Cytopathology - Gynecological Consult Request Form
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1University of NC Hospitals
Chapel Hill, NC 27514
CYTOPATHOLOGY - GYNECOLOGICAL CONSULT REQUEST
Outreach Clinics Only:
MIM # 1084
Clinic Code______________
Clinic Location ___________
Collection Date
Collection Time
Collected By
Requesting MD
MD Code
Beeper #
DIAGNOSIS/ CLINICAL INFORMATION (Relevant Findings, Previous PAP Results)
TESTING REQUESTED
ICD10 Code(s)
□
Diagnostic PAP
(order when clinical disease state suspected & supported by ICD10 Code)
□
Screening PAP
(limited to 1 every 2 yrs for Medicare, Medicaid, TriCare)
□
High Risk Screening
(< 16 yr & sexually active, multiple sex partners, history of STD, DES Exposure)
□
HPV Testing
□
HPV Reflex
(Current ASCUS Diagnosis Only)
□
□
□
□
SPECIMEN SOURCE
Vaginal
Cervix
Endocervix
Vulvar Scraping
□
□
HISTORY FOR GYN SMEARS (Check All that Apply)
QUALITY OF SPECIMEN
Satisfactory
Unsatisfactory Due To:
□
Yes LMP _______/______/______
Excess Blood
□
Concomitant Tissue Biopsies Taken
Obscuring Inflammation
□
□
Pregnant
Poor Preservation
□
□
Post Partum/ Lactating
No Endocervical Epithithelium
□
□
Abnormal Bleeding
Smears Excessively Thick
□
□
Menopause Date__________________________
Smears Dried Before Fixation
□
□
Hysterectomy Date________________________
Inadequate Cellularity
□
□
Radiation/ Chemotherapy Date_______________
Actinomyces
□
□
Treatment for Dysplasia Procedure Date________
Yeast
□
□
IUD In Place
Trichomonads
□
□
DES Exposure
Coccobacilli
□
□
Hormones Specify _________________
Herpes
Cytotech Diagnosis:
Cytopathologist Diagnosis:
Cyto Tech:
Date:
Time:
Cytopathologist:
□
□
Medicare Patient:
Yes
No
Medicare will only pay for services that it determines to be reasonable and necessary under section 1862 (a)(1) of the Medicare Law.
When ordering tests for which Medicare reimbursement will be sought, physicians should order only those individual tests that are
necessary for the diagnosis and treatment of a patient, rather than for screening services.
I certify that this test ordered is medically necessary.
Ordering Provider Signature ________________________________________________________
Date_____________ Time___________________
REV 12/15
Chart Location: Lab
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