Page 1 of 40 Cover Letter NewCopy of 2016 Expanded Test List (2)

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1 Multiple Component, Reflex, Confirmatory and Accepted Clinical Practice Tests Department of Pathology and Laboratory Medicine 2016 Texas Health Medical Laboratory / Texas Health Harris Methodist Fort Worth Hospital / Texas Health Specialty Hospital / Texas Health Burleson/ Texas Health Willow Park The Centers for Medicare and Medicaid Services (CMS) will reimburse only for tests that meet the Medicare coverage criteria and are reasonable and necessary to treat or diagnose an individual patient. Tests ordered, including components of organ and disease related panels, will be billed and paid when all components are medically necessary per CMS criteria. The United States Department of Health & Human Services, Office of Inspector General, takes the position that an individual who knowingly causes a false claim to be submitted may be subject to sanctions or remedies available under civil, criminal and administrative law. A valid order must document the diagnosis and/or symptoms that support the clinical reason for the diagnostic test. This can include the ICD code, but must include the narrative diagnosis. Failure to provide proper documentation on the requisition form may result in the denial of claims. Medicare Coverage Database (MCD), which includes National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) can be accessed at The following information is intended to inform the Medical Staff of routine practices in the Department of Pathology and Laboratory Medicine based on physician orders for laboratory testing. The tables document the following: Test orders that require multiple subparts for completion {for example, an order for IgG subclasses by definition converts into an order for quantitation of IgG 1; IgG 2; IgG 3; and IgG 4 with the appropriate charge for each subclass of IgG}. Tests that require multiple additional tests to be performed to achieve the ordered results {for example, urine drug screen consists of individual tests for benzodiazepines; cocaine; amphetamine; cannabinoids; opiates; and barbiturates}. Tests results which indicate additional testing is required {for example, an order for a urine culture may result in the identification of one or more organisms with susceptibilities as indicated}. Additional information may also be obtained from the THFW homepage select THFW Lab Test Catalog. The attached document is divided into the following sections: I. Multiple Component Tests This section delineates tests that contain multiple component tests as determined by a single order in that one test ordered by the physician results in the performance of multiple tests with associated codes and charges. 1. Tests Referred to Outside Laboratories (pages 3-11) 2. Microbiology (page 12) 3. Immunology (page 13) 4. AMA s Organ or Disease Specific Panels (pages 14-15) 5. Chemistry (pages 16) 6. Hematology (page 17) 7. oocoagulation (pages 18) 8. Transfusion Services (page 19) Page 1 of 40 Cover Letter NewCopy of 2016 Expanded Test List (2)

2 II. Reflex, Confirmatory and/or Accepted Clinical Practice Testing This section delineates tests that may be added to the original order based on initial laboratory findings without an additional physician order. 1. Microbiology (pages 25-27) 2. Chemistry (pages 28) 3. Hematology (page 29) 4, Transfusion Services (pages 30-32) 5. Anatomical Pathology (page 33) Page 2 of 40 Cover Letter NewCopy of 2016 Expanded Test List (2)

3 Section I. Multiple Component Tests The following section delineates tests that contain multiple component tests as determined by a single order; - that is, one test order by the physician results in multiple tests being performed with associated codes/charges. Tests Referred to Outside Laboratories (Multiple Component Tests) Test Ordered Component Parts CPT Acetylcholine Receptor Antibody Panel Acetylcholine Receptor Binding Antibody Acetylcholine Receptor Blocking Antibody Acetylcholine Receptor Modulating Antibody Adenovirus Antibodies Adenovirus Antibodies, IgG Adenovirus Antibodies, IgM AFP Maternal Screen 3 AFP hcg Estriol Alkaline Phosphatase, isoenzymes Alkaline phosphatase, total Alkaline phosphatase Isoenzymes Alpha-1-Antitrypsin Phenotype Alpha-1-antitrypsin, total Alpha-1-antitrypsin, phenotype Amiodarone & Metabolite Amiodarone Desethylamiodarone Amylase, Isoenzymes Amylase, total Amylase, pancreatic Aspergillus Antibody Aspergillus Antibody (CF) Aspergillus Antibody (ID) Bartonella henselae (Cat Scratch) Antibodies, IgG & IgM by IFA Bartonella henselae IgG Bartonella henselae IgM Beta-2 Glycoprotein 1 Antibodies, IgG & IgM Beta-2 Glycoprotein I, IgG Beta-2 Glycoprotein I, IgM Blastomyces Antibody Blastomyces Antibody (CF) Blastomyces Antibody (ID) Bordetella Pertusis Abs Bordetella pertussis Antibody, IgG * Bordetella pertussis Antibody, IgM * Carbamazipine Free and Total Carbamazipine FVL Isolation - Reflex if APC Resistance is Cardiolipin Antibodies Cardiolipin IgG Cardiolipin IgM Carisoprodal and Meprobamate Carisoprodal Meprobamate Page 3 of 40 Tests Referred NewCopy of 2016 Expanded Test List (2)

4 Test Ordered Component Parts CPT CD4 and Absolute First marker Additional Marker Page 4 of 40 Tests Referred NewCopy of 2016 Expanded Test List (2)

