Molecular Testing: Regulatory Issues 44Frank S. Ong, Wayne W. Grody, and Kingshuk Das

Contents

44.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1092

44.2 Federal Regulation: ClinicalLaboratory Improvement Act . . . . . . . . 1092

44.2.1 Chronology of Clinical

Laboratory Improvement Act

Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1092

44.2.2 Laboratories Regulated by Clinical

Laboratory Improvement Act . . . . . . . . . . . 1092

44.2.3 Categories of Testing . . . . . . . . . . . . . . . . . . . . 1093

44.2.4 Clinical Laboratory Improvement Act

Certification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1094

44.2.5 Proficiency Testing . . . . . . . . . . . . . . . . . . . . . . 1096

44.2.6 Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1097

44.2.7 Quality Control and Assurance . . . . . . . . . 1098

44.2.8 Personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1102

44.2.9 Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1103

44.2.10 Enforcement of Regulations . . . . . . . . . . . . 1104

44.3 Other Governmental Regulations andRegulatory Agencies . . . . . . . . . . . . . . . . . . . 1104

44.3.1 State Departments of Health . . . . . . . . . . . . 1105

44.3.2 Office of the Inspector General . . . . . . . . . 1105

44.3.3 Centers for Medicare and Medicaid

Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1105

44.3.4 United States Food and Drug

Administration, Office of In Vitro

Diagnostic Device Evaluation and

Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1105

44.3.5 Equal Employment Opportunity

Commission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1106

44.3.6 Occupational Safety and Health

Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . 1106

44.3.7 Environmental Protection Agency . . . . . . 1106

44.3.8 Nuclear Regulatory Commission . . . . . . . 1106

44.3.9 Department of Transportation . . . . . . . . . . . 1106

44.3.10 Health Insurance Portability and

Accountability Act . . . . . . . . . . . . . . . . . . . . . . 1107

44.3.11 Ban on Physician Self-referral

(Stark Law) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1107

44.3.12 Three-Day Rule . . . . . . . . . . . . . . . . . . . . . . . . . . 1107

44.4 Nongovernmental Agencies . . . . . . . . . . . 1107

44.4.1 College of American Pathologists . . . . . . 1107

44.4.2 Commission on Office Laboratory

Accreditation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1108

44.4.3 Joint Commission on Accreditation of

Healthcare Organizations . . . . . . . . . . . . . . . 1108

Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1108

F.S. Ong, MD

Department of Pathology and Laboratory Medicine,

Cedars-Sinai Medical Center, Los Angeles, CA, USA

W.W. Grody, MD, PhD

Divisions of Medical Genetics and Molecular Pathology,

Departments of Pathology and Laboratory Medicine,

Pediatrics, and Human Genetics, UCLA School of

Medicine, Los Angeles, CA, USA

K. Das, MD (*)

Department of Pathology and Laboratory Medicine,

UCLA David Geffen School of Medicine, Los Angeles,

CA, USA

L. Cheng, D.Y. Zhang, J.N. Eble (eds.), Molecular Genetic Pathology,DOI 10.1007/978-1-4614-4800-6_44, # Springer Science+Business Media New York 2013

1091

44.1 Introduction

• In response to reports of erroneous Pap smear

testing, subsequent public outcry, and skepti-

cism of quality standards in clinical laborato-

ries as a whole, in 1967, the Clinical

Laboratory Improvement Act (CLIA) was

passed, and the underpinnings of the first

consistent set of federal laboratory regulations

were laid, with the following consequences

– CLIA determined standards for all clinical

laboratories

– Legislation provided necessary oversight

of clinical laboratories (molecular diagnos-

tic laboratories comprising a minor numer-

ical subset) to ensure patient safety through

quality laboratory operations

– Clinical laboratories have become among

the most intensely regulated parts of the

entire system of healthcare in the United

States

– It is paramount to understand not only these

federal regulations but also state and local

– Regulations in order to establish and oper-

ate a modern, compliant molecular diag-

nostic laboratory

• The following chapter will provide an over-

view of the various regulatory issues facing

such laboratories. It is important to note that

the regulatory issues presented here are com-

mon to most clinical laboratories; however,

those issues most specific and pertinent to

molecular testing will be highlighted

44.2 Federal Regulation: ClinicalLaboratory Improvement Act

44.2.1 Chronology of ClinicalLaboratory Improvement ActRegulations

• CLIA 1967: CLIA was passed in 1967 in

response to questionable clinical laboratory

practices involving Pap smear testing.

However, several issues were identified with

this Act

– It was most applicable to only large

independent laboratories

– Oversight and enforcement of standards

was inconsistent

– Proficiency testing was found to be fairly

ineffective

– Many smaller laboratories, including

physician-operated laboratories, were

increasing in popularity, though largely

immune to such regulation

• CLIA ’88: In order to address these issues, in

1988, Congress enacted Public Law 100–578,

a revision of Section 353 of the Public Health

Service Act (42 U.S.C. 263a) that amended the

Clinical Laboratory Improvement Act of 1967

(also known as Clinical Laboratory Improve-

ment Amendments of 1988, or CLIA ’88)

requiring the Department of Health and

Human Services (HHS) to establish regula-

tions to ensure quality and reliable clinical

laboratory testing

– In 1990, rules were proposed

– In 1992, HHS published the final rules

(with comment), establishing CLIA ’88

regulations that describe requirements for

all laboratories performing clinical testing

– Since the 1992 final rules, there have been

numerous notices and regulations

published, revising CLIA ’88

44.2.2 LaboratoriesRegulated by ClinicalLaboratory Improvement Act

• There are two types of laboratories regulated

by CLIA, those meeting either definition listed

under 42 Code of Federal Regulations (CFR),

Section 493.2– . . .a facility for the biological, microbiological,

serological, chemical, immunohematological,

hematological, biophysical, cytological, patho-

logical, or other examination of materials

derived from the human body for the purpose

of providing information for the diagnosis, pre-

vention, or treatment of any disease or impair-

ment of, or the assessment of the health of,

human beings. These examinations also include

procedures to determine, measure, or otherwise

describe the presence or absence of various

substances or organisms in the body.

