ADAMTS13 Activity and Inhibitor Profile
| PATIENT INFO |
| Patient Name: |
| Medical Record #: |
| BD: / / Sex: F M |
| PHYSICIAN INFO |
| Physician Name : |
| Address: |
| Ph: ( ) - Fax: ( ) - |
| Additional Report to: |
| Ph: ( ) - Fax: ( ) - |
| TESTS REQUESTED | |
| Test Name: | ICD9 Code: (required) |
| 1. ADAMTS13 Activity and Inhibitor Profile | |
| 2. | |
| 3. | |
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| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
ADM13
Test Workstation :
MAYO
Specimen Type:
Blood
Tube Type:
Light Blue (Sodium citrate) tube
Collection Volume:
5.0 mL
Storage:
Strict Frozen
Availability:
Sent to Reference Laboratory
Methodology:
ADMFX/61211: Fluorescent Resonance Energy Transfer (FRET)
ADMIS/61213, ADMBU/61214: Mixing Studies
Special Instructions:
If collected at an offsite location, send by a STAT Courier to Hospital lab.
Lab/Phone:
330-543-8418
TAT:
24 hours to 3 days
Additional Info:
Testing begins with ADAMTS13 activity assay. If the ADAMTS13 activity is <30%, an inhibitor screen will be performed to look for specific ADAMTS13 inhibition. If specific inhibition is apparent, the titer of the inhibitor will be determined.
CPT Code:
85397 and (85335x2 if appropriate)
Panel Includes:
CPT code 85397 (activity assay)
CPT code 85335 (Inhibitor Screen assay, if appropriate)
CPT code 85335 (Bethesda titer, if appropriate)
