Lab Order Form - Emory Johns Creek Hospital
Lab Order Form - Emory Johns Creek Hospital
Lab Order Form - Emory Johns Creek Hospital
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PHYSICIAN INFORMATION<br />
PHYSICIAN / GROUP NAME _________________________________________ PHONE NO________________________ FAX NO ________________________<br />
CITY, STATE, ZIP ____________________________________________________ NPI #______________________________________________________________<br />
Patient Information<br />
Medical Necessity Information<br />
Last Name<br />
Sign, symptom, diagnosis or ICD9-CM info. is required on all tests ordered.<br />
Narrative Diagnosis<br />
First Name<br />
MI<br />
ICD9-CM Codes<br />
Social Security No.<br />
Phone No.<br />
Birthdate<br />
1.<br />
2.<br />
3.<br />
Sex<br />
M<br />
Chart No.<br />
F<br />
STAT<br />
Other Tests<br />
Marital Status<br />
Room No.<br />
Phone ( ) ____________________<br />
or<br />
Fax ( ) ____________________<br />
CPT ✔ Tests or Panels<br />
Panel or Single Tests may be selected<br />
80051 Electrolytes Panel<br />
84295 Sodium<br />
84132 Potassium<br />
82435 Chloride<br />
82374 Carbon Dioxide<br />
80048 Basic Metabolic Panel<br />
80051 Na, K, CL, CO2<br />
84520 BUN<br />
82310 Calcium<br />
82565 Creatinine<br />
82947 Glucose<br />
80053 Comprehensive<br />
Metabolic Panel<br />
80048 Basic Metabolic Panel<br />
82040 Albumin<br />
84075 Alkaline Phos.<br />
82247 Bilirubin, Total<br />
84450 SGOT/AST<br />
84460 SGPT/ALT<br />
84155 Total Protein<br />
80076 Hepatic Function<br />
(Liver) Panel<br />
82040 Albumin<br />
82247 Bilirubin, Total<br />
82248 Bilirubin, Direct<br />
84450 AST/SGOT<br />
84460 ALT/SGPT<br />
84075 Alkaline Phos.<br />
84155 Total Protein<br />
ICD9-CM<br />
M S D X<br />
Collected by<br />
4.<br />
Code provided by<br />
Specimen Information<br />
Date Drawn Time Drawn Fasting<br />
Random<br />
A.M.<br />
P.M.<br />
Code received by<br />
ABN Signed?<br />
Yes No<br />
24 Hour Urine<br />
Volume ____________________________<br />
CPT ✔ Tests or Panels (cont’d) ICD9-CM CPT ✔ Single Tests (cont’d) ICD9-CM CPT ✔ Single Tests (cont’d)<br />
Panel or Single Tests may be selected 82378 CEA<br />
84702 Beta HCG Quant<br />
80069 Renal Function Panel 82550 CK (CPK)<br />
84146 Prolactin<br />
80048 Basic Metabolic Panel 85378 Dimer<br />
84153 PSA<br />
82040 Albumin<br />
80162 Digoxin <br />
G0103 PSA Screen<br />
84100 Phosphorus<br />
80101x7 Drug Screen, Urine<br />
85610 PT with INR <br />
80061 Lipid Profile<br />
82670 Estradiol<br />
Is pt. taking Coumadin? Y N <br />
82465 Cholesterol<br />
82728 Ferritin<br />
85730 PTT <br />
84478 Triglycerides<br />
82746 Folate<br />
Is pt. taking Heparin? Y N <br />
83718 HDL Cholesterol<br />
83001 FSH<br />
85044 Retic Count<br />
80074 Acute Hepatitis Panel 82977 Gamma GT<br />
86592 RPR<br />
86709 Hepatitis A Antibody IGM 83036 Hgb A1C (Glycohemo) 86762 Rubella Ab<br />
86705 Hepatitis B Core<br />
85014 Hematocrit<br />
85651 Sed Rate<br />
Antibody IGM<br />