1092 F.S. Ong et al.

– Laboratories seeking payment under the

Medicare and Medicaid Programs

• Virtually all clinical laboratories, including

molecular diagnostic labs, will fit into at least

one, if not both categories, and therefore fall

under CLIA regulation

• Includes any laboratory falling under federal

jurisdiction (although regulations may be

modified for these laboratories)

• Notable exceptions to CLIA regulation are

– Laboratories performing only forensic

testing, including molecular testing labora-

tories performing only forensic DNA

analysis

– Laboratories testing human specimens that

do not meet the aforementioned criteria in

42 CFR, Section 493.2; typically academic

or private sector research laboratories,

many of which employ molecular genetic

methodologies

– Laboratories certified by Substance Abuse

andMental Health Services Administration

(SAMHSA), typically providing drug test-

ing under SAMHSA regulations

• However, all other testing performed by

such laboratories is subject to CLIA reg-

ulation, as necessary

• With regard to molecular testing, any

pharmacogen(etic/omic) testing, if used

for diagnostic purposes and/or seeking

Medicare/Medicaid reimbursement for

such testing, may be subject to CLIA

regulation

44.2.3 Categories of Testing

• CLIA regulations recognize three categories

of laboratory testing (waived, moderate

complexity, and high complexity) and

enforce regulations specific to these

categories

44.2.3.1 Waived Testing• This category consists of tests simple enough

that they require minimal regulatory oversight

by CLIA. According to 42 CFR Sec. 493.15,

these tests are either

– “Cleared by FDA for home use” or

– “Employ methodologies that are so simple

and accurate as to render the likelihood of

erroneous results negligible” or

– “Pose no reasonable risk of harm to the

patient if the test is performed incorrectly”

• Common examples of such testing include

many urine pregnancy tests (visual interpreta-

tion) and blood glucose monitoring devices

cleared by the FDA for home use

– The list of waived testing is determined and

maintained by HHS

– At the time of this writing, there are no

waived molecular genetic tests available,

although methodologies exist that may

make such testing possible

44.2.3.2 Moderate and High ComplexityTesting

• All other testing is divided into tests of moderate

and high complexity, according to grading

based on seven criteria (see 42CFRSec. 493.17)

– Knowledge required to perform test

– Training and experience required to per-

form test

– Reagents and material preparation

– Characteristics of operational steps

– Calibration, quality control, and profi-

ciency testing materials

– Test system troubleshooting and equip-

ment maintenance

– Interpretation and judgment

• A subcategory of moderate complexity testing

is known as provider-performed microscopy

procedures (PPM). To be considered PPM

procedure, test must meet several criteria

(42 CFR Sec. 493.19)

– Performed by either a physician or other

professional healthcare provider, on own

patient or patient of group practice or on

specimen obtained during visit

– Procedure must be moderate complexity

– Test is performed with microscope (bright

field or phase contrast)

– Specimen is labile, or delay in performing

test could compromise accuracy

– Control materials not available to monitor

entire testing process

44 Molecular Testing: Regulatory Issues 1093

– Limited specimen handling/processing

required

– Testing limited to list determined by

HHS (examples include direct wet

mount microbiology procedures, urine

sediment examination, qualitative semen

analysis)

• At the time of this writing, only 12 tests listed

as PPM procedures, with no molecular diag-

nostic assay listed; however, above criteria do

not preclude PPM approval for future molec-

ular diagnostic testing

44.2.3.3 Determination of TestingComplexity

• Testing manufacturers submit supporting data

to the US Food and Drug Administration

(FDA) for determination based upon above

criteria

• For noncommercial systems, laboratory or

group involved submits such application for

determination by Centers for Disease Control

and Prevention (CDC)

• If a test is not listed in the Federal Register

notices, it is automatically categorized highcomplexity, until applicable determination

process completed

– All molecular diagnostic testing at the time

of this writing categorized as moderate or

high complexity

– Nature of molecular diagnostic testing, as

an evolution of basic/translational research,

generally obviates new testing be catego-

rized high complexity

• A clinical laboratory may perform any of three

types of testing, or any combination thereof, if

CLIA certificate permits (see below)

44.2.4 Clinical LaboratoryImprovement Act Certification

• Any laboratory regulated by CLIA must have

current (unrevoked or unsuspended) CLIA

certificate

• There are five types of CLIA certificates

– Certificate of waiver

– Certificate for PPM procedures

– Certificate of registration

– Certificate of compliance

– Certificate of accreditation

• Applications for CLIA certificate submitted

on behalf of every laboratory location, with

following exceptions

– If laboratory is not at fixed location (such as

a mobile lab or temporary facility), single

application may be filed on behalf of pri-

mary site

– Nonprofit, federal, state, or local govern-

ment laboratories offering limited menu of

moderate complexity and/or waived tests

(�15 total tests), for public health pur-

poses, can file one application

– Multiple laboratories within hospital sys-

tem, located in contiguous buildings on

same campus or same physical location/

street address, under common direction

can file single application

44.2.4.1 Certificate of Waiver• Laboratories performing only waived testing

must carry such certificate (as noted earlier, no

molecular diagnostic tests currently catego-

rized as waived)

• However, when waived molecular diagnostic

testing does become available, a laboratory

operating under this certificate must notify

HHS (or designee) before

– Performing and reporting any nonwaived

testing

– Within 30 days of any change in owner,

name, location, or director

• Certificate of waiver valid for maximum of

2 years

44.2.4.2 Certificate for Provider-Performed MicroscopyProcedures

• Certificate for PPM procedures required for

– Laboratories performing PPM procedures

– Certificate of waiver laboratories intending

to perform PPM procedures

• As already noted, currently no molecular diag-

nostic testing falls under category of PPM

procedures

1094 F.S. Ong et al.

• Laboratories must notify HHS (or designee)

before

– Performing and reporting results for

moderate and/or high complexity testing

– Within 30 days of any change in owner,

name, location, or director

• Certificate for PPM procedures valid for max-

imum of 2 years

44.2.4.3 Certificate of Registration• Required of

– Laboratories performing moderate and/or

high complexity testing

– Laboratories issued certificate of waiver or

certificate for PPM procedures intending to

perform moderate and/or high complexity

testing

• Pending inspection by HHS to demonstrate

compliance with regulations governing mod-

erate and/or high complexity testing

• Certificate of registration valid for maximum

of 2 years (or until inspection conducted,

whichever is shorter)

• Laboratory must notify HHS (or designee)

within 30 days of any change in owner,

name, location, director, or technical supervi-

sor (high complexity testing only)

44.2.4.4 Certificate of Compliance• Certificate of compliance may be issued after

successful HHS inspection of laboratory,

authorizing waived, PPM procedures, moder-

ate complexity, high complexity, or any com-

bination of testing thereof

• Laboratories operating under this certificate

must notify HHS (or designee) within

30 days of any changes in owner, name, loca-

tion, director, or technical supervisor (high

complexity testing only) and

– Within 6 months after performing testing

not included on certificate

– Within 6 months after any deletions or

change in test methodology for any test on

certificate

• Certificate of compliance valid for maximum

of 2 years

44.2.4.5 Certificate of Accreditation• To perform waived, PPM procedures, moder-

ate complexity, high complexity, or any com-

bination of testing thereof, a laboratory can

pursue a certificate of accreditation (in lieu of

or in addition to certificate of compliance)