5 Test Ordered Component Parts CPT Chlamydia Antibody Panel, IgG and IgM C. pneumoniae, IgG C. trachomatis, IgG C. psittaci, IgG C. pneumoniae, IgM C. trachomatis, IgM C. psittaci, IgM Chromosome Analysis, Amniotic Fluid (AF) AF Chromosome Analysis AF Additional Karyotype Chromosome Bone Marrow Study Chromosome Culture, Bone Marrow Chromosome Analysis Chromosome Study Whole Blood Chromosome Culture, with blood Chromosome Analysis CK Isoenzymes CK Total CK Iso Clomipramine & Metabolite Clomipramine Desmethylclomipramine CMV Antibody IgG & IgM CMV Antibody IgG CMV Antibody IgM Coccidioides Antibody, CSF Coccidioides CF Coccidioides IgG Coccidioides IgM Coccidioides ID Coccidioides Antibodies Panel, Serum by CF, ID, ELISA Cocci Ab (CF) Cocci Ab (ID) Cocci Ab, IgG (EIA) Cocci Ab, IgM (EIA) Coxsackie B Viral Antibody Coxsackie B1 Antibody Coxsackie B3 Antibody Coxsackie B5 Antibody Coxsackie B2 Antibody Coxsackie B4 Antibody Coxsackie B6 Antibody Chlamydia trachomatis Culture (ARUP) Culture Stain Viral Culture and CMV Culture (ARUP) Viral culture Shell vial Page 5 of 40 Tests Referred NewCopy of 2016 Expanded Test List (2)

6 Test Ordered Component Parts CPT Dengue Fever Virus Antibodies Dengue fever IgG Dengue fever IgM Drug Screen Qual, Serum Mult Drug Class, Serum x 3 G0479 Drug Screen Qual, Urine Multi Drug Class, Urine x 3 G0479 Drug Screen, Meconium Stool, Amphetamines G0480 Stool, Cocaine G0480 Stool, Opiates G0480 Stool, PCP G0480 Stool, Methadone G0480 Stool, Benzodiazpines G0480 Stool, Barbiturates G0480 Stool, Propoxyphene G0480 Stool, THC G0480 Echo Virus Antibody Titer Echovirus Type Echovirus Type Echovirus Type Echovirus Type Echovirus Type Ehrlichia chaffeensis Antibodies IgG & IgM by IFA Ehrlichia chaffeensis IgG Ehrlichia chaffeensis IgM Epstein-Barr (EBV) Antibody Panel EBV IgG-VCA EBV Anti-nuclear antigen EBV IgM-VCA EBV Anti-early antigen Extractable Nuclear Antigen Antibodies (RNP, Smith, Scleroderma, SSA, & SSB) SSA (Ro) (ENA) Antibody, IgG SSB (La) (ENA) Antibody, IgG RNP (U1) (Ribonucleic Protein) (ENA) Antibody, IgG Scleroderma (Scl-70) (ENA) Antibody, IgG Smith (ENA) Antibody, IgG Factor V Leiden {FVL}, molecular dx FVL Isolation FVL Amplification FVL Probe, Each x x 2 Fluoxetine & Metabolite Fluoxetine Norfluoxetine Page 6 of 40 Tests Referred NewCopy of 2016 Expanded Test List (2)

7 Test Ordered Component Parts CPT Fungal Antibodies Coccidioides Antibody Blastomyces Antibody Histoplasma Antibody Aspergillus Antibody Gliadin Antibody Gliadin Antibodies, IgG Gliadin Antibodies, IgA Glomerular Basement Membrane Antibodies, IgA & IgG (IFA) Glomerular Basement Membrane Antibody, IgA (IFA Glomerular Basement Membrane Antibody, IgG (IFA Page 7 of 40 Tests Referred NewCopy of 2016 Expanded Test List (2)

8 Test Ordered Component Parts CPT Glomerular Basement Membrane Antibody Panel Glomerular Basement Membrane Antibody, IgA (IFA) Glomerular Basement Membrane Antibody, IgG (IFA) Glomerular Basement Membrane Antibody, IgG by Multi- Analyte Fluorescent Detection Helicobacter Pylori Antibody H. pylori Antibody, IgG H. pylori Antibody, IgA Hepatitis A Virus Panel Hepatitis A Virus Antibodies (Total Hepatitis A Virus Antibody, IgM Histoplasma Antibodies by CF & ID Histoplasma Antibody (ID) Histoplasma Antibody (CF) Mycelia Histoplasma Antibody (CF) Yeast Herpes Simplex Virus Type 1 and/or 2 Antibodies, IgG & IgM HSV I II IgG HSV I II IgM Hypersensitivity Pneumonitis II Aspergillus flavus Aspergillus fumigatus # Aspergillus fumigatus # Saccharomonospora viridis Thermoactinomyces candidus Thermoactinomyces sacchari Hypersensitivity Pneumonitis I Aspergillus fumigatus # Aspergillus fumigatus # Aureobasidium pullulans Pigeon serum Micropolyspora faeni Thermoactinomyces vulgaris # IgG Subclasses, (1, 2, 3, 4) IgG Subclass IgG Subclass IgG Subclass IgG Subclass Immunofixation Electrophoresis (IFE) Monoclonal Protein Detection Quantitation IgG & Characterization SPE, IFE, IgA, IgG, IgM IgM IgA Electrophoretic fractionation & quantitation Immunofixation electrophoretic Total protein by refractometer Page 8 of 40 Tests Referred NewCopy of 2016 Expanded Test List (2)

9 Test Ordered Component Parts CPT IFE Qn - Bence Jones Protein, Quantitative Free Kappa & Lambda Light Chains, Total protein Urine IFE Nephelometry,kappa Nephelometry,lambda Page 9 of 40 Tests Referred NewCopy of 2016 Expanded Test List (2)