85018 Hemoglobin<br />
84480 T3 Total<br />
87340 Hepatitis B Surface<br />
86701 HIV 1 Ab w/Western<br />
84479 T3 Uptake<br />
Antigen<br />
Blot confirmation<br />
84439 T4 Free<br />
86803 Hepatitis C Antibody<br />
83540 Iron<br />
84436 T4 Total<br />
83550 Iron Binding (TIBC)<br />
84403 Testosterone Total<br />
83615 LD (LDH)<br />
80198 Theophylline <br />
83655 Lead<br />
84443 TSH<br />
CPT ✔ Single Tests<br />
ICD9-CM 83002 LH Luteinizing Hormone 81001 Urinalysis w/Micro,<br />
86900 ABO Blood Group<br />
80178 Lithium<br />
auto if indicated<br />
86901 RH (D) Type<br />
83735 Magnesium<br />
82575 Urine Creatinine Clearance 24hr<br />
86850 Antibody Screen<br />
86308 Mono<br />
84156 Urine Total Protein 24 hr<br />
86920 xm packed cells ____units 80184 Phenobarbital <br />
84540 Urine Urea Nitrogen 24 hr<br />
82150 Amylase<br />
80185 Phenytoin/Dilantin <br />
CPT ✔ Microbiology<br />
86038 Antinuclear Antibody<br />
85049 Platelet Count Auto<br />
Aerobic Culture<br />
82607 B-12 Vitamin<br />
84703 Pregnancy, Qual. Serum<br />
Source________________<br />
86141 hs-CRP<br />
81025 Pregnancy, Qual. Urine<br />
Anaerobic Culture<br />
80156 Carbamazepine/Tegretol REQUIRED LAST DOSE<br />
Source________________<br />
85025 CBC w/auto diff<br />
DATE____________________<br />
A.M.<br />
Other<br />
85007 Manual Diff.<br />
TIME ____________________ P.M.<br />
Source________________<br />
<strong>Order</strong>ing Physician (Print Name)<br />
ICD9-CM<br />
ICD9-CM<br />
Only tests or Medicare Approved Panels that are medically necessary for the diagnosis or treatment of a<br />
Medicare or Medicaid patient will be reimbursed. Screening tests will not be reimbursed and should not be<br />
submitted for payment. The OIG states that a physician who orders medically unnecessary tests for which<br />
Medicare or Medicaid reimbursement is claimed may be subject to civil penalties under the False Claims Act.<br />
Date/Time<br />
Physician Authorization<br />
<strong>Lab</strong>oratory Requisition<br />
0340200916 (5/07)<br />
Original - Chart Yellow Copy - Client Pink Copy - <strong>Lab</strong>
PHYSICIAN INFORMATION<br />
PHYSICIAN / GROUP NAME _________________________________________ PHONE NO________________________ FAX NO ________________________<br />
CITY, STATE, ZIP ____________________________________________________ NPI #______________________________________________________________<br />
Patient Information<br />
Medical Necessity Information<br />
Last Name<br />
Sign, symptom, diagnosis or ICD9-CM info. is required on all tests ordered.<br />
Narrative Diagnosis<br />
First Name<br />
MI<br />
ICD9-CM Codes<br />
Social Security No.<br />
Phone No.<br />
Birthdate<br />
1.<br />
2.<br />
3.<br />
Sex<br />
M<br />
Chart No.<br />
F<br />
STAT<br />
Other Tests<br />
Marital Status<br />
Room No.<br />
Phone ( ) ____________________<br />
or<br />
Fax ( ) ____________________<br />
CPT ✔ Tests or Panels<br />
Panel or Single Tests may be selected<br />
80051 Electrolytes Panel<br />
