clonality Studies (IGH)

BCR-ABL1 Quantitative PCR

The result is positive, negative or indeterminate, but not “insufficient for interpretation” The result is positive, negative or indeterminate, but not “insufficient for interpretation” The result is positive, negative or indeterminate, but not “insufficient for interpretation” The result is positive, negative or indeterminate, but not “insufficient for interpretation”

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Reflex Test(s)

CPT

Physician Interpretation

G0452

Physician Interpretation

G0452

Physician Interpretation

G0452

IGK clonality and Phys Interp Physician Interpretation G0452

Reflex Testing (LTR54334)

Last Review Date: 6/3/2014 3:22:28 PM

TABLE 2 BRAF V600 Gene Mutation Analysis The result is positive, negative or indeterminate, but not “insufficient for interpretation” The result is positive, negative or CKIT Targeted Mutation Analysis indeterminate, but not “insufficient for interpretation” EGFR Targeted Mutation Analysis The result is positive, negative or indeterminate, but not “insufficient for interpretation” The result is positive, negative or GLA Sequencing (full gene, single indeterminate, but not “insufficient exon and two exons) for Fabry for interpretation” Disease The result is positive, negative or G6PC Sequencing (full gene, single indeterminate, but not “insufficient exon and two exons) for GSD1a for interpretation” The result is positive, negative or GAA Sequencing (full gene, single indeterminate, but not “insufficient exon and two exons) for GSD II for interpretation” The result is positive, negative or GBE1 Sequencing (full gene, single indeterminate, but not “insufficient exon and two exons) for GSD IV for interpretation” HFE Targeted Mutation Analysis for The result is positive, negative or indeterminate, but not “insufficient Hemochromatosis for interpretation” The result is positive, negative or IDH1 Mutation Analysis indeterminate, but not “insufficient for interpretation” The result is positive, negative or IDH2 Mutation Anaylsis indeterminate, but not “insufficient for interpretation” The result is positive, negative or IGH Somatic Mutation Analysis indeterminate, but not “insufficient for interpretation”

Physician Interpreation

G0452

Physician Interpretation

G0452

Physician Interpretation

G0452

Physician Interpretation

G0452

Physician Interpretataion

G0452

Physician Interpretation

G0452

Physician Interpretation

G0452

Physician Interpretation

G0452

Physician Interpretation

G0452

Physician Interpretation

G0452

Physician Interpretation

G0452

Initial Test

Reflex Criteria

Reflex Test(s)

CPT

JAK2 Targeted Mutation Analysis

The result is positive, negative or indeterminate, but not “insufficient for interpretation” The result is positive, negative or indeterminate, but not “insufficient for interpretation” The result is positive, negative or indeterminate, but not “insufficient for interpretation”

Physician Interpretation

G0452

Physician Interpretation

G0452

Physician Interpretation

G0452

KRAS Mutation Analysis

MLH1 Sequencing (full gene, single exon, two exons) for HNPCC

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TABLE 2 The result is positive, negative or indeterminate, but not “insufficient for interpretation” The result is positive, negative or indeterminate, but not “insufficient for interpretation” MSH6 Sequencing (full gene, single The result is positive, negative or indeterminate, but not “insufficient exon, two exons) for HNPCC for interpretation” The result is positive, negative or MSI DNA Screening for HNPCC indeterminate, but not “insufficient for interpretation” MYH9 Sequencing (full gene, single The result is positive, negative or indeterminate, but not “insufficient exon, two exons) for interpretation” The result is positive, negative or NPM1 Targeted Mutation Analysis indeterminate, but not “insufficient for interpretation” The result is positive, negative or PHKA2/PHKG2 Sequencing (full gene, single exon, two exons) for GSD indeterminate, but not “insufficient for interpretation” IX PYGM sequencing (full gene, single The result is positive, negative or indeterminate, but not “insufficient exon, two exons) for GSD V for interpretation” The result is positive, negative or SLC37A4 Sequencing (full gene, indeterminate, but not “insufficient single exon, two exons) for GSD 1B for interpretation” SUOX Sequencing (full gene, single The result is positive, negative or exon, two exons) For Sulfite Oxidase indeterminate, but not “insufficient for interpretation” Deficiency The result is positive, negative or T-Cell Clonality (TCR-Gamma) indeterminate, but not “insufficient for interpretation” TGFB1 Sequencing (full gene, single The result is positive, negative or indeterminate, but not “insufficient exon, two exons) for Granular and for interpretation” Lattice Corneal Dystrophies The result is positive, negative or TMPRSS6 Sequencing (full gene, indeterminate, but not “insufficient single exon, two exons) for Iron Refractory, Iron Deficiency Anemia for interpretation”

