Reference lab do extra testing?

[Mabel Adams]

Do those in the US who use non-ARC IRLs get charged for ABO & Rh on every specimen sent, even if all that is ordered is a non-ABO/Rh antigen type?  Also, if you order a k type on a patient (say, you have already done the K type but need to see if this father is homozygous for K) does your reference lab test (and charge) for both K and k regardless of how you order it?  Lastly, if the order is for, say, Kpa testing (where the antisera requires IAT testing), does the IRL charge you for a DAT on the patient?  We are having a hard time passing on these charges for tests that weren't ordered by the provider.

[Ensis01]

I would be horrified if any reference lab did not do an IgG DAT on the patient cells prior to a IAT pheno test, Kp(a) in your example, and very surprised if it was not charged for.

I would be mildly surprised if any reference lab did not also type for the antithetical antigen ordered. However if you document on the order your result (big K neg for example) then it may depend on your accreditation, for example if you are AABB accredited they won’t test else they will.

I would expect an ABO/Rh done and charged for on every Work-up, with the exceptions of DAT only evaluations (eluate), and antigen phenotyping only.

I suggest getting your director involved and having a discussion with your reference lab’s manager and / or director to clarify respective policy and reach an agreement.

[applejw]

We routinely reflexively test (and charge) for antithetical antigens for questions related to fetal risk for HDFN. We routinely perform an ABO/Rh type on specimens where only an antibody screen is ordered for a pre-natal patient (no charge if previous history). We routinely perform and charge for a DAT/ABO/Rh type/Antibody screen for antigen phenotyping for Daratumumab and hemoglobinopathy patients.

[Sonya Martinez]

Our reference lab only charges for the ABORH if they had to do extra work to determine it such as DTT treat the cells.  We wouldn't order specific patient antigen typing but rather an entire profile which is now done using NGS.  We order and result a DAT if we antigen type a patient so yes I would expect the IRL to do it as well.  I had out CDM team add billing procedure codes so I can manually bill the patient for the testing that is billed to us.  

We have a contract with our IRL that specifically states what is charged and when.  Maybe you need an agreement as well.

[David Saikin]

If I send an abid to my IRL, no matter what I have done, they do an:  ABORh, Absc, Rh Phenotype, DAT, and finally ABID.    If I order a titer of a specific antibody they do a type, abid, dat, rh pheno (if not on file), and finally the titer.   I did lots of abids and other special tests only performing what the other hospitals wanted and nothing extraneous.  If i needed a phenotype or DAT or anything else that completing the testing required, it was done.

[Mabel Adams]

In other lab testing, we would not expect the reference lab to do additional tests and charge for them beyond what is ordered.  I understand the need when doing an antibody workup as these things are interrelated.  Why would a reference lab need the ABO/Rh of the father of a baby of a pregnant woman with anti-Kpa?   I know that they should do a DAT before using IAT antisera, but to me that is QC, and need not be a reportable test, nor charged for in this case.  Molecular would be more expensive than typing for Kpa/Kpb antigens serologically and cost is a barrier to getting the testing done.

I have tried in the past so I doubt that I can have any impact whatsoever on the policies of our reference lab but I was wondering if I might find somewhere else to send these antigen type specimens that will do only the testing we order. 

[Ensis01]

If you ordered Kp(a) antigen testing only.

We would test, and if negative charge and report IgG DAT and the Kp(a) only. If the Kp(a) were positive we would also do the antithetical high incidence Kp(b) antigen. There would be a comment on the report saying words to the effect that no other testing was performed per your request. 

the DAT is required investigational testing to validate the IAT results, and is therefore charged and reported. The reagents used in testing require QC, which is not charged or reported.

In my experience reference labs, like hospital blood banks, evolve their policies to better help meet their local customer requirements, which are varied. So talking to your reference lab manager to understand both positions may enable reaching an understanding. If that doesn’t work I guess you could, with lab director permission, refuse to pay for tests not ordered. I have however no clue of the ramifications of that course of action

[RichU]

Just an observation....

When I worked in a reference lab in the UK we tested the patient's cells against AB serum in parallel when performing IAT typing. This was part of the testing protocol and there was no DAT required.

I would only think about doing a DAT if this negative control was positive.

Is there a charge for running a monoclonal control with monoclonal typing reagents?