10 Test Ordered Component Parts CPT Influenza Virus Antibodies Influenza A Antibody IgG Influenza B Antibody IgG Influenza A Antibody IgM Influenza B Antibody IgM Immunoglobulins, Serum Quantitative Immunoglobulin A, Serum Immunoglobulin G, Serum Immunoglobulin M, Serum Immunoglobulins, CSF Quantitative Immunoglobulin A, CSF Immunoglobulin G, CSF Immunoglobulin M, CSF Lactate dehydrogenase {LD} Isoenzymes Total LD LD Isoenzyme Diazepam & Metabolite Diazepam Nordiazepam Lymphocyte Subset Panel CD4 Absolute CD CD CD Lymphocyte Transplantation CD3 CD Additional Marker Lymphocyte Mitogen Proliferation x5 Lymphocyte Subset Panel 7 - Congenital Immunodeficiencies Initial Marker Additional Marker x 9 Heavy Metals Panel 3, Blood Arsenic Lead Mercury Heavy Metals Panel 3, Urine Arsenic Lead Mercury Methsuximide & Normethsuximide Methsuximide Normethsuximide Microalbumin; urine Creatinine Microalbumin Mycoplasma Antibody Mycoplasma Antibody, IgG Mycoplasma Antibody, IgM Ova and Parasite, Feces Ova and Parasite Trichrome Stain Page 10 of 40 Tests Referred NewCopy of 2016 Expanded Test List (2)

11 Test Ordered Component Parts CPT Parvovirus B19 Antibody, IgG & IgM Parvovirus B19 IgG Parvovirus B19 IgM Page 11 of 40 Tests Referred NewCopy of 2016 Expanded Test List (2)

12 Test Ordered Component Parts CPT Phenytoin, Total & Free Dilantin Phenytoin, Free Platelet Antibody; Direct Assay IgG IgM Protein Electrophoresis Total Protein Electrophoretic fractionation & quantitation Protein Electrophoresis; CSF Total Protein Electrophoretic fractionation & quantitation PSA Free PSA total PSA free Q-Fever Antibodies Q-Fever Antibody Phase I Q-Fever Antibody Phase II Respiratory Syncytial Virus Antibodies, IgG & IgM Respiratory Syncytial Virus Antibodies, IgG Respiratory Syncytial Virus Antibodies, IgM Rocky Mountain Spotted Fever RMSF Antibody, IgG RMSF Antibody, IgM Rubella Antibodies, IgG & IgM Rubella Antibodies, IgG Rubella Antibodies, IgM Rubeola Antibodies Rubeola Antibody, IgG Rubeola Antibody, IgM Saccharomyces cerevisiae Antibodies, IgG & IgA Saccharomyces cerevisiae Antibodies, IgG Saccharomyces cerevisiae Antibodies, IgA Testosterone, Free & Total (Includes SHBG) Testosterone, Total SHBG Testosterone, Free & Total Female Child (Includes SHBG) Testosterone, Total SHBG Thyroglobulin Thyroglobulin Thyroglobulin Antibody Thyroid Antibody Group Thyroid Peroxidase Antibody Thyroglobulin Antibody Torch (IgG) Torch Toxo, IgG Torch Rubella, IgG Torch CMV, IgG Torch HSV I/II IgG Page 12 of 40 Tests Referred NewCopy of 2016 Expanded Test List (2)

13 Test Ordered Component Parts CPT Torch (IgM) Torch Toxo, IgM Torch Rubella, IgM Torch CMV, IgM Torch HSV I/II IgM Toxoplasma Antibody Toxoplasma IgG Toxoplasma IgM Page 13 of 40 Tests Referred NewCopy of 2016 Expanded Test List (2)

14 Test Ordered Component Parts CPT Typhus Typhus IgG Typhus IgM Varicella Zoster Antibody V. Zoster IgG V. Zoster IgM VMA & HVA; urine VMA - Vanillylmandelic acid HVA - Homovanillic acid von Willebrand Panel Factor V III von Willebrand Factor Ag von Willebrand Factor Activity West Nile Virus Abs, IgG & IgM by ELISA, Serum West Nile Virus Antibodies, IgG West Nile Virus Antibodies, IgM West Nile Virus Abs, IgG & IgM by ELISA, CSF West Nile Virus Antibodies, IgG, CSF West Nile Virus Antibodies, IgM, CSF Anti-Nuclear Antibody (ANA) If negative, charge for (ANA) Antinuclear Antibody (86038). If positive, reflex to (ANA) Antinuclear Antibody; titer (86039). Celiac Disease Panel Cocaine & Benzoylecgonine IgA; if < 7 mg/dl, add ttg IgG; if negative and patient is < 3 years of age, add x2 Gliadin IgG & IgA. If IgA is > 7, add ttg IgA; if negative and patient is < 3 years of age, add x2 Gliadin IgG & IgA If negative, charge for single drug class method, each drug class (80101). If positive, reflex to drug confirmation, each procedure (80102). Drug Screen, Meconium x9 Screen; if positive add appropriate CPT Code for drug confirmed: Marijuana; Cocaine; Opiates; Phencyclidine; Amphetamines;82205 Barbituates; Methadone; Benzodiazepines; Propoxyphene Page 14 of 40 Tests Referred NewCopy of 2016 Expanded Test List (2)

15 Test Ordered Component Parts CPT Endomysial Antibody If negative, bill for immunoassay for analyte other than infectious antibody or infectious agent antigen, qualitative or semiquantitative; multiple step method (83516). If positive, reflex to fluorescent noninfectious agent antibody; screen, each antibody (86256). Page 15 of 40 Tests Referred NewCopy of 2016 Expanded Test List (2)

