Fillable 20211213 CSI Hematopathology- Requisition- Form CV R2

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20211213 CSI Hematopathology- Requisition- Form CV R2

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Bone Marrow Asp Na-Heparin EDTA Other
Blood Na-Heparin EDTA Other
Smears Air-Dried Fixed Stained
Slides Stained Unstained Touch Preps
Tissue FNA Body Fluid (specify type)
Paraffin Block(s) Pick best block
PML-RARA AML Panel 1 AML Panel 2 AML Panel 3 AML Panel 4
MDS BCR-ABL1 MPN MPN/Eosinophilia B-ALL T-ALL
Follicular HGBL/Triple-Hit Burkitt Only Marginal Zone MALT Only
CLL/SLL CLL/MCL MCL Only Myeloma/PCD LPL/Waldenstrom
T-PLL ALK (Lymphoma) HER2 Bladder Cancer X/Y Sex Mismatch
1p/19q EGFR (Brain) Other:
FLT3
Reflexes:
If FLT3 and cytogenetic results are normal, reflex to NPM1+CEBPA Panel
If FLT3+ with monocytic differentiation, reflex to NPM1
If NPM1+ & FLT3-,
reflex to IDH1/IDH2
If inv(16) or t(8;21), reflex to KIT exons 8, 17
IDH1+IDH2
(with NPM1 Mutation - HEME) IDH1+IDH2 (GBM) KIT (D816V)
BCR-ABL1 Screening p190+p210
(No previous results on file at CSI)
BCR-ABL1 Follow-up: (select p190 or p210) ABL1 Kinase Domain Mutation
PML-RARA BRAF (HCL)
JAK2 V617F JAK2 reflex Exon 12 JAK2 reflex CALR, MPL IgVH
(CLL/SLL)
Bcell (IGH reflex to IGK) Tcell (Gamma reflex to Beta) IGH-BCL2 MYD88
Solid Tumors: KIT (GIST) KIT reflex PDGFRA (GIST) KIT (Melanoma)
MSI (Submit Normal Tissue + Tumor) PCR MGMT Methylation
EGFR
- T790M (Lung) ALK FISH ROS1 FISH EGFR - T790M reflex ALK+ROS1
KRAS BRAF NRAS KRAS reflex BRAF+NRAS Other:
C•RESULTS Lung Panel
(PD-L1 - IHC, BRAF, EGFR w/T790M reflex to ALK+ROS1)
C•RESULTS Colorectal Carcinoma Panel (KRAS, NRAS, BRAF, MMRP by IHC)
Leukemia/Lymphoma
( Global C•FLOW)
PNH*( Global only - Blood only)
ZAP70 ( Global C•FLOW)
DNA Ploidy+p57 ( Global)
DNA Ploidy+S-Phase
( Global)
Reflex testing as medically necessary (could include FISH, Cyto, IHC, or PCR)
Smears submitted for correlation only
Profiles
Global
†
C•IHC (Web) C•IHC (Slide-Only)
ER/PR
ER/PR/HER2
ER/PR/HER2/Ki-67
ER/PR/HER2/Ki-67/p53
HER2 by IHC
Reflex to HER2 FISH if IHC: 0 1+ 3+
†
GLOBAL HER2 IHC cases will automatically reflex 2+ equivocal results based on 2013 ASCO/CAP HER2 guidelines.
2580 Westside Parkway, Alpharetta, GA 30004
PH 1-800-459-1185 FAX 1-888-809-9071
INSURER POLICY # GROUP #
INSURER POLICY # GROUP #
#
#
#
#
#
#
#
#
#
#
#
Requisition
CLIENT IDENTIFICATION
BILLING INFORMATION
DIAGNOSIS INFORMATION
PLEASE PROVIDE CBC
CONSULTATION SERVICES
§
FLOW CYTOMETRY
IMMUNOHISTOCHEMISTRY
FISH ANALYSIS
Global C•FISH (Tech-Only)
Reflex as medically necessary (could include FISH, Cyto, IHC, or PCR)
MOLECULAR ASSAYS Reflex as medically necessary
(could include FISH, Cyto, IHC, or PCR)
CYTOGENETICS
INSURANCE INFORMATION
Attached face sheet/insurance Primary Ins: Self Spouse Child Other Secondary Ins: Self Spouse Child Other
PATIENT IDENTIFICATION
Date Packaged / /
Collection Date Time
Date of Discharge ABN is available
Date Pulled from Archive
Body Site
Formalin Fixed Other Fixation
Cold Ischemia Time
(min) Fixation Time (hours)
Bill to:
Client Insurance Patient
New Diagnosis Post-Therapy Relapse Remission
Previous Cytogenetics/FISH: Normal Abnormal
(Please Provide Report)
Allogeneic Bone Marrow Transplant Donor Sex: Male Female
Chromosome Analysis
‡
Chromosome Analysis with reflex to FISH/PCR as medically necessary
(See reverse for complete probe/panel list.)