Physician Interpretation

G0452

Physician Interpretation

G0452

Physician Interpretation

G0452

Physician Interpretation

G0452

Physician Interpretation

G0452

Physician Interpretation

G0452

Physician Interpretation

G0452

Physician Interpretation

G0452

Physician Interpretation

G0452

Physician Interpretation

G0452

Physician Interpretation

G0452

TCR-Beta and Phys. Interp Physician Interpretation

G0452

Physician Interpretation

G0452

Initial Test

Reflex Test(s)

CPT

MOCS1 and MOCS2 Gene Sequencing (full gene, single exon, two exons) MSH2 Sequencing (full gene, single exon, two exons) for HNPCC

Reflex Criteria

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TABLE 2 The result is positive, negative or TP53 Targeted Mutation Analysis (full gene, single exon, two exons) for indeterminate, but not “insufficient for interpretation” prognosis in CLL, primary CNS neoplasms or the diagnosis of LiFraumeni Syndrome

Physician Interpretation

G0452

Bone Marrow Engraftment Analysis Significant change from previous findings requiring review of clinical history and other pathology reports and tests

Physician Interpretation

G0452

Cystic Fibrosis Targeted Mutation Analysis

Diagnostic testing (not carrier screening)

Physician Interpretation

G0452

Fragile X testing

Unexpected or Unusual findings Physician Interpretation requiring review of clinical history, physician notes or the results of other clinical tests

G0452

Prader Willi/Angelman Syndrom Testing

Unexpected or Unusual findings Physician Interpretation requiring review of clinical history, physician notes or the results of other clinical tests

G0452

Duke University Health System Clinical Laboratories and Duke University Hospital Department of Pathology Laboratories List of Universally Accepted Confirmatory or Adjunctive Tests Which by Professional Practice Standards or Regulations Do Not Require an Attending Physician’s Order:

Laboratory Section: Histopathology Laboratory Initial Test: 1. 88302 Level II Surgical Pathology Gross And Microscopic Examination

2. 88304 Level III Surgical Pathology Gross And Microscopic Examination

Confirmatory or Adjunctive Tests: Technical only (902-907) additional slides 88311 Decalcification 88312 Special stains group I for microorganisms 88313 Special stains group II all other 88318 Determinative histochemistry to identify chemical components 88319 Determinative histochemistry to identify enzyme constituents 88342 Immunohistochemistry 88348 Electron microscopy Technical only (902-907) additional slides 88311 Decalcification 88312 Special stains group I for microorganisms

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TABLE 2

3. 88305 Level IV Surgical Pathology Gross And Microscopic Examination

88313 Special stains group II all other 88318 Determinative histochemistry to identify chemical components 88319 Determinative histochemistry to identify enzyme constituents 88342 Immunohistochemistry 88346 Immunofluorescent study 88347 Immunofluorescent study indirect method 88348 Electron microscopy Technical only (902-907) additional slides 88311 Decalcification 88312 Special stains group I for microorganisms 88313 Special stains group II all other 88318 Determinative histochemistry to identify chemical components 88319 Determinative histochemistry to identify enzyme constituents 88342 Immunohistochemistry 88346 Immunofluorescent study 88347 Immunofluorescent study indirect method 88348 Electron microscopy 88362 Nerve teasing preparations

Laboratory Section: Histopathology Laboratory (continued) Initial Test: 4. 88307 Level V Surgical Pathology Gross And Microscopic Examination

5. 88309 Level VI Surgical Pathology Gross And Microscopic Examination

Confirmatory or Adjunctive Tests: Technical only (902-907) additional slides 88311 Decalcification 88312 Special stains group I for microorganisms 88313 Special stains group II all other 88318 Determinative histochemistry to identify chemical components 88319 Determinative histochemistry to identify enzyme constituents 88342 Immunohistochemistry 88346 Immunofluorescent study 88347 Immunofluorescent study indirect method 88348 Electron microscopy Technical only (902-907) additional slides 88311 Decalcification 88312 Special stains group I for microorganisms 88313 Special stains group II all other