• Lab must secure a certificate of registration

(valid for a period of no more than 2 years),

carrying valid certificate of compliance,

and then

– Become accredited by private nonprofit

entity approved by HHS for this purpose

– Provide HHS with proof of accreditation

(within 11 months of receiving certificate

of registration or, if certificate of compli-

ance is held, prior to expiration of that

certificate)

• Lab must notify HHS and HHS-approved

accreditation program within 30 days of

change in owner, name, location, director, or

supervisor (high complexity testing only) and

– Notify the HHS-approved accreditation

program no later than 6 months after dele-

tion or change of testing methodologies

– Notify HHS-approved accreditation pro-

gram no later than 6 months after

performing testing for which laboratory is

not accredited (for reevaluation of

compliance)

– Maintain HHS-approved accreditation,

including allowing accreditation program

to release relevant data to HHS for scrutiny,

and allow HHS validations and inspections

as well

• Certificate of accreditation is valid for nomore

than 2 years

44.2.4.6 Department of Health andHuman Services-ApprovedLaboratory AccreditationPrograms and ClinicalLaboratory Improvement ActExemption

• The Centers for Medicare and Medicaid Ser-

vices (CMS) oversee the CLIA program on

behalf of HHS. The aforementioned certificate

of accreditation process may be thought of as

a CMS-approved laboratory accreditation

44 Molecular Testing: Regulatory Issues 1095

program “deeming” a laboratory compliant

with relevant CLIA regulations

– Such CMS-approved nonprofit laboratory

accreditation organizations are described

as having CLIA “deeming authority”

• Laboratory can also be exempted from CLIA

requirements by CMS, if licensed or approved

in certain states. These states are described as

having been granted an “exemption” that

allows licensed/approved laboratories in

those states exemption from CLIA require-

ments, as long as certain criteria are met

• For private nonprofit laboratory accreditation

organizations to be granted “deeming author-

ity” or state licensure/approval programs to be

granted “exemptions,” CMS must approve

their respective regulations to be at least as

stringent as CLIA regulations. Such authority

given by CMS cannot exceed 6 years. A list of

such organizations made publically available

by CMS. At the time of this writing, the fol-

lowing states have exempt status

– New York

– State of Washington

• The following private nonprofit accreditation

organizations have “deeming authority”

– AABB (formerly the American Associa-

tion of Blood Banks)

– American Osteopathic Association

– American Society for Histocompatibility

and Immunogenetics

– College of American Pathologists (CAP)

– Joint Commission on Accreditation of

Healthcare Organizations (JCAHO)

– COLA (Commission on Office Laboratory

Accreditation)

44.2.5 Proficiency Testing

• Every laboratory conducting nonwaived test-

ing must engage in proficiency testing (PT)

program approved by CMS for each CLIA

regulated specialty/subspecialty and each

CLIA regulated analyte/test for which it is

certified or seeks certification

• The following are specialties/subspecialties

regulated by CLIA, which encompass

analytes/tests regulated by CLIA and thus

have specific CMS-prescribed PT

requirements

– Microbiology (specialty): bacteriology,

mycobacteriology, mycology, parasitol-

ogy, and virology

– Diagnostic immunology: syphilis serology

and general immunology

– Chemistry: routine chemistry, endocrinol-

ogy, and toxicology

– Hematology: no subspecialties

– Pathology: cytology (limited to gyneco-

logic examinations)

– Immunohematology: ABO group and

D (Rho) typing, unexpected antibody

detection, compatibility testing, and anti-

body identification

• Molecular testing is not recognized as spe-

cialty/subspecialty by CLIA; therefore, there

are no specific CLIA requirements for molec-

ular PT; however

– Laboratories performing nonwaived testing

not regulated by CLIAmust adhere to alter-

native performance assessment for such

tests/analytes, including molecular testing

– Minimum guidelines require alternative

assessment twice per year for each such

assay

44.2.5.1 Proficiency Testing Guidelines• Proficiency testing samples must be treated in

same manner as patient specimens

– Within regular clinical patient workload

– By routine testing personnel

– Using routine laboratory methods

– Without communicating with any other

laboratory regarding PT samples (until

after PT event due date)

– If laboratory has multiple sites performing

test, no communication is allowed regard-

ing PT results (until after PT event due date)

– Must not send samples or aliquots to any

other laboratory for analysis that laboratory

is certified to conduct (violation can result

in revocation of certificate)

• Any laboratory receiving PT samples

from another laboratory must report to

CMS

1096 F.S. Ong et al.

– All records must be kept for at least 2 years

from PT event

• If laboratory has certificate suspended or

limited due to PT performance failure on

at least one specialty/subspecialty and

analyte/test

– Must perform satisfactorily on two consec-

utive PT events before certificate reinstate-

ment and Medicare/Medicaid approval

addressed

– Suspension/limitation of certificate and/or

Medicare/Medicaid penalties are at least

6 months in duration

44.2.5.2 Alternative PerformanceAssessment

• If specialty/subspecialty or analyte/test is not

listed within CLIA guidelines, then alternative

performance assessment must be performed in

lieu of CMS-approved PT programs. This is

the case for all molecular testing at the time of

this writing

– Recommended to participate in other PT

programs, whenever available

– Programs available for limited number of

molecular genetic analytes (CAP PT

programs)

• Molecular PT samples often do not chal-

lenge entire testing process (i.e., sample

may be purified DNA; therefore, it

does not interrogate nucleic acid

extraction)

• Rare genetic disorders present further

challenge: adequate samples may be dif-

ficult to procure; few laboratories will

perform such testing

• Recommended strategies for alternative per-

formance assessment in molecular testing

– Because external quality assessments avoid

bias of internally based assessments,

recommend

• Available PT programs

• Interlaboratory exchange

• Acquire externally derived PT materials

– However, if such options are unavailable

• Repeat testing of blinded (internal)

samples

• Blinded testing of known external

samples

• Sample exchange with research facility

or foreign laboratory

• Split samples for method comparison

with different instrument or method

• Interlaboratory data comparison

44.2.6 Facilities

• Laboratories performing nonwaived testing

must meet certain criteria for facility quality

– Adequate space, ventilation, and utilities

– Procedures and controls to minimize

contamination of specimens, equipment,

and reagents

• For molecular testing

– This includes unidirectional workflow

for nucleic acid amplification

procedures (not contained in closed

systems)

