Jump To:

• Introduction
• General Laboratory Reflex Testing
• Blood Bank and Coagulation Reflex Testing
• Microbiology Reflex Testing
• Molecular Reflex Testing
• Pathology Reflex Testing

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Introduction

Diagnostic Laboratory Services offers medically necessary reflex testing to facilitate effective and efficient patient care while remaining compliant with state and federal regulations governing the ordering of laboratory tests.

Reflexed tests are any test that automatically results in the order of one or more secondary tests based on preset criteria applied to the initial test. The secondary tests are almost always an additional charge above the initial test. When ordering a reflexed test, you must consider whether the secondary tests are medically necessary for the specific patient and for the specific situation in which the order is placed. If you consider the secondary tests unnecessary, order the initial test without the reflex.

Certain reflex testing has been predetermined based on specific criteria accepted as standard-of-care by the medical community. These tests will always reflex because the initial test result is not useful without the reflex test result and, therefore, individual components may not be available for ordering.

Note: The reflex test list provided below includes only tests performed by DLS. For tests that are referred out, please see each reference laboratory’s website for details.

General Laboratory Reflex Testing

Order Code	Test Name
59R	VDRL, CSF If VDRL is reactive, sent to Hawaii Department of Health for confirmation.
142R	Cholesterol, Reflex to Lipid Profile If Cholesterol is ≥ 200 mg/dL, Lipid Profile is performed.
380R	TSH, w/ Reflex to Free T4 If TSH is <0.30 or >4.20 uIU/mL, Free T4 is performed. (Central, North Hawaii, Molokai, KCH, KVMH, Punchbowl, West Oahu, Wahiawa) If TSH is <0.27 or >4.20 uIU/mL, Free T4 is performed. (Guam ITC) If TSH is <0.45 or >5.33 uIU/mL, Free T4 is performed. (WCCHC)
450R	HCG, Qual., Reflex to Quant. If hCG is positive, Quantitiative hCG is performed.
502R	Hepatitis A Antiody, Reflex to IgM If total HAV Ab is positive, HAV IgM is performed.
505R	PSA, Screen, w/ Reflex to Free PSA If Total PSA is >4.00 ng/mL, Free PSA is performed.
505RD	PSA, Diagnostic, w/ Reflex to Free PSA If Total PSA is >4.00 ng/mL, Free PSA is performed.
542R	HCV Antibody w/ Reflex to RNA Quantitative & Genotype If HCV is reactive, HCV Quant w/ Reflex to Genotype is performed.
636R	UA, w/o Micro, w/ Reflex to Albumin, UR If urine protein is negative, quantitative Urine Albumin is performed.
637R	UA, Micro Only w/ Reflex to C&S If the microscopic shows WBC >5/hpf and/or bacteria >moderate, Urine Culture is performed.
652	UA, Complete, w/ Reflex to C&S If dipstick is positive for leukocyte and/or nitrites or the microscopic shows WBC >5/hpf and/or bacteria >moderate, Urine Culture is performed.
695R	RPR, Reflex to Titer If RPR is reactive, Titer is performed and sent to DOH for confirmation.
915R	Lipid Profile w/ Reflex LDL-D If Triglycerides are >400 mg/dL, Direct LDL is performed.
4983R	Cryptococcus Ag, CSF, Rflx Culture If CSF Cryptococcus Antigen testing is positive, Fungus Culture is performed.
6853R	Milk, IgE, Reflex Component Panel If Milk Specific IgE is greater than or equal to 0.1 kU/L, Milk Component Panel is performed.
6866R	Peanut, IgE, Reflex Component Panel If Peanut Specific IgE is greater than or equal to 0.1 kU/L, Peanut Component Panel is performed.
6898R	Egg White, IgE, Reflex Comp. Panel If Egg White Specific IgE is greater than or equal to 0.1 kU/L, Egg Component Panel is performed.
7055R	HCV Antibody w/ Reflex to HCV RNA Quantitative If HCV Antibody is positive, HCV RNA Quant is performed.
7760	HIV-1/2 Ag/Ab with Reflex If HIV 1/2 Ag/Ab is positive, Geenius HIV 1/2 Supplemental assay is performed.
810MR	Medical Urine Drug Screen Reflex to Amphetamine/Metamphetamine Confirmation If Amphetamine/Metamphetamine positive, Amphetamine/Metamphetamine confirmation perfromed.
8497R	CK, Total Reflex to Troponin I, HS Male: If Total CK is >308 IU/L, Troponin T is performed. Female: If Total CK is >192 IU/L, Troponin T is performed.