16 Test Ordered Component Parts CPT Factor VIII Activity with Reflex to Bethesda Quantitative, Factor VIII Factor VIII; if reflexed, add Bethesda Quantitative Factor IX Activity with Reflex to Bethesda Quantitative, Factor IX Hemoglobin Evaluation with Reflex to Electrophoresis and/or RBC Solubility 85250; if reflexed, add Bethesda quantitative Hemoglobin fractionation and quantitation; chromatography (83021) Chromatography; Electrophoresis and/or Sickling of RBC, reduction Heterophile Antibody by Latex Agglutination with Reflex to Titer Heterophile antibody; if reflexed, add Heterophile titer Human Immunodeficiency Virus 1,2 Combined Antibodies with Reflex to HIV HIV-1, 2; if reflexed, add HIV-1 Confirmation by Western Blot confirmation Human Immunodeficiency Virus 2 Antibody, with Reflex to Confirmation HTLV-1/2 Antibody HIV2; if reflexed add HIV IFA If negative, charge antibody; virus, not elsewhere specified (86790). Human Immunodeficiency Virus (HIV) Phenotype Comprehensive Methaqualone If reactive, reflex to HTLV or HIV antibody, confirmatory test (eg, Western Blot) (86689) first ten drugs; x1 each additional drug If negative, charge drug screen, qualitative; single drug class method (eg, immunoassay, enzyme assay), each drug class (80101). LSD, Serum or Plasma LSD, Urine Myocardial Antibody Neutrophil cytoplasm Antibody {ANCA}; IgG If positive, reflex to column chromatography/mass spectrometry; quantitative, single stationary and mobile phase (82542) Drug screen; if confirmed Drug screen; if confirmed If negative, charge fluorescent noninfectious agent antibody screen, each antibody (86255) If positive, reflex to fluorescent noninfectious agent antibody titer, each antibody (86256). If negative, charge fluorescent noninfectious agent antibody screen, each antibody (86255) If positive, reflex to fluorescent noninfectious agent antibody titer, each antibody (86256). Page 16 of 40 Tests Referred NewCopy of 2016 Expanded Test List (2)

17 Test Ordered Component Parts CPT Neuronal Nuclear Antibody (ANNA) IgG by IFA with Reflex to Titer & Immunoblot, Serum ANNA; if reflexed, add ANNA titer and Immunoblot Purkinje Cell Cytoplasmic Antibody by IFA with Reflex to Titer & Immunoblot Reptilase Time with Reflex to Reptilase Time 1:1 Mix F-Actin (Smooth Muscle) Antibody, IgG by ELISA with Reflex to Smooth Muscle Antibody, IgG Titer Striated Muscle Antibody, IgG with Reflex to Titer VDRL, CSF 86255; if reflexed, add Titer; Immunoblot Reptilase time; if reflexed add Reptilase time 1:1 mix Actin IgG; if reflexed, add ASMR Titer Striated muscle; if reflexed, add Striated muscle titer If non-reactive, charge for Treponema pallidum screen; (86592). If reactive, reflex to Treponema pallidum titer (86593). Page 17 of 40 Tests Referred NewCopy of 2016 Expanded Test List (2)

18 Section I: Multiple Component Tests Microbiology The following section delineates tests that contain multiple component tests as determined by a single order. That is, one test order by the physician results in multiple tests being performed with associated codes/charges. Test Ordered Component Parts CPT Typing, Salmonella Salmonella, Method A Salmonella, Method B Salmonella, Method C Salmonella, Method D Salmonella, Method E Salmonella, Method G Typing, Shigella Shigella, Method A Shigella, Method B Shigella, Method C Shigella, Method D Shigella, Method A-D Typing, Streptococcus Typing, Strep Group A Typing, Strep Group B Typing, Strep Group C Typing, Strep Group F Typing, Strep Group G Page 18 of 40 Micro NewCopy of 2016 Expanded Test List (2)

19 Section I. Multiple Component Tests Immunology The following section delineates tests that contain multiple component tests as determined by a single order. That is, one test order by the physician results in multiple tests being performed with associated codes/charges. Test that may be added on to order based on result CPT Reflex Test CPT Treponemal IgG - Reflex to RPR Titer Titer Cryptococcal Antigen - Reflex to Titer Titer Cryptococcal Antigen CSF - Reflex to Titer Titer Page 19 of 40 Immunology NewCopy of 2016 Expanded Test List (2)

20 Section I. Multiple Component Tests The following section delineates tests that contain multiple component tests as determined by a single order. That is, one test order by the physician results in multiple tests being performed with associated codes/charges. AMA Organ Panels Tests may be ordered individually based on Medical Necessity. CPT for individual test Panel Ordered CPT for Panel Component Parts Acute Hepatitis Panel Hepatitis B Surface Antigen (HBsAg) Hepatitis B Core Antibody (HBcAb), IgM Antibody Hepatitis C Antibody Hepatitis A Antibody (HAAb), IgM Antibody Basic Metabolic Panel (BMP) Glucose Blood Urea Nitrogen Creatinine Sodium Potassium Chloride Carbon Dioxide (CO2) Calcium Comprehensive Metabolic Panel (CMP) Glucose Blood Urea Nitrogen Creatinine Sodium Potassium Chloride Carbon Dioxide (CO2) Calcium Total Protein Albumin Alkaline Phosphatase AST (SGOT) ALT (SGPT) Bilirubin, Total Page 20 of 40 AMA Organ Panels NewCopy of 2016 Expanded Test List (2)

