Unique Plan Description: IM Female Yearly Exam Clinic
Plan Selection Display: IM Female Yearly Exam Clinic
PlanType: Medical                                 
Version: 2          
Begin Effective Date: 2020-11-01 07:40:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2023-02-20 10:43:43
Available at all facilities: Yes

IM Female Yearly Exam Clinic
Laboratory
	CBC with Diff
		T;N, Routine, spec type = Blood
	Comprehensive Metabolic Panel
		T;N, Routine, spec type = Blood
	TSH
		T;N, Routine, spec type = Blood
	Lipid Panel
		T;N, Routine, spec type = Blood
	Urogram
		T;N, Routine, Routine, spec type = Urine
	UA
		T;N, Routine, Routine, spec type = Urine
	UA (Culture if Positive)
		T;N, Routine, Routine, spec type = Urine
	Hemoglobin A1C
		T;N, Routine, spec type = Blood
	Uric Acid
		T;N, Routine, Once, spec type = Blood
	Microalbumin Urine Random (Spot)
		T;N, Routine, Routine, spec type = Urine Random
	Microalbumin Urine MPC
		T;N, Routine, Routine, spec type = Urine Random
	GYN Request (PAP)
		T;N, Routine TL PAP CERVICAL, Routine
		T;N, Routine TL PAP CV & VAG, Routine
		T;N, Routine TL PAP VAGINAL, Routine
		T;N, Routine PAP CERVICAL, Routine
		T;N, Routine PAP CERV & VAG, Routine
		T;N, Routine PAP VAGINAL, Routine
	GYN Pap with HPV High Risk Co-Test
		T;N, Routine TL PAP CERVICAL, Routine
		T;N, Routine TL PAP CV & VAG, Routine
		T;N, Routine TL PAP VAGINAL, Routine
	GYN Pap with Reflex to HPV High Risk
		T;N, Routine TL PAP CERVICAL, Routine
		T;N, Routine TL PAP CV & VAG, Routine
		T;N, Routine TL PAP VAGINAL, Routine
	HPV High Risk with 16 and 18 Genotyping
		T;N, Routine, spec type = Cervix
		T;N, Routine, spec type = Vaginal
	Wet Prep - PC/FH
		T;N, Routine, spec type = Genital
	Pregnancy Test Urine
		T;N, Routine, Routine, spec type = Urine
	LH
		T;N, Routine, spec type = Blood
	FSH
		T;N, Routine, spec type = Blood
	Anti Mullerian Hormone
		T;N, Routine, spec type = Blood
	GC/Chlamydia PCR-MH/WH/PC
		T;N, Routine, spec type = Cervix
		T;N, Routine, spec type = Vaginal
	GC/Chlamydia(Rapid) DNA - FH/JE
		T;N, Routine, spec type = Cervix
		T;N, Routine, spec type = Urine
		T;N, Routine, spec type = Vaginal
	Urine GC/Chlamydia PCR - MH/WH/PC
		T;N, Routine, spec type = Urine
	GC/Chlamydia(Rapid) DNA - FH/JE
		T;N, Routine, spec type = Urine
	Vitamin B12 Level
		T;N, Routine, spec type = Blood
	Vitamin D 25-Hydroxy Level (preferred for deficiency)
		T;N, Routine, spec type = Blood
	Basic Metabolic Panel
		T;N, Routine, spec type = Blood
	CK
		T;N, Routine, spec type = Blood
	Immunochemical Fecal Occult Blood-PC/FH
		T;N, Routine, spec type = Stool
Point of Care
	Wet Mt Physician Perform
		
	Hemoglobin POC - PC (lab)
		T;N, spec type = Blood
Diagnostic Tests

	Complete pre and post PFT's
		T;N
	zzDXA Scan
		T;N
	Echo w Doppler resting
		T;N
Radiology
	Chest 2 View
		T;N, Routine
	Mammo Bil Screen
		T;N, Routine, Encounter for screening mammogram for malignant neoplasm of breast
		T;N, Routine, Personal history of malignant neoplasm of breast | Encounter for screening mammogram for malignant neoplasm of breast
	Mammo Implants Screen
		T;N, Routine, Encounter for screening mammogram for malignant neoplasm of breast
		T;N, Routine, Personal history of malignant neoplasm of breast | Encounter for screening mammogram for malignant neoplasm of breast
Medications

	tuberculin purified protein derivative (PPD) (In Office)
		0.1 mL, Injection, IntraDermal, Once, NOW
	cyanocobalamin (Vit B12) (In Office)
		1,000 mcg, Injection, IM-Intramuscular, Once, NOW
	Shingrix intramuscular injection
		0.5 mL, IM-Intramuscular, Once, repeat dose in 2 to 6 months, # 2 EA, 0 Refill(s)
Immunizations
	influenza virus vaccine (*QUADrivalent) (In Office)
		0.5 mL, Suspension, IM-Intramuscular, Once, T;N, Encounter for immunization
	meningococcal conjugate vaccine (MenQuadfi) (In Office)
		0.5 mL, Solution, IM-Intramuscular, Once, T;N, Encounter for immunization
	pneumococcal 20-valent conjugate vaccine (Prevnar 20) (In Office)
		0.5 mL, Suspension, IM-Intramuscular, Once, T;N, Encounter for immunization
	tetanus/diphth/pertuss (Tdap/Adacel) (In Office)
		0.5 mL, Suspension-Injection, IM-Intramuscular, Once, T;N, Encounter for immunization
	tetanus-diphth toxoids adult/adol (Td-Tenivac)(In Office)
		0.5 mL, Injection, IM-Intramuscular, Once, T;N, Encounter for immunization
	zoster vaccine, recomb, adjuv (Shingrix)(In Office)
		0.5 mL, Suspension, IM-Intramuscular, Once, NOW, Encounter for immunization
	human papillomavirus vaccine (Gardasil 9) (In Office)
		0.5 mL, Solution, IM-Intramuscular, Once, T;N, Encounter for immunization
	hepatitis A adult vaccine (Vaqta) (In Office)
		1 mL, Injection, IM-Intramuscular, Once, NOW, Encounter for immunization
	hepatitis B adult vaccine (Recombivax HB) (In Office)
		1 mL, Solution-Injection, IM-Intramuscular, Once, T;N, Encounter for immunization
Patient Care

	94760 Pulse Oximetry- Single
		
	ECG w/ interpretation and report
		
Consults/