Blood Bank and Coagulation Reflex Testing

Order Code	Test Name
13	Blood Group and Rh If there is a discrepancy in Blood Group and/or Rh type, the discrepancy will be investigated. Additional tests may include Antibody Screen and Direct Antiglobulin Test. See below for reflex testing if these additional tests are positive.
14	Antibody Screen If Antibody Screen is positive, Antibody Identification (ID) is performed. Additional tests may include: Antibody Identification Antibody ID (Absorption) Antibody ID (Inhibition) Antibody ID (Enzyme) Antibody ID (Special – Reference lab) RBC Antigens (1AG – 8AG) Rh Phenotype, Complete Direct Antiglobulin Test (IgG and C3) Antibody Titer
18	Direct Antiglobulin Test (IgG and C3) A positive Direct Antiglobulin Test will be further characterized to determine if it is IgG, complement or both. Additional tests may include Direct Antiglobulin Test (IgG), Direct Antiglobulin Test (C3), Antibody ID (Elution).
5486	Coagulation Mixing Study If no PT/PTT ordered, PT/PTT is performed. If only PTT ordered, PT is performed. If only PT ordered, PTT is performed. If PT is abnormal, PT mix, incubated PT, incubated PT mix, Thrombin Time and Anti-Xa is performed. If Thrombin Time is prolonged, Fibrinogen is performed. If PTT is abnormal, PTT mix, incubated PTT, incubated PTT mix, Thrombin Time and Anti-Xa is performed. If Thrombin Time is prolonged, Fibrinogen is performed. If PT and PTT is abnormal, PT/PTT mix, incubated PT/PTT, incubated PT/PTT mix, Thrombin Time and Anti-Xa is performed. If Thrombin Time is prolonged, Fibrinogen is performed.
6674	Lupus Anticoagulant DRVVT If no PT/PTT ordered, PT/PTT/DRVVT Screen/DRVVT Confirm is performed. If only PTT ordered, PT/DRVVT Screen/DRVVT Confirm is performed. If only PT ordered, PTT/DRVVT Screen/DRVVT Confirm is performed. If DRVVT Screen Ratio is abnormal, DRVVT Screen Mix, Thrombin Time, and Anti-Xa is performed.