21 CPT for individual test Panel Ordered CPT for Panel Component Parts Electrolytes on - Reflex if APC ResistancSodium Potassium Chloride Carbon Dioxide (CO2) Lipid Panel Cholesterol Lipoprotein, HDL Direct Triglycerides Liver Panel (Hepatic Function) ALT (SGPT) Albumin Alkaline Phosphatase AST (SGOT) Bilirubin, Direct Bilirubin, Total Total Protein Renal Panel Glucose Blood Urea Nitrogen Creatinine Sodium Potassium Chloride Carbon Dioxide (CO2) Calcium Albumin Phosphorus Page 21 of 40 AMA Organ Panels NewCopy of 2016 Expanded Test List (2)

22 Section I. Multiple Component Tests The following section delineates tests that contain multiple component tests as determined by a single order. That is, one test order by the physician results in multiple tests being performed with associated codes/charges. Chemistry: Tests (Multiple Component Tests) Test Ordered Component Parts CPT Notes Bilirubin, Fractions (HML test name: Bilirubin, Total Bilirubin, Total & Direct) Bilirubin, Direct Bilirubin, Indirect N/A Drug Screen, Urine Benzodiazepines G0480 One charge for panel. Limit one per day. Can be ordered individually. Cocaine Metabolite G0480 Can be ordered individually. Amphetamine/ Can be ordered individually. Methamphetamine G0480 Cannabinoids G0480 Can be ordered individually. Opiates G0480 Can be ordered individually. Barbiturates G0480 Can be ordered individually. Glucose Tolerance, 2 hour Fasting glucose Glucose + 3 specimens 1 hour glucose N/A 2 hour glucose N/A Gestational Glucose Tolerance, 3 hour Fasting glucose Glucose + 3 specimens 1 hour glucose N/A 2 hour glucose N/A 3 hour glucose Additional glucose specimen ACTH Stimulation Panel Cortisol 0, 30 and 60 minutes two or more cortisols Page 22 of 40 Chemistry NewCopy of 2016 Expanded Test List (2)

23 Section I. Multiple Component Tests The following section delineates tests that contain multiple component tests as determined by a single order. That is, one test order by the physician results in multiple tests being performed with associated codes/charges. Hematology: Tests (Multiple Component Tests) Test Ordered Component Parts CPT CBC with Manual Diff Hemogram W/PLTS Manual Differential CBC with Automated Diff Hemogram W/PLTS Auto Diff HAR NA Reflex Manual Diff NA Reflex Smear Review NA Page 23 of 40 Hematology NewCopy of 2016 Expanded Test List (2)

24 Section I. Multiple Component Tests Coagulation The following section delineates tests that contain multiple component tests as determined by a single order. That is, one test order by the physician results in multiple tests being performed with associated codes/charges. Test Ordered Component Parts CPT DRVVT DRVVT DRVVT 1:1 mix DRVVT ratio Lupus/Mixing Study Heparin XA and Thrombin Time Lupus/Mix Study NA may be performed but are not charged. PT PTT-LA DRVVT DRVVT 1:1 mix DRVVT ratio PT 1:1 zero minutes inc PT T-LA zero minutes undiluted PTT-LA 1:1 zero minutes PTT-LA 1 hr undiluted PTT-LA 1:1 one hour Hexagonal Phosphate LA Path Interp Platelet Function Assay (PFA) Circulating Anticoagulant PT Circulating Anticoagulant PTT Activated Protein C Resistance PFA Panel NA PFA-epi PFA-adp PT Undiluted PT 1: Circulating Anticoagulant Path Review PTT Undiluted PTT 1:1 0 minutes PTT 1:1 one hour Circulating Anticoagulant Path Review APC Resistance Factor V Leiden FVL Isolation - Reflex if APC Resistance is Page 24 of 40 Coagulation NewCopy of 2016 Expanded Test List (2)

25 FVL Probe Page 25 of 40 Coagulation NewCopy of 2016 Expanded Test List (2)

26 Section I. Multiple Component Tests The following section delineates tests that contain multiple component tests as determined by a single order. That is, one test order by the physician results in multiple tests being performed with associated codes/charges. Transfusion Services: Tests (Multiple Component Tests) Blood Bank Orderable Initial Test Performed CPT RhoGAM Workup, Mother's Specimen ABO Blood Group Rh Blood Type Weak D Antibody Screen Fetal Cell Screen RhoGAM Workup, Newborn's Specimen Coombs Direct Cord Rh Blood Type Transfusion Reaction Pathologist Evaluation. The following are performed and not billed: Clerical check, DAT, ABO Rh verification, urinalysis, repeat antibody screen, etc. as needed/appropriate Type and Crossmatch ABO Blood Group Rh Blood Type Crossmatch Antibody Screen Computer Crossmatch Immediate-spin Crossmatch Type, Screen & Hold (TS&H) ABO Blood Group Rh Blood Type Antibody Screen ROTEM Coag/Fibrinolysis assay, whole blood viscoelastic clot assessment Page 26 of 40 Blood Bank NewCopy of 2016 Expanded Test List (2)