Hospital status when specimen collected:
Hospital Inpatient Hospital Outpatient Non-Hospital Outreach/Clinic Patient
Additional Tests, Comments, or Differential Diagnosis
Medicare # Medicaid # Pre-Authorization #
Primary Ins. Secondary Ins.
Two unique identifiers are required on requisition & specimen
CSI GENIUS MMAP™
(Multiple Myeloma Assessment Protocol)
Flow Cytometry and Cytogenetics (reflex to FISH as medically necessary)
#
#
ICD-10 Code(s):
(ICD-10 information is required)
‡
Signature is required for orders of cytogenetic testing that include products of conception and/or constitutional analysis. Ordering physician confirms that above patient has been informed and provided consent for
testing.
Original and Second Copy (White /Canary) - CSI Laboratories Bottom Copy (Pink) - Client PAC001-01/09/19
Authorized Signature Phone Number for STAT Cases:
LABORATORY TESTS REQUESTED (highlighted items are available as tech-only) (specimen requirements on back)
Physician Notice: Only tests or diagnostic services that are medically necessary should be ordered. Appropriate ICD-10 information must be provided in the specified area above.
Payers, including Medicare and Medicaid, generally do not pay for screening tests. ABN is required for Medicare patients if ICD-10 codes provided do not support reasoning for testing.
SPECIMEN INFORMATION
Last Name First Name Middle Initial
Address City State ZIP
DOB Age Gender SSN Phone
Ordering Physician MRN
Treating Physician Specimen ID
M / F
Diagnostic Consultation - One of the consultation levels listed below will be
performed based on the specimen and report materials received.
•Consultation and report on referred slides prepared elsewhere (88321)
•Consultation and report on referred material requiring preparation of slides (88323)
•Consultation, comprehensive, with review of records and specimens, with report
on referred material (88325)
PD-L1 IHC (global only) MMRP [ Global C•IHC (Web) C•IHC (slide-only)]
Global Interpretation (specify stains) :
2580 Westside Parkway, Alpharetta, GA 30004
P: 1-800-459-1185 | F: 1-888-809-9071
Date packaged:
Hematopathology Requisition
CSI_12132021_R2
SINGLE GENE ASSAYS
NEXT GENERATION SEQUENCING
SPECIMEN INFORMATION (Two unique ideners are required on requision & specimen)
CLIENT IDENTIFICATION PATIENT IDENTIFICATION
INSURANCE / BILLING INFORMATION - REQUIRED: Please include face sheet and front/back of paent’s insurance card.
CLINICAL INFORMATION *
LABORATORY TESTS REQUESTED (Specimen requirements on back)
Test Opons
Diagnosc Consultaon � Consultaon level performed based on specimen and
report materials/informaon provided*
Global Interpretaon (specify stains):
FLOW CYTOMETRY
Reex as medically necessary (could include FISH, Cyto, IHC or PCR � see reverse
for complete probe/panel list)
CYTOGENETICS
MOLECULAR
ADDITIONAL TESTS, COMMENTS OR DIFFERENTIAL DIAGNOSIS
HOLD
CULTURE & HOLD
Global Tech Global Tech
ALK (Lymphoma) LPL/Waldenstrom Panel
AML Panel 1 MALT Panel
AML Panel 2 Marginal Zone Panel
AML Panel 3 MCL
AML Panel 4 MCL w/ reex CLL/SLL Panel
AML w/ Monocytosis MDS Panel
B-ALL Panel MPN/Eosinophilia Panel
Burki Lymphoma MPN Panel
CLL/MCL Panel Myeloma/PCD Panel
CLL/SLL Panel PML-RARA-Roune
CML (BCR-ABL1) PML-RARA-STAT
Eosinophilia Panel T-ALL Panel
Follicular Panel T-PLL Panel
HGBL/Triple-Hit Panel X/Y Sex Mismatch
Other:_______________________
HOLD
HOLD
‡
Signature required for orders of cytogenec tesng that include products of concepon and/or constuonal analysis.
