3.0 Requisition Form Instructions


Title of Manual: Specimen Collection

Version No: 1.1

Title: Requisition Form Instructions

Effective Date: 11/01/09
Revised Date: 06/23/14

Document #: GPA.SPC.3.0


I. PURPOSE

Greensboro Pathology Associates provides clients with test requisitions. All test requisitions should be preprinted with client information. All specimens submitted must be sent with a corresponding test requisition. Please retain a duplicate copy of the requisition.

II. MATERIALS

Reagents

Supplies

Equipment

• Requisition
• ABN


III. PROCEDURE

All requisitions should include the following information:

1. Patient Information
Please print the patient full last and first name with middle initial. Indicate date of birth, sex, social security number (optional). Indicate patient’s phone number, address, city, state, and zip code.

2. Billing Instruction
Check bill office or patient/other and enter the appropriate insurance, Medicare, &/or Medicaid information. Please indicate the responsible party name and relationship to the patient.

3. Insurance Information
    a. Please attach a copy of the front and back of the insurance card.

    b. For Medicare patients, provide the nine-digit Medicare number, usually the social security number
        with an alpha suffix. For Medicare patients, please indicate responsible party and complete address with
        date of birth.
    c. Medicaid numbers are also normally nine digits, however, they are not usually the social
        security number.
    d. If bill patient / insurance is checked, please provide the following information:
           • Insurance company’s name and plan/group name
           • Insurance company’s address
           • Insurance Policy Number / Group Number
           • Employer name
           • Subscriber name (Name of insured)
           • Patient relationship to insured

4. Specimen Information
    a. Procedure Date: Indicate the collection date of when the specimen was taken.
    b. Place of Service / Patient Status: Indicate the place of service if other than what is preprinted on
        the requisition.
    c. Surgeon/Clinician Obtaining Specimen: Indicate the ordering physician.
    d. Copy of Report to: Please indicate if you would like a report to be sent to additional physician(s).
    e. Clinical History / Information: Provide relevant clinical history and information.
    f. ICD-9 Codes: Indicate relevant diagnosis (ICD-9) codes.
    g. Rush Specimen Handling: Check “Rush” if the specimen requires immediate stat processing upon
        arrival into the laboratory.


Pathology Testing


1. Specimen Information
    a. Surgical Procedure: Please indicate the type of surgical procedure used to obtain the specimen.
    b. Tissue Removed: Please indicate type of tissue and location of tissue removal.

Clinical Testing

1. Specimen Information
    a. Include the time the specimen was taken for clinical specimens (blood, urine, etc.) as well as
        fasting time.
    b. Indicate the test(s) from the source material provided.

Cytology Testing

1. Specimen Information
    a. Indicate the test(s) from the source material(s) provided including ancillary tests.
    b. Routine Pap: Check box for routine Pap screening. Medicare has defined high risk Pap screening as
        one or more of the following:
           • Fewer than 3 normal Pap tests within the previous 7 years.
           • History of a sexually transmitted disease (including HIV infection.)
           • Early onset of sexual activity (under 16 years of age.)
           • Multiple sexual partners (5 or more in a lifetime.)
           • Daughters of women who took DES during pregnancy.
           • Of childbearing age and abnormal exam in the last 3 years.
    c. Diagnostic Pap: Check box for diagnostic Pap test if patient has a history of abnormality or signs
        and symptoms of medical necessity. The diagnosis ICD-9 codes must be medically appropriate for the
        patient’s condition and consistent with documentation in the patient’s medical record.

2. Patient History
It is important to provide any previous patient history, such as last menstrual period (LMP), Post-Menopausal, Hormone Therapy, IUD Hysterectomy, etc. LMP is important for accurate interpretation and mandatory if the patient is pre-menopausal. If the patient has had a hysterectomy, indicate if the cervix is present.

3. Medicare Advance Beneficiary Notice
Please remember to have patients read and sign the separate full-page Advance Beneficiary Notice form
when necessary.

Medicare has established a statutory or frequency limitation on coverage for the Pap test. As such, Medicare patients should routinely read and sign the Advance Beneficiary Notice with Pap tests. The new Advanced Beneficiary Notice developed by the Centers for Medicare and Medicaid Services has become a requirement for certain types of tests. This new form will is provided by Greensboro Pathology Associates to our clients.

IV. QUALITY CONTROL

V. CALCULATIONS/CALIBRATION

VI. INTERPRETATIONS

VII. METHOD PERFORMANCE SPECIFICATIONS

VIII. REFERENCES

IX. RELATED DOCUMENTS

• GPA ABN Updated E:1/1/09
• GPA Cyto_Clin Requisition E:10/1/13
• GPA Cyto_Surg Requisition E:10/1/13

X. DOCUMENT HISTORY

MINOR REVISION
(Laboratory Director’s Signature on Original Subsequent Document Attached)

X - MAJOR REVISION
(Requires Laboratory Director & Department Director Signature - where applicable)

Reason for Change

06/23/14 New Document Control Format



Laboratory Director

(Signature)

Date

Natalie Depcik-Smith, MD
(Print)



Department Director

(Signature)

Date


(Print)



Designee

Date

(Print)

(Signature)

(Print)

(Signature)

(Print)

(Signature)

(Print)

(Signature)

(Print)

(Signature)



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