27 Section I. Multiple Component Tests The following section delineates tests that contain multiple component tests as determined by a single order. That is, one test order by the physician results in multiple tests being performed with associated codes/charges. Transfusion Services: Blood & Blood Products (Multiple Component Tests) Blood Bank Product Ordered Blood Components CPT Platelet apheresis, Crossmatch, Leuko-reduced, Irradiated Platelets, Leuko-reduced Pheresis P9035 Platelet crossmatch, complete Irradiation Fee Platelet apheresis, HLA Matched, Leuko-reduced, Irradiated Irradiation Fee Platelets, Pheresis, HLA Match P9052 Autologous Deglycerolized RBCs (Red Blood Cells) Autologous Frozen Blood P9039 Donor Group and Type Deglycerolized Service Fee per Carter BloodCare Autologous Frozen at Carter BloodCare Frozen Blood Storage 3 months Autologous Frozen Blood P9039 Donor Group and Type Autologous Leukoreduced Red Cells Autologous Leukoreduced Red Cells P9021 Donor Group and Type Autologous Whole Blood Autologous Whole Blood P9010 Donor Group and Type Cryo, Pooled Cryoprecipitate, each unit P9012 Pooling Charge Cryo Leukocytes, Pheresis, Irradiated Leukocytes Single Donor P9050 Irradiation Fee Neonatal Leuko-reduced Red Cell, Irradiated Neonatal Leuko-Reduced RBC P9040 Irradiation Fee Sickle-Dex Donor Unit Type Neonatal Leuko-reduced Red Cells Neonatal Leuko-Reduced RBC P9040 Sickle-Dex Platelet Concentrate, Leuko-reduced, Volume Depletion Volume Reduction FVL Isolation - Reflex if APC Resistance is P9031 Page 27 of 40 BB Components NewCopy of 2016 Expanded Test List (2)

28 Transfusion Services: Blood & Blood Products (Multiple Component Tests) Blood Bank Product Ordered Blood Components CPT Reconstituted Whole Blood for exchange transfusion RBC Leuko-reduced P9016 Fresh Frozen Plasma P9017 Irradiation Fee Splitting Fee CMV Negative Unit Sickle-Dex Donor Unit Hct Pooling Fee, RBCs Red Cells, Directed, Leuko-reduced, Irradiated Irradiation Fee Leukocyte-reduced Red Cell P9016 Page 28 of 40 BB Components NewCopy of 2016 Expanded Test List (2)

29 Section I. Multiple Component Tests The following section delineates tests that contain multiple component tests as determined by a single order. That is one test order by the physician results in multiple tests being performed with associated codes/charges. Cytology and Histology: Tests (Multiple Component Tests and/or Test Clarification) The referral of a specimen to Anatomic Pathology (Surgical Pathology, Cytology, etc.) represents a request for a pathology consultation. If in the judgment of the pathologist, additional routine, histochemistry, cytochemistry, electron microscopy, and/or immunohistochemistry stains/techniques are indicated, they may be ordered by the pathologists. Test Ordered Component Tests CPT Bladder, renal pelvis washing Liquid Based Preparation-Non Gyn Cytology-Monolayer Body Fluids (abdominal, pleural, pericardial) Cell Block - Level 4 Gross & Micro or Rapid Cell Block-Cellient (if needed) Liquid Based Preparation-Non Gyn Cytology-Monolayer Cell Block - Level 4 Gross & Micro or Rapid Cell Block-Cellient (if needed) Bronchial Brushings Liquid Based Preparation-Non Gyn Cytology-Monolayer Bronchial Washing r/o Pneumocystis carinii (PCP) Cell Block - Level 4 Gross & Micro or Rapid Cell Block-Cellient (if needed) Liquid Based Preparation-Non Gyn Cytology-Monolayer Cell Block - Level 4 Gross & Micro or Rapid Cell Block-Cellient (if needed) Special Stain-organism Bronchial Washings Liquid Based Preparation-Non Gyn Cytology-Monolayer Cell Block - Level 4 Gross & Micro or Rapid Cell Block-Cellient (if needed) Cerebrospinal Fluid Concentration and Filter Prep Cell Block - Level 4 Gross & Micro or Rapid Cell Block-Cellient (if needed) Common Bile Duct Brushing Prepare/interpret Smears; Less than Page 29 of 40 Anatomical Pathology NewCopy of 2016 Expanded Test List (2)

30 Test Ordered Component Tests CPT Common Bile Duct Brushing Fluid Liquid Based Preparation-Non Gyn Cytology-Monolayer Cell Block - Level 4 Gross & Micro or Rapid Cell Block-Cellient (if needed) Cyst Fluid (various sites) Liquid Based Preparation-Non Gyn Cytology-Monolayer Cell Block - Level 4 Gross & Micro or Rapid Cell Block-Cellient (if needed) Cyto Smears; other source; preparation, screening, and interp. Touch Prep Path Consult Cytologic Exam during surgery Touch Prep Touch Prep each additional Duodenal Brushing Fluid Liquid Based Preparation-Non Gyn Cytology-Monolayer Cell Block - Level 4 Gross & Micro or Rapid Cell Block-Cellient (if needed) Duodenal Washing Liquid Based Preparation-Non Gyn Cytology-Monolayer Cell Block - Level 4 Gross & Micro or Rapid Cell Block-Cellient (if needed) Fine Needle Aspirate (FNA) Pathologist Performed FVL Isolation - Reflex if APC Resistance is FNA Immediate Adequacy Assessment FNA Immediate Adequacy Assessment each additional FNA Interpretation + Report Cell Block - Level 4 Gross & Micro or Rapid Cell Block-Cellient (if needed) Fine Needle Aspirate (FNA) - Radiology- Endoscopy FNA Immediate Adequacy Assessment FNA Immediate Adequacy Assessment each additional FNA Interpretation + Report Cell Block - Level 4 Gross & Micro or Rapid Cell Block-Cellient (if needed) Gastric Brushing Liquid Based Preparation-Non Gyn Cytology-Monolayer Cell Block - Level 4 Gross & Micro or Rapid Cell Block-Cellient (if needed) Gastric Washing Liquid Based Preparation-Non Gyn Cytology-Monolayer Page 30 of 40 Anatomical Pathology NewCopy of 2016 Expanded Test List (2)