Ordering physician conrms that above paent has been informed and provided consent for tesng.
Original and Second Copy (White / Canary) CSI Laboratories
Boom Copy (Pink) - Client
Global Tech Global
Leukemia / Lymphoma PNH (blood only)
CLL Prognosc: CD49d/CD200
Smears submied for correlaon only
THERAPY Current Therapy Prior (>1 month ago)
An-CD19 Therapy An-CD20 Therapy An-CD30 Therapy
An-CD38 Therapy Erythropoien Therapy G-CSF Therapy
Bone Marrow TransplantAbnormal Previous Cytogenecs / FISH (Provide Report)
New Diagnosis Relapse Remission
FISH
(see reverse for additional panels/probes and reflex testing)
Last Name: First Name: Middle Inial:
Gender: M F DOB: MRN:
Ordering Physician: Treang Physician:
Age:
AML Mutaon Analysis Panel: FLT3/IDH1/IDH2 *IF karyotype is normal or non-informave,
REFLEX to CEBPA/NPM1; *IF inv(16) or t(8;21), REFLEX to KIT, Exons 8 and 17
BCR-ABL1 follow-up: (select p190 or p210)
B-Cell clonality (IGH reex to IGK)
JAK2 V617F JAK2 reex Exon 12 (PV)
PML-RARA FLT3 IDH1, IDH2
BCR-ABL1 screening p190, p210 (No previous results at CSI)
ABL1 kinase domain mutaon
T-Cell clonality (TCRG reex to TCRB)
JAK2 reex to CALR, MPL (ET, PMF)
KIT (D816V)
IGVH (CLL/SLL)IGH-BCL2 MYD88BRAF (HCL)
Hematology Prole: 177 DNA genes (see reverse for specic genes tested)
Hematology PLUS Prole: 177 DNA + 1408 RNA genes (see reverse for specic DNA genes tested)
Liquid Biopsy, Hematology Prole: 177 Genes (full list of genes on reverse)
Authorized Signature: Phone Number for STAT Cases:
PLEASE PROVIDE CBC
(ICD-10 informaon is required)
IDC-10 Code(s):
Physician Noce: Only tests or diagnosc services that are medically necessary should be ordered. Appropriate
ICD-10 informaon must be provided in the specied area above. Payers, including Medicare and Medicaid,
generally do not pay for screening tests. ABN is required for Medicare paents if ICD-10 codes provided do not
support reasoning for tesng.
