Directory of Services - Hitachi Chemical Diagnostics

TABLE OF CONTENTSServices....................................................................................... Page 2Supplies...................................................................................... Page 2Contact Information……….......................................................... Page 2Specialized Services & Support……………….………………….. Page 2Billing.......................................................................................... Page 3CPT Codes for a Clinical Allergy Practice.................................. Page 4ICD-9 Codes............................................................................… Page 5Requisition Form……………………………………………………. Page 6Collecting, Preparing and Storing Serum..............................….. Page 7Shipping Serum Samples........................................................... Page 8Turn-Around-Time...................................................................... Page 8Additional Testing....................................................................... Page 8Panel List........................................................................…….... Page 936 Allergen Inhalant Panels.........................................…... Pages 10-14Combination Panels............................................................ Pages 15-17Food Panel................................................……………….… Page 17Individual Allergens......................……........................................ Page 18Panel Summary Matrix………………………………………….…… Page 19Specific Allergens Reported by Group…………….……….….….. Page 20

Allos Reference LaboratoryDIRECTORY OF LABORATORY SERVICESBILLINGAllos Reference Laboratory provides credit to all referring physicians,hospitals and reference laboratories. Monthly, summarized invoicestatements are sent to all customers with outstanding balances. AllosReference Laboratory accepts Visa ® and MasterCard ® for payment oflaboratory services.Direct Client Billing• Fill in the patient’s name, complete address, date of birth, date of seracollection, telephone number and ICD-9 Code in the space provided.• Payment is due upon receipt of Invoice Statement.• Refer to the “Patient Fee Schedule” for pricing.Please note: California State Law prohibits the offering of professionalcourtesy testing.Patient Pre-pay• Fill in the patient’s name, complete address, date of birth, date of seracollection, and telephone number in the space provided.• Payment can be made in one of two ways: 1) In the form of acheck/money order payable to “Allos Reference Laboratory,” or 2) viaVisa or MasterCard. Payment must be included with the specimen.Failure to include payment will delay testing.• Refer to the “Patient Fee Schedule” for pricing.Insurance/Third Party Billing• Fill in the patient’s name, complete address, date of birth, date of seracollection, telephone number and ICD-9 code in the space provided.• Attach a copy of the patient’s insurance card(s) to requisition form.• Include your Physician UPIN number and Physician signature on therequest form.• Refer to the “Patient Fee Schedule” for pricing.3

Allos Reference LaboratoryDIRECTORY OF LABORATORY SERVICESCPT CODINGThe following CPT Codes have been identified courtesy of the 2011 AMACPT Code Book. Allos Reference Laboratory is happy to provide thisinformation, but cannot be liable for any misfiled claims.DescriptionCPT CodeCollection of venous blood by venipuncture 36415Handling and/or conveyance of specimen fortransfer from the physician’s office to alaboratoryAllergen Specific IgE; Quantitative orSemiquantitative, Each Allergen20 Allergen Panel x 2025 Allergen Panel x 2536 Allergen Panel x 3699000860034