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TABLE 2

6. 88323 Consultation And Report On Referred Material Requiring Preparation Of Slides

7. 88325 Consultation, Comprehensive, With Review of Records And Specimens, With Report On Referred Material

8. 88331 Pathology Consultation During Surgery With Frozen Section

88318 Determinative histochemistry to identify chemical components 88319 Determinative histochemistry to identify enzyme constituents 88342 Immunohistochemistry 88346 Immunofluorescent study 88347 Immunofluorescent study indirect method 88348 Electron microscopy Technical only (902-907) additional slides 88312 Special stains group I for microorganisms 88313 Special stains group II all other 88318 Determinative histochemistry to identify chemical components 88319 Determinative histochemistry to identify enzyme constituents 88342 Immunohistochemistry 88348 Electron microscopy Technical only (902-907) additional slides 88311 Decalcification 88312 Special stains group I for microorganisms 88313 Special Stains group II all other 88318 Determinative histochemistry to identify chemical components 88319 Determinative histochemistry to identify enzyme constituents 88342 Immunohistochemistry 88348 Electron microscopy 88332 Additional tissue block with frozen section

Laboratory Section: Cytopathology Laboratory Initial Test: 1. CPT 88108- Cytopathology-concentration technique, smears and interpretation (cytospin)

Confirmatory or Adjunctive Tests: Technical and professional fee additional slides/services 88305 Cell Block 88312 Special stains group I for microorganisms 88313 Special stains group II all other 88318 Determinative histochemistry to identify chemical components 88319 Determinative histochemistry to identify enzyme constituents 88342 Immunohistochemistry 88346 Immunofluorescent study

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TABLE 2 2. CPT 88112- Cytopathology-liquid-based slide prep technique, smears and interpretation

3. CPT 88104- Cytopathology-fluids, washings or brushings, except cervical or vaginal; smears with interpretations

4. CPT 88107- Cytopathology-fluids, washings or brushings, except cervical or vaginal; smears and filter preparation with interpretation

5. CPT 88323- Consultation And Report On Referred Material Requiring Preparation Of Slides

6. CPT 88325- Consultation, Comprehensive, With Review of Records And Specimens, With Report On Referred Material

88347 Immunofluorescent study indirect method Technical & professional fee additional slides/services 88305 Cell Block 88312 Special stains group I for microorganisms 88313 Special stains group II all other 88318 Determinative histochemistry to identify chemical components 88319 Determinative histochemistry to identify enzyme constituents 88342 Immunohistochemistry 88346 Immunofluorescent study 88347 Immunofluorescent study indirect method Technical & professional fee additional slides/services 88305 Cell Block 88312 Special stains group I for microorganisms 88313 Special stains group II all other 88318 Determinative histochemistry to identify chemical components 88319 Determinative histochemistry to identify enzyme constituents 88342 Immunohistochemistry 88346 Immunofluorescent study 88347 Immunofluorescent study indirect method Technical & professional fee additional slides/services 88305 Cell Block 88312 Special stains group I for microorganisms 88313 Special stains group II all other 88318 Determinative histochemistry to identify chemical components 88319 Determinative histochemistry to identify enzyme constituents 88342 Immunohistochemistry 88346 Immunofluorescent study 88347 Immunofluorescent study indirect method Technical & professional fee additional slides/services 88305 Cell Block 88312 Special stains group I for microorganisms 88313 Special stains group II all other 88318 Determinative histochemistry to identify chemical components 88319 Determinative histochemistry to identify enzyme constituents 88342 Immunohistochemistry 88346 Immunofluorescent study 88347 Immunofluorescent study indirect method Technical & professional fee additional slides/services 88305 Cell Block 88312 Special stains group I for microorganisms

