46-50 Coombe RoadNew Malden • Surrey KT3 4QF

Call 020.8336.7750 or visit our website at www.gdx.net/uk

Gut Pathogen Pro�le GASTROINTESTINALComprehensive Parasitology

COLLECTION TRAY (3)

YELLOW-TOPTUBE

GREEN-TOP TUBES (3)

COLLECTION MATERIALS FOR STOOL

• Disposable gloves (3)• Test requisition form• Biohazard bags with absorbent pads (3)

• Specimen collection packaging (save box to ship specimen back to lab)

1 OR 3 DAY STOOL PATIENT COLLECTION INSTRUCTION FOR THE FOLLOWING PROFILE(S)

GI Effects® Gut Pathogen Profile* #2207Comprehensive Parasitology Profile #DIG05

ADDITIONAL MATERIALS

If any items are missing or expired, or liquid is spilled, call Client Services at 020 8336 7750

CAUTION: Tubes contain poisonous liquid. KEEP OUT OF REACH OF CHILDREN. For eye contact, flush with water for 15 mins. For skin contact, wash with soap and water. For ingestion, contact poison control center immediately.

IMPORTANT PREP BEFORE PATIENT TAKES TEST For full details and explanations refer to: www.gdx.net/tests/prep

• Please consult with your physician before stopping any medications. Wait at least 4 weeks from colonoscopy or barium enema.

• 2-4 weeks before test: Discontinue antibiotics, antiparasitics, antifungals, probiotic supplements (acidophilus, etc.); if adding on the H. pylori test, discontinue proton pump inhibitors (PPIs) and bismuth.

• 2 days before test: Discontinue interfering substances including rectal suppositories, enemas, activated charcoal, laxatives, mineral oil, castor oil, and/or bentonite clay.

• Plan collection to allow for return shipping of specimens Monday through Friday and within 24 hours after final collection.

• C. difficile testing will not be performed on individuals under 2 years old.

©2019 Genova Diagnostics IS-MM-70827-UK rev0119

WHEN READY TO SHIP, ENSURE THE FOLLOWING:

q All tubes are:

q Tightly closed

q Marked with first and last name, collection date, and stool consistency

q Sealed in biohazard bag with absorbent pad

q All sections of requisition form completed.

q Payment included.

q All specimens placed back in original box.

SHIP THE SPECIMEN(S) TO THE LABPlease refer to the shipping instruction insert found in your sample collection pack.

COLLEC TION

Europe

£355.00

£40.00£55.00£40.00

£85.00

£40.00£35.00£20.00

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GENOVA DIAGNOSTICS •••••

Phlebotomy Code p C I

Requisition # 123-456-78

l!ll:-'.l!l m Full Option Note: This form must be completed (including responsible party signature) and returned with specimen in order to process this test. INOVA Medical Group 21785 Filigree Ct Ste 100 Ashburn, VA 20147-6214 703-554-11 00Please select ordering practitioner:□ C Connolly (A02SA) □ G Dondlinger (A71GG) □ A Lee (A82LN) □ H Noelle (A39W9) □ H Phillips (A47A5)

X

iA:¥1NMH:fli1iiij•ffii@Matti• Please document medical necessity and the specific order for the test in the patient's medical record or progress notes with a signature and dale from the referring physician In addition to providing a diagnosis code below.

Billing Options Check only one option below. If no billing option selected, Practitioner account may be billed.

Bill Practitioner Account Complete on reverse: Not available in the states of NY, NJ, and RI

Bill Medicare or Tricare Complete on reverse: Medicare Advantage Plans use the Bill Insurance option below All Medicaid plans use No Insurance option, except for Medicaid of NC

Bill Insurance with Patient Payment* Complete on reverse:

Initial Insurance Payment from Patient: �--_,

No Insurance Billing - (Cash Pay)* Pre-payment- please include full Cash Price amount Amount Enclosed: $ -----l Payment plan- please include 25% of the Cash Price amount*• Initial Installment: �---1

*For payments & pricing please visit www.gdx.net/prc or ask yourhealthcare practitioner.

Potential ICD-10 Codes and Conditions IMPORTANT: Please select or add the approprate /CD 10 diagnosis code{s).