Allos Reference LaboratoryDIRECTORY OF LABORATORY SERVICESICD-9 DIAGNOSTIC CODINGIt is the physician’s responsibility to determine which code to use when billingfor specific procedures and services. ICD-9 Diagnostic codes commonlyassociated with in vitro allergy testing are listed as they appear in the 2011ICD-9-CM Code Book.Allergic Rhinitis:Gastroenterology (continued):472.0.................. Chronic Rhinitis 558.42................. Eosinophilic Colitis477.8.................. Other Allergens, Rhinitis 530.13................. Eosinophilic Esophagitis477.0.................. Pollen Rhinitis 535.71................. Eosinophilic Gastritis471.0.................. Polyps (nasal cavity) (with Hemorrhage)471.8.................. Polyps (sinuses) 535.70................. Eosinophilic Gastritis474.10................ Tonsil & Adenoid Hypertrophy (without Hemorrhage)474.11................ Tonsil / Hypertrophy Alone 558.41................. Eosinophilic Gastroenteritis530.10................. Esophagitis, UnspecifiedEar:783.41................. Failure to Thrive382.9.................. Otitis Media, Unspecified 783.3................... Feeding Problem381.01................ Serious Otitis Media Acute 530.19................. Gastroesophagitis, Unspecified381.10................ Serious Otitis Media Chronic 787.03................. Vomiting Alone536.2................... Vomiting, PersistentEye:372.05................ Acute Atopic Conjunctivitis Respiratory:372.14................ Chronic Atopic Conjunctivitis 493.90................. Asthma, Unspecified493.91................. Asthma, Unspecified w/ StatusFood Anaphylaxis:786.2................... Cough995.62................ Crustaceans 493.00................. Extrinsic Asthma995.68................ Eggs 493.01................. Extrinsic Asthma w/ Status995.65................ Fish 786.07................. Wheezing995.66................ Food Additives995.63................ Fruits / Vegetables Sinus:995.67................ Milk Products 461.9................... Acute Unspecified Sinusitis995.64................ Nuts / Seeds 473.9................... Chronic Unspecified Sinusitis995.69................ Other Specified Foods:_________ 461.8................... Pan Acute Sinusitis, Unspecified995.61................ Peanut995.60................ Unspecified Skin:995.3.................. Unspecified Allergy Rxn. 995.1................... Angioneurotic Edema691.8................... Atopic DermatitisGastroenterology:693.1................... Dermatitis Due to Food Ingestion789.00................ Abdominal Pain, Unspecified Site 692.9................... Dermatitis, Unspecified789.06................ Abdominal Pain, Epigastric 692.5................... Food Contact Dermatitis789.07................ Abdominal Pain, Generalized 698.9................... Pruritus789.09................ Abdominal Pain, 708.9................... UrticariaOther Specific Site / Multiple 708.0................... Urticaria Allergic535.00................ Acute Gastritis (w/out Hemorrhage) 708.1................... Urticaria Idiopathic558.3.................. Allergic Colitis (ID Type)558.9.................. Colitis / Gastroenteritis, Other:Noninfectious, Unspecified995.0................... Anaphylactic Shock, Other787.9................... Diarrhea 269.9................... Nutritional Deficiency, Unspecified5

ALLOSReference LaboratoryReference #Patient (Last, First, MI)AddressCitySexCollection DateDate of BirthBill To:ICD-9 Code(s)SS NumberPhone( )Freeze Date:Thaw Date:Insurance (Attach front and back copy of card)No Medicaid or Medicare1. 2. 3. 4.HITACHI CHEMICAL DIAGNOSTICS, INC.630 Clyde Court, Mountain View, CA 94043Phone: (800) 272-6278 Fax: (650) 969-2745Patient Payment Agreement:I acknowledge that if my insurance denies payment, I agreeto be personally and fully responsible for payment of anyoutstanding balanceFor Lab Use OnlyRequesting PhysicianUPIN#Provider #Physician SignatureGroup/Laboratory NameAddressCityStateZipPhone #Fax #Bill To: PhysicianLaboratoryPatient Pre-Pay: Include Check or Credit Card onlyCheck payable to Allos Reference LaboratoryPayments Visa ® Master Card ®Card NumberPrint Name on CardExpiration DateSignatureDateSignatureFax Report To:_____________________________Accession #IgE PanelsRequire 2ml serum per panel*(36 Allergen, Specific IgE Assay)Additional Individual Allergens1402 Eastern Combination1418 Moderate Food1404 Northeastern Inhalant1405 Northwestern Inhalant1406 Pediatric Combination1407 Southeastern Inhalant1408 Southern Combination1409 Southwestern Inhalant1410 Western Combination1411 Western Inhalant________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Specimen for Split Sample Comparison Testing:PLEASE INCLUDE YOUR RESULTS WITH THE SERUM SAMPLE*Optigen ® Universal Specific IgE panelRequires only 0.5 ml serum(20 Allergen Specific IgE Assays)3001 Optigen ® Universal 20Order Additional Supplies:Kits to MAIL Samples to Allos Labs10 20 Specify # _________Extra Requisitions: Quantity __________White - ARL Laboratory Canary - Billing Pink - Client Rev. 9/10

Allos Reference LaboratoryDIRECTORY OF LABORATORY SERVICESCOLLECTING, PREPARING AND STORING SERUMAll patient specimens should be handled as being potentially biohazardous.Universal precautions should be followed.1. Draw blood into a 5-10 mL red top or serum separator tube.i. Serum separator tubes (SST) contain an inert material, whichseparates the serum from the cells when centrifuged.ii. Hemolyzed or lipemic serum may adversely affect theperformance of the CLA Allergen Specific IgE Assay. If sample islipemic or hemolyzed, redraw sample.2. Allow blood to clot in the original tube for 30 minutes.3. Centrifuge clotted blood 10-20 minutes at 2k-3k x g in original tube.4. Transfer serum from the primary tube into an appropriately labeled,clean plastic transport tube. Ensure no red blood cells are transferred.Each CLA® Panel requires a minimum of 2.0 mL of serum. EachOPTIGEN® Panel requires a minimum of 0.5 mL of serum.5. Label plastic tubes with the following:i. Patient’s Nameii. Ordering physician’s nameiii. Date of collection74.0mL2.0mL0.5mL6. Complete request form. The following information is required:i. Patient’s full nameii. Physician’s nameiii. Patient’s DOB, Sex (optional)iv. Billing Informationv. Date serum collectedvi. Test or panels requested7. Store serum sample in refrigerator (2-8° C) if not shipped on day ofcollection (avoid shipping on Fridays and before holidays). If samplesare to be shipped in excess of five days from collection, they should befrozen (-20° +/- 10° C). Freeze and thaw dates should be noted on therequisition form.8. Samples older than one month will not be accepted for testing.9. Lipemic, hemolyzed or insufficient samples will not be accepted.

Allos Reference LaboratoryDIRECTORY OF LABORATORY SERVICESSHIPPING SAMPLESAllos Reference Laboratory encourages the prevention of specimen leakageand accidental exposure to biological agents. Our mailers, when usedproperly, comply with current packaging standards for biological products.1. For proper sample collection and storage, please refer to the “Collecting,Preparing Storing Serum” section on page six.2. Tighten the lid on the specimen vials. If the specimens are frozen, thawfirst, then re-tighten the lids.3. Wrap the specimen vials in absorbent material.4. Seal the wrapped vials in the second pocket of the sample bag.5. Place the folded requisition form in the first pocket of the sample bag.6. Fold the sample bag and place inside the pre-addressed bubble mailer,seal and drop in the mail.Overnight shipping is available upon request.TURN AROUND TIMESTest results are available approximately three business days after receivingthe sample. Results are faxed upon completion of assay and a hard copy ofall results is mailed to the requesting provider.Allos Reference Laboratory closes for approximately ten days over the winterholidays. A specific schedule is provided annually before Thanksgiving.ADDITIONAL TESTINGIn some cases, clients may require additional testing. Please contact AllosReference Laboratory and provide the patient’s name, accession number andadditional tests to be done. All orders must be submitted in writing.Extra serum is stored for one month after receipt of the sample.8

Allos Reference LaboratoryDIRECTORY OF LABORATORY SERVICESALLERGEN PANELS36 ALLERGEN INHALANT PANELS PageNortheastern Inhalant Panel, 36 Allergens (1404) 9Northwestern Inhalant Panel, 36 Allergens (1405) 10Southeastern Inhalant Panel, 36 Allergens (1407) 11Southwestern Inhalant Panel, 36 Allergens (1409) 12Western Inhalant Panel, 36 Allergens (1411) 13COMBINATION PANELSEastern Combination Panel, 36 Allergens (1402) 14Southern Combination Panel, 36 Allergens (1408) 14Western Combination Panel, 36 Allergens (1410) 15Pediatric Combination Panel, 36 Allergens (1406) 15OPTIGEN ® Universal 20 Panel, 20 Allergens (3001) 16FOOD PANELModerate Food Panel, 25 Allergens (1418) 179

Allos Reference LaboratoryDIRECTORY OF LABORATORY SERVICES36 ALLERGEN INHALANT PANELSNortheastern Inhalant Panel, 36 Allergens (1404)TreesAlder, WhiteAsh, WhiteBeech, AmericanBirch, WhiteBox Elder, MapleCottonwood, EasternElm, WhiteHickory, ShellbarkOak, WhitePine MixPrivetSycamore, AmericanGrassesBermuda GrassMeadow FescuePerennial RyeOrchard Grass/CocksfootTimothy GrassWeedsBurningbushCockleburEnglish PlantainLamb's QuartersMarshelder, RoughMugwortNettlePigweedRagweed, ShortSheep SorrelAnimal EpidermalsCatCockroach MixDogHousedust & MitesHousedustMite, FarinaeMoldsAlternariaAspergillusCladosporiumPenicillium10

Allos Reference LaboratoryDIRECTORY OF LABORATORY SERVICES36 ALLERGEN INHALANT PANELSNorthwestern Inhalant Panel, 36 Allergens (1405)TreesAsh, WhiteAspen, QuakingBirch/Alder MixBox Elder, MapleCedar, MountainCottonwood, BlackElm MixOak MixPine MixPrivetSycamore, AmericanWalnut/Hickory/Pecan MixWillow, ArroyoGrassesSweet VernalGrassWeedsBurningbushCockleburEnglish PlantainLamb's QuartersMarshelder, RoughNettlePigweedRagweed, FalseRagweed, WesternRussian ThistleSagebrush MixShadscaleSheep SorrelWaterhempAnimal EpidermalsCatDogMitesMite, FarinaeMoldsAlternariaAspergillusCandidaCladosporiumPenicillium11

Allos Reference LaboratoryDIRECTORY OF LABORATORY SERVICES36 ALLERGEN INHALANT PANELSSoutheastern Inhalant Panel, 36 Allergens (1407)TreesAcaciaAsh, WhiteBeech, AmericanBirch/Alder MixBox Elder, MapleCedar, MountainCottonwood, EasternElm, WhiteMelaleucaMulberry MixOak, WhitePine MixPrivetSycamore, AmericanWalnut/Hickory/Pecan MixGrassesBahia GrassBermuda GrassTimothy GrassWeedsCockleburEnglish PlantainLamb's QuartersMarshelder, RoughPigweedRagweed, ShortSheep SorrelWaterhempAnimal EpidermalsCatCockroach MixDogHousedust & MitesHousedustMite, FarinaeMoldsAlternariaAspergillusCandidaCladosporiumPenicillium12

Allos Reference LaboratoryDIRECTORY OF LABORATORY SERVICES36 ALLERGEN INHALANT PANELSSouthwestern Inhalant Panel, 36 Allergens (1409)TreesAsh, WhiteBirch/Alder MixBox Elder, MapleCedar, MountainCottonwood, EasternElm, WhiteMesquiteMulberry MixOak MixOlivePine MixPrivetSycamore, AmericanWalnut/Hickory/Pecan MixGrassesBermuda GrassKentucky BlueGrassPerennial RyeWeedsBurningbushCockleburEnglish PlantainLamb's QuartersMarshelder, RoughPigweedShadscaleRagweed, ShortRussian ThistleSagebrush MixSheep SorrelWaterhempAnimal EpidermalsCatDogHousedust & MitesHousedustMite, FarinaeMoldsAlternariaAspergillusCladosporium13

Allos Reference LaboratoryDIRECTORY OF LABORATORY SERVICES36 ALLERGEN INHALANT PANELSWestern Inhalant Panel, 36 Allergens (1411)TreesAcaciaAsh, WhiteBirch, WhiteBox Elder, MapleCedar, MountainCottonwood, BlackElm MixEucalyptusOak, WhiteOliveSycamore, AmericanWalnut/Hickory/Pecan MixWillow, ArroyoGrassesBermuda GrassKentucky BlueGrassJohnson GrassWeedsBurningbushCockleburEnglish PlantainLamb's QuartersMugwortPigweedRagweed, FalseRagweed,WesternRussian ThistleSagebrush MixShadscaleSheep SorrelAnimal EpidermalsCatCockroach MixDogMitesMite, FarinaeMoldsAlternariaAspergillusCandidaCladosporium14

Allos Reference LaboratoryDIRECTORY OF LABORATORY SERVICESCOMBINATION PANELSEastern Combination Panel, 36 Allergens (1402)TreesAsh, WhiteBox Elder, MapleCottonwood, EasternElm, WhiteHickory, ShellbarkOak, WhiteGrassesBermuda GrassSweet Vernal GrassTimothy GrassWeedsCockleburEnglish PlantainLamb's QuartersMugwortRagweed, ShortAnimalEpidermalsCatCockroach MixDogHousedust &MitesHousedustMite, FarinaeMoldsAlternariaAspergillusCladosporiumPenicilliumFoodsAlmondCornEgg, WholeGarlicMilkOrangePeanutPotatoRiceShellfish MixSoybeanWheatYeast, Baker'sSouthern Combination Panel, 36 Allergens (1408)TreesBox Elder, MapleElm MixMelaleucaOak, WhitePine MixWalnut/Hickory/Pecan MixGrassesBahia GrassBermuda GrassTimothy GrassWeedsEnglish PlantainLamb's QuartersPigweedRagweed, ShortSheep SorrelAnimalEpidermalsCatCockroach MixDogMitesMite, FarinaeMoldsAlternariaAspergillusCladosporiumPenicilliumFoodsAlmondCornEgg, WholeGarlicMilkOrangePeanutPotatoRiceShellfish MixSoybeanVegetable MixWheatYeast, Baker's15

Allos Reference LaboratoryDIRECTORY OF LABORATORY SERVICESCOMBINATION PANELSWestern Combination Panel, 36 Allergens (1410)TreesAcaciaCedar, MountainCottonwood, BlackElm MixOak, WhiteOliveWalnut/Hickory/Pecan MixGrassesBermuda GrassTimothy GrassWeedsEnglish PlantainLamb's QuartersPigweedRagweed, FalseSagebrush MixAnimalEpidermalsCatCockroach MixDogMitesMite, FarinaeMoldsAlternariaAspergillusCandidaCladosporiumPenicilliumFoodsAlmondCornEgg, WholeGarlicMilkOrangePeanutPotatoRiceShellfish MixSoybeanWheatYeast, Baker'sPediatric Combination Panel, 36 Allergens (1406)TreesBox Elder, MapleCedar, MountainElm MixOak MixOlive/Privet/Ash MixWalnut/Hickory/Pecan MixGrassesBermuda GrassGrass MixWeedsAtriplex MixEnglish PlantainLamb's QuartersPigweedRagweed Mix IRumex MixSagebrush MixAnimalEpidermalsCatCockroach MixDogHousedust &MitesHousedustMite, FarinaeMoldsAlternariaAspergillusCandidaCladosporiumPenicilliumFoodsCornEgg, WholeMilkOrangePeanutRiceShellfish MixSoybeanTomatoWheatYeast, Baker's16

Allos Reference LaboratoryDIRECTORY OF LABORATORY SERVICESCOMBINATION PANELSOPTIGEN ® Universal 20 Panel, 20 Allergens (3001)TreesBirch, WhiteGrassesTimothy GrassInsectCockroach MixEnvironmentalLatexWeedsMugwortRagweed Mix IAnimalEpidermalsCatDogHousedust &MitesMite, FarinaeMite,PteronyssinusMoldsAlternariaAspergillusCladosporiumFoodsCodfishCow’s MilkEgg WhitePeanutRiceSoybeanWheatFood PanelModerate Food Panel, 25 Allergens (1418)AlmondAppleBarleyBean, WhiteBeefChickenChocolateCornEgg, WholeGarlicMilkOatOnion MixOrangePeanutPorkPotatoRiceShellfish MixSoybeanTomatoTunaVegetable MixYeast, BakersWheat17

Allos Reference LaboratoryDIRECTORY OF LABORATORY SERVICESINDIVIDUAL ALLERGENSAllergens not found in a specific panel may be requested. Please call forpricing of specific allergens and/or the availability of allergens not listed.Animal EpidermalsChicken DuckCockatiel GerbilCowGooseGuinea PigHamsterHorseMouseParakeetRabbitRatFoodsPlease SpecifyGrassesPlease SpecifyInsect VenomsFire Ant VenomHymenoptera Panel (Honey Bee, Paper Wasp, White Faced& Yellow Hornet, Yellow Jacket)MoldsBotrytis Fusarium Epicoccum Mucor RhizopusOther Pollens / AllergensPlease SpecifyTreesPlease SpecifyWeedsPlease Specify18

Allos LabPanel MatrixAnimal EpidermalsEastern Comb.Moderate FoodNE InhalantNW InhalantOPTIGEN® U20Pediatric Comb.SE InhalantSouthern Comb.SW InhalantWestern Comb.Western Inhal.Allos Reference LaboratoryDIRECTORY OF LABORATORY SERVICESEastern Comb.Moderate FoodNE InhalantNW InhalantOPTIGEN® U20Pediatric Comb.SE InhalantSouthern Comb.SW InhalantWestern Comb.Western Inhal.Cat x x x x x x x x x x Acacia x x xDog x x x x x x x x x x Alder, White xCockroach Mix* x x x x x x x x Ash, White x x x x x xEnvironmental Aspen, Quaking xLatex x Beech, American x xFoods Birch, White x x xAlmond x x x x Birch/Alder Mix* x x xApple x Box Elder, Maple x x x x x x x xBarley x Cedar, Mountain x x x x x xBean, White x Cottonwood, Black x x xBeef x Cottonwood, Eastern x x x xChicken x Elm Mix* x x x x xChocolate x Elm, White x x x xCodfish x Eucalyptus xCorn x x x x x Hickory, Shellbark x xEgg White x Melaleuca x xEgg, Whole x x x x x Mesquite xGarlic x x x x Mulberry Mix* x xMilk x x x x x x Oak Mix* x x xOat x Oak, White x x x x x xOnion Mix* x Olive x x xOrange x x x x x Olive/Privet/Ash Mix* xPeanut x x x x x x Pine Mix* x x x x xPork x Privet x x x xPotato x x x x Sycamore, American x x x x xRice x x x x x x Walnut/Hickory/Pecan Mix* x x x x x x xShellfish Mix* x x x x x Willow, Arroyo x xSoybean x x x x x x Housedust & MitesTomato x x Housedust x x x x xTuna x Mite, Farinae x x x x x x x x x xVegetable Mix* x x Mite, Pteronyssinus xWheat x x x x x x WeedsYeast, Baker's x x x x x Atriplex Mix* xGrasses Burningbush x x x xBahia Grass x x Cocklebur x x x x x xBermuda Grass x x x x x x x x English Plantain x x x x x x x x xGrass Mix* x Lamb's Quarters x x x x x x x x xJohnson Grass x Marshelder, Rough x x x xKentucky Blue Grass x x Mugwort x x x xMeadow Fescue x Nettle x xOrchardGrass/Cocksfoot x Pigweed x x x x x x x xPerennial Rye x x Ragweed Mix I* x xSweet Vernal Grass x x Ragweed,Short x x x x xTimothy Grass x x x x x x Ragweed, False x x xMolds Ragweed, Western x xAlternaria x x x x x x x x x x Rumex Mix* xAspergillus x x x x x x x x x x Russian Thistle* x x xCandida x x x x x Sagebrush Mix* x x x x xCladosporium x x x x x x x x x x Shadscale x x xPenicillium x x x x x x x Sheep Sorrel x x x x x xWaterhemp x x x* Mix based on specific allergens. See Page 20 for the constituents of each.Trees19

Allos Reference LaboratoryDIRECTORY OF LABORATORY SERVICESSpecific Allergens Reported by GroupThe following screens are reported as a mix based on specific allergenswithin each mix. The constituents of each are listed below. To see whichPanel(s) they are located on, see the Panel Matrix on page 19.Atriplex MixLenscaleShadscaleWingscaleElm MixElm, WhiteChinese ElmFall Blooming ElmHackberryBirch/Alder MixAlder, MountainAlder, SpeckledAlder, WhiteBirch, WhiteCockroach MixCockroach, AmericanCockroach, GermanGrass MixAnnual Blue GrassKentucky Blue GrassMeadow FescueOrchard Grass/CocksfootPerennial RyeRedtop GrassSalt GrassSweet Vernal GrassTimothy GrassMulberry MixRed MulberryWhite MulberryOak MixCalifornia Black OakCalifornia Live OakGambel OakScrub OakWestern White OakWhite OakOlive/Privet/Ash MixAsh, ArizonaAsh, WhiteOlivePrivetOnion MixWhite OnionYellow OnionPine MixAustrian Black PineLodgepole PineVirginia Scrub PineYellow PonderosaPineRagweed Mix IRagweed, GiantRagweed, ShortRumex MixCurly DockSheep SorrelSagebrush MixCoastal SageMugwortWormwoodShellfish MixClamCrabShrimpWalnut/Hickory/Pecan MixBitternut HickoryBlack WalnutEnglish WalnutPecanShellbark HickoryShagbark HickoryWhile HickoryVegetable MixBroccoliPepper, GreenTomatoZucchini20