Microbiology Reflex Testing

Order Code	Test Name
93	Lower Resp Tract Culture w/ Gram Stain If growth present, pathogens are identified and sensitivities done on each pathogen. All IDs and sensitivities are charged; workups limited to six isolates. ID test code per isolate. If unable to identify isolate, identification by 16S rRNA sequencing may be performed. If isolate identified as Staph aureus, and patient is an inpatient, an “MRSA, Rapid Test” may be done (dependent on sufficient growth). Sensitivity test code per isolate (dependent on method used): Agar Dilution method Disk method Microtiter MIC method
308	Vibrio Stool Culture If growth suspicious for Vibrio is present, identification is done and charged if growth is identified as Vibrio sp. ID test code per isolate.
311	Yersinia Stool Culture If growth suspicious for Yersinia is present, identification is done and charged if growth is identified as Yersinia sp. ID test code per isolate.
617	Throat Culture If growth suspicious for Staphylococcus aureus is present, identification is done and charged if growth is identified as Methicillin Resistant Staph aureus. ID test code per isolate.
618	MRSA Culture Screen If growth suspicious for Staphylococcus aureus is present, identification is done and charged if growth is identified as Methicillin Resistant Staph aureus. ID test code per isolate.
619	Blood Culture All growth is identified and charged. Sensitivities are charged on all growth for which susceptibility testing standards are available. ID test code per isolate. If unable to identify isolate, identification by 16S rRNA sequencing may be performed. If isolate identified as Staph aureus, and patient is an inpatient, an “MRSA, Rapid Test” may be done (dependent on sufficient growth). Sensitivity test code per isolate (dependent on method used): Agar Dilution method Disk method Microtiter MIC method
620	CSF Culture & Gram Stain All growth is identified and charged. Sensitivities are charged on all growth for which susceptibility testing standards are available. ID test code per isolate. If unable to identify isolate, identification by 16S rRNA sequencing may be performed. If isolate identified as Staph aureus, and patient is an inpatient, an “MRSA, Rapid Test” may be done (dependent on sufficient growth). Sensitivity test code per isolate (dependent on method used): Agar Dilution method Disk method Microtiter MIC method
621	Anaerobic Culture If growth present, identifications are done and charged on all anaerobic isolates. If unable to identify isolate, identification by 16S rRNA sequencing may be performed. ID test code per isolate.
622	Stool Culture w/ Shiga Toxin If growth suspicious for Salmonella, Shigella, Campylobacter, E.coli 0157, Aeromonas, or Plesiomonas is present, identification is done and charged if growth is identified as a stool pathogen. ID test code per isolate.
624	Miscellaneous Culture If growth present, identifications are done and charged according to source type. Sensitivities are done and charged on pathogens. (Work-ups limited to three isolates.) ID test code per isolate. ID test code per anaerobic isolate. If unable to identify isolate and from a critical source, identification by 16S rRNA sequencing is performed. If isolate identified as Staph aureus, and patient is an inpatient, an “MRSA, Rapid Test” may be done (dependent on sufficient growth). Sensitivity test code per isolate (dependent on method used): Agar Dilution method Disk method Microtiter MIC method
625	GC Screen If growth suspicious for GC is present, identification is done and charged if growth is identified as GC. ID test code per isolate.
626	Urine Culture If growth present, identifications are done on predominant and/or significant organisms and sensitivities are also done if these organisms are pathogens. All IDs and sensitivities are charged. ID test code per isolate. If isolate identified as Staph aureus, and patient is an inpatient, an “MRSA, Rapid Test” may be done (dependent on sufficient growth). Sensitivity test code per isolate (dependent on method used): Agar Dilution method Disk method Microtiter MIC method
626C	Cath Urine Culture If growth present, identifications are done on predominant and/or significant organisms and sensitivities are also done if these organisms are pathogens. All IDs and sensitivities are charged. ID test code per isolate. If isolate identified as Staph aureus, and patient is an inpatient, an “MRSA, Rapid Test” may be done (dependent on sufficient growth). Sensitivity test code per isolate (dependent on method used): Agar Dilution method Disk method Microtiter MIC method
644	Body Fluid Culture and Gram Stain If growth present, identifications are done on predominant and/or significant organisms and sensitivities are also done if these organisms are pathogens. All IDs and sensitivities are charged. ID test code per isolate. If isolate identified as Staph aureus, and patient is an inpatient, an “MRSA, Rapid Test” may be done (dependent on sufficient growth). Sensitivity test code per isolate (dependent on method used): Agar Dilution method Disk method Microtiter MIC method
645	Fungus Culture, (Not Hair, Skin or Nail) If growth is isolated, identifications are performed on any mold or yeast present. All IDs are charged. ID test code per isolate, yeast. ID test code per isolate, mold. Dimorphic fungi (e.g. C. immitis, Blastomyces, Histoplasma) to be reflexed to a DNA Probe Test to be performed by a reference lab.
651	Acid Fast Smear and Culture If growth is isolated, further testing done as follows: TB DNA probe is done. If TB DNA probe is positive, TB sensitivity is done. NOTE: sensitivity is charged for each drug tested. If TB sensitivity is resistant to 1 drug: Isolate is referred to reference lab for single drug MIC testing. If drug is Rifampin, isolate is referred to reference lab for secondary drug panel. If drug is PZA, isolate is referred to reference lab for Mycobacterial MIC testing. If TB sensitivity is resistant to 2 or more drugs: Isolate is referred to reference lab for primary drug panel. If isolate is resistant to Rifampin, isolate is also referred for a secondary drug panel. If TB DNA probe is negative, MALDI-TOF identification is done and charged. If identification by MALDI-TOF is acceptable, sample referred to reference lab for sensitivity testing. If identification by MALDI-TOF is unacceptable, sample referred to reference lab for further ID/sensitivity testing.
661	VRE Culture Screen If growth suspicious for Enterococcus is present, identification is done and charged if growth is identified as Vancomycin Resistant Enterococcus. ID test code per isolate.
4105	Bone Marrow Culture All growth is identified and charged. Sensitivities are charged on all growth for which susceptibility testing standards are available. ID test code per isolate. If unable to identify isolate, identification by 16S rRNA sequencing may be performed. If isolate identified as Staph aureus, and patient is an inpatient, an “MRSA, Rapid Test” may be done (dependent on sufficient growth). Sensitivity test code per isolate (dependent on method used): Agar Dilution method Disk method Microtiter MIC method