31 Test Ordered Component Tests CPT Cell Block - Level 4 Gross & Micro or Rapid Cell Block-Cellient (if needed) Gyn Cytology Conventional Pap Pap Smear The Bethesda System (TBS) Gyn Cytology Conventional Pap w/ QC Pap Smear TBS + QC Gyn Cytology Maturation Index Maturation Index Gyn Cytology Thin Prep Pap Test Monolayer Pap Gyn Cytology Thin Prep Pap Test w/ QC Monolayer Pap + QC Miscellaneous Fluid Liquid Based Preparation-Non Gyn Cytology-Monolayer Level 4 Gross & Micro Cell Block - Level 4 Gross & Micro or Rapid Cell Block-Cellient (if needed) Needle Aspirate Fluid Liquid Based Preparation-Non Gyn Cytology-Monolayer Cell Block - Level 4 Gross & Micro or Rapid Cell Block-Cellient (if needed) Needle Aspirate Smears Prepare/interpret Smears; Less than Extended study >5 smears and/or stains Pelvic Washings Liquid Based Preparation-Non Gyn Cytology-Monolayer Cell Block - Level 4 Gross & Micro or Rapid Cell Block-Cellient (if needed) Renal pelvic brushing Liquid Based Preparation-Non Gyn Cytology-Monolayer Cell Block - Level 4 Gross & Micro or Rapid Cell Block-Cellient (if needed) Sex Chromatin Identification; Barr Bodies Buccal Smear Urine, voided or catheterized Liquid Based Preparation-Non Gyn Cytology-Monolayer Cell Block - Level 4 Gross & Micro or Rapid Cell Block-Cellient (if needed) Page 31 of 40 Anatomical Pathology NewCopy of 2016 Expanded Test List (2)

32 Section II: Reflex, Confirmatory and/or Accepted Clinical Practice Testing This section delineates tests that may be added to the original order based on initial laboratory findings without an additional physician order. Microbiology Test that may be added on to culture work up: CPT Concentration, Infectious Agents Culture, Stool, Additional Pathogens Culture Typing, Identification by Probe Homogenization, Tissue, Culture Identification, AFB (Acid Fast Bacillus) Identification, Fungus, Mold Identification, Fungus, Yeast Identification Aerobe Identification Anaerobe MRSA Screen (Methicillin Resistant Staphylococcus Aureus) MIC, Bacteria, Yeast or Mold Sensitivity, Agar Diffusion Stain, AFB (Acid Fast Bacillus) Stain, Direct Gram Stain, Fungus Susceptibility by Enzyme Susceptibility, Agar Dilution Shiga Toxin E coli O Shiga Toxin Typing, Miscellaneous Multiple CPTs See Section I, Component Tests Typing, Salmonella Multiple CPTs See Section I, Component Tests Typing, Shigella Multiple CPTs See Section I, Component Tests Fungus Culture, source CSF will reflex to Cryptococcal Antigen, CSF Anaerobic culture when indicated by specimen source, body site or clinical information. Sites included: Deep wounds, Sterile body fluids, tissue, aspirated, bone Page 32 of 40 Micro Add-ons NewCopy of 2016 Expanded Test List (2)

33 Section II: Reflex, Confirmatory and/or Accepted Clinical Practice Testing This section delineates tests that may be added to the original order based on initial laboratory findings without an additional physician order. Microbiology A blood culture order, when positive for growth, will result in molecular tests to detect the following: Organism Target: Gram Positive Panel CPT CODE All Targets NOT DETECTED Staphylococcus sp S. aureus S. aureus meca Detected S. epidermidis S. epidermidis meca Detected S. lugdunensis Streptococcus sp S. agalactiae S. pyogenes S. pneumoniae S. anginosus gp E. faecalis E. faecalis vana Detected E. faecalis vanb Detected E. faecium E. faecium vana Detected E. faecium vanb Detected ORGANISM TARGET: Gram Negative Panel CPT CODE All Targets NOT DETECTED Acinetobacter sp Citrobacter sp Enterobacter sp Proteus sp Page 33 of 40 Micro Add-ons NewCopy of 2016 Expanded Test List (2)

34 E. coli K. pneumoniae K. oxytoca P. aeruginosa CTX-M Resistance Factor KPC Resistance Factor NDM Resistance Factor VIM Resistance Factor IMP Resistance Factor OXA Resistance Factor Page 34 of 40 Micro Add-ons NewCopy of 2016 Expanded Test List (2)

35 Section II: Reflex, Confirmatory and/or Accepted Clinical Practice Testing This section delineates tests that may be added to the original order based on initial laboratory findings for an additional charge without an additional physician order. Chemistry Test Order Hepatits C Antibody if positive reflex to HCV RNA Hepatitis B Surface Antigen if positive reflex to confirmation. HIV1/HIV2 Antibody + HIV2 Antigen Assay if positive reflex to HIV1/HIV2 Antibody (Multispot) If Multispot negative reflex to HIV1 NAAT (Aptima) Reflex/Confirmation Hepatitis C Antibody (CPT 86803). If Hepatitis C Antibody Signal Cutoff Ration S/O reflex to HCV RNA Quant PCR (CPT 87522). Hepatitis B Surface Antigen (CPT 87340). If positive reflex to HBsAg confirmation sent to THHEB (CPT 87341). Multispot (HIV 1 Antibody CPT and HIV 2 Antibody CPT 86702) Aptima sent to Dallas County Health Department. Page 35 of 40 Chem add-ons NewCopy of 2016 Expanded Test List (2)