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TABLE 2

7. CPT 88172- Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen

8. CPT 88173- Cytopathology, evaluation of fine needle aspirate; interpretation and report

9. CPT 88142, P3000 & G0123-Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation

88313 Special Stains group II all other 88318 Determinative histochemistry to identify chemical components 88319 Determinative histochemistry to identify enzyme constituents 88342 Immunohistochemistry 88346 Immunofluorescent study 88347 Immunofluorescent study indirect method Technical &professional fee additional slides/services 88305 Cell Block 88312 Special stains group I for microorganisms 88313 Special Stains group II all other 88318 Determinative histochemistry to identify chemical components 88319 Determinative histochemistry to identify enzyme constituents 88342 Immunohistochemistry 88346 Immunofluorescent study 88347 Immunofluorescent study indirect method CPT 88141-Cytopathology, cervical or vaginal (any reporting system); requiring interpretation by physician

Laboratory Sections: Carl Rapid Response Laboratory, Franklin Core Clinical Laboratory, Morris Building Clinical Laboratory, and Outpatient Clinical Laboratories Initial Test: Automated Blood Count (ABC) Or ABC/ Automated Differential, Any Instrument Flag

Confirmatory or Adjunctive Tests: Blood film review and/ or manual white blood cell (WBC) differential

Laboratory Section: Clinical Microbiology Disclaimer: Printed copies are not the official document. See on-line version.

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TABLE 2 Initial Test: Culture Bacteria Body Fluid, CSF, Sputum/ETA/BAL, Tissue, Ear, Dialysis Fluid, Other Source Without Anaerobes, Other Source With Anaerobes Culture Bacteria Tissue Culture Bacteria Blood, Body Fluid, CSF, Catheter Tip, Sputum/ETA/BAL, Tissue, Ear, Eye, Dialysis Fluid, Cystic Respiratory, Other Source Without Anaerobes, Other Source With Anaerobes, Stool, Urine. Culture Group A Strep Culture Group B Strep Culture GC Culture Yersinia

Culture Bacteria Body Fluid, Tissue, Other Source With Anaerobes Culture Bacteria Blood Culture Bacteria Stool

Culture AFB Respiratory Culture AFB Other Source Culture AFB Blood

Culture Fungus Culture Fungus Blood Culture Fungus, Skin, Hair, Nail

Culture Candida Screen

Culture Virus Culture Herpes simplex

Confirmatory or Adjunctive Tests: 87205 Gram stain

87176 Grind tissue Bacterial identification (87077-definitive, 87088-Urine ID, 87143-GLC, 87147-Streptex, 87150-Amp Probe, 87158other methods) based on method(s) used for each appropriate aerobic isolate. Bacterial susceptibility testing (87181-KB, 87184-MIC, 87186-Etest, or 87185-beta-lactamase) for each appropriate isolate based on method used. Yeast identification-87106 or mold identification 87107 (definitive) for each appropriate isolate. Fungal susceptibility testing (87181-Etest, 87186-MIC) for each drug/yeast isolate based on physician request and test method used as appropriate for yeast isolated. 87075 Anaerobic Culture 87076 Anaerobe identification (definitive) for each anaerobic isolate. 87076 Anaerobe identification (definitive) for each anaerobic isolate. 87046 Cult isol & prel/Campylo (routine) 87046 Cult isol&prelim/E. coli 157 (routine) 87046 Cult isol&prelim/Vibrio when requested. 87176 Grind/homogenize specimen (tissue only) 87015 Concentration of specimen (appropriate sources) 87206 AFB Smear (non-blood sources) 87149 or 87118 AFB identification (by probe or biochemicals) for each isolate 87190 AFB susceptibility each drug (5) for each isolate 87210 or 87220 - KOH Prep (appropriate source) 87210 India ink and 86403 Cryptococcal antigen (CSF only) 87106-Yeast or 87107-mold identification (definitive) for each isolate 87181, 87186. Fungal susceptibility testing (Etest, MIC) for each drug/yeast isolate based on physician request and test method used as appropriate for yeast isolated. 87106 Yeast identification (definitive) for each isolate 87181, 87186. Fungal susceptibility testing (Etest, MIC) for each drug/yeast isolate based on physician request and test method used as appropriate for yeast isolated. 87253 Viral identification (definitive) for each virus identified

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Reflex Testing (LTR54334)

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TABLE 2 Malaria Smear (Thick And Thin Films) Microfilariae Exam Parasite Complete Exam

RPR

87015 Concentration of specimen 87177 Parasite complete exam/conc & Id and 88312 Parasite complete exam/trichrome stain 87207 Microsporidia exam when noted on request 86593 RPR quantitative to determine actual titer 86781 Treponema pallidum Confirm to confirm reactive RPR results