4106	Catheter Tip Culture If growth present, identifications are done and charged on all isolates. Sensitivities are done and charged on all pathogens and non-pathogens showing a significant colony count; workups limited to six isolates. ID test code per isolate. If unable to identify isolate, identification by 16S rRNA sequencing may be performed. If isolate identified as Staph aureus, and patient is an inpatient, an “MRSA, Rapid Test” may be done (dependent on sufficient growth). Sensitivity test code per isolate (dependent on method used): Agar Dilution method Disk method Microtiter MIC method
4533	Organism ID – Fungal All fungal isolates are identified and charged. Culture itself is not charged as these are submitted as pre-cultured specimens, but a handling fee will be assessed if mixed isolates are received ID test code per isolate, yeast. ID test code per isolate, mold. Dimorphic fungi (e.g. C. immitis, Blastomyces, Histoplasma) to be sent to a reference lab for confirmatory testing and identification.
4534	Organism ID – AFB All mycobacterial isolates are identified and charged. Culture itself is not charged as these are submitted as pre-cultured specimens, but a handling fee will be assessed if mixed isolates are received. If growth is isolated, further testing is done as follows: TB DNA probe is done. If TB DNA probe is positive, TB sensitivity is done. NOTE: sensitivity is charged for each drug tested. If TB sensitivity is resistant to 1 drug: Isolate is referred to reference lab for single drug MIC testing. If drug is Rifampin, isolate is referred to reference lab for secondary drug panel. If drug is PZA, isolate is referred to reference lab for Mycobacterial MIC testing. If TB sensitivity is resistant to 2 or more drugs: Isolate is referred to reference lab for primary drug panel. If isolate is resistant to Rifampin, isolate is also referred for a secondary drug panel. If TB DNA probe is negative, MALDI-TOF identification is done and charged. If identification by MALDI-TOF is acceptable, sample referred to reference lab for sensitivity testing. If identification by MALDI-TOF is unacceptable, sample referred to reference lab for further ID/sensitivity testing.
4535	Organism ID – Anaerobic All anaerobic isolates are identified and charged. Culture itself is not charged as these are submitted as pre-cultured specimens, but a handling fee will be assessed if mixed isolates are received. ID test code per isolate. If unable to identify isolate, identification by 16S rRNA sequencing may be performed.
5512	Genital Culture If growth present, identifications are done and charged according to source type. Sensitivities are done and charged on pathogens in significant numbers. (Work-ups limited to three isolates.) ID test code per isolate. If unable to identify isolate, identification by 16S rRNA sequencing may be performed. If isolate identified as Staph aureus, and patient is an inpatient, an “MRSA, Rapid Test” may be done (dependent on sufficient growth). Sensitivity test code per isolate (dependent on method used): Agar Dilution method Disk method Microtiter MIC method
5519	Abscess Culture If growth present, identifications are done and charged according to source type. Sensitivities are done and charged on pathogens. (Work-ups limited to three isolates.) ID test code per isolate. If unable to identify isolate, identification by 16S rRNA sequencing may be performed. If isolate identified as Staph aureus, and patient is an inpatient, an “MRSA, Rapid Test” may be done (dependent on sufficient growth). Sensitivity test code per isolate (dependent on method used): Agar Dilution method Disk method Microtiter MIC method
5521	Aspirate Culture If growth present, identifications are done and charged according to source type. Sensitivities are done and charged on pathogens. (Work-ups limited to three isolates.) ID test code per isolate. If unable to identify isolate, identification by 16S rRNA sequencing may be performed. If isolate identified as Staph aureus, and patient is an inpatient, an “MRSA, Rapid Test” may be done (dependent on sufficient growth). Sensitivity test code per isolate (dependent on method used): Agar Dilution method Disk method Microtiter MIC method
5535	Wound Culture If growth present, identifications are done and charged according to source type. Sensitivities are done and charged on pathogens. (Work-ups limited to three isolates.) ID test code per isolate. If unable to identify isolate, identification by 16S rRNA sequencing may be performed. If isolate identified as Staph aureus, and patient is an inpatient, an “MRSA, Rapid Test” may be done (dependent on sufficient growth). Sensitivity test code per isolate (dependent on method used): Agar Dilution method Disk method Microtiter MIC method
5783	Tissue Culture with Gram Stain If growth present, identifications are done and charged according to source type.  Sensitivities are done and charged on pathogens. ID test code per isolate. If unable to identify isolate, identification by 16S rRNA sequencing may be performed. If isolate identified as Staph aureus, and patient is an inpatient, an “MRSA, Rapid Test” may be done (dependent on sufficient growth). Sensitivity test code per isolate (dependent on method used): Agar Dilution method Disk method Microtiter MIC method
5823	Prostatitis Culture If growth present, identifications are done on all organisms with colony counts >1,000 organisms/mL and sensitivities are also done if these organisms are pathogens. All IDs and sensitivities are charged. ID test code per isolate. If unable to identify isolate, identification by 16S rRNA sequencing may be performed. If isolate identified as Staph aureus, and patient is an inpatient, an “MRSA, Rapid Test” may be done (dependent on sufficient growth). Sensitivity test code per isolate (dependent on method used): Agar Dilution method Disk method Microtiter MIC method
6204R	GBS Screen, DNA NAAT w/ Reflex Sensi Positive results will reflex to a no charge culture for isolation of GBS for susceptibility testing by Microtiter MIC method.
6233	Fungus Culture, Hair/Nail/Skin If growth is isolated, identifications are performed on any mold or yeast present. All IDs are charged. ID test code per isolate, yeast. ID test code per isolate, mold. Dimorphic fungi (e.g. Cimmities, Blastomyces, Histoplasma) to be reflexed to a DNA Probe Test to be performed by a reference lab.
N/A	Unusually resistant or atypical sensitivity patterns Supplemental testing may be performed; test code dependent on method used. Agar Dilution method Microtiter MIC method Referral to a Reference Laboratory for Broth Dilution or confirmatory testing. Resistant inpatient Pseudomonas aeruginosa will reflex to Carbapenemase testing based on: Resistance to imipenem AND Resistance to extended spectrum cephalosporins AND Non-susceptible to meropenem screen test
N/A	Unusual or difficult identifications Supplemental testing may be performed; test code dependent on method used. Bacterial ID by DNA Sequencing. Referral to a Reference Laboratory; dependent on whether isolate is a bacteria, yeast, mold or AFB.

