Test Summary Sheet for:

Purpose
Exclusion Screen
Method(s)
Gas Chromatography (GC)
Suggested CPT Code(s)
80307
New York State Approval Status

Approved

Known Interference(s)
Protriptyline [GC]: Desmethylsertraline (Sertraline metabolite); Norcyclobenzaprine (Cyclobenzaprine metabolite)
Turnaround Time

5 days (If Positive: 12 days)

Test Includes
1 Amitriptyline Elavil®; Endep® Gas Chromatography (GC) ng/mL 100 Antidepressant
2 Nortriptyline Amitriptyline Metabolite; Aventyl®; Pamelor® Gas Chromatography (GC) ng/mL 100 Antidepressant
3 Clomipramine Anafranil® Gas Chromatography (GC) ng/mL 100 Antidepressant
4 Desmethylclomipramine Clomipramine Metabolite Gas Chromatography (GC) ng/mL 100 Antidepressant
5 Imipramine Tofranil® Gas Chromatography (GC) ng/mL 100 Antidepressant
6 Desipramine Imipramine Metabolite; Norpramin®; Pertofrane® Gas Chromatography (GC) ng/mL 100 Antidepressant
7 Doxepin Sinequan® Gas Chromatography (GC) ng/mL 100 Antidepressant
8 Desmethyldoxepin Doxepin Metabolite Gas Chromatography (GC) ng/mL 100 Antidepressant
9 Trimipramine Surmontil® Gas Chromatography (GC) ng/mL 100 Antidepressant
10 Desmethyltrimipramine Trimipramine Metabolite Gas Chromatography (GC) ng/mL 100 Antidepressant
11 Fluoxetine Prozac® Gas Chromatography (GC) ng/mL 100 Antidepressant
12 Norfluoxetine Fluoxetine Metabolite Gas Chromatography (GC) ng/mL 100 Antidepressant
13 Protriptyline Vivactil® Gas Chromatography (GC) ng/mL 100 Antidepressant Desmethylsertraline (Sertraline metabolite); Norcyclobenzaprine (Cyclobenzaprine metabolite)
14 Maprotiline Ludiomil® Gas Chromatography (GC) ng/mL 100 Antidepressant
15 Trazodone Desyrel® Gas Chromatography (GC) mcg/mL 0.2 Antidepressant
16 Amoxapine Asendin® Gas Chromatography (GC) ng/mL 100 Antidepressant
17 Mirtazapine Remeron® Gas Chromatography (GC) ng/mL 100 Antidepressant

Test Also Known As
Adapin®; Rhotrimine®; Triptil®
Reflex Tests
Test Code Test Name
5450U Antidepressants Confirmation, Urine
Specimen Type
Urine
Requested Volume
3 mL
Minimum Volume
1.4 mL
Special Handling
None
Specimen Container
Plastic container (preservative-free)

Additional Collection Instructions

Transport Temperature
Refrigerated
Light Protection
Not Required
Rejection Criteria
None

Rejection criteria pertain to clinical specimen submissions only.

Stability
Room Temperature: 7 day(s)
Refrigerated: 11 day(s)
Frozen (-20 °C): 14 day(s)
1 Amitriptyline Elavil®; Endep® Gas Chromatography (GC) ng/mL 100 Antidepressant
2 Nortriptyline Amitriptyline Metabolite; Aventyl®; Pamelor® Gas Chromatography (GC) ng/mL 100 Antidepressant
3 Clomipramine Anafranil® Gas Chromatography (GC) ng/mL 100 Antidepressant
4 Desmethylclomipramine Clomipramine Metabolite Gas Chromatography (GC) ng/mL 100 Antidepressant
5 Imipramine Tofranil® Gas Chromatography (GC) ng/mL 100 Antidepressant
6 Desipramine Imipramine Metabolite; Norpramin®; Pertofrane® Gas Chromatography (GC) ng/mL 100 Antidepressant
7 Doxepin Sinequan® Gas Chromatography (GC) ng/mL 100 Antidepressant
8 Desmethyldoxepin Doxepin Metabolite Gas Chromatography (GC) ng/mL 100 Antidepressant
9 Trimipramine Surmontil® Gas Chromatography (GC) ng/mL 100 Antidepressant
10 Desmethyltrimipramine Trimipramine Metabolite Gas Chromatography (GC) ng/mL 100 Antidepressant
11 Fluoxetine Prozac® Gas Chromatography (GC) ng/mL 100 Antidepressant
12 Norfluoxetine Fluoxetine Metabolite Gas Chromatography (GC) ng/mL 100 Antidepressant
13 Protriptyline Vivactil® Gas Chromatography (GC) ng/mL 100 Antidepressant Desmethylsertraline (Sertraline metabolite); Norcyclobenzaprine (Cyclobenzaprine metabolite)
14 Maprotiline Ludiomil® Gas Chromatography (GC) ng/mL 100 Antidepressant
15 Trazodone Desyrel® Gas Chromatography (GC) mcg/mL 0.2 Antidepressant
16 Amoxapine Asendin® Gas Chromatography (GC) ng/mL 100 Antidepressant
17 Mirtazapine Remeron® Gas Chromatography (GC) ng/mL 100 Antidepressant

Interface Map

LOINC® Information

The CPT Codes provided in this document are based on AMA Guidelines and are for informational purposes only. NMS Labs Does not assume responsibility for billing errors due to Reliance on the CPT Codes listed in this document.

*The information contained in this document represents database configurations, as they will appear on the effective date listed above.