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GBP
GREEN BELT PROJECT

Test Code GBP 
Test GREEN BELT PROJECT 
Description Useful for the diagnosis of thrombotic disorders.

Panel includes the following tests;

Antithrombin III Activity
Beta-2-Glycoprotein, IgG, IgM
Cardiolipin Antibodies, IgA, IgG, IgM
Factor V Leiden Mutation
Fibrinogen
Homocysteine, Total
Lupus Anticoagulant Screen
Partial Thromboplastin Time
Protein C Activity
Protein S Activity
Prothrombin 20210 Mutation
INR
Thrombin Time

**Further testing will be performed at an additional charge for the following tests:

Abnormal LUPUS ANTICOAGULANT screen will reflex to;
PTT mixing study,
Platelet neutralization,
PTT using Factor sensitive reagent.

Abnormal THROMBIN TIME of greater than 30 seconds will reflex to;
Reptilase Time.

NOTE: All tests included in panel may be ordered individually.

NOTE: This test, when ordered on Medicare patients, is subject to the National Coverage Determination (NCD) policies "Partial Thromboplastin Time (PTT)" and "Prothrombin Time (PT)". Please verify that the diagnosis code (ICD-9) you have chosen demonstrates medical necessity for the test as documented in the physician's patient record. The CMS web site or the NorDx Limited Coverage Documentation Guide are available to assist you with this verification. A properly executed Advanced Beneficiary Notice (ABN) must be submitted with the specimen if medical necessity is not demonstrated by the ICD-9 code chosen. 

Specimen
Required Collection Tubes3 Lavendar (EDTA) Tubes, 1 Plain Red or SST, and 4 Blue (3.2% Sodium Citrate) Tubes
Patient InstructionsFasting
Miscellaneous InformationINR, Protein C Activity, and Protein S Activity effected by Counadin Therapy

Link to THROMBOTIC RISK PANEL.Rev1doc.doc
Link to TRPRO Component Spreadsheet
Link to HIGH_HEMATOCRIT_GUIDE.FINAL.ppt
Link to Processing_checklist.doc

FACTOR V LEIDEN (FVDNA), PROTHROMBIN 20210 (PTDNA) AND LAHCT (Part of LUPUS):

Patient Instructions: NONE
Collection Tube: 2 Lavender (EDTA)
Processing Instructions: NONE (whole blood assays)
Storage/Transportation: Room temperature
Rejection Criteria: Hemolyzed specimen is not acceptable


HOMOCYSTEINE, TOTAL:

Patient Instruction: FASTING
Collection tube: 1 Lavender (EDTA)
Processing instructions: Spin, separate off 1.0 ml
plamsa, freeze immediately. Label
aliquot tube with Patient name, DOB,
and "EDTA PLASMA".
Storage/Transportation: Frozen
Rejection criteria: NONE


ANTITHROMBIN III, FIBRINOGEN, LUPUS ANTICOAGULANT, PROTEIN C and S, REPTILASE TIME, THROMBIN TIME, INR, and PTT:

Patient Instruction: PC, PS, and INR affected by Coumadin
therapy
Collection tube: 4 Blue (3.2% Sodium Citrate)
Processing instructions: Double spin, separate in 5-7 1.0ml aliquots, freeze immediately. Label
aliquot tubes with Patient name, DOB,
and "CITRATE PLASMA".
Lavender (EDTA) Processing: Send whole
Storage/Transportation: Frozen
Rejection criteria: High Hematocrit (greater then 55%),
Gross hemolysis, clotted specimens,
underfilled tubes (<90% filled)

NOTE: See detailed "double spin" procedure


CARDIOLIPIN ANTIBODIES and BETA-2-GLYCOPROTEIN ANTIBODIES:

Patient instructions: NONE
Collection tube: 1 Plain Red or SST
Processing instructions: Spin, separate off 3.0 ml serum
Storage/Transportation: Room Temperature
Rejection criteria: Hemolyzed specimen is not acceptable 

Reference Values An interpretive report will be issued. 
Analytic Time 14 days 
Day(s) Test Set Up Varies 
CPT Code(s) 83090  Homocystine
83890  Extraction
83896 4  Nucleic acid probe
83898  PCR Amplification
83900  Nucleic Acid Amplification
83903  Melting Curve Analysis
83912 2  Interpretation and Report
85300  Antithrombin III Activity
85303  Protein C Activity
85306  Protein S Activity
85597  Platelet neutralization for lupus inhibitor, if indicated
85610  PT
85635  Reptilase time, if indicated
85670  Thrombin Time
85730  Lupus Anticoagulant Screen
85730  PTT with sensitive reagent, if indicated
85730  PTT
85732  PTT mixing studies, if indicated
86146 2  Beta-2-glycoprotein antibody, each
86147 3  Cardiolipin antibodies, each

Special Instructions