– Separate areas for specimen prepara-

tion, reagent preparation, amplifica-

tion, and detection

– Appropriate equipment, reagents, and

supplies

– Compliance with applicable federal, state,

local regulations

– Adequate and accessible safety procedures

to protect from physical, chemical,

biochemical, electrical hazards, and

biohazards

– Records, slides, blocks, and tissues stored

under proper conditions for preservation

– Test requisitions and authorizations

retained for at least 2 years

– Test procedures retained for at least 2 years

after procedure discontinued

– Retain quality control and patient result

records for at least 2 years

– Retain analytical system performance

records for lifetime of use (no less than

2 years total)

– Retain proficiency testing records for at

least 2 years

– Retain quality assurance records for at least

2 years

44 Molecular Testing: Regulatory Issues 1097

– Retain (or be able to retrieve) test reports

for at least 2 years after reporting (pathol-

ogy reports for at least 10 years)

– If slides/blocks/tissues are retained by the

molecular diagnostic laboratory, cytology

slides must be retained for at least 5 years

from examination, histopathology slides

for at least 10 years from examination,

blocks for at least 2 years from examina-

tion, and tissue until a diagnosis is made

• Note that several professional practice

guidelines recommend, although not

required by CLIA, that molecular

testing specimens should be retained as

long as they are stable, and at least until

next PT event, to allow retesting of

specimens in the event assay error is

identified

– If laboratory closes operation, all retained

samples and records must be maintained

for the required time frames listed

44.2.7 Quality Control and Assurance

• Laboratories conducting nonwaived testing

must develop and document quality control

and assurance procedures that monitor the

preanalytic, analytic, and postanalytic phases

of testing, in addition to general laboratory

practices, and provide for continuous quality

improvement

44.2.7.1 General Laboratory Quality• The laboratory must

– Ensure confidentiality of patient

information

– Ensure specimen identification and

integrity

– Document problems and complaints and

necessary investigations

– Identify communication issues between

laboratory and end users

– Develop policies on personnel competency

– Identify tests/analytes not evaluated by a

CMS-approved PT program (at least twice

per year) or for which CMS-approved PT

program is unavailable

– Document and review any problems, cor-

rective actions, effectiveness of corrective

actions, and any necessary revisions to

policies/procedures

• All of the above guidelines are useful for any

clinical laboratory, including those

conducting molecular testing

44.2.7.2 Preanalytic Phase• All laboratories performing nonwaived testing

must

– Receive written/electronic request for

patient testing (from individual authorized

to request such testing)

• Laboratory may accept verbal test

requests if written/electronic authoriza-

tion received within 30 days (or docu-

mentation of efforts to obtain)

• Test requisition must list

– Name and other suitable identifiers of

requestor, including (as necessary)

contact person for reporting alert

value(s)

– Patient name or unique patient

identifier

– Sex and age or date of birth of patient

– Test(s) to be performed

– Source, as necessary

– Date (and time, if necessary) of

specimen collection

– Additional necessary information for

interpretation

– Note that patient chart or medical

record may suffice as test requisition,

provided it is available to laboratory at

time of test, and CMS (upon request)

– Information transcribed accurately

– Establish specimen submission, handling,

and referral policies

– Establish and maintain preanalytic quality

control and assurance procedures

• For molecular testing, the majority of labora-

tory errors occur in preanalytic phase

– Major culprit thought to be inappropriate

test ordering, likely resulting from inade-

quate information of those ordering testing

(including clerks, nursing staff, and

clinicians)

1098 F.S. Ong et al.

• Users may not understand limitations/

specifications of test, risking

misinterpretation

• Users may incorrectly order test, due to

inappropriate indication or method

– Therefore, although not required by CLIA,

it is common professional practice that lab-

oratory convey relevant test information

clearly and accurately to users, including

• Intended use of test

• Indications for testing

• Test method

• Analytical and clinical specifications

• Limitations of test

– Also, although not required by CLIA, it is

common professional practice for labora-

tory to request information relevant to test

analysis and interpretation, particularly for

molecular genetic testing, for example

• Gender

• Ethnicity

• Selected clinical/laboratory information

• Pedigree or family history

• Informed consent and/or pretest genetic

counseling (recommended prior to

testing for many heritable conditions,

required by law in many states)

44.2.7.3 Analytic Phase• All laboratories conducting nonwaived testing

must

– Maintain a written procedure manual for

each assay performed

– Select appropriate test systems and estab-

lish and maintain criteria for proper opera-

tion of the test systems

– Establish criteria and maintain proper stor-

age of reagents and specimens

• Error rates in analytic phase of testing for

molecular assays reported to range between

0.06% and 0.12% (comparable to nongenetic

testing)

– Errors reportedly encompass all phases of

analytic process, including specimen

handling

– For instance, mutations or polymorphisms

leading to false-positive or false-negative

results have been reported for some

common molecular genetic tests (such

as cystic fibrosis mutations and HFE-associated hereditary hemochromatosis

testing)

– Such interferences are difficult to predict or

evaluate during method evaluation, as they

are specific by definition from specimen to

specimen, and exert effects on assay spe-

cific to each variant

Analytical Test Validation or Verification

• All laboratories must establish or verify per-

formance specifications for test systems

implemented after April 24, 2003

– To verify and document performance spec-

ifications of unmodified, FDA-cleared/

approved test systems, a laboratory must

demonstrate comparable performance

specifications to those obtained by the man-

ufacturer for the following parameters

• Accuracy

• Precision

• Reportable range

• Reference intervals – verify that manu-

facturer’s stated intervals appropriate

for laboratory-specific patient

population

– To establish and document performance

specifications (for a modified FDA-

cleared/approved test; or test system not

subject to FDA clearance or approval,

such as a laboratory-developed test, or test

system without provided specifications),

the laboratory must determine the follow-

ing parameters, as applicable

• Accuracy

– Note that for a molecular test evalu-

ating multiple targets, all variants

should be included

– For rare variants alternative samples

such as cell lines or synthetic nucleic

acid constructs may be necessary

• Precision

• Analytical sensitivity

• Analytical specificity (including

interfering substances)