Collecon Date: Time: Date of Discharge:
Body Site:
Formalin Fixed: Yes No Other Fixaon:
Oncology Chromosome Analysis Non-Oncology Chromosome Analysis
†
POC Chromosome Analysis
†
Microarray Analysis
Bone Marrow asp Na-Heparin EDTA
Blood Na-Heparin EDTA Other
Smears Air-Dried Fixed Stained
Slides Stained Unstained Touch Preps
Tissue FNA Body Fluid (specify type):
Paran Block(s): Pick Best Block:
Specimen ID: Block ID:
Hospital status when specimen collected (must choose one): Hospital Inpaent Hospital Outpaent Non-Hospital Outreach / Clinic Paent
Prior Authorizaon Number:
Bill to: Client Bill Insurance Paent/Self Pay Split Bill: Client (TC) and Insurance (PC)
Bill charges to other hospital/facility:
Account Name & C-Number
click to sign
signature
click to edit
PLEASE CALL CSI CLIENT SERVICES AT (800) 459-1185 TO INQUIRE ABOUT TESTS NOT LISTED BELOW
SPECIMEN REQUIREMENTS SHIP SPECIMENS WITH COLD PACK
Flow Cytometry
Peripheral Blood 3 mL in sodium heparin (green top) - preferred or 3 mL in EDTA (purple top)
Bone Marrow Aspirate 1-2 mL in sodium heparin (green top) - preferred or 1-2 mL in EDTA (purple top)
FreshTissue Mulple 2-3 mm pieces of ssue in RPMI transport media (opmum RPMI to ssue rao is 15:1; mulple vials are acceptable)
Body Fluids Mix 1:1 in RPMI transport media
PNH Prole 3 mL peripheral blood in EDTA (purple top) preferred, should be processed within 24 hours of collecon
Cytogenecs
Peripheral Blood 5 mL in sodium heparin (green top)
Bone Marrow Aspirate 2-3 mL in sodium heparin (green top)
Cord Blood 2-5 mL in sodium heparin (green top)
Fresh Tissue Mulple 2-3 mm pieces of ssue in RPMI transport media (opmum RPMI to ssue rao is 15:1; mulple vials are acceptable)
FISH
Peripheral Blood 3 mL in sodium heparin (green top) - preferred or 3 mL in EDTA (purple top)
Bone Marrow Aspirate 2-3 mL in sodium heparin (green top) - preferred or 3 mL in EDTA (purple top)
Fresh Tissue Mulple 2-3 mm pieces of ssue in RPMI transport media (opmum RPMI to ssue rao is 15:1; mulple vials are acceptable)
Formalin-Fixed Paran-
Embedded Tissue
Minimum 0.2 x 0.2 x 0.2 cm ssue; non-decalcied ssue only (FISH only)
Molecular
Peripheral Blood 5-10 mL EDTA tube (purple top) - preferred; ACD (yellow top) acceptable
Bone Marrow 1-2 mL in EDTA tube (purple top) - preferred; ACD (yellow top) acceptable
Fresh Tissue Minimum of 250 mg ssue in RPMI transport media
Formalin-Fixed Paran-
Embedded Tissue
1 H&E slide and 6-8 unstained slides, 5-7 microns of BM clot or ssue xed with 10% NBF xave. Please circle tumor for microdissecon. Alternavely, the FFPE block of the BM clot can be
sent for seconing in our lab.
IHC 1 H&E slide with its corresponding paran block (10% neutral buered formalin) - preferred
HEMATOLOGY PROFILE AND LIQUID BIOPSY GENES TESTED FOR ABNORMALITIES
ABL1 BCL2 CBL CDKN2C DICER1 FAS IDH2 KMT2A MPL PAX5 PTCH1 SMAD2 TGFBR2
AKT1 BCL2L1 CBLB CEBPA DNMT3A FBXW7 IGF1R KMT2B MRE11A PBRM1 PTEN SMAD4 TP53
AKT2 BCL6 CBLC CHEK1 EP300 FLT3 IKZF1 KMT2C MTOR PDGFRA PTPN11 SMARCA4 TSC1
AKT3 BCOR CCND1 CHEK2 ERG GATA1 IKZF3 KMT2D MUTYH PDGFRB RAD21 SMARCB1 TSC2
ALK BCORL1 CCND3 CIC ETV6 GATA2 IRF4 KRAS MYC PHF6 RAD50 SMC1A TSHR
AMER1 BCR CD274 CREBBP EZH2 GATA3 JAK1 MAP2K1 MYD88 PIK3CA RAD51 SMO WT1
APC BIRC3 CD79A CRLF2 FAM175A GEN1 JAK2 MAP2K2 NFKBIA PIK3R1 RB1 SOCS1 ZNF217
ARID1A BLM CD79B CSF1R FAM46C GNAQ JAK3 MAP2K4 NOTCH1 PIK3R2 RHOA SRC ZRSR2
ARID1B BRAF CDH1 CSF3R FANCA GNAS KAT6A MAP3K1 NOTCH2 PIM1 RNF43 SRSF2 MEF2B
ARID2 BRCA1 CDK12 CTNNA1 FANCC H3F3A KDM5C MAP3K14 NOTCH3 PLCG1 RUNX1 STAG2
ASXL1 BRCA2 CDK4 CTNNB1
FANCD2 HNF1A KDM6A MAPK1 NPM1 POLD1 SDHB STAT 3
ATM BTK CDK6 CUX1 FANCE HOXB13 KDR MCL1 NRAS POLE SETBP1 STK11
ATRX CALR CDKN2A CXCR4 FANCF HSP90AA1 KEAP1 MDM2 NSD1 PPM1D SETD2 TERT
B2M CARD11 CDKN2B DDR2 FANCG IDH1 KIT MDM4 PALB2 PPP2R1A SF3B1 TET2
*CONSULTATION LEVELS
CPT Code 88321 Consultaon and report on slides NOT prepared by CSI Laboratories
CPT Code 88323 Consultaon and report on slides prepared by CSI Laboratories (includes review of pathology report only; no other addional medical records review)
CPT Code 88325
Consultaon and report on slides prepared by CSI Laboratories, including complete medical records review (complete medical records include but are not limited to pathology reports, surgical notes, radiology reports,
laboratory results, etc.)