Treponema pallidum Confirm

86592 RPR 86593 RPR quantitative if RPR reactive for actual titer

CSF VDRL

86593 VDRL quantitative to determine actual titer when VDRL is reactive

Laboratory Section: Flow Cytometry Initial Test: Leukemia Immunophenotyping of Bone Marrow, Fine Needle Aspiration, Cerebral Spinal Fluid, Pleural Fluid, Peritoneal Fluid, Tissue, Peripheral Blood

Confirmatory or Adjunctive Tests: Leukemia Immunophenotyping 88187 2 to 8 antibodies tested 88188 9 to 15 antibodies tested 88189 16 or more antibodies tested

Additional Flow Cytometry tests to identify prognostic markers and / or therapeutic targets will be performed in patients diagnosed with the appropriate leukemia / lymphoma.

Laboratory Section: Immunopathology Initial Test: Immunopathology of Native or transplant Kidney, Heart, or Lung Biopsy

Confirmatory or Adjunctive Tests: 88342 Immunohistochemistry 88346 Immunofluorescent study 88347 Immunofluorescent study indirect method 88348 Electron microscopy

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TABLE 2

Laboratory Section: Transfusion Service Initial Test: 1. Type And Screen

2. Newborn Type And Screen

3. Red Cell Blood Product Order

Confirmatory or Adjunctive Tests: 86901 ABO discrepancy 86901 ABO Rh recheck 86978 Adsorption procedure 86870 Antibody panel/blood 86885 Antibody screen (IAT) 86886 Antibody titer-blood 86903 Antigen typing 86157 Cold agglutinins titer-blood 86156 Cold screen 86880 Direct antiglobin (DAT) 86860 Eluate blood 86886 HTLA titer 86970 Pretreat RBC-chem, drug 86972 Pretreat RBC-density 86971 Pretreat RBC-enzyme 86975 Pretreat serum-drugs 86977 Pretreat serum-inhibitors 83891 RBC Antigens-Molecular Bioarray 83892 83890 88384 83901 times 40 86901 ABO discrepancy 86901 ABO Rh recheck 86870 Antibody panel/blood 86885 Antibody screen (IAT) 86903 Antigen typing 86860 Eluate blood 86900 Type and screen/ABO type 86901 Type and screen/Rh type 86885 Type and screen/Ab screen 86901 ABO recheck 86920 Crossmatch 86922 Crossmatch-extended 86903 Antigen typing 85013 Hematocrit blood 86945 Irradiation blood product 86931 Deglycerolization handling fee Reconstituted RBC handling fee Red blood cells handling fee 85660 Sickle cell screen 86078 Transfusion reaction

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Reflex Testing (LTR54334)

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TABLE 2

Laboratory Section: Transfusion Service (continued) Initial Test: 4. Platelet Product Order

5. Plasma Product Order

6. Post-Natal Rh Immunoglobulin

7. Pre-Natal Rh Immunoglobulin

8. DAT (Direct Antiglobulin Test)

9. Antibody Titer 10. RBC Phenotype 11. ABO/Rh Type

Confirmatory or Adjunctive Tests: 86078 Transfusion reaction 86900 Type and screen/ABO type 86901 Type and screen/Rh type 86901 ABO recheck 86985 Volume reduction fee-platelet 86945 Irradiation blood product 86965 Platelet handling fee-pheresis 86965 Platelet handling fee-pooled 86965 Platelet HLA best match fee 86920 Platelet Crossmatch 86022 Platelet antibodies direct 86023 Platelet antibodies indirect 86022-Platelet antibodies-drug induced 86022 Platelet specific antigen-PL A1 typing 86900 Type and screen/ABO type 86901 ABO recheck 86901 Type and screen/Rh type 86885 Type and screen/Ab screen 86078 Transfusion reaction workup 86927 Plasma products handling fee 86900 Type and screen/ABO type 86901 Type and screen/Rh type 86885 Type and screen/Ab screen 85461 Fetal screen 86901 ABO Rh recheck 86900 Type and screen/ABO type 86901 Type and screen/Rh type 86885 Type and screen/Ab screen 86901 ABO Rh recheck 86900 ABO and Rh type/ABO type 86901 ABO and Rh type/Rh type Antibody screen (IAT) 86156 Cold screen 86880 DAT C3 86880 86860 DAT IGG 86860 Eluate Blood 86870 Antibody panel/blood 86901 ABO Rh recheck 86870 Antibody panel/blood 86901 ABO Rh recheck 86880 Direct antiglobin (DAT) 86901 ABO discrepancy 86901 ABO recheck 86156 Cold screen