– Note that in addition to common

exogenous or endogenous

44 Molecular Testing: Regulatory Issues 1099

interfering substances, other

alleles, homologous sequences,

and contaminants may need to be

assessed on a case-by-case basis

for positive/negative interference

• Reportable range

• Reference intervals; for molecular

genetic testing, this may consti-

tute the reference sequence

• Any other performance character-

istic required for test performance

(such as clinical sensitivity/

specificity)

• Test system maintenance must be performed

and documented at least according to manu-

facturer’s recommendations

– If the test system is laboratory-developed

or such protocols are not available, the lab-

oratory must establish such maintenance

protocols to ensure reliable test results

Calibration Procedures

• Calibration and calibration verification are

necessary to ensure and document accuracy

of testing and should interrogate the entire

reportable range of the test system. The labo-

ratory must

– Follow the manufacturer’s recommenda-

tions using provided materials (if possible)

or

– Use laboratory-established acceptance

criteria and frequency (based on method

verification or establishment) using trace-

able (to reference method or material) cal-

ibration materials

• Include at least a minimal, a midpoint,

and maximum value near upper limit of

the reportable range

– Must occur at least every 6 months and

whenever any of the following occur

• Complete change of reagents

• Major preventive maintenance or repair

of test system

• Control materials detect potential fail-

ure mode, and other measures have not

identified a source

• More frequent calibration verification

required

Quality Control Procedures

• Each test system must utilize control proce-

dures that monitor entire analytical process, to

detect real-time failure modes, as well as

developing trends that may signal future fail-

ure. These control procedures should be devel-

oped in accordance with each test’s

verification or establishment of performance

characteristics. Quality control (QC) should

also determine long-term accuracy and

precision

• QCs should be performed

– In same manner as patient specimens

– According to specifications verified or

established in laboratory

– At least once each day, patient testing is

performed

• For quantitative testing, two control

materials of different concentrations

• For qualitative testing, a negative and

positive control

– For testing involving extractions, at least

one control should interrogate the extrac-

tion procedure

– After complete change of reagents

– After major preventive maintenance or

repair

– With different lot of calibrator material, if

calibrators used as control material

– All control procedures should be

documented

• Specific QC issues for molecular testing

– For molecular testing involving

amplification

• At least two controls are required

• If reaction inhibition is of concern,

include control to sensitive to inhibition

(spike-in, or endogenous)

– Although not required by CLIA, it is com-

mon professional practice

• To minimize or detect contamination by

nucleic acid target or amplicon

– At least one no template control

(NTC) sample should be tested,

starting with amplification step

– Preferable to test NTC through entire

analytical process (i.e., starting with

extraction step)

1100 F.S. Ong et al.

• If multiple genotypes to be assayed,

rotate positive controls over time, to

avoid excessive number of controls

per run

• For rare variants with no natural

controls available, use artificial or cell

line controls

• For sequencing assays, bidirectional

sequencing can be confirmatory

• If using pre-extracted DNA control

(thus not controlling for extraction),

can assay surrogate for DNA extraction

in each sample such as exogenous spike-

in control or internal control gene(s)

• If laboratory develops nucleic acid con-

trols, must avoid cross-contamination of

patient specimens and reagents

Comparison of Test Results

• Between laboratory methods: laboratories

performing same test using different methods

or same method at multiple sites must perform

comparison testing twice per year to establish

and document relationship

• Between results: laboratories must identify

potential testing inconsistencies, based on

criteria such as patient age, sex, diagnosis,

and/or other test parameters or previous results

44.2.7.4 Postanalytic Phase• All laboratories that perform nonwaived test-

ing must monitor their postanalytic systems,

including

– Test reporting

• Accuracy and timeliness

• Reports must indicate patient identifica-

tion, name and address of laboratory

location, date reported, date performed,

specimen source, and result and allow

access to reference intervals

• Reports can only be released to autho-

rized persons, person responsible for

using test result (if applicable), and lab-

oratory that requested test

• Theremust be amechanism for reporting

alert values to responsible entities

• Reports must be maintained and readily

accessible

• The laboratorymust have a procedure formon-

itoring, assessing, and correcting postanalytic

systems and documenting these activities

Postanalytic Issues Specific to Molecular

Testing

• Most frequently encountered error is misinter-

pretation of test results by healthcare pro-

viders, often due to misunderstanding of

testing limitations

– As mentioned earlier, this can be remedied

in preanalytical arena

• Clinical validity and utility difficult to assess

because of rapid evolution of testing

– Validity challenging with regard to

genotype–phenotype correlations because

novel/emerging targets are less character-

ized, in addition to the presence of variants

of uncertain significance

– Clinical utility difficult to determine as

clinical impact of emerging diagnostics

often requires more time and sample

numbers, as opposed to analytical valida-

tion of assays

• Because of the implications of test results

from molecular testing, laboratories should

consider including additional information not

required by CLIA, in clear, concise, and infor-

mative fashion, including

– Test indication

– Test method

– Test specifications and limitations

– Current standard nomenclature, as well as

commonly used terms (to avoid confusion

regarding results)

– Detailed interpretation

– Genetic counseling recommendation, when

applicable

– Implications of test results for family

members

– Updated or amended reports as new infor-

mation becomes available

• Previously reported deleterious muta-

tions may be reclassified as benign

variants/polymorphisms, or vice versa

• Laboratories may consider placing

a system to amend reports and contact

patients and providers, in the event of

44 Molecular Testing: Regulatory Issues 1101

such changes, and to maintain

a database of variants to identify those

patients more readily

– Retain reports for at least 25 years, as

opposed to minimal CLIA guidelines

• Molecular genetic diagnoses are essen-

tially a lifetime diagnosis that may need

to be referenced and also may affect

future relatives of the proband; also,

new knowledge may surface that will

alter original diagnosis

Release of Molecular Testing Reports

• As required by CLIA, laboratories may

only release test results to authorized persons,

the person responsible for using the test

results (if applicable), and the laboratory

that initially requested the test (42 CFR

493.1291)

– Note that molecular genetic test results

may be necessary for the healthcare of fam-

ily members of patients

• Healthcare provider of family member

would need to receive authorization

from patient to request patient test

information

• Laboratory should request and confirm

patient’s authorization before releasing

results

44.2.8 Personnel

• Laboratories performing nonwaived testing

are regulated with respect to all personnel

involved in testing

44.2.8.1 Provider-PerformedMicroscopy Procedures

• The laboratory must have

– Qualified director (42 CFR Sec. 493.1357)

• Qualified to manage and direct the per-

sonnel and perform PPM procedures

• Carrying current license as laboratory

director issued by state, if required

• Either a physician, midlevel practitioner

(authorized by the state to practice inde-

pendently), or a dentist

• Who directs no more than five

laboratories

– Qualified testing personnel (42 CFR

Sec. 493.1363)

