Laboratory Outpatient Order Form
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1LABORATORY OUTPATIENT ORDER FORM
Attn: PATIENT - You MUST bring this form
with you to the hospital. If you do not have
this form, your Procedure will not be done.
501 Redmond Rd., Rome, Georgia
(706) 802-3570 (706) 802-3944 Fax
Patient Information
Medical Necessity Information
First
Sign, Symptom, or Diagnosis and ICD-9 info required on all tests ordered
MI
LAST
Name
NAME
Narrative Diagnosis
ICD-9
St.
City
Address
1
Birthdate
Social Security
Sex
No.
M
F
Primary Ins:
2
Pre-cert #
ID#
M
0
0
VERIF. #
3
Physician Name
4
Office Phone/Contact
Fax
ABN Signed?
Code provided
Code received
Appointment: Date
Time
by
by
No
Yes
Specimen Information
Arrival Time :
AM/PM
Phone ( )
Collected by:
COMMENTS:
STAT
or Fax ( )
Time Drawn
24 Hour Urine
Date Drawn
Fasting
AM
Volume
PM
Random
TESTS or PANELS
CPT
ICD9
TESTS or PANELS (cont'd)
CPT
ICD9
SINGLE TESTS
CPT
ICD9
SINGLE TESTS
CPT
ICD9
Iron
83540
ABO Blood Group
86900
Lipid Profile
80061
Electrolytes Panel
80051
Iron Binding (TIBC)
83550
RH (D) Type
86901
Sodium
84295
Cholesterol
82465
LD (LDH)
83615
AFP - Maternal
82105
Potassium
84132
Triglycerides
84478
Lead
83655
Chloride
Gest. age (wks)
HDL Cholesterol
83718
82435
LH Luteinizing Hormone
83002
Twins?
Race:
Carbon Dioxide
82374
Acute Hepatitis Panel
80074
Lithium
80178
Insulin Dep. Diabetic?
Hepatitis A Antibody IGM
86709
Basic Metabolic Panel
80048
Magnesium
83735
Amylase
82150
Hepatitis 8 Core Antibody IGM
86705
Na, K, CL, C02
80051
Mono
86306
Anti Nuclear Antibody
86038
Hepatitis 8 Surface Antigen
87340
BUN
84520
Phenobarbital
80184
Antibody Screen
86850
Hepatitis C Antibody
86803
Calcium
82310
Phenytoin/Dilantin
80185
B-12 Vitamin
82607
Creatinine
82565
TORCH Panel
80090
Phosphorus
84100
Glucose
82947
C-Reactive Protein
86140
CMV Ab
86644
Platelet Count
Comprehensive Metabolic Panel
80053
Carbamazepinarregretol
80156
Herpes Simplex Ab
86694
Pregnancy, Qual.
Basic Metabolic Panel
80048
CBC Options - Mark Choice
Urine
Serum
81025
Rubella Ab
86792
Albumin
82040
Beta HCG Quant
84702
Toxoplasma Ab
86777
Hemogram, no pit no dif
85021
Alkaline Phos.
84075
Prolactin
Arthritis Panel
80072
Hemogram / pit no dif
85027
84146
Bilirubin, Total
82247
Fluor Ab Scr
86255
Hemogram / ph / auto dif
85025
PSA
84153
SGOT/AST
84450
PT with INR
85610
ESR (Sed Rate)
85651
CEA
82378
SGPT/ALT
84460
PTT
85730
RA (Rheumatoid)
86430
CK (CPK)
82550
*
Pt. taking Coumadin?
Y
N
Total Protein
84155
Uric Acid
84550
Creatinine Clearance
82575
*
Pt. taking Heparin?
Y
N
Hepatic Function (Liver) Panel
80076
*
80162
Digoxin
RPR
86592
82040
ALBUMIN
Drug Screen, Urine
Bilirubin, Total
82247
T3 Uptake
84479
* REQUIRED
Last Dose
Estradol
82670
Bilirubin, Direct
82248
T4
84436
Ferritin
82728
AST/SGOT
T4 Free
84439
84450
Folate
82746
ALT/SGPT
84460
TSH
84443
FSH
83001
Date:
Alkaline Phos.
84075
Testosterone Total
84403
Gamma GT
82977
Total Protein
84155
*
80198
Theophylline
Hgb Al C (Glycohemo)
83036
Renal Function Panel
80069
Urinalysis w/Micro, auto
81001
Hematocrit
85014
Basic Metabolic Panel
80048
Urinalysis no Micro, auto
81003
Hemoglobin
85018
Albumin
82040
UA w/culture if needed
81001
Time:
Specify Criteria for Culture
87086
HIV 1 and HIV 2
86703
Phosphorus
84100
Aspirate
Clean Catch
Cath
MICROBIOLOGY
Source:
Antibiotic Therapies:
Gram Stain If Needed?
Y
N
87110
87045
Culture Chlamydia
Culture Stool
87106
Culture Throat
Beta Strap Screen (throat)
87880
Culture Fungus
87070
Identification If Positive?
Y
N
Chlamydia DNA Probe
87490
Culture GC
87081
Culture Viral
87252
Sensitivity If Positive?
Y
N
87590
87252
GC DNA Probe
What Virus?
Culture Herpes
Only tests or Medicare Approved Panels that are
87116
87070
82270
medically necessary for the diagnosis or treatment of a Medicare
Occult Blood Stool
Culture AFB
Culture Routine
or Medicaid patient will be reimbursed.
87075
87006
87177
Culture Anaerobic
Culture Urine, Colony Ct
Ova & Parasites
Certain Screening tests will not be reimbursed and should not be
submitted for payment. The OIG states that a physician who
87040
87324
Clean Catch
Cath
Aspirate
C. diff. Toxin
Culture Blood
orders medically unnecessary tests for which Medicare or
Medicaid reimbursement is claimed may be subject to civil
Physician Signature
Date/Time
penalties under the False Claims Act.
O:LAB0001 (REV. 07/04)
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