36 Section II: Reflex, Confirmatory and/or Accepted Clinical Practice Testing This section delineates tests that may be added to the original order based on initial laboratory findings without an additional physician order. Hematology Tests that may be added on to: CPT Notes: Complete Blood Count (CBC) Manual Differential or smear review N/A Criteria used for reflex smear review are based on instrument flags and/or results of specified portions of the testing process reported on the hemogram. Pathologist Smear Review Order for this test is requested by the bench technologist based on departmental criteria (Criteria available upon request). Can also be ordered by physician. Body Fluid Cell Count Pathologist Body Fluid Review Order for this test is requested by the bench technologist based on departmental criteria (Criteria available upon request). Can also be ordered by physician. CSF Cell Count Pathologist CSF Review Order for this test is requested by the bench technologist based on departmental criteria (Criteria available upon request). Can also be ordered by physician, if desired. Page 36 of 40 Hematology Add-ons NewCopy of 2016 Expanded Test List (2)

37 II. Reflex, Confirmatory and/or Standard Clinical Practice Testing The following section delineates tests that may be added to the original order based on initial laboratory findings without an additional physician order. Test Order Possible Additional Charges CPT Crossmatch Result Computer Crossmatch Crossmatch AHG Crossmatch by Carter BloodCare Antigen Except ABO/Rh (donor unit phenotype) Autologous Fee Outside Autologous Collection Fee Carter BloodCare Donor Antigen Fee CMV Negative Unit Irradiation Fee Sickle-Dex RBC Washing Fee Rare Donor Unit RH Blood Type Weak D RHIG WKUP, Cord Blood (RhoGAM Workup, Cord Blood) RHIG WKUP, Mother (RhoGAM Workup, Mother's specimen) Type, Screen & Hold (TS&H) or Type and Crossmatch Weak D Chemical Pretreatment of RBC's Antibody Identification Antigen Except ABO/Rh (donor unit phenotype) Antibody Neutralization Chemical Pretreatment of RBC's Direct Coombs (polyspecific) Cirect Coombs Complement Direct Coombs, IgG Hgb F by Blood Center Pathologist Evaluation Screen, Post RhoGAM (RHIG) ABO by Carter Blood Care ABO Type Discrepancy by Carter BloodCare FVL Isolation - Reflex if APC Resistance is Page 37 of 40 Blood Bank Add-ons NewCopy of 2016 Expanded Test List (2)

38 Test Order Possible Additional Charges CPT Type, Screen & Hold (TS&H) or Type and Crossmatch (cont) Absorption Cold second absorption Absorption Cold third absorption Absorption Warm Absorption Warm second absorption Absorption Warm third absorption Adsorption Phenotype by Carter BloodCare Antibody Elution Antibody Elution by Carter BloodCare Antibody ID Prewarm Technique Antibody Identification Antibody Identification by Carter BloodCare Antibody Inhibition Incubation Antibody Neutralization Antibody Neutralization Lewis Antigen Antibody Neutralization P1 Antigen Antibody Screen, Each Technique Antibody Titer Antibody Titer by Carter BloodCare Antigen Except ABO/Rh (patient phenotype) Antigen Screening by Carter BloodCare Carter BloodCare Routine pick up Fee Carter BloodCare STAT pick up Fee Chemical Pretreatment of RBC's Chloroquine/Dithiothreitol Treatment by Carter Cold Agglutinin Screen by Carter BloodCare Cold Agglutinin Titer by Carter BloodCare Cold Agglutinins Complete Phenotype by Carter BloodCare DAT by Carter Blood Care Direct Coomb, Complement Direct Coombs (DAT), Polyspecific Direct Coombs, IgG Donath Landsteiner by Carter BloodCare Page 38 of 40 Blood Bank Add-ons NewCopy of 2016 Expanded Test List (2)

39 Test Order Possible Additional Charges CPT Type, Screen & Hold (TS&H) or Type and Crossmatch (cont) High titer/low avidity (HTLA) Antibody Titer Indirect AHG by Carter BloodCare Neocyte Harvest by Carter BloodCare Pathologist Evaluation Patient Antigen Type, single by Carter BloodCare Rare Cell ID by Carter BloodCare RBC Treatment by Carter BloodCare Rh Phenotype by Carter BloodCare RH Type by Carter BloodCare Rh Type Discrepancy by Carter BloodCare Select Cell ID by Carter BloodCare Weak D Page 39 of 40 Blood Bank Add-ons NewCopy of 2016 Expanded Test List (2)

40 II. Reflex, Confirmatory and/or Standard Clinical Practice Testing The following section delineates tests that may be added to the original test order based on initial laboratory findings by surgeon, pathologist, or clinician. Possible Additional Tests CPT Additional frozen block Touch Prep/IOC, additional site Decal Special Stain (per block, per specimen) Other Special Stain (per block, per specimen) Oil Red O (per block, per specimen) Consult on outside slides Consult, prepare slides Consultation, comprehensive Human Papillomavirus (HPV), high risk types Immunohistochemistry (IHC)* (per antibody, per specimen, or first antibody per slide) *G0461 G0462 (federal payers) Immunohistochemistry (IHC) additional stains IP, quantitative, manual Immunofluorescence (IF) In-situ hybridization (ISH) ISH quantitative, manual Electron Microscopy (EM) DNA, Image Analysis Page 40 of 40 Anat Path Add-ons NewCopy of 2016 Expanded Test List (2)