• Who possess a current license issued by

the state, if required

• Either a physician, midlevel practitioner

(authorized by the state to practice inde-

pendently), or a dentist

44.2.8.2 Moderate Complexity Testing• The laboratory must have

– A qualified director (42 CFR

Sec. 493.1405)

• Responsible for overall operation and

administration of laboratory, including

employment of competent personnel

• Accessible to laboratory for onsite, tele-

phone, or electronic consultation

• Who may direct no more than five

laboratories

– A qualified technical consultant (42 CFR

Sec. 493.1411)

• Responsible for technical and scientific

oversight of laboratory

• Available to provide onsite, telephone,

or electronic consultation

– A qualified clinical consultant (42 CFR

Sec. 493.1417)

• Who provides consultation regarding

appropriateness of testing and interpre-

tation of results

• Available to provide clinical consulta-

tion to clients

• Qualified testing personnel (42 CFR

Sec. 493.1423)

• Responsible for specimen processing,

test performance, and reporting results

44.2.8.3 High Complexity Testing• Laboratories performing high complexity test-

ing must have

– A qualified director (42 CFR

Sec. 493.1443)

• Responsible for overall operation of lab-

oratory, including employment of com-

petent personnel

1102 F.S. Ong et al.

• If qualified, may perform duties of the

technical supervisor, clinical consultant,

general supervisor, and/or testing per-

sonnel or delegate these responsibilities

• Must be accessible to laboratory to pro-

vide onsite, telephone, or electronic

consultation

• May direct no more than five

laboratories

– A qualified technical supervisor (42 CFR

Sec. 493.1449)

• Responsible for the technical and scien-

tific oversight of the laboratory

• Accessible to the laboratory to provide

onsite, telephone, or electronic

consultation

– A qualified clinical consultant (42 CFR

Sec. 493.1455)

• Provides consultation regarding appro-

priateness of testing ordered and

interpretation of results

• Available to provide consultation to

clients

– A qualified general supervisor (42 CFR

Sec. 493.1461)

• Responsible for day-to-day supervision

or oversight of the laboratory operation

and personnel

• Accessible to testing personnel at all

times; testing is performed to provide

onsite, telephone, or electronic

consultation

– Qualified testing personnel (42 CFR

Sec. 493.1489)

• Responsible for specimen processing,

test performance, and results reporting

44.2.9 Inspection

• Basic inspections: all laboratories issued

a CLIA certificate and CLIA-exempt labora-

tories must permit CMS or a CMS agent to

conduct validation and/or compliance inspec-

tions, which may include

– Testing of samples or performing

procedures

– Interviews of personnel

– Observation of testing

– Examination of all records

44.2.9.1 Laboratories Issueda Certificate of Waiver orProvider-PerformedMicroscopy

• Not subject to biennial inspections

• However, CMS or a CMS agent may conduct

an inspection at any time to

– Determine if laboratory constitutes “immi-

nent and serious risk” to public health

– Evaluate complaints

– Determine whether laboratory performing

tests outside scope of certificate

– Collect information regarding appropriate-

ness of waived or PPM procedures

44.2.9.2 Laboratories Issueda Certificate of Compliance

• Laboratory issued certificate of registration

must permit initial inspection to assess labo-

ratory compliance with applicable CLIA

regulations

• CMS or a CMS agent may conduct subsequent

inspections on biennial basis (or with other

frequency, based on compliance history)

44.2.9.3 Inspection of ClinicalLaboratory Improvement Act-Exempt Laboratories or ThoseRequesting or Issueda Certificate of Accreditation

• CMS or a CMS agent may conduct validation

inspection of any accredited or CLIA-exempt

laboratory at any time

– CMS or a CMS agent may conduct com-

plaint inspection of CLIA-exempt labora-

tory (or one requesting or issued certificate

of accreditation) at any time upon receiving

complaint

– If validation or complaint inspection results

in noncompliance

• Laboratory-issued certificate of accred-

itation is subject to full review

• CLIA-exempt laboratory is subject to

appropriate enforcement actions under

state licensure program

44 Molecular Testing: Regulatory Issues 1103

44.2.10 Enforcement of Regulations

• The Clinical Laboratory Improvement Act of

1967, amended by CLIA ’88, set forth require-

ments for all laboratories performing diagnos-

tic testing on human specimens and

– Required federal certification of such

laboratories

– Granted the Secretary of HHS broad

authority for enforcement, allowing

• Intermediate sanctions

• Suspension, limitation, or revocation of

certification

• Civil suit (for laboratory activity posing

“significant hazard” to public health)

• Imprisonment or fine (for conviction of

intentional violation of CLIA

regulations)

44.2.10.1 Basis of Sanctions• Violations of CLIA regulations are detected by

– Deficiencies found by CMS (or its agents)

– Proficiency testing results

• One or more of the following sanctions

imposed upon finding “condition level” viola-

tions (42 CFR Sec. 493.1806 for additional

information), based on one or more following

factors

– Deficiencies pose “immediate jeopardy”

– Nature, incidence, severity, and duration of

deficiencies

– Repeated offenses

– Accuracy, extent, and availability of labo-

ratory records, with regard to deficiency

– Relationship of multiple deficiencies

– Overall compliance history

– Intended outcome of sanctions

– Whether laboratory has taken opportunity

to correct deficiencies

– Recommendation by state agency as to

appropriate sanction(s)

44.2.10.2 Types of Sanctions• Principal sanctions

– Three principal CLIA sanctions

• Suspension

• Limitation

• Revocation of CLIA certificate

• Alternative sanctions

– A directed plan of correction

– State onsite monitoring

– Civil money penalty

– Civil suit

– Criminal sanctions: individual convicted of

intentionally violating CLIA regulation

may be imprisoned or fined

• Additional sanctions

– For laboratories approved for Medicare

reimbursement

• Principal sanction: cancellation of labo-

ratory approval for Medicare

reimbursement

• Alternative sanctions

– Suspension of payment for subset of

tests performed on or after sanction-

ing date

– Suspension of payment for all tests

performed on or after sanctioning

date

• Medicare consequences

– Suspension or revocation of any CLIA cer-

tificate leads to CMS cancellation of labo-

ratory approval for Medicare

reimbursement

– Limitation of any CLIA certificate leads to

CMS limitation of Medicare approval to

specialties/subspecialties still authorized

by certificate

• Medicaid consequences

– Reimbursement under state plans limited if

CLIA certificate and/or state licensure/

approval is limited

44.3 Other GovernmentalRegulations and RegulatoryAgencies

• In addition to the Department of Health and

Human Services (HHS) and its CMS branch

for overseeing CLIA regulations, other

branches of federal and state governments

have regulatory impact on laboratories – and

HHS and its branches (including CMS) have

other regulatory oversight of clinical laborato-

ries, in addition to CLIA regulations.

