Broad Range Microbiology PCR

Infectious Disease Laboratories : Microbiology

PATIENT INFO

Patient Name:

Medical Record #:

BD: / / Sex: F M

PHYSICIAN INFO

Physician Name :

Address:

Ph: ( ) - Fax: ( ) -

Additional Report to:

Ph: ( ) - Fax: ( ) -

TESTS REQUESTED
Test Name:	ICD9 Code: (required)
1. Broad Range Microbiology PCR
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SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

BROPC/WASH

Specimen Type:

Fresh Frozen tissue, body fluid (non-bloody), paraffin embedded tissue. Eswab is acceptable.

Tube Type:

Sterile container

Collection Volume:

Fresh frozen tissue, paraffin embedded tissue, or non-bloody body fluid accepted.

Cause for Rejection:

Blood, serum, plasma, stool, formalin tissue not acceptable. Reject if collected in swabs other than Eswabs

Storage:

Tissue, body fluid-Frozen, paraffin embedded tissue- Room temp

Availability:

Sent to Reference Laboratory

Methodology:

Polymerase Chain Reaction (PCR)

Special Instructions:

Specify Broad Range PCR: -Bacterial PCR (reflex to Next Generation Sequencing for polymicrobial specimens) -Fungal PCR -AFB PCR (including non-tuberculous Mycobacteria)

Lab/Phone:

330-543-8412

Additional Info:

Bacterial PCR -respiratory and genitourinary samples may also be submitted and will include reflexed testing to Next Generation sequencing. Eswab is the only validated swab specimen that is acceptable. - Fungal PCR- BAL or skin scrapings also acceptable. - AFB PCR- sputum tested for MTB Complex and/or M. avium complex only.

CPT Code:

Bacterial PCR or Fungal PCR CPT code 87801; MTB PCR -87556, Non Tuberculosis PCR- 87551; Next Gen. Bacterial Sequencing -87801

Synonyms:

Bacterial PCR, Fungal PCR, Mycobacterial PCR, AFB PCR