K58.0 Irri table Bowel Syndrome With Dianhea

K58.9 Irri table Bowel Syndrome Without Dianhea

R10.9 Unspecified Abdominal Pain

R14.0 Abdominal Distension (Gaseous)

R19.7 Dianhea, Unspecified

K59.00 Constipation, Unspecified

R14.1 Gas Pain

K52.89 Other Specified Noninfective Gastroenteritis And Colitis

K52.29 Other Allergic And Dietetic Gastroenteritis And Colitis

R14.3 Flatulence

Other Codes: _______________________ ____,

Definition of Medical Necessity All claims submitted to Medicare/Medicaid for Genova Diagnostics' laboratory services must be for tests that are medically necessary. ''Medically necessary" is defined as a test or procedure that is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malfonned body member. Consequently, tests perfonned for screening purposes will not be reimbursed by the Medicare program. Physicians may deem it medically necessary to order a single test or a portion of a profile. CPT & ICD-10 Codes Due to the possibility of regulatory and/or methodology changes, CPT and ICD-10 codes are subject to change without prior notification.

THIS SPACE FOR LAB USE ONLY

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GUT PATHOGEN PROFILE-#16

_GI Effects IIP 100 CP 279 Gut Pathogen Profile #2207

Profile Components/CPT Codes _Bacteriology, Aerobic _Bacteriology, Anaerobic _Yeast Culture _Parasite Identification _Cryptosporidium, PCR

87045, 87046 x3 87075 87102 87209,87177

_Entamoeba histolytica, PCR 1---------- 87505 _Girdia lamblia, PCR _Cyclospora, PCR

_Macroscopic Exam for Worms 87169

Add-on Tests Additional charges apply, please see fee schedule for details.

_Helicobacter pylori Stool Antigen EIA (HpSA)#2133 87338

Diarrhea Present: _Enterohemonhagic E. coli Shiga-like toxin EIA #2132 87427

_Campylobacter specific antigen EIA #2130 87449

_Clostridium difficile EIA #2131 87324

GI Effects Gut Pathogen Profile is not currently available in New Yotk State

Consistency of Stool Specimen Chart

Formed/normal Hard/constipated Loose stool Watery/diarrhea

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Stool Collection Day 2 (of 3-day Collection)

Follow Steps 4 through 9 using the DAY 2 bag containing the GREEN-TOP TUBE.

Stool Collection Day 3 (of 3-day Collection) or Day 1 (if taking a 1-Day only Collection)

Follow Steps 4 through 9 using the DAY 3 bag containing the GREEN-TOP TUBE and YELLOW-TOP TUBE.

Ensure the final collection date is written on the reverse side of the requisition form underneath your signature.

Record Stool Consistency section based on chart below:

Send specimens within 24 hours of completing collection.

Refer to shipping instructions included in collection pack

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Completely fill out front and back of test requisition form. Failure to provide all information will result in delay of test processing.

Unless otherwise instructed by your clinician, please follow the instructions for a 3-day test. If you are taking a 3-day test perform all steps below.If you are taking a 1-day test only follow instructions for day 3, using the tubes in the day 3 bag. Send back the unused tubes in the shipping box for proper disposal.

Stool Collection Day 1 (of 3-day Collection)

Follow Steps 4 through 9 using the DAY 1 bag containing the GREEN-TOP TUBE.

Put on latex glove.

Collect stool specimen using enclosed collection tray. DO NOT contaminate specimen with urine or water from toilet. Record stool consistency on tube label using permanent marker.

Remove cap and using the attached spoon, pick up several stool portions from different areas in tray. Fill to red fill line marked on tube. DO NOT OVERFILL.

NOTE: If a worm is seen, DO NOT place it in vial with stool. Instead place it in the GREEN TUBE WITHOUT scooping additional stool. Alternatively, a worm can be placed in a clean glass jar with rubbing alcohol, with no additional stool added to jar. Make note on requisition form that a worm was seen and write WORM on the vial.

Mix and mash the specimen with spoon until thoroughly mixed and smooth.NOTE: Do not mix and mash specimen if there is a worm inside.

Tightly close tube, shake tube until mixed. NOTE: Do not shake tube if there is a worm inside.

Write your first and last name, and date of collection on tube label. Place tube in biohazard bag corresponding to day's collection, seal bag, and refrigerate until ready to ship.

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