Mycoplasma pneumoniae, Qualitative PCR
| PATIENT INFO |
| Patient Name: |
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| BD: / / Sex: F M |
| PHYSICIAN INFO |
| Physician Name : |
| Address: |
| Ph: ( ) - Fax: ( ) - |
| Additional Report to: |
| Ph: ( ) - Fax: ( ) - |
| TESTS REQUESTED | |
| Test Name: | ICD9 Code: (required) |
| 1. Mycoplasma pneumoniae, Qualitative PCR | |
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| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
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Test ID :
LAB261
Specimen Type:
Swab
Bronchoalveolar lavage (BAL)
Wash
Tracheal Aspirate
Cerebrospinal Fluid (CSF)
Bronchoalveolar lavage (BAL)
Wash
Tracheal Aspirate
Cerebrospinal Fluid (CSF)
Collection Volume:
Swab: 1 Flocked Swab in 3.0 mL of M4 Viral Transport Medium
BAL, Wash, or Tracheal Aspirate: 2.0 mL collected in a Sterile Container (1.2 mL minimum)
Cerebrospinal Fluid: 1.0 mL collected in a CSF Tube/Container (0.2 mL minimum)
Cause for Rejection:
Quantity Not Sufficient
Specimen Not Received
Specimen Mislabeled
Specimen Not Labeled
Broken/Spilled in Transport
Unacceptable Type or Source Submitted
Wrong Container
Improperly Preserved/Processed
Sample Stored at Incorrect Temperature
Improper Swab
Multiple Swabs per Vial of M4 VTM
Swab Not Present in M4 VTM vial
Swab Not Placed in M4 VTM Vial (Dry Swab)
Sample Exceeds Holding Time
Storage:
Refrigerated
Availability:
Mon-Fri (7:30-16:00)
Methodology:
Real-Time Polymerase Chain Reaction
Lab/Phone:
330-543-8722
TAT:
1-3 days
CPT Code:
87581
Synonyms:
M. pneumoniae DNA
Mpne
Mpne
