(Example Test) - Test Name (Required Fields)

Last Modified: 5/9/2022 11:18:11 AM

  Medicare Medical Necessity Restrictions May Apply
Medical Necessity Documentation: This is Medical Necessity Documentation --

Client Notes: This information is for the Outreach Clients including all the PPG Clients.
Patient Preparation: This will include any patient preparation instructions or requirements for a lab test
Specimen Requirements: This is the a specimen(s) that is required / The bolded are just the tube that needs to be drawn./ (Required Field)
Collection Instructions: Collection & Processing Instructions for the specimen requirments of the specimen aboove
   Examples: Centrifuge w/in 30 minutes; use bedadine not alcolhol
Minimum Volume: Minimum Volume
Neonatal Volume: Neonatal Volume
Transport & Storage: Temperature/Stability: The temp requirements for storage, and/or shipping and how long stabe at those temperatures. Order will always be Ambient, Refrigerated, Frozen if one is preferred it will be noted.
This is for the specimen listed in "Specimen Requirment" ONLY
Rejection Criteria: Rejection Criteria
Reference Range: Reference Ranges (Required Field)
Critical Ranges:

Critical/Toxic Ranges

Test Comments: Anything pertaining to the result or reference ranges, critical ranges.

Possible Reflexing rules (IFA Hep reflexed if Positive)
Any extra notes that would be on the report (Isolates for some clinical sites may represent colonization or normal flora)
Methodology: Methodology (Required Field)
Clinical Significance: Clinical Significance of the test,  Rule out explanations, etc.

Other needed documentation or information that does not fit anywhere else...

Custom Panel: Yes


Stat Eligible: Yes
Turn Around Time: From Time of reciept to reported
Days Performed: Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday
Sites Performed: Parkview Hospital Randallia, Parkview Huntington, Parkview LaGrange, Parkview Noble, Parkview Regional Medical Center, Parkview Whitley, Indiana Blood Center, Quest - Chantilly, Quest - Valencia, South Bend Medical Foundation
PHL Test Code: SOFT
EPIC Test Code: EPIC Test Code
Send Out Test Code: Sendout Lab Code
Alternate Test Names: All other name possibilities
Included Tests:

All Tests included in the test, panel, profile...

CPT Coding: CPT Coding (Required Field)

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