A B C D E F G H I J K L M N O P Q R S T U V W X Y Z #

Biopsy

Message
Human tissue and foreign material removed in the operating rooms, wards, clinics, and emergency room, with some exemptions as listed below, must be sent to the Histology Laboratory for examination. Instructions for submission of routine tissue specimens follow. 

If there is any question regarding appropriate handling of tissue specimens, call Histopathology at ext. 3-1524/1526 for instructions or contact a pathologist.  The duty pathologist can be reached by pager.
  
Any tissue which requires special handling procedures: Consult a pathologist first before the biopsy or procedure. 
The duty pathologist can be reached by pager.
  
Exceptions:
The only specimens exempt from submission to the histology laboratory are those listed below. With the exception of bullets and missiles, any specimen may be submitted to the laboratory at the discretion of the clinician.  Any specimens not submitted to the laboratory should be clearly described and documented in the clinical record.
  1. Bullets and other missiles should be maintained with a chain of custody form and given directly to Security for legal purposes.
  2. Teeth, liposuction contents, inter-vertebral disc material, and infant prepuces need not be submitted. 
  3. Grossly normal placentas need not be submitted. Submission of placentas is at the discretion of the Obstetrics and Gynecology department.
  4. Orthopedic devices and foreign bodies need not be submitted but should be clearly documented in the clinical record if not submitted.
 


Test Code
Biopsy


Instructions

All specimens will be submitted with either a CHCS order entry document or a Tissue Examination Request
[NAVHOSPPTSVA 6510/44 series
It must be completely filled out with:

1. The provider’s full name.
2. The patient’s first and last name.
3. Social security number with FMP.
4. Age.
5. Ward/clinic/MOR.
6. Specimens anatomic site.
7. Two submitting staff initials.
8. Specimen identifier (A, B, C, etc) if more than one container / specimen is to be submitted.
9. Duty station with phone number for active duty personnel.
In addition, pre-operative diagnosis should be included with pertinent clinical data.

Note: All tissue specimens submitted to Histology from internal NMCP sources must have 2 verifying initials on the specimen containers. If they don’t, the specimen will not be accepted. This is command policy. In addition, all patient and specimen source information must be on the specimen container and exactly match the specimen source indicated in the order.

  1. When placing the order in CHCS, the ordering provider must verify that the Patient’s name, FMP, social security number, date of birth and specimen source on the specimen container are correct. Specimens from different body sites must be placed in separate, completely labeled, containers.
  2. Surgical Pathology specimens must be labeled and requisitions prepared in the room where the surgical procedure is performed. The ordering provider must ensure that the specimen container(s) are correctly labeled with complete and correct patient information, including full name, FMP, SSN, and date of birth, and with the correct specimen identifier (A, B, C, etc) and specimen source (body site). The provider should verify that the specimen identifier(s) (A, B, C, etc) and body sites in the orders correspond to the identifier(s) and body sites on the specimen container(s.)

Note: Routine specimens should be submitted in adequate fixative (10% neutral buffered formalin). A volume of fixative 10-20 times the volume of the tissue specimen submitted is required for optimal fixation. In cases where fixative has not been added, the histopathology technician or laboratory technician will add fixative to the container after consulting with a pathologist.

For ships and branch clinics that mail surgical specimens to Naval Medical Center, Portsmouth, a leak proof screw top container that seals tightly must be used in addition to some type of absorbent material in order to avoid fixative leaking during shipment. Fixative leakage results in inadequate tissue preservation, and histological detail is destroyed. Tissue submission request chits should be separate from the tissue container to protect from leakage. .


Transport Container


A leak proof screw top container that seals tightly must be used.

Any tissue which requires special handling procedures: Consult a pathologist first before the biopsy or procedure.
The duty pathologist can be reached by pager.
Specific guidelines for some special biopsies can be found within the JDOS application.




Transport Temperature
Room temperature


Reject Criteria (Eg, hemolysis? Lipemia? Thaw/Other?)
Missing or incomplete patient name on container or lab order form.
Missing or incomplete patient FMP and/or social security number on container or lab order form.
Missing or incomplete anatomic site on container or lab order form.
No double initials for specimen submitted within NMCP clinics on container (two staff members from the submitting clinic must initial the specimen container).
Illegible container lable or lab order form.
Patient information on container different from patient information on lab order form.
No lab order form submitted with specimen.
No specimen submitted with lab order form.


Limitations


Medical devices, including orthopedic hardware and foreign bodies are submitted for gross diagnosis only.  In the case of serialized medical hardware, the manufacturer and serial number will be included in the pathology report.



 Fixative leakage results in inadequate tissue preservation, and histological detail is destroyed.
SPECIMENS EXEMPT FROM MICROSCOPIC EXAMINATION: Medical devices, including orthopedic hardware and foreign bodies are submitted for gross diagnosis only. In the case of serialized medical hardware, the manufacturer and serial number will be included in the pathology report.
 Fixative leakage results in inadequate tissue preservation, and histological detail is destroyed.
SPECIMENS EXEMPT FROM MICROSCOPIC EXAMINATION: Medical devices, including orthopedic hardware and foreign bodies are submitted for gross diagnosis only. In the case of serialized medical hardware, the manufacturer and serial number will be included in the pathology report.
 Fixative leakage results in inadequate tissue preservation, and histological detail is destroyed.
SPECIMENS EXEMPT FROM MICROSCOPIC EXAMINATION: Medical devices, including orthopedic hardware and foreign bodies are submitted for gross diagnosis only. In the case of serialized medical hardware, the manufacturer and serial number will be included in the pathology report.
 Fixative leakage results in inadequate tissue preservation, and histological detail is destroyed.
SPECIMENS EXEMPT FROM MICROSCOPIC EXAMINATION: Medical devices, including orthopedic hardware and foreign bodies are submitted for gross diagnosis only. In the case of serialized medical hardware, the manufacturer and serial number will be included in the pathology report.
 dical devices, including orthopedic hardware and foreign bodies are submitted for gross diagnosis only.  In the case of serialized medical hardware, the manufacturer and serial number will be included in the pathology reportMedical devices, including orthopedic hardware and foreign bodies are submitted for gross diagnosis only.  In the case of serialized medical hardware, the manufacturer and serial number will be included in the pathology report. Prior to surgery, patient must request in writting any removed hardware if he choses to. 
Do to safety concerns, no tissue will be released to a patient.
Fixative leakage results in inadequate tissue preservation which will destroy histological detail.


  




The CPT Codes provided in this document are based on AMA guidelines and are for informational purposes only. CPT coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payor being billed. Any Profile/panel component may be ordered separately. Reflex tests are performed at an additional charge.