Centralized Core Laboratory - University of Washington :
Send Out
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
2.
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6.
SPECIMEN INFO
Collection Date & Time:
Collected By:
Hospital:
Test ID :
BROPC
Test Workstation :
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 nontuberculous 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
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 nontuberculous 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