FISH PANELS WITH REFLEX CONDITIONS. (FOR TECH-ONLY SERVICES, REFLEX OPTIONS MUST BE INITIATED BY SIGNING PATHOLOGIST)
AML - Panel 1 - [t(15;17)/PML-RARA]
*IF NEGATIVE, REFLEX TO: t(8;21)/RUNX1T1-RUNX1, inv16/CBFB-Break apart, KMT2A(MLL)-Break apart
*IF gain of RARA, REFLEX TO: RARA-Break apart
AML - Panel 2 - [5q/EGR1, 7q/CEP7, CEP8, 20q, RB1-LAMP1, KMT2A(MLL)-Break apart, t(9;22)/BCR-ABL1]
AML - Panel 3 - [5q/EGR1, 7q/CEP7, KMT2A(MLL)-Break apart, t(8;21)/RUNX1T1-RUNX1, inv16/CBFB-Break apart, t(9;22)/BCR-ABL1]
*IF NEGATIVE, REFLEX TO: RB1-LAMP1, 20q, CEP8
AML - Panel 4 - [t(8;21)/RUNX1T1-RUNX1, inv16/CBFB-Break apart, KMT2A(MLL)-Break apart] - global
AML with monocyc dierenaon - [inv16/CBFB-Break apart, KMT2A(MLL)-Break apart] - global
B – ALL - [ t(9;22)/BCR-ABL1, KMT2A(MLL)-Breakapart, t(12;21)/ETV6-RUNX1, CRLF2-Breakapart, CEP4/CEP10/CEP17] - global
*IF NEGATIVE, REFLEX TO: [9p21/CDKN2A-CEP9, IGH- Breakapart , MYC-Breakapart] - global
*IF gain of ETV6, REFLEX TO: [ETV6-Breakapart] - global
Burki Only - [t(8;14)/IGH-MYC, MYC-Break apart]
*IF GAIN of IGH, REFLEX: [t(14;18)/IGH-BCL2, BCL6-Break apart, BCL2-Break apart]
*IF clinically indicated for MCL, REFLEX: [t(6:14)/CCND3-IGH, t(11;14)/CCND1-IGH, CCND1-Break apart, CCND2-Break apart]
CLL/SLL + Mantle cell - [CLL1/(ATM/TP53), CLL2/(13q14.3/LAMP1/CEP12),IGH-Break apart, MYB-CEP6, RB1-LAMP1, t(11;14)/CCND1-IGH]
*IF IGH Rearranged, REFLEX: t(14;18)/IGH-BCL2
*IF unresolved queson of MCL, REFLEX: [t(6:14)/CCND3-IGH, CCND1-Break apart, CCND2-Break apart]
CLL/SLL - [CLL1/(ATM/TP53), CLL2/(13q14.3/LAMP1/CEP12),IGH-Break apart, MYB-CEP6, RB1-LAMP1]
*IF IGH Rearranged, REFLEX: [t(11;14)/CCND1-IGH] and/or [t(6:14)/CCND3-IGH, t(14;18)/IGH-BCL2,CCND2-Break apart] if indicated
CML - [t(9;22)/BCR-ABL1]
*IF POSITIVE, REFLEX: (BCR-ABL1(p210/p190) by RT-PCR
Eosinophilia - [PDGFRA-Break apart, PDGFRB-Break apart, FGFR1-Break apart], JAK2-Break apart
Follicular Center Lymphoma - [t(14;18)/IGH-BCL2, BCL6-Break apart, BCL2-Break apart]
*IF GAIN IGH, REFLEX: [t(8;14)/IGH-MYC, MYC-Break apart]
*IF queson of MCL by Flow, REFLEX: [t(6:14)/CCND3-IGH, t(11;14)/CCND1-IGH, CCND1-Break apart, CCND2-Break apart]
