Medicare Medical Necessity Restrictions May Apply
Medical Necessity Documentation:
Client Notes:
Patient Preparation:
Specimen Requirements:
3.0 mL Whole Blood in a Lavender Top Tube - EDTA
Collection Instructions:
Mix tube by inversion 5 times
Specimens must not be clotted. Overfilling or underfilling may allow blood to clot. Specimens may be rejected due to blood changes or deterioration resulting from improper storage or age of specimen
Minimum Volume:
1.5 mL Whole Blood
Neonatal Volume:
0.4 mL Whole Blood Lavender Microtainer
Transport & Storage: Temperature/Stability:
24 hours Ambient
72 hours Refrigerated
Reference Range:
For Pediatric Reference Ranges refer to
Addendum B
Males > 14 YrsWBC: 3.5 - 10.5 th/ul
RBC: 4.3 - 5.7 mi/ul
Hgb: 13.5 - 17.2 g/dl
Hct: 40.0 - 54.0%
MCV: 82.0 - 98.0 fl
MCH: 27.0 - 33.0 pg
MCHC: 32.0 - 36.0 g/dl
Platelet: 150.0 - 450.0 th/ul
RDWSD: 36.4 - 54.5 fl
RDWCV: 11.5 - 14.5%
MPV: 8.6 - 12.6 fl
PCI/PRMC/PVH/PDH: IPF: 0.9-7.2%
Females > 14 Yrs
WBC: 3.5 - 10.5 th/ul
RBC: 4.0 - 5.2 mi/ul
Hgb: 12.0 - 15.5 g/dl
Hct: 35.0 - 48.0%
MCV: 82.0 - 98.0 fl
MCH: 27.0 - 33.0 pg
MCHC: 32.0 - 36.0 g/dl
Platelet: 150.0 - 450.0 th/ul
RDWSD: 36.4 - 54.5 fl
RDWCV: 11.5 - 14.5%
MPV: 8.6 - 12.6 fl
PCI/PRMC/PVH/PDH: IPF 0.9-7.2%
Critical Ranges:
Pediatric (< = 15 days old) Low Critical Limits
WBC: < = 2.0 t/ul
Hgb: < = 10.0 g/dl
Platelet: < = 30.0 t/ul
Pediatric (< = 15 days old) High Critical Limits
WBC: > = 39.0 t/ul
Hgb: > = 24.0 g/dl
Hct: > = 70.0%
Platelet:
> = 850 t/ul
Low Critical Limits
WBC:
< = 1.5 t/ul
Hgb: < = 6.0 g/dl
Platelet: < = 30 t/ul
High Critical Limits
WBC: > = 40.0 t/ul
Hgb: > = 19.0 g/dl
Platelet: > = 850 t/ul
NICU >15 days old Critical Limits:
HCT: <=30% and >=70%
Platelet: <= 100.0 th/ul
NICU >15 days old Critical Limits:
HCT: <=25% and >=70%
Platelet: >= 600 th/ul
Oncology Wards Low Critical Limits:
WBC: <=1.0 t/ul
Hgb: <=5.0 g/dl
Platelet: <=20 th/ul
OHP Low Critical Limit:
Hgb: <= 7.5 g/dl
Platelet: <=50 th/ul
Test Comments:
IPF (Immature Platelet Fraction) is a measurement of thrombopoietic activity that helps determine the cause of thrombocytopenia (platelet production vs. platelet destruction)
PCI, PRMC, PVH: If PH <50,000, IPF% (Imm PH fract will be reflexed)
Methodology:
Blood Cell Analyzer
Clinical Significance:
Documentation:
Custom Panel:
No
PRODUCTION SCHEDULE
Stat Eligible:
Yes
Days Performed:
Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday
Sites Performed:
Parkview Cancer Institute, Parkview Dekalb Hospital, Parkview Huntington Hospital, Parkview LaGrange Hospital, Parkview Noble Hospital, Parkview Randallia Hospital, Parkview Regional Medical Center, Parkview Southwest , Parkview Wabash Hospital, Parkview Warsaw , Parkview Whitley Hospital
PHL Test Code:
CBCND
EPIC Test Code:
LAB294
Alternate Test Names:
CBC; CBC No Differential; Hemogram; Hemogram (CBC/No Diff)
Included Tests:
Hematocrit (Hct); Hemoglobin (Hgb); Mean Corpuscular Hemoglobin (MCH); Mean Corpuscular Hemoglobin Concentration (MCHC); Mean Corpuscular Volume (MCV); Mean Platelet Volume (MPV); Platelet (PLT); Red Blood Cell Count (RBC); Red Cell Distribution Width Standard Deviation (RDWSD); Red Cell Distribution Width Coefficient Variation (RDWCV); White Blood Cell Count (WBC)
CPT Coding:
85027 (Reflex 85055)