Fillable Histocompatibility Laboratory Requisition Form printable pdf download

Patient's Full Name _______________________________________

University of North Carolina Hospitals

McLendon Clinical Laboratories

Last

First

Middle

UNC Medical Record #

___________________________________

Histocompatibility Laboratory, 1st Floor East Wing

101 Manning Drive

Date of Birth________________ Sex: ________

Chapel Hill, North Carolina 27514

Ph (919) 966-4057, Fax (919) 966-7897

HLA Outpatient Order Form MIM# 1203

Clinic Name:_____________________________________________

Clinic Code:_________________

Clinic Address:____________________________________________

Attending MD

:___________________________________________________

ID#:________________________________

Phone #:___ ___ ___ / ___ ___ ___ - ___ ___ ___ ___

Fax #:

___ ___ ___ / ___ ___ ___ - ___ ___ ___ ___

___

One Time. Testing must be done within ____ days (< 30 days)

___

Testing should occur every ____ month(s) for up to 12 months

___

Testing should occur every ____ weeks for up to 12 months

Diagnosis (ICD-10) Code(s):

1)____________

2)____________

3)____________

4)____________

5)____________

6)____________

Collection Date:___________________

Time:__________ am / pm

Collected By: ______________________________________

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 purposes.



HLA Testing - Patient

CODE

HLA Testing - Donor

CODE

Solid Organ Transplant Workup

4510

HLA Organ Donor Workup

4733

HLA - Antibody Screen

4570

HLA - Bone Marrow Donor Transplant Workup (Blood)

4250

HLA - Bone Marrow Patient Transplant Workup (Blood)

4260

HLA - Bone Marrow Donor Transplant Workup (Swab)

4220

HLA - Bone Marrow Patient Transplant Workup (Swab)

4225

Miscellaneous, (Other Tests)

HLA-B27 by Flow Cytometry

4480

HLA - DSA Post Transplant

4258

HLA-Disease Association Workup

4453

HLA-B57

4257

Write All Diagnoses That Apply in the Diagnosis section above

Common Diagnosis (Reason for test)

ICD-10

Common Diagnosis (Reason for test)

ICD-10

Z52.4

N18.3

Kidney donor

Chronic kidney disease, stage 3 (moderate)

Kidney transplant evaluation

Z01.818

N18.4

Chronic kidney disease, stage 4 (severe)

Encounter for examination of potential donor for organ and tissue

Z00.5

N18.5

Chronic kidney disease, stage 5

E1Ø.29

N18.6

Type 1 diabetes mellitus with other diabetic kidney complication

End stage renal disease

E11.29

N18.9

Type 2 diabetes mellitus with other diabetic kidney complication

Chronic kidney disease, unspecified

D57.1

N11.Ø

Sickle-cell disease without crisis

Nonobstructive reflux-associated chronic pyelonephritis

D59.3

N2Ø.Ø

Hemolytic-uremic syndrome

Calculus of kidney

Hypertensive chronic kidney disease with stage 5 chronic kidney disease or

I12.Ø

N13.729

end stage renal disease

Vesicoureteral-reflux with reflux nephropathy without hydroureter, unspecified

Wegener's granulomatosis without renal involvement

M31.3Ø

N39.Ø

Urinary tract infection, site not specified

M31.1

M32.1Ø

Thrombotic microangiopathy

Systemic lupus erythematosus, organ or system involvement unspecified

K76.7

Q61.3

Hepatorenal syndrome

Polycystic kidney, unspecified

NØØ.3

Q61.4

Acute nephritic syndrome with diffuse mesangial proliferative glomerulonephritis

Renal dysplasia

NØ4.3

Q61.5

Nephrotic syndrome with diffuse mesangial proliferative glomerulonephritis

Medullary cystic kidney

NØ3.3

Q63.8

Other specified congenital malformations of kidney

Chronic nephritic syndrome with diffuse mesangial proliferative glomerulonephritis

NØ8

S36.9ØXS

Glomerular disorders in diseases classified elsewhere

Unspecified injury of unspecified intra-abdominal organ, sequela

Adverse effect of unspecified drugs, medicaments and biological substances,

NØ3.8

T5Ø.9Ø5A

Chronic nephritic syndrome with other morphologic changes

initial encounter

NØ3.9

T86.1Ø

Chronic nephritic syndrome with unspecified morphologic changes

Unspecified complication of kidney transplant

NØ5.9

V89.9XXS

Unspecified nephritic syndrome with unspecified morphologic changes

Person injured in unspecified vehicle accident, sequela

NØ5.8

Z85.528

Unspecified nephritic syndrome with other morphologic changes

Personal history of other malignant neoplasm of kidney

N17.Ø

C64.9

Acute kidney failure with tubular necrosis

Malignant neoplasm of unspecified kidney, except renal pelvis

N18.1

Sarcoidosis, unspecified

D86.9

Chronic kidney disease, stage 1

Sequelae of other specified infectious and parasitic diseases

Chronic kidney disease, stage 2 (mild)

N18.2

B94.8

Please write in unlisted diagnoses codes in the Diagnoses section above.

I certify that all tests ordered are medically necessary.

Ordering Provider Signature:______________________________________ ID#:______________ Date:__________ Time:

Revised 11/10/15

Chart Location:Provider Orders

Histocompatibility Laboratory Requisition Form

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