84295 Sodium<br />
84132 Potassium<br />
82435 Chloride<br />
82374 Carbon Dioxide<br />
80048 Basic Metabolic Panel<br />
80051 Na, K, CL, CO2<br />
84520 BUN<br />
82310 Calcium<br />
82565 Creatinine<br />
82947 Glucose<br />
80053 Comprehensive<br />
Metabolic Panel<br />
80048 Basic Metabolic Panel<br />
82040 Albumin<br />
84075 Alkaline Phos.<br />
82247 Bilirubin, Total<br />
84450 SGOT/AST<br />
84460 SGPT/ALT<br />
84155 Total Protein<br />
80076 Hepatic Function<br />
(Liver) Panel<br />
82040 Albumin<br />
82247 Bilirubin, Total<br />
82248 Bilirubin, Direct<br />
84450 AST/SGOT<br />
84460 ALT/SGPT<br />
84075 Alkaline Phos.<br />
84155 Total Protein<br />
ICD9-CM<br />
M S D X<br />
Collected by<br />
4.<br />
Code provided by<br />
Specimen Information<br />
Date Drawn Time Drawn Fasting<br />
Random<br />
A.M.<br />
P.M.<br />
Code received by<br />
ABN Signed?<br />
Yes No<br />
24 Hour Urine<br />
Volume ____________________________<br />
CPT ✔ Tests or Panels (cont’d) ICD9-CM CPT ✔ Single Tests (cont’d) ICD9-CM CPT ✔ Single Tests (cont’d)<br />
Panel or Single Tests may be selected 82378 CEA<br />
84702 Beta HCG Quant<br />
80069 Renal Function Panel 82550 CK (CPK)<br />
84146 Prolactin<br />
80048 Basic Metabolic Panel 85378 Dimer<br />
84153 PSA<br />
82040 Albumin<br />
80162 Digoxin <br />
G0103 PSA Screen<br />
84100 Phosphorus<br />
80101x7 Drug Screen, Urine<br />
85610 PT with INR <br />
80061 Lipid Profile<br />
82670 Estradiol<br />
Is pt. taking Coumadin? Y N <br />
82465 Cholesterol<br />
82728 Ferritin<br />
85730 PTT <br />
84478 Triglycerides<br />
82746 Folate<br />
Is pt. taking Heparin? Y N <br />
83718 HDL Cholesterol<br />
83001 FSH<br />
85044 Retic Count<br />
80074 Acute Hepatitis Panel 82977 Gamma GT<br />
86592 RPR<br />
86709 Hepatitis A Antibody IGM 83036 Hgb A1C (Glycohemo) 86762 Rubella Ab<br />
86705 Hepatitis B Core<br />
85014 Hematocrit<br />
85651 Sed Rate<br />
Antibody IGM<br />
85018 Hemoglobin<br />
84480 T3 Total<br />
87340 Hepatitis B Surface<br />
86701 HIV 1 Ab w/Western<br />
84479 T3 Uptake<br />
Antigen<br />
Blot confirmation<br />
84439 T4 Free<br />
86803 Hepatitis C Antibody<br />
83540 Iron<br />
84436 T4 Total<br />
83550 Iron Binding (TIBC)<br />
84403 Testosterone Total<br />
83615 LD (LDH)<br />
80198 Theophylline <br />
83655 Lead<br />
84443 TSH<br />
CPT ✔ Single Tests<br />
ICD9-CM 83002 LH Luteinizing Hormone 81001 Urinalysis w/Micro,<br />
86900 ABO Blood Group<br />
80178 Lithium<br />
auto if indicated<br />
86901 RH (D) Type<br />
83735 Magnesium<br />
82575 Urine Creatinine Clearance 24hr<br />
86850 Antibody Screen<br />
86308 Mono<br />
84156 Urine Total Protein 24 hr<br />
86920 xm packed cells ____units 80184 Phenobarbital <br />
84540 Urine Urea Nitrogen 24 hr<br />
82150 Amylase<br />
80185 Phenytoin/Dilantin <br />
CPT ✔ Microbiology<br />
86038 Antinuclear Antibody<br />
85049 Platelet Count Auto<br />
Aerobic Culture<br />
82607 B-12 Vitamin<br />
84703 Pregnancy, Qual. Serum<br />
Source________________<br />