1104 F.S. Ong et al.

The following are selected federal and state

regulatory agencies that have significant impact

on the modern molecular diagnostic laboratory

44.3.1 State Departments of Health

• As described in Section III under CLIA certi-

fication, various state Departments of Health

exert a spectrum of regulatory influence over

clinical laboratories

• New York state and state of Washington have

been granted “exemption” by CMS

– Clinical laboratories licensed in the state of

New York or Washington is eligible for

CLIA-exempt status

44.3.2 Office of the Inspector General

• The Office of the Inspector General (OIG) is

a division of the Department of Health and

Human Services

• Established in 1976, involved in auditing and

identifying inefficiency, fraud, and abuse of

HHS programs, including Centers for Medi-

care and Medicaid Services

• Impact on clinical laboratories is to identify

fraud and abuse of CMS with respect to clin-

ical laboratory testing, particularly issues of

reimbursement and medical necessity of

testing

– Molecular diagnostics is a rapidly evolving

field, so medical necessity of this type of

testing is often not well disseminated, and

therefore reimbursements are at risk for

denial without a certain amount of

vigilance

44.3.3 Centers for Medicare andMedicaid Services

• A division of HHS, together the CMS are the

largest healthcare entity in the United States

• The Medicare and Medicaid programs were

enacted in 1965, as Title XVIII and Title

XIX of the Social Security Act, targeting

healthcare to individuals aged 65 or older,

impoverished youths lacking parenting

(including their caretakers), the blind, and

those with disabilities

• Currently Medicare primarily covers the

elderly; however, it also provides coverage

for some persons with disability or end-stage

renal disease

• Medicaid primarily covers low-income indi-

viduals through cooperation with state

programs

• The impact of CMS through CLIA has already

been presented; however, CMS also sets reim-

bursement rates for laboratory testing that not

only impacts its own healthcare system but

also is referenced by many other third party

payers

– Because of the reagent and labor costs of

most molecular diagnostic assays, as well

as difficulties with reimbursement of such

leading edge technology and testing, CMS

reimbursement rates are vital to the opera-

tion of the modern molecular diagnostic

laboratory

44.3.4 United States Food and DrugAdministration, Office of InVitro Diagnostic DeviceEvaluation and Safety

• The Food and Drug Administration (FDA) is

a division of HHS, and its Office of In Vitro

Diagnostic Device Evaluation and Safety

(OIVD) was founded in 2002 to consolidate

regulation of in vitro diagnostic devices

(IVDs) and test kits

• The OIVD regulates both in-home and labo-

ratory IVDs

• As noted earlier in Section III, the OIVD also

regulates commercial in vitro diagnostic test-

ing complexity (waived vs. moderate/high

complexity) for CMS

• Of the three divisions (Chemistry and Toxi-

cology Devices, Immunology and Hematol-

ogy Devices, and Microbiology Devices), it

is the Division of Immunology and Hematol-

ogy Devices (DIHD) that regulates the

44 Molecular Testing: Regulatory Issues 1105

majority of IVDs and test kits that would be

encountered in a molecular diagnostic

laboratory

44.3.5 Equal EmploymentOpportunity Commission

• Created by Title VII of the Civil Rights Act of

1964 (amended by Congress in the Equal

Employment Opportunity Act of 1972), the

Equal Employment Opportunity Commission

(EEOC) enforces federal laws prohibiting dis-

crimination against applicants or employees

on the basis of race, religion, sex, age, disabil-

ity, or genetic information

• Most employers with 15+ employees, labor

unions, and employment agencies are covered

by EEOC

• Hiring of personnel for molecular diagnostics

laboratories is subject to the applicable EEOC

regulations

44.3.6 Occupational Safety and HealthAdministration

• A division of the United States Department of

Labor, the Occupational Safety and Health

Administration (OSHA) was created by Con-

gress with the Occupational Safety and Health

Act of 1970

• This administration promotes and enforces

healthy and safe workplace standards to pro-

tect employees

• As a place of employment, molecular diagnos-

tic laboratories must adhere to OSHA stan-

dards to protect their employees, which are

the single greatest asset to any laboratory

44.3.7 Environmental ProtectionAgency

• The Environmental Protection Agency (EPA)

was established in 1970 because of concerns

over pollution and the physical environment

• In order to protect the environment, research,

monitoring, standards, and enforcement were

enacted

• The molecular diagnostic laboratory must dis-

pose of environmentally hazardous laboratory

materials in accordance with EPA standards

– Commonly occurring such materials

include ethidium bromide, formalin, and

xylene

44.3.8 Nuclear RegulatoryCommission

• US Nuclear Regulatory Commission (NRC)

was established in 1974 to create and enforce

federal guidelines ensuring safe use of radio-

active materials (for nonmilitary purposes

only) and protect the public and environment

• NRC provides oversight through licensing,

inspections, and enforcement of regulations

of nuclear products such as nuclear power

plants, nuclear medicines, and other radioac-

tive materials (such as research reagents)

• Although most molecular diagnostic laborato-

ries have replaced radioactive reagents such as

Southern blot probes and radiolabeled nucle-

otides, with fluorescent or chemiluminescent

analogs, if a radioactive material is employed

in the laboratory, its use is governed by NRC

guidelines

44.3.9 Department of Transportation

• The Department of Transportation (DOT) was

established in 1966 to provide efficient, eco-

nomical, and environmentally conscious

national transportation system

• Primary agency in federal government regard-

ing safety, adequacy, and efficiency of trans-

portation system

• DOT is responsible for regulating transport of

biohazard materials (including human

specimens)

