PATIENT INFORMATION SPECIMEN INFORMATION FACILITY INFORMATION

[Pages:2]Prorenata Laboratories, LLC

Toll Free: 1-888-680-0014 ? Fax: 1-833-297-0961 8222 S. 48th Street, Suite 210 ? Phoenix, Arizona 85044

Director: Joshua Bornhorst, Ph.D., DABCC, FACB CLIA# 03D2147626

PATIENT INFORMATION

Last Name:____________________________________________ First Name:__________________________________________D.O.B.____________________________ Ordering Doctors Name:___________________________________________

SPECIMEN INFORMATION

Date of collection (MM/DD/YY):____________________________________ Time of Collection:________________________________________________

FACILITY INFORMATION

Facility Name:____________________________________________________

Printed Physician Name

Patient/Guardian Signature Patient/Guardian Signature

Date Date

ICD-10 CODES

Physician Signature Physician Signature

ANTIBIOTIC RESISTANCE

Carcinoma in situ of cervix (D06.9) or vulva

Z16.30 Resistance to unspecified

(D07.1) or vagina (D07.2)

antimicrPoabtiaiel dnrtu/gGsuardian Signature D07.30 CarcinDomaatein situ of unspecified

Z16.31 Resistance to antiparasitic drug(s)

female genital organs ( ) D07.39

Z16.32 Resistance to antifungal drug(s)

Carcinoma in situ of other female

Z16.33 Resistance to antiviral drug(s)

genital organs

Z16.35 Resistance to multiple antimicrobial

D07.60 Carcinoma in situ of unspecified

drugs

male genital organs ( ) D07.61

Z16.39 Resistance to other specified

Carcinoma in situ of scrotum

antimicrobial drugs

D07.69 Carcinoma in situ of other male

Z16.341 Resistance to single

genital organs

antimycobacterial drug

N30.00 Acute cystitis without hematuria

Z16.342 Resistance to multiple

N30.10 Interstitial cystitis (chronic) without

antimycobacterial drugs

hematuria

N30.40 Irradiation cystitis without

GENITO-URINARY

hematuria

A60.00 HSV of urogenital system,

N30.90 Cystitis, NOS without hematuria

unspecified

N70.93 Salpingitis and oophoritis, NOS

A60.1 HSV infection, perianal skin/rectum

N71.9 Inflammatory disease of uterus,

A60.9 Anogenital herpes viral infection,

NOS

unspecified

N73.9 Female pelvic inflammatory

A63.0 Anogenital (venereal) warts

disease, NOS

A64 Unspecified sexually transmitted

N72 Inflammatory disease of cervix

disease

uteri (with or without ulcer or

B00.9 Herpes viral infection, unspecified

erosion)

B37.3 Candidiasis, vulva/vagina

N76.0 Acute vaginitis

B37.49 Candidiasis, other urogenital

N76.1 Subacute/chronic vaginitis

B37.9 Candidiasis, unspecified

Ulceration of vagina (N76.5) or vulva (N76.6)

C53.9 Malignant neoplasm of cervix uteri,

N82.0 Vesicovaginal fistula

unspecified

N82.9 Female genital tract fistula, NOS

N82.1 Other female urinary-genital tract

fistulae

N82.4 Other female Pinhteysstiincaila-gnenSitiaglntraatcutre

fistulae

N86 Erosion, ectropion of cervix uteri

N87.9 Dysplasia of cervix uteri

N88.0 Leukoplakia of cervix uteri

N89.3 Dysplasia of vagina

N90.3 Dysplasia of vulva

N90.4 Leukoplakia of vulva

N41.0 Acute prostatitis

N41.1 Chronic prostatitis

N41.9 Inflammatory disease of prostate,

unspecified

N34.1 Nonspecific urethritis

N34.3 Urethral syndrome, NOS

N39.0 Urinary tract infection, site not

specified

N49.9 Inflammatory disorder of

unspecified male genital organ

R10.2 Pelvic/perineal pain

R30.0 Dysuria

R30.9 Painful micturiton, unspecified

R31.9 Hematuria, unspecified

R35.8 Polyuria, NOS

R36.9 Urethral discharge, unspecified

R35.0 Frequency of micturiton

R39.15 Urgency of Urination

R39.198 Other difficulties with micturition

BACTERIA Escherichia coli Pseudomonas aeruginosa Enetrococcus faecium, faecalis Enterobacter aerogenes, cloacae Klebsiella pneumoniae/ oxytoca Acinobacter baumannii Proteus mirabilis, vulgaris Prevotella bivia Serratia marcescens Citrobacter koseri Citrobacter freundii/braakii Morganella Morganii Bacteroides fragilis

URINARY TRACT INFECTION

Providencia Stuartii Staphylococcus aureus* Staphylococcus (coagulase negative:

epidermidis, haemolyticus, lugdunensis, saprophyticus) Staphylococcus saprophyticus Streptococcus, Group A [pyogenes] Viridians Group Streptococcus (anginosus, oralis, pasteuranus) Haemophilus influenzae Corynebacterium urealyticum Mobiluncus curtissi, mobilunucs mulieris Ureaplasma urealyticum, parvum

streptoccoccus agalactia (group B) gardnerella vaginalis

FUNGAL Candida albicans, glabrata, parapsilosis,

tropicalis STI trichomonas vaginalis neisseria gonorrhoeae chlamydia trachomatis Mycoplasma genitalium, hominis ANTIBIOTIC RESISTANCE Class D oxacillinase OXA-48 Class D oxacillinase OXA--51 qnrA1, A2, B2

INSURANCE INFORMATION & REQUIRED ATTACHMENTS

Date Date

R39.89 Other and unspecified symptoms

and signs involving the urinary

systemDate

R39.9 Unspecified symptoms and signs

involving the GU system

R50.9 Fever, unspecified

R80.0 Isolated proteinuria

R82.3 Hemoglobinuria

R82.90 Other unspecified abnormal

findings in urine (positive nitrite or

leukocyte esterase)

R87.614 Cytologic evidence malignancy,

cervix or vagina (R87.624)

R87.610 Atypical squamous cells of

undetermined significance (ASC-

US), cytologic smear of cervix () or

vagina (R87.620)( ) ASC-US, can't

exclude high grade squamous

intraepithelial lesion (ASC-H), cervix

(R87.611) or vagina (R87.621)

R87.612 Low grade squamous intraepithelial

lesion (LGSIL), cytologic smear of

cervix or vagina (R87.622)

R87.613 High grade squamous

intraepithelial lesion (HGSIL),

cytologic smear of cervix or vagina

(R87.623)

R87.810 Cervical high risk human

papillomavirus (HPV) DNA test positive

R87.811 Vaginal high risk human

papillomavirus (HPV) DNA test positive

tet B, tet M ermB, C; mefA dfr (A1, A5), sul (1,2) probes

(Sulfamethoxazole and trimethoprim) IMP, NDM, VIM Groups (Carbapenem) ACT, MIR, FOX, ACC Groups (Beta Lactams) PER-1/VEB-1/GES-1 Groups (ESBL) VanA, VanB (Vancomycin) Sul I Sul II MRSA* Mec-A gene Class A -lactamase; blaKPC Class A -lactamase; CTX-M-Group1 Class B metallo--lactamase; blaNDM qnrB & qnrS

Urinary Tract Pathogens Specimen Collection Instructions

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