86141 hs-CRP<br />
81025 Pregnancy, Qual. Urine<br />
Anaerobic Culture<br />
80156 Carbamazepine/Tegretol REQUIRED LAST DOSE<br />
Source________________<br />
85025 CBC w/auto diff<br />
DATE____________________<br />
A.M.<br />
Other<br />
85007 Manual Diff.<br />
TIME ____________________ P.M.<br />
Source________________<br />
<strong>Order</strong>ing Physician (Print Name)<br />
ICD9-CM<br />
ICD9-CM<br />
Only tests or Medicare Approved Panels that are medically necessary for the diagnosis or treatment of a<br />
Medicare or Medicaid patient will be reimbursed. Screening tests will not be reimbursed and should not be<br />
submitted for payment. The OIG states that a physician who orders medically unnecessary tests for which<br />
Medicare or Medicaid reimbursement is claimed may be subject to civil penalties under the False Claims Act.<br />
Date/Time<br />
Physician Authorization<br />
<strong>Lab</strong>oratory Requisition<br />
0340200916 (5/07)<br />
Original - Chart Yellow Copy - Client Pink Copy - <strong>Lab</strong>
PHYSICIAN INFORMATION<br />
PHYSICIAN / GROUP NAME _________________________________________ PHONE NO________________________ FAX NO ________________________<br />
CITY, STATE, ZIP ____________________________________________________ NPI #______________________________________________________________<br />
Patient Information<br />
Medical Necessity Information<br />
Last Name<br />
Sign, symptom, diagnosis or ICD9-CM info. is required on all tests ordered.<br />
Narrative Diagnosis<br />
First Name<br />
MI<br />
ICD9-CM Codes<br />
Social Security No.<br />
Phone No.<br />
Birthdate<br />
1.<br />
2.<br />
3.<br />
Sex<br />
M<br />
Chart No.<br />
F<br />
STAT<br />
Other Tests<br />
Marital Status<br />
Room No.<br />
Phone ( ) ____________________<br />
or<br />
Fax ( ) ____________________<br />
CPT ✔ Tests or Panels<br />
Panel or Single Tests may be selected<br />
80051 Electrolytes Panel<br />
84295 Sodium<br />
84132 Potassium<br />
82435 Chloride<br />
82374 Carbon Dioxide<br />
80048 Basic Metabolic Panel<br />
80051 Na, K, CL, CO2<br />
84520 BUN<br />
82310 Calcium<br />
82565 Creatinine<br />
82947 Glucose<br />
80053 Comprehensive<br />
Metabolic Panel<br />
80048 Basic Metabolic Panel<br />
82040 Albumin<br />
84075 Alkaline Phos.<br />
82247 Bilirubin, Total<br />
84450 SGOT/AST<br />
84460 SGPT/ALT<br />
84155 Total Protein<br />
80076 Hepatic Function<br />
(Liver) Panel<br />
82040 Albumin<br />
82247 Bilirubin, Total<br />
82248 Bilirubin, Direct<br />
84450 AST/SGOT<br />
84460 ALT/SGPT<br />
84075 Alkaline Phos.<br />
84155 Total Protein<br />
ICD9-CM<br />
M S D X<br />
Collected by<br />
4.<br />
Code provided by<br />
Specimen Information<br />
Date Drawn Time Drawn Fasting<br />
Random<br />
A.M.<br />
P.M.<br />
Code received by<br />
ABN Signed?<br />
Yes No<br />
24 Hour Urine<br />
Volume ____________________________<br />
CPT ✔ Tests or Panels (cont’d) ICD9-CM CPT ✔ Single Tests (cont’d) ICD9-CM CPT ✔ Single Tests (cont’d)<br />
