Medicare Medical Necessity Restrictions May Apply
Medical Necessity Documentation:
Client Notes:
Patient Preparation:
Specimen Requirements:
(4) 1.0 mL Frozen serum aliquots in individual plastic vials from, 2 - SST Gold Top Tubes
and
3.0 mL Frozen Whole Blood in a Lavender Top Tube - EDTA
and
(6) - 1.0 mL plasma aliquots specimens in individual plastic vials from, 6 Blue Top Tubes - 3.2% Na Citrate
Collection Instructions:
Blue Top Tubes should be processed as Platelet Poor Specimens
Instructions for platelet-poor plasma:
1. Draw a plain red top tubes first to remove tissue fluid contamination.
2. Draw blood into a buffered citrate collection tube (light blue top) filled to proper level. Do not overfill.
3. The blood-to-anticoagulant ratio should be 9:1; inadequate filling of the collection device will decrease this ratio and
may lead to inaccurate results.
4. Invert gently 6 times to mix. Process immediately.
5. Centrifuge for 15 min at 2500 x g.
6. Remove plasma using a plastic pipette to transfer into a new tube.
7. Repeat centrifugation at 2500 x g for 15 minutes to assure complete platelet removal.
8. Dispense the plasma into 6 or more plastic tubes using a plastic transfer pipette. Label tubes appropriately.
9. Freeze immediately
10. Specimen must remain frozen at all times.
Transport & Storage: Temperature/Stability:
Serum & Plasma: Frozen
Whole Blood EDTA: Frozen
Rejection Criteria:
Hemolysis
Reference Range:
Refer to Interpretive Results
Critical Ranges:
Test Comments:
If 58653, APC Resistance, is < 1.6 Ratio, then order reflexes to code 17900, Factor V (Leiden).
Methodology:
Multiple
Clinical Significance:
Deep vein thrombosis (DVT) and pulmonary embolism (PE) are a common cause of morbidity and mortality.
Assessing for thrombophilia risk factors helps determine the intensity and duration of anticoagulant therapy.
Documentation:
Most Commonly prescribed medications offered for therapy
Xa inhibitors (Eliquis, Xaretto)
Thrombin inhibitors (Pradaxa, Plavix, Lovenox)
Coumadin
Custom Panel:
No
PRODUCTION SCHEDULE
Sites Performed:
Quest - Chantilly
PHL Test Code:
VTWC
EPIC Test Code:
LAB2993
Send Out Test Code:
18156
Alternate Test Names:
Hypercoagulability Panel; Thrombophilia Panel
Included Tests:
Antithrombin III Activity; Cardiolipin Antibody (IgG); Cardiolipin Antibody (IgM); Factor VIII Activity,Clotting; Factor V (Leiden) Mutation Analysis; Prothrombin Gene Analysis; Coagulation Consultation; Homocysteine (Cardiovascular); dRVVT Screen w/rfl dRVVT Confirm & dRVVT 1:1 Mix; Beta2-Glycoprotein I Antibody (IgG); Beta2-Glycoprotein I Antibody (IgM); Activated Protein C Resistance; Hexagonal Phase Confirmation
CPT Coding:
81240, 83090, 85240, 85300, 85307, 85598, 85613, 86146 x 2, 86147 x 2 (Reflex 81241, 85597, 85613)