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TABLE 2 Direct antiglobin (DAT)

Laboratory Section: Morris Building Clinical Laboratory Initial Test: Bone Marrow Aspirate Smear Interpretation

Confirmatory or Adjunctive Tests: 88313 PAS stain (special stains group 2) 88319 Myeloperoxidase (determinative histochemistry to identify enzyme components) 88319 Esterase (determinative histochemistry to identify enzyme components)

Laboratory Section: Duke Raleigh Hospital Laboratory Initial Test:

Confirmatory or Adjunctive Tests:

1. DAT (Direct Antiglobulin Test)

Billirubin

2. Automated Differential

Manual Differential performed if any of the following occurs: a) Poor scatterplot discrimination b) Incomplete computation messages for differential results c) WBC or differential region flags d) Instrument suspect messages e) Instrument definitive message f) Absolute lymphocyte value > 15 x 10

3. HIV

Western blot to confirm positive EIA test-86701 or HIV 1/2 Antibody w/ HIV1 AG - 87389

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TABLE 2

Laboratory Section: Durham Regional Hospital Initial Test: 1. Type And Screen

2. Newborn Type And Screen

3. Red Cell Blood Product Order

4. Platelet Product Order

Confirmatory or Adjunctive Tests: 86900 ABO 86901 Rh 86978 Adsorption procedure 86870 Antibody panel/blood 86850 Antibody screen (IAT) 86886 Antibody titer-blood 86903 Antigen typing 86880 Direct antiglobin (DAT) 86860 Eluate blood 86886 HTLA titer 86970 Pretreat RBC-chem, drug 86972 Pretreat RBC-density 86971 Pretreat RBC-enzyme 86975 Pretreat serum-drugs 86977 Pretreat serum-inhibitors 86900 ABO 86901 Rh 86870 Antibody panel/blood 86850 Antibody screen (IAT) 86903 Antigen typing 86860 Eluate blood 86920 Crossmatch 86922 Crossmatch-extended 86903 Antigen typing 86945 Irradiation blood product 86931 Deglycerolization handling fee Reconstituted RBC handling fee Red blood cells handling fee 85660 Sickle cell screen 86078 Transfusion reaction workup handling fee Wash blood fee-RBC’s 86078 Transfusion reaction workup 86900 ABO type 86901 Rh type 86885 Ab screen Wash blood fee-platelets 86945 Irradiation blood product 86965 Platelet handling fee-pheresis 86965 Platelet handling fee-pooled 86965 Platelet HLA best match fee 86920 Crossmatch

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Reflex Testing (LTR54334)

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TABLE 2

Laboratory Section: Durham Regional Hospital (continued) Initial Test: 5. Plasma Product Order

6. Post-Natal Rh Immunoglobulin

7. Pre-Natal Rh Immunoglobulin

8. DAT (Direct Antiglobulin Test)

9. Antibody Titer 10. RBC Phenotype

11. ABO/Rh Type

12. RPR

Confirmatory or Adjunctive Tests: 86900 ABO type 86901 Rh type 86850 Ab screen 86078 Transfusion reaction workup 86927 Plasma products handling fee 86900 ABO type 86901 Rh type 86850 Ab screen 85461 Fetal screen 86901 ABO Rh recheck 86870 Antibody panel Type and screen 86900 ABO type 86901 Rh type 86850 Ab screen 86901 ABO Rh recheck 86900 ABO type 86901 Rh type 86850 Antibody screen (IAT) 86880 DAT C3 86880 86860 DAT IGG 86860 Eluate Blood 86870 Antibody panel/blood 86850 Ab screen 86870 Antibody panel/blood 86900 ABO 86901 Rh 86880 Direct antiglobin (DAT) 86901 ABO Rh 86900 ABO 86156 Cold screen Direct antiglobin (DAT)

86593 RPR quantitative to determine actual titer 86781 Treponema pallidum Confirm to confirm reactive RPR results

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