Panel or Single Tests may be selected 82378 CEA<br />
84702 Beta HCG Quant<br />
80069 Renal Function Panel 82550 CK (CPK)<br />
84146 Prolactin<br />
80048 Basic Metabolic Panel 85378 Dimer<br />
84153 PSA<br />
82040 Albumin<br />
80162 Digoxin <br />
G0103 PSA Screen<br />
84100 Phosphorus<br />
80101x7 Drug Screen, Urine<br />
85610 PT with INR <br />
80061 Lipid Profile<br />
82670 Estradiol<br />
Is pt. taking Coumadin? Y N <br />
82465 Cholesterol<br />
82728 Ferritin<br />
85730 PTT <br />
84478 Triglycerides<br />
82746 Folate<br />
Is pt. taking Heparin? Y N <br />
83718 HDL Cholesterol<br />
83001 FSH<br />
85044 Retic Count<br />
80074 Acute Hepatitis Panel 82977 Gamma GT<br />
86592 RPR<br />
86709 Hepatitis A Antibody IGM 83036 Hgb A1C (Glycohemo) 86762 Rubella Ab<br />
86705 Hepatitis B Core<br />
85014 Hematocrit<br />
85651 Sed Rate<br />
Antibody IGM<br />
85018 Hemoglobin<br />
84480 T3 Total<br />
87340 Hepatitis B Surface<br />
86701 HIV 1 Ab w/Western<br />
84479 T3 Uptake<br />
Antigen<br />
Blot confirmation<br />
84439 T4 Free<br />
86803 Hepatitis C Antibody<br />
83540 Iron<br />
84436 T4 Total<br />
83550 Iron Binding (TIBC)<br />
84403 Testosterone Total<br />
83615 LD (LDH)<br />
80198 Theophylline <br />
83655 Lead<br />
84443 TSH<br />
CPT ✔ Single Tests<br />
ICD9-CM 83002 LH Luteinizing Hormone 81001 Urinalysis w/Micro,<br />
86900 ABO Blood Group<br />
80178 Lithium<br />
auto if indicated<br />
86901 RH (D) Type<br />
83735 Magnesium<br />
82575 Urine Creatinine Clearance 24hr<br />
86850 Antibody Screen<br />
86308 Mono<br />
84156 Urine Total Protein 24 hr<br />
86920 xm packed cells ____units 80184 Phenobarbital <br />
84540 Urine Urea Nitrogen 24 hr<br />
82150 Amylase<br />
80185 Phenytoin/Dilantin <br />
CPT ✔ Microbiology<br />
86038 Antinuclear Antibody<br />
85049 Platelet Count Auto<br />
Aerobic Culture<br />
82607 B-12 Vitamin<br />
84703 Pregnancy, Qual. Serum<br />
Source________________<br />
86141 hs-CRP<br />
81025 Pregnancy, Qual. Urine<br />
Anaerobic Culture<br />
80156 Carbamazepine/Tegretol REQUIRED LAST DOSE<br />
Source________________<br />
85025 CBC w/auto diff<br />
DATE____________________<br />
A.M.<br />
Other<br />
85007 Manual Diff.<br />
TIME ____________________ P.M.<br />
Source________________<br />
<strong>Order</strong>ing Physician (Print Name)<br />
ICD9-CM<br />
ICD9-CM<br />
Only tests or Medicare Approved Panels that are medically necessary for the diagnosis or treatment of a<br />
Medicare or Medicaid patient will be reimbursed. Screening tests will not be reimbursed and should not be<br />
submitted for payment. The OIG states that a physician who orders medically unnecessary tests for which<br />
Medicare or Medicaid reimbursement is claimed may be subject to civil penalties under the False Claims Act.<br />
Date/Time<br />
Physician Authorization<br />
<strong>Lab</strong>oratory Requisition<br />
0340200916 (5/07)<br />
Original - Chart Yellow Copy - Client Pink Copy - <strong>Lab</strong>
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