3910 Washington Parkway, Suite B Idaho Falls, ID 83404 Ph: 208.529.8330 Fax: 208.523.3318 444 Hospital Way, Ste. 611 Pocatello, ID 83201 Ph: 208.529.8330 Fax: 208.232.0755 2001 S Woodruff Ave. Ste 15B Idaho Falls, ID 83404 Ph: 208.529.8330 Fax: 208.523.3318 101 E Main Street Rexburg, ID 83440 Ph: 208.529.8330 Fax: 208.523.3318 Client Bill Please circle tests needed and provide relevant ICD10 codes. CPT 36000 82951 CPT 80051 80048 80053 80061 80076 80069 80074 80055 CPT 82040 84075 84460 82150 89600 86850 86038 84450 82248 82247 84520 86304 85025 82465 82533 86140 86141 82565 82575 82627 83718 82310 83721 85652 82670 82728 82746 83001 82947 SPECIALTY TESTS Insulin Resistance Test SST Glucose Tolerance Test SST PANELS Electrolyte Panel SST Basic Metabolic SST Comprehensive Metabolic SST Lipid Panel SST Hepatic Panel SST Renal Panel SST Hepatitis, Acute SST Prenatal Panel (120) INDIVIDUAL TESTS Albumin SST ALK Phos SST ALT (SGPT) SST Amylase SST ABO/RH PRPL Antibody Screen PRPL ANA with Reflex (2) SST AST (SGOT) SST Bilirubin, Direct SST Bilirubin, Total SST BUN SST CA-125 SST CBC w/Auto Diff PRPL Cholesterol, Total SST Cortisol SST C-Reactive Protein (CRP) SST CRP-High Sensitivity SST Creatinine SST Creatinine Clearance SST DHEA-S SST Direct HDL SST Calcium SST Direct LDL SST ESR - Sed Rate PRPL Estradiol SST Ferritin SST Folate/Folic Acid SST FSH SST Glucose SST ICD10 ICD10 ICD10 ICD10 ICD9 CPT 85014 85018 83036 86708 86705 86317 87340 86803 86703 83090 86677 86695 86696 82784 83525 83540 83550 80178 83690 83002 83735 82043 83921 84100 84132 84702 81025 84703 84144 80197 84146 84153 83970 85610 85730 86480 86430 86762 84270 86592 84402 INDIVIDUAL TESTS CONT. Hematocrit PRPL Hemoglobin PRPL Hemoglobin A1C PRPL Hep A Total AB SST Hep B Core IgM AB SST Hep B Surfact AB SST Hep B Surface AG SST Hep C Antibody SST HIV SST Homocysteine SST H Pylori PRPL or Stool HSV-1 lgG SST HSV-2 lgG SST IgA, Total SST Insulin SST Iron, Total SST Iron Binding Capacity SST Lithium SST Lipase SST LH SST Magnesium SST Malb/Crea Ratio, Urine Methylmalonic Acid (MMA) SST Phosphorus SST Potassium SST Pregnancy HCG, Quant. SST Pregnancy HCG, Qual SST Pregnancy HCG Urine Progesterone SST Prograf (Tacrolimus) PRPL Prolactin SST PSA SST PTH SST Protime/INR BLUE PTT BLUE Quantiferon-TB Plus RF/Rheumatoid Factor SST Rubella SST SHBG SST Treponema (RPR) SST Testosterone Free SST ICD10 Patient Bill CPT 84403 84432 86800 86376 84478 84481 84443 84439 84436 84550 82340 81003 81001 87086 84156 82306 80164 82652 82607 82607 CPT 87505 87493 87505 87481 87081 87502 87651 87505 87505 87040 87070 Source: Time: CPT Insurance Bill INDIVIDUAL TESTS CONT. Testosterone, Total SST Thyroglobulin SST Thyroglobulin AB SST Thyroid Peroxidase AB SST Triglycerides SST TTG, IgA SST TSH SST Free T3 SST Free T4 SST Total T4 SST Uric Acid SST Urine Calcium/Creat Ratio Urine Dip Urine Microscopic Urine Culture Urine Total Protein/Creat Ratio Valproic Acid Vit D, 1, 25-Dihydroxy Vitamin D25 Hydroxy SST Vitamin B12 SST MICROBIOLOGY CT/NG/TRICH SWAB/UR Clostridium Difficile, Stool Bacterial Panel, Stool MRSA/MSSA, SWAB Group B Strep PCR SWAB Influenza Screen SWAB Strep Screen SWAB Parasite Panel, Stool Viral Panel, Stool Blood Culture Wound Culture ADDITIONAL TESTS ICD10 ICD10 ICD9 ICD10 * Panel includes: ABO/RH/Antibody Screen, RPR, Rubella, CBC, HepB Sur Ag, HIV. PATIENT INFORMATION Required Information Referring Physician: Patient Name: Sex: M Date: F DOB: Fasting: Y or N Time: PLEASE LIST YOUR OFFICE / FACILITY / LOCATION Address: INSURANCE INFORMATION (Please attach copy) Phone: ) ) ExpressLabIdaho.com 03/19