Requisition Form - Atherotech

FILLING OUT A REQUISITION FORM

BARCODE

phone: 877.901.8510

fax: 205.314.7403

C-598401

lipid

panel

PATIENT INFORMATION

REQUESTING PHYSICIAN, LAB OR INSTITUTION

1

_______________________________________________________________

Last Name

First Name

Middle Name

_______________________________________________________________

Address

99899 - ABC Family Practice

4

123 Doctors Way

_______________________________________________________________

City

State

Zip

Birmingham, AL 35123

________________________

M / F

_________________________________

Date of Birth

Gender

SSN

JOHN SMITH, MD

SALLY JONES, NP

BILLING INFORMATION

TOM MILLER, PA-C

2

Insurance

Patient

Physician

1. Copy both sides of the patient’s insurance card(s) and attach to requisition.

2. Indicate primary and secondary diagnosis.

SPECIMEN INFORMATION

Draw Date

_______________

Client ID/Specimen #

_____________________

ATHEROTECH LAB USE ONLY

3

Draw Time

_______________

12 hr Fasting

Y

N

Temp.______c

SST_____ LAV_____ P/O_____ Urine_____ Other_______

DIAGNOSIS:

Please mark appropriate clinical diagnosis code(s). Check all that apply. (Required)

Below is a list of common diagnostic codes associated with CVD risk testing as an aid in selecting a code. This is not to be viewed as the complete list. Please refer to the ICD-9

Code Book when making your diagnosis and use the ICD-9 code(s) that most accurately describes the patient’s condition regardless of its inclusion on this requisition.

ICD-9 Code Diagnosis

ICD-9 Code Diagnosis

ICD-9 Code Diagnosis

ICD-9 Code Diagnosis

5

244.9

Hypothyroidism NOS

272.2

Mixed hyperlipidemia

414.01

Crnry athrsci natve vssl

______

Other __________________

250.00

Diabetes

272.4

Hyperlipidemia NEC/NOS

780.79

Malaise and fatigue NEC

______

Other __________________

268.9

Vitamin D deficiency NOS

272.9

Lipoid metabol dis NOS

790.21

Impaired fasting glucose

______

Other __________________

272.0

Pure hypercholesterolemia

401.9

Hypertension

V58.69

Long-term use meds NEC

______

Other __________________

272.1

Pure hyperglyceridemia

402.9

Hypertensive Heart Disease

V70.0

Routine medical exam

______

Other __________________

INDIVIDUAL TEST CPT:

VAP includes a direct measured triglyceride value obtained by a separate enzymatic test. CPT codes used for billing Medicare and third party payors are as follows: (83701 & 84478).

VAP+ Lipid Panel includes 3 separate procedures: VAP, TRIGs, and LDL-P. CPT codes used for billing Medicare and third party payors are as follows: (83701, 83704, 84478-59).

CBC reflex: An abnormal CBC w/Diff (85025) that meets certain criteria will be reflexed to a manual differential (85007). If indicated, a pathologist review (85060)

will also be performed. If you do not want this reflex to be performed, please indicate.

DO NOT REFLEX.

VAP Technology

4005 B-12

3019 GGT

3029 Magnesium

4001 T3, Free

(82607)

(82977)

(83735)

(84481)

1007 VAP+ Lipid Panel

3008 Bilirubin, Total

3022 Glycated Albumin

6009 PCSK9 Total

4002 T4, Free

6

(83701,

(82247)

(82985)

(84238)

(84439)

2002 CBC w/Differential

3021 GlycoMark™

6010 PCSK9 Functional

3036 Uric Acid

(85025)

(84378)

(83520)

(84550)

83704, 84478-59)

1001 VAP Lipid Panel

8002 Comprehensive Metabolic

3023 HbA1c

3033 Protein, Total

4017 Vitamin D

(83036)

(84155)

(25OH) (82306)

Panel**

3024 Homocysteine

4010 PSA, Total

(83701, 84478)

(80053)

(83090)

(84153)

____ ______________ (_____)

1100 Vertical Lipoprotein

4024 C-peptide

3026 Insulin

4014 Testosterone Free and

(84681)

(83525)

____ ______________ (_____)

3025 C-Reactive Protein–hs

3027 Iron

Bioavailable Calculated

Particle (VLP) LDL-P

(83704)

(83540)

(82040,

7004 Iron, TIBC calculated,

____ ______________ (_____)

(86141)

84270, 84403)

Additional Tests

3013 Creatine Kinase (CK)

& % Transferrin Saturation

3034 Transferrin

(84466)

3002 Alkaline Phosphate

____ ______________ (_____)

(84075)

4015 TSH

(82550)

calculated (Iron, Transferrin)

(84443)

3003 ALT

(84460)

____ ______________ (_____)

3015 Cystatin C

4016 TSH Reflex to FT4 and

(82610)

(83540, 84466)

3006 AST

(84450)

3018 Ferritin

3017 Lp(a) Immunoassay

FT3

(82728)

(83695)

(84443, 84439, 84481)

8001 Basic Metabolic Panel**

4007 Folate

5001 Lp-PLA

(82746)

/PLAC

®

(83698)

(80048)

2

**For a complete listing of tests contained in these

Refer to the back of this page for specimen collection and processing instructions.

panels, please refer to the back of this page.

TEST SELECTION(S):

Physicians should only order tests that are medically necessary and reasonable for the diagnosis or treatment of a Medicare or Medicaid patient for which reimbursement

is claimed. All tests included in panels may be ordered individually. By submitting this sample, I certify that I have obtained and documented informed consent for genetic

testing, if ordered, in accordance with applicable law.

DR. JOHN SMITH BASELINE

DR. JOHN SMITH FOLLOW UP PANEL

VAP & Triglycerides

VAP & Triglycerides

7

C-Reactive Protein-hs

C-Reactive Protein-hs

Comprehensive Metabolic Panel

GlycoMark

Creatine Kinase (CK)

HbA1c

Cystatin C

Insulin

GGT

Lp-PLA2/PLAC

HbA1c

NT-ProBNP

Homocysteine

Vitamin D

Insulin

--------------------

Lp_PLA2/PLAC

TSH

T3, Free

T4, Free

Uric Acid

Vitamin D

------------------------

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LAST

LAST

LAST

LAST

8

FIRST

FIRST

FIRST

FIRST

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AT-STDREQ12.23.13

How to Fill Out a Requisition Form:

1. Patient Information: Complete each field

6. Standard Panels and Individual Tests: Please

of this section.

check the appropriate box for all necessary

panels and tests. Atherotech only processes

2. Billing Information: Please check the

tests and panels marked in this section. For any

appropriate box and provide the requested

tests not listed on the front, please refer to the

information to streamline the billing process.

Directory of Services located on the back. These

additional tests would need to be written into

3. Specimen Information: Please fill out

the blank spaces provided.

all specimen data.

7. Custom Panels: Please check the

4. Requesting Physician, Lab or Institution:

appropriate box for a custom panel. If you

Please mark the appropriate ordering

would like to update or make changes to

clinician when multiple clinicians are

your current custom panels, please refer to

associated with the practice. If you

the Panel Authorization Criteria on the next

need to add an ordering clinician to the

page. If you would like assistance with this

Requisition Form, please reference the Panel

process, contact your local representative.

Authorization Criteria on the next page.

8. Patient Labels: Use these to mark

5. Diagnosis: Please check the appropriate ICD-9

specimen tubes and blood draw logs with

code(s) for insurance reimbursement. Multiple

first and last names and requisition ID to

codes may be checked for multiple tests.

help identify tubes at our facility.

ReqForm.14.1.14