HGBL/Triple Hit - [t(8;14)/IGH-MYC, MYC-Break apart, t(14;18)/IGH-BCL2, BCL6-Break apart, BCL2-Break apart]
*IF clinically indicated for MCL, REFLEX: [t(6:14)/CCND3-IGH, t(11;14)/CCND1-IGH, CCND1-Break apart, CCND2-Break apart]
LPL/Waldenstrom [MYB-CEP6, IGH-Break apart]
MALT Only - [MALT1-Break apart, BCL6-Break apart,t(11;18)/BIRC3-MALT1]
*IF MALT1 rearranged, REFLEX TO: [ t(14;18)/IGH-MALT1]
Marginal Zone - [7q/CEP7, CEP12, BCL6-Break apart, MALT1-Break apart, IGH-Break apart, TP53/CEP17]
*IF MALT1-Break apart rearranged, REFLEX TO: [t(11;18)/BIRC3-MALT1, t(14;18)/IGH-MALT1]
*IF IGH-Break apart rearranged, REFLEX TO: [t(11;14)/CCND1-IGH, CCND1-Break apart, t(14;18)/IGH-BCL2]
*IF unresolved queson of MCL, REFLEX: [t(6:14)/CCND3-IGH, CCND2-Break apart]
Mantle Cell - [t(11;14)/CCND1-IGH, CCND1-Break apart]
*IF Negave and clinically indicated, REFLEX: [t(6:14)/CCND3-IGH, CCND2-Break apart]
Mantle cell, Reex CLL/SLL - [t(11;14)/CCND1-IGH,CCND1-Break apart]
*IF NEGATIVE, REFLEX TO: [CLL/SLL Panel]
*IF Negave and clinically indicated, REFLEX: [t(6:14)/CCND3-IGH, CCND2-Break apart]
MDS - [5q/EGR1, 7q/CEP7, CEP8, 20q, RB1-LAMP1, KMT2A(MLL)-Break apart, TP53/CEP17]
MPN - [t(9;22)/BCR-ABL1, 5q/EGR1, 7q/CEP7, CEP8, 9p21/CDKN2A-CEP9, 20q, RB1-LAMP1]
MPN/Eosinophilia - [t(9;22)/BCR-ABL1, 4q12/PDGFRA-Break apart, PDGFRB-Break apart, FGFR1-Break apart], JAK2-Break apart
Myeloma/PCD Panel - [1p/1q, RB1-LAMP1, IGH-Break apart, TP53/CEP17, t(11;14)/CCND1-IGH, CEP9/CEP11]
*IF IGH is rearranged, but Negave for t(11;14)/CCND1-IGH; REFLEX TO: [t(4:14)/FGFR3-IGH, t(6:14)/CCND3-IGH, t(14;16)/IGH-MAF, t(14;20)/IGH-MAFB]
*IF GAIN of CCND1, without GAIN of CEP11, REFLEX: [CCND1-Break apart]
PML-RARA [t(15;17)]
T-ALL - [t(9;22)/BCR-ABL1, (9p21)/CDKN2A-CEP9, KMT2A(MLL)-Break apart]
*IF NEGATIVE, REFLEX TO: [1p33, t(5;14), t(10;11), 7q/CEP734, 14q11.2]
T-PLL [TCL1 for inversion 14 and t(14;14); TRA for t(X;14)]
CSI_12132021_R2
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20211213 CSI Hematopathology- Requisition- Form CV R2

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Completed 18 June 2022

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