Specimen Collection

Cytopathology Specimens Acceptance and Rejection

In order to provide quality patient care and to reduce chances of potential misidentification of specimens and slides we require that the guidelines outlined below be followed when submitting specimens or slides for cytologic evaluation.

The requisition form must contain:

  • The patient's first and last name.
  • The patient's unique identification number (eg. Unit History #, Social Security #)
  • The patient's date of birth
  • The requesting physician's full name - UTMB physicians also required to submit the physician billing ID number.
  • The source of the specimen (eg. cervix, vagina, vaginal cuff)
  • The date the specimen was collected
  • The reason for the test – submitted as an ICD-9 code or as a descriptive diagnosis.
  • Please provide any other pertinent clinical information/history that is available and if pap smear is submitted, last menstrual period (LMP) should be provided.
  • When submitting a screening pap smear on a Medicare patient, please provide the ICD-9 code for either a low risk patient (V76.2) or a high risk patient (V15.89)
  • When submitting a diagnostic pap smear on a Medicare patient, please provide the appropriate ICD-9 code for the sign/symptom or reason it is diagnostic

Specimen Labeling:

  1. Slides submitted must be clearly labeled in pencil with the patient's full name, including first and last name. No initials, please.
  2. A unique patient identification number must be provided, either written in pencil on the slide; written on the specimen container, or provided as a requisition adhesive label placed on the slide container.
  3. Pap smears with no identification written on the slide will not be accepted for evaluation.
  4. One patient's pap smear slide should be submitted per specimen carton.
  5. Slides broken beyond repair will not be accepted. Those with the label end intact (patient name readable) and with the remaining slide large enough to fit in the staining machine will be accepted.
  6. If the patient's name/identification number written on the requisition form does not match the name/identification number on the specimen container/slide, the specimen will be rejected, and a new specimen will be required.
  7. Depending upon contract agreements, additional patient information may be required.

Questions concerning these guidelines may be addressed to the laboratory supervisor at 409-772-2872 or 409-772-2873.

Reviewed 6/22/12 by Robert Stewart