2017 Sensieva Requisition Form Updates

ALERT -  Download the Form Updates

October 12, 2017

InSource Diagnostics is providing this notice in accordance with its compliance program and the recommendations by the Office of Inspector General (OIG) and reflects our commitment to conduct business in compliance with all federal, state, and local laws. We recently discovered errors on the FORM-ISD-00093-v1 .0-General Clinical Form. By issuing this statement, we hope to notify all our clients of the changes that are included and educate them as to how this will affect their orders.

To follow is a summary of the changes. If you need any additional information please contact our customer service team at 626-386-5277.

Current Language Change(s)
On the front of the requisition form, under Sensieva VENA/ Generic Profile, there are changes to the "Basic Metabolic Panel" The test should require "Fasting"
On the front of the requisition form, under Sensieva VENA/ Individual Tests, there is a test entitled "Cholesterol" The test should be titled "Cholesterol - Total"
On the front of the requisition form, under Sensieva VENA/ Individual Tests, there is a test entitled "T-Uptake" The test should be titled "T3 Uptake"
N/A On the front of the requisition form, under Sensieva VENA/ Individual Tests, there should be a test titled "T3, Free (FT3)"
Tube: R, G, T
Sample: S
Code: 4015
On the back of the requisition form, under Sensieva VENA / Generic Profile, there are changes to the "Thyroid Panel" The reflex should read:
Abnormal Low: FT3 and FT4
Abnormal High: FT4 and TPO for high
Billing Codes/Pricing:
Abnormal Low: 84481; 84439 Price: $23.05+$31.82
Abnormal High 84439; 86376 Price: $23.05+$32.33
On the back of the requisition form, under Sensieva VENA / Generic Profile, there are changes to "Men's Health" Billing Codes:
85025; 80053; 80061; 82627; 82670; 83001; 83002; 84144; 84410; 84443; 82306
Price: $328.06
On the back of the requisition form, under Sensieva VENA / Generic Profile, there are changes to "Men's Hormone" Test Includes:
DHEA-S, FSH, LH, Estradiol (E2), Progesterone, SHBG, Testosterone - Total, Testosterone-Free, Testosterone-Bioavailable, 25OH Vitamin D, TSH
Billing Codes:
82627; 82670; 83001; 83002; 84144; 84410; 84443; 82306
Price: $284.54
Medicare Coverage Determination:
NCD 190.22; LCD L36692
On the back of the requisition form, under Sensieva VENA / Generic Profile, there are changes to "Women's Health" Test Includes:
CBC, CMP, Lipid, Women's Hormone Panel
Billing Codes:
85025; 80053; 80061; 82627; 82670; 83001; 83002; 84144; 84443; 82306
Price: $255.51
On the back of the requisition form, under Sensieva VENA / Generic Profile, there are changes to "Women's Hormone" Billing Codes:
82627; 82670; 83001; 83002; 84144; 84443; 82306
Price: $211.99
Medicare Coverage Determination:
NCD 190.22; LCD L36692
On the back of the requisition form, under Sensieva VENA/ Individual Tests, there is a test entitled "Cholesterol" The test should be titled "Cholesterol - Total"
On the back of the requisition form, under Sensieva VENA/ Individual Tests, there is a test entitled "T-Uptake" The test should be titled "T3 Uptake"
N/A On the back of the requisition form, under Sensieva VENA/ Individual Tests, there should be a test titled "T3, Free (FT3)"
Billing Code: 84481
Price: $23.24
Medicare Coverage Determination:
NCD 190.22

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