Molecular Reflex Testing

Order Code	Test Name
5442R	HCV Quant w/ Reflex to Genotype If HCV viral load is >=300 IU/mL, HCV Genotyping is performed.
5509R	HBV Quant w/ Reflex to Genotype If HBV viral load is >=600 IU/mL, HBV Genotyping is performed.
6738R	Pap Smear w/ Reflex to HPV HPV reflex testing according to ACOG guidelines (age dependent).
7123	C. difficile GDH/Toxin w/ Reflex to NAAT Discordant antigen / toxin results will reflex to Nucleic Acid Amplification Testing.

Pathology Reflex Testing

Order Code	Test Name
6738R	Pap Smear w/ Reflex to HPV HPV reflex testing according to ACOG guidelines (age dependent)
	Cytology w/ Reflex to UroVysion FISH Assay Negative or Atypical urine cytology result to reflex to UroVysion FISH Assay
	All Tissues Further testing will be done dependent on abnormal findings which may include, IHC, Flow Cytometry, special stains, ER/PR, HER2, FISH, MMR, NGS
Pathology Tissue Exam	Breast Malignancies Further testing will be done dependent on abnormal findings which may include, ER/PR, HER2, HER2 FISH, Ki-67, ONCOTYPE
	Bone Marrow Further testing will be done dependent on abnormal findings which may include,Flow Cytometry, Cytogenetics, NGS, HEME FISH, IHC
	Endometrial malignacies Further testing will be done dependent on abnormal findings which may include, ER/PR, HER2, and MMR
	Ovarian malignancies Further testing will be done dependent on abnormal findings which may include, ER/PR, HER2, and MMR
	Upper GI malignancies Further testing will be done dependent on abnormal findings which may include, IHC, MMR, HER2
	Colorectal malignancies Further testing will be done dependent on abnormal findings which may include, IHC, MMR
Non-GYN Cytology for	All body fluids Further testing will be done dependent on abnormal findings which may include, IHC, Flow Cytometry, special stains, ER/PR, HER2, FISH, MMR, NGS
Fine Needle Aspiration	All sources Further testing done dependent on abnormal findings which may include, IHC, Flow Cytometry, special stains

Revised: 05/2026