• All specimens received and referred by clini-

cal laboratories must adhere to DOT

guidelines

1106 F.S. Ong et al.

44.3.10 Health Insurance Portabilityand Accountability Act

• The Health Insurance Portability and

Accountability Act (HIPAA) of 1996 (Public

Law 104–191), an amendment to the Internal

Revenue Code of 1986, aimed to improve

portability and continuity of health insurance;

decrease inefficiency, fraud, and abuse in

health insurance and healthcare; promote

healthcare savings accounts; improve accessi-

bility to long-term care; and simplify admin-

istration of health insurance

• Onebenefitof thisActwasa reformtohealthcare

information management known as the HIPAA

Privacy Rule, safeguarding patient “protected

health information (PHI)” from unauthorized

written, oral, or electronic dissemination

• This Act is the basis for many current individ-

ual healthcare information standards and must

be followed by all clinical laboratories

44.3.11 Ban on Physician Self-referral(Stark Law)

• A provision in the Omnibus Budget Reconcil-

iation Act of 1989 (OBRA 1989), known as

“Stark I” (named for Congressman Pete Stark,

who sponsored bill), barred physicians from

self-referring Medicare patients for laboratory

services (effective 1992)

• There have been several additional provisions

(known as Stark II and III), now among other

changes governing self-referral for Medicare

and Medicaid patients

• Directors of molecular diagnostic laboratories

must understand these provisions, especially

those who are also clinicians (and thus may

refer testing to a laboratory they direct), in

order to avoid unintentional wrongdoing

44.3.12 Three-Day Rule

• Omnibus Budget Reconciliation Act of 1990,

OBRA 1990, Pub. L. 101–508; Preservation of

Access to Care for Medicare Beneficiaries and

Pension Relief Act of 2010, Pub. L. 111–192,

Section 102

• These laws require that diagnostic services

(including laboratory testing), or other ser-

vices related to an inpatient admission, pro-

vided by the admitting hospital (or an entity

owned/operated by the hospital) for admitted

patient during the 3 days preceding date of

admission is considered part of the inpatient

stay (for admission to a hospital paid under

inpatient prospective payment system,

“IPPS”). The payment window for admission

to a hospital not paid by IPPS (such as psychi-

atric, inpatient rehabilitation, long-term care,

children’s, and cancer hospitals) is 1 day pre-

ceding the date of admission

• These laws state that reimbursement for testing

performed in a molecular diagnostic laboratory

under any of the circumstances listed above

would be included on a DRG system

44.4 Nongovernmental Agencies

• In addition to governmental organizations and

regulations, there are many nongovernmental

agencies that impact molecular diagnostic lab-

oratories. An exhaustive list is beyond the

scope of this writing; however, three signifi-

cant organizations will be introduced

44.4.1 College of AmericanPathologists

• The CAP, a nonprofit organization, was formed

in 1947 to promote pathology education,

research, practice, and service for patients,

physicians, hospitals, and the general public

• As noted earlier, CAP is a CLIA-deemed

authority

• CAP accreditation recognized by JCAHO

• Offers the largest proficiency testing program

in the United States

• Offers a wide range of proficiency testing pro-

grams for molecular diagnostic laboratories,

including genetic and somatic mutation testing

• Offers an accreditation program tailored to

molecular diagnostic laboratories

44 Molecular Testing: Regulatory Issues 1107

44.4.2 Commission on OfficeLaboratory Accreditation

• COLA is a nonprofit organization originally

founded in 1988 to assist physician office lab-

oratories (POLs) comply with CLIA

• COLA laboratory accreditation program

granted CLIA deeming authority in 1993

• COLA accreditation recognized by JHACO

• Expanded program to include accreditation of

hospital and independent laboratories

• Accredits following types of laboratories:

physician office, community hospital, mobile

clinic, Veterans Administration, and Depart-

ment of Defense

• CMS-approved to accredit the following spe-

cialties: chemistry, hematology, microbiol-

ogy, immunology, and immunohematology/

transfusion services

44.4.3 Joint Commission onAccreditation of HealthcareOrganizations

• Founded in 1951, JCAHO is an independent

and nonprofit organization that evaluates and

accredits healthcare organizations

• To maintain accreditation, a healthcare orga-

nization undergoes onsite surveys at least

every 3 years, with laboratories surveyed at

least every 2 years

• In surveying a healthcare organization, JCAHO

typically surveys the laboratory as well

• Has accreditation programs for following

healthcare organizations: hospital, home

care, behavioral health, laboratory, ambula-

tory (including office-based surgery and pri-

mary care medical home), long-term care, and

critical access hospitals

• Has CLIA-deemed authority, and is CMS-

approved to accredit all CLIA specialties

• JCAHO accreditation also satisfies select state

licensure and insurer requirements for

laboratories

Further Reading

Centers for Medicare and Medicaid Services (http://www.

cms.gov/)

Chronology of CLIA regulations (http://wwwn.cdc.gov/

clia/chronol.aspx)

CLIA (http://wwwn.cdc.gov/clia/pdf/PHSA_353.pdf, http://

wwwn.cdc.gov/clia/regs/toc.aspx)

CMS-deemed authorities and Exempt States (http://www.

cms.gov/CLIA/13_Accreditation_Organizations_and

_Exempt_States.asp#TopOfPage)

COLA (http://www.cola.org/)

College of American Pathologists (CAP, http://www.cap.

org/apps/cap.portal)

Environmental Protection Agency (http://www.epa.gov/)

Good Laboratory Practices for molecular genetic testing

for heritable diseases and conditions (http://www.cdc.

gov/mmwr/pdf/rr/rr5806.pdf)

Health Insurance Portability and Accountability Act

(HIPAA, http://www.hhs.gov/ocr/privacy/hipaa/under-

standing/index.html)

Joint Commission on Accreditation of Healthcare Orga-

nizations (JCAHO, http://www.jointcommission.org/)

List of CLIA waived testing (https://www.cms.gov/CLIA/

downloads/waivetbl.pdf)

Listing of provider-performed microscopy procedures

(https://www.cms.gov/CLIA/downloads/ppmp.list.pdf)

New York State Department of Health (http://www.

health.ny.gov/)

Occupational Safety and Health Administration (http://

www.osha.gov/index.html)

Office of Inspector General, United States Department of

Health and Human Services (http://oig.hhs.gov/)

Searchable database of CLIA testing (http://www.accessdata.

fda.gov/scripts/cdrh/cfdocs/cfCLIA/search.cfm)

Stark Rule Phase III (http://www.gpo.gov/fdsys/pkg/FR-

2007-11-15/pdf/07-5655.pdf)

State of Washington Department of Health (http://www.

doh.wa.gov/)

Three Day Rule (https://www.cms.gov/AcuteInpa-

tientPPS/08a_Three_Day_Payment_Window.asp)

United States Department of Transportation (http://www.

dot.gov/)

United States Equal Employment Opportunity Commis-

sion (http://www.eeoc.gov/)

United States Food and Drug Administration (http://www.

fda.gov/)

United States Nuclear Regulatory Commission (http://

www.nrc.gov/)

1108 F.S. Ong et al.