HACKENSACK UNIVERSITY MEDICAL CENTER - HUMCMD.net

HACKENSACK UNIVERSITY MEDICAL CENTER30 Prospect Avenue, Hackensack, NJ 07601 • (201) 996-4222GENERAL LABORATORY TESTREQUISITIONHUMC Doctor Number:(License Number if not on Staff)PHYSICIAN INFORMATION (Please Print)Ordering PhysicianTelephone:Fax:Send Copies of Results: Physician 1: Phone #:(First Name, Last Name) Physician 2: Phone #:PATIENT INFORMATION (Please Print)Date:Patient’s Name:Last First InitialSocial Security #:Birthdate (Mo/Day/Yr):Sex: ❑ Male ❑ FemaleTelephone (Day):Telephone (Evening):Physician Notice and Other Persons Legally Authorized to Order Tests for which Medicare reimbursement is sought: Medicare does not cover routinescreening tests and will only pay for tests that meet the Medicare coverage criteria. Medicare will only pay for tests which Medicare considers reasonableand necessary and supported by the patient's medical record.Federal Regulation (Balanced Budget Act Section 4317(b)) requires that physicians and practitioners provide diagnostic information when ordering itemsor services furnished by another entity.ICD-9 DIAGNOSIS CODES(include all codes for reason for visit, applicable family history or chronic condition)1. 4. 7.2. 5. 8.3. 6. 9.S - Serum/gel L - Lav/Whole Blood B - Blue ▲ - Carrier Specific Limited Test * Additional Testing - See BackORGAN/DISEASE PANELS CHEMISTRY/IMMUNOLOGY (cont) ❑ HDL ▲S ❑ T3 Uptake ▲S URINE/STOOLS (cont)(SEE BACK FOR TESTS) ❑ AmylaseS ❑ HbA1c ▲L ❑ T4 ▲S ❑ Occult Blood screen❑ Acute Hepatitis Panel ▲ S ❑ ALTS ❑ Hepatitis B surface ab ▲ S ❑ T4 Free ▲S ✛ see back❑ Basic Metabolic Panel S ❑ ANA*S ❑ Hepatitis B surface ag ▲ S ❑ TSH ▲S ❑ Protein (requires❑ Complete Metabolic Panel S ❑ ASOS ❑ Hepatitis B core ab ▲ S ❑ Triglycerides ▲S 24 hr. urine collection)❑ Electrolyte Panel S ❑ ASTS ❑ Hepatitis A ab ▲ S ❑ Uric AcidS❑ Hepatic Function Panel S ❑ Bilirubin, TotalS ❑ Hepatitis C ab ▲ SMICROBIOLOGY❑ Lipid Panel ▲S ❑ Bilirubin, DirectS ❑ Heterophile (Monotest) S THERAPEUTIC DRUGS❑ Source❑ Renal Function Panel S ❑ BUNS ❑ IgAS❑ Digoxin ▲S ❑ Routine Culture (Gram stain,❑ CRP (C-Reactive Protein) S ❑ IgGS❑ DilantinS ID/susceptibility performed ifHEMATOLOGY ❑ CalciumS ❑ IgMS❑ LithiumS indicated, at additional charge)❑ CBC (includes auto diff) ▲ L ❑ Cholesterol ▲S ❑ Iron ▲ (Fe)S❑ PhenobarbitalS ❑ Genital Culture (GC only)❑ Manual Differential ▲ ❑ ChlorideS ❑ Iron/IBC ▲S❑ TheophyllineS ❑ Genital Culture❑ Platelet Count ▲ L ❑ Carbon Dioxide (CO2) S ❑ LDS❑ Valproic AcidS (Grp B strep only)❑ Hematocrit/Hemoglobin ▲ L ❑ CreatinineS ❑ Magnesium ▲S Please complete for all drugs: ❑ AFB (TB)culture & smear❑ PT ▲B ❑ CEA ▲2L ❑ Phosphorus, Inorg. (PO4) S❑ Fungus culture❑ PTT ▲B ❑ CK ▲S ❑ Protein, totalS❑ Gram Stain Only❑ FibrinogenB ❑ CKMB ▲S ❑ Protein electrophoresis* S❑ Ova/Parasites (X )❑ Retic CountL ❑ Cortisol AM PM S ❑ ProgesteroneS Time of Dose am / ❑ Urine culture, routine ▲❑ Sed Rate (ESR) L ❑ EstradiolS ❑ ProlactinSpm❑ Virology (Specify - See Manual❑ Hgb Electrophoresis* L ❑ FSHS ❑ PSA ▲ PSA Diagnostic Sfor Test Menu)❑ Special Coagulation Studies ❑ LHS ❑ PSA screen † see back ▲ SURINE/STOOLS❑ General Isolation(call lab)❑ Folate/Vitamin B12 S ❑ RA ▲S❑ Urinalysis ▲❑ PCR HIV-RNA viral load❑ Ferritin ▲S ❑ RPR (VDRL) ▲* S❑ Urinalysis w/microscopic ▲ ❑ PCR ChlamydiaCHEMISTRY/IMMUNOLOGY ❑ GGTP ▲S ❑ RubellaS❑ Creatinine Clearance❑ PCR Chlamydia & GC Combo❑ Glucose ▲S ❑ SodiumS❑ AlbuminS(requires timed serum & urine) ❑ Viral antibody determination❑ HCG, quant. ▲S ❑ T3 Total ▲S❑ Alk. PhosS❑ Occult Blood ▲SpecifyPhysician’s Signature:Date:HUMC GENERAL LABORATORY TESTS MEDICAL RECORD REV 4/14/03 HBF

LABORATORY SERVICESSAMPLE CODESARTHRITIS PANEL - Uric acid, sed. rate, ANA, Rubella.BASIC METABOLIC PANEL (CHEM 7) - CO2, chloride, creatinine, glucose, potassium, sodium, BUN.COMPREHENSIVE METABOLIC PANEL (CHEM12) - albumin, calcium, chloride, alk. phos., total bilirubin, creatinine,glucose, potassium, total protein, sodium, SGOT, BUNELECTROLYTE PANEL (CHEM 4) - CO2, CHLORIDE, POTASSIUM, SODIUM.HEPATIC FUNCTION A (CHEM 6) - albumin, alk phos, Bilirubin (direct and total), SGOT, SGPTHEPATITIS PANEL - HbsAg, HbsAb, HbcAg, HAAB, HbcAbLIPID PANEL - cholesterol, triglycerides, HDLOBSTETRIC PANEL - CBC (inc. diff), HbsAg, Rubella, RPR, ABO, RHTHYROID PANEL - total thyroxine (T4), T3 resin uptakeTHYROID PANEL WITH TSH - total thyroxine (T4), T3 resin uptake, TSHTORCH ANTIBODY PANEL - CMV, RUBELLA, Herpes simplex, ToxoplasmaAdditional Information:Hemoglobin electrophoresis - iron and TIBC performed if indicatedHepatitis testing includes RIBA if indicatedCODE DESCRIPTION789.00 ABDOMINAL PAIN790.6 ABNORMAL BLOOD CHEMISTRY790.92 ABNORMAL COAGULATION PROFILE792.1 ABNORMAL FIND-STOOL CONTENTS794.9 ABNORMAL FUNCTION STUDY NEC794.8 ABNORMAL LIVER FUNCTION STUDY783.21 ABNORMAL LOSS OF WEIGHT795.0 ABNORMAL PAP SMEAR-CERVIX626.0 ABSENCE OF MENSTRUATION595.0 ACUTE CYSTITIS535.0 ACUTE GASTRITIS S HEMOR460 ACUTE NASOPHARYNGITIS462 ACUTE PHARYNGITIS314.01 ADA WITH HYPERACTIVITY995.3 ALLERGY, UNSPECIFIED704.00 ALOPECIA NOS569.0 ANAL & RECTAL POLYP285.9 ANEMIA NOS413.9 ANGINA PECTORISV28.8 ANTENATAL SCREENING NEC424.1 AORTIC VALVE DISORDER447.6 ARTERITIS NOS716.90 ARTHROPATHY NOS-UNSPEC627.4 ARTIF MENOPAUSE STATES493.90 ASTHMA W/O STATUS ASTHATICUS427.31 ATRIAL FIBRILLATION627.3 ATROPHIC VAGINITIS401.1 BENIGN HYPERTENSION211.3 BENIGN NEOPLASM LG BOWEL222.2 BENIGN NEOPLASM PROSTRATE296.7 BIPOLAR AFFECTIVE DISORDER298.9 BLOOD DISEASE NOS239.2 BONE/SKIN NEOPLASM NOS239.6 BRAIN NEOPLASM NOS592.0 CALCULUS OF KIDNEY602.0 CALCULUS OF PROSTATE174.9 CARCINOMA BREAST NOS153.9 CARCINOMA COLON NOS162.9 CARCINOM LUNG, AS PRIMARY SITE183.0 CARCINOMA OVARY185 CARCINOMA PROSTATE427.9 CARDIAC DYSRHYTHMIA NOS786.50 CHEST PAIN NOS786.6 CHEST SWELLING/MASS/LUMP585 CHRONIC RENAL FAILURE428.0 CONGESTIVE HEART FAILURE780.39 CONVULSIONS496 COPD414.01 CORONARY ARTERY DISEASE786.2 COUGH436 CVA277.00 CYSTIC FIBROS W/O ILEUS595.9 CYSTITIS NOSCODE DESCRIPTIONV72.2 DENTAL EXAMINATION311 DEPRESSIVE DISORDER NEC692.9 DERMATITIS NOS250.01 DIABETES MELLITUS, INSULIN DEPEND250.00 DIABETES, NON INSULIN DEPEND787.91 DIARRHEA009.2 DIARRHEA, INFECTIOUS722.93 DISC DISORD NEC/NOS-LUMB528.5 DISEASES OF LIPS246.9 DISORDER OF THYROID NOS374.89 DISORDERS OF EYELID NEC780.4 DIZZINESS AND GIDDINESS625.3 DYSMENORRHEA622.1 DYSPLASIA OF CERVIX276.9 ELECT/FLUID DISCORD NEC790.93 ELEVATED PSA492.8 EMPHYSEMA NEC424.90 ENDOCARDITIS UNSPECIFIED259.9 ENDOCRINE DISORDER NOS785.6 ENLARGEMENT LYMPH NODES345.90 EPILEPSY NOS-NOT INTRACTV70.4 EXAM-MEDICOLEGAL REASONS626.2 EXCESSIVE MENSTRUATION625.9 FEMALE GENITAL SYMPTOMS NOS628.9 FEMALE INFERTILITY NOS774.6 FETAL/NEONATAL JAUND NOS780.6 FEVER558.9 GASTROENTERITIS, NON VIRAL574.20 GB CALCULUS W/0 CHOL780.9 GENERAL SYMPTOMS NECV26.3 GENETIC COUNSELING240.9 GOITER NOSV72.3 GYNECOLOGIC EXAMINATION784.0 HEADACHE389.9 HEARING LOSS NOS429.9 HEART DISEASE NOSV42.2 HEART VALVE REPL NEC599.7 HEMATURIA459.0 HEMORRHAGE NOS573.3 HEPATITIS NOSV67.51 HIGH-RISK TX NEC EXAM272.4 HYPERLIPIDEMIA NEC/NOS600.9 HYPERPLASIA OF PROSTATE401.9 HYPERTENSION NOS251.2 HYPOGLYCEMIA NOS244.9 HYPOTHYROIDISM NOX356.9 IDIO PERIPH NEUROPAT NOS279.3 IMMUNITY DEFICIENCY NOS136.9 INFECT/PARASITE DIS NOS075 INFECTIOUS MONONUCLEOSIS280.9 IRON DEF ANEMIA NOS626.4 IRREGULAR MENSTRUATION564.1 IRRITABLE COLONCODE DESCRIPTION782.4 JAUNDICE NOS719.06 JOINT EFFUSION-L/LEG719.46 JOINT PAIN-L/LEG719.40 JOINT PAIN-UNSPEC714.30 JUVENILE RHEUMATIC ARTHRITISV42.0 KIDNEY TRANSPLANT STATUS783.40 LACK NORM PHYSIOL DEVEL272.9 LIPOID METAB DISORD NOSV42.7 LIVER TRANSPLANT STATUS686.9 LOCAL AKIN INFECTION NOS782.2 LOCAL SUPERF SWELLINGV58.69 LONG-TERM USE MEDS NEC444.22 LOWER EXTREMITY EMBOLISM959.7 LOWER LEG INJURY NOS724.2 LUMBAGO722.10 LUMBAR DISC DISPLACEMENT724.2 LUMBOSACRAL NEURITIS NOS611.72 LUMP OR MASS IN BREAST088.81 LYME DISEASE780.79 MALAISE AND FATIGUE606.9 MALE INFERTILITY NOS199.1 MALIGNANT NEOPLASM NECV70.3 MED EXAM NEC-ADMIN627.9 MENOPAUSAL DISORDER NOS627.9 MENOPAUSAL SYNDROME626.8 MENSTRUAL DISORDER NEC626.6 METRORRHAGIA346.90 MIGRAIN NOS/NOT INTRACT424.0 MITRAL VALVE DISORDER396.9 MITRAL/AORTIC DISEASE NOS446.1 MUCOCUTAN LN SYNDROME622.7 MUCOUS POLYP OF CERVIX728.89 MUSCLE/LIGAMENT DIS NEC729.1 MYALGIA AND MYOSITIS NOS117.9 MYCOSES NEC & NOS300.9 NEUROTIC DISORDER NOS782.1 NONSPECIF SKIN ERUPT NEC241.0 NONTOX UNINODULAR GOITER783.9 NUTRIT/METABOLIC DISORDER278.00 OBESITY NOSV71.89 OBSERV. SUSPECTED CONDITION438.89 OLD CVA412 OLD MYOCARDIAL INFARCT715.90 OSTEOARTHRITIS, NOS729.5 PAIN IN LIMB423.9 PERICARDIAL DISEASE NOS486 PNEUMONIA, ORGANISM NOS627.1 POSTMENOPAUSAL BLEEDINGV72.4 PREG EXAM-PREG UNCONFIRMV22.2 PREG STATE, INCIDENTAL427.60 PREMATURE BEATS NOS287.3 PRIMARY THROMBOCYTOPENIAV26.29 PROCREATIVE MGMT-INVESTIGATIONCODE DESCRIPTION617.0 UTERINE ENDOMETRIOSIS602.8 PROSTATIC DISORDERS NEC791.0 PROTEINURIA427.0 PSVT415.19 PULMON EMBOL/INFARCT NEC272.0 PUR HYPERCHOLESTEROLEM427.1 PVT569.3 RECTAL & ANAL HEMORRHAGE555.9 REGIONAL ENTERITIS NOS586 RENAL FAILURE NOS593.9 RENAL/URETER DISORD NOS786.09 RESPIRATORY ABNORMALORM NEC714.0 RHEUMATOID ARTHRITISV20.2 ROUTINE CHILD HEALTH EXAMV70.0 ROUTINE MEDICAL EXAM626.1 SCANTY MENSTRUATIONV78.8 SCREEN-BLOOD DIS NECV78.9 SCREEN-BLOOD DIS NOSV77.99 SCREEN-ENDOCRINE NECV76.89 SCREEN-NEOPLASM NECV77.0 SCREEN-THYROID DISORDERV73.89 SCREENING VIRAL DIS NECV73.5 SCREENING-ARBOVIRUS DIS706.2 SEBACEOUS CYST427.81 SINOATRIAL NODE DYSFUNCT709.9 SKIN DISORDER NOS782.0 SKIN SENSATION DISTURB780.57 SLEEP APNEA NEC/NOS724.02 SPINAL STENOSIS-LUMBAR721.90 SPONDYL NOS W/O MYELOPATHY738.4 SPONDYLOLISTHESIS536.8 STOMACH FUNCT DISORD NEC034.0 STREP SORE THROAT218.0 SUBMUCOUS LEIOMYOMAV22.1 SUPERVIS OTH NORMAL PREGV67.00 SURGERY FOLLOW-UP784.2 SWELLING IN HEAD & NECK729.81 SWELLING OF LIMB780.2 SYNCOPE AND COLLAPLE710.0 SYST LUPUT ERYTHEMATOSUS287.5 THROMBOCYTOPENIA NOS451.2 THROMBOPHLEBITIS LEG NOS242.90 THYROTOXOSIS W/O CRISIS435.9 TIA529.9 TONGUE DISORDER NOS556.9 ULCERATIVE COLITIS NOS411.1 UNSTABLE ANGINA788.41 URINARY FREQUENCY599.9 URINARY TRACT DISORDER NOS599.0 URINARY TRACT INFECTION616.10 VAGINITIS008.8 VIRAL ENTERITIS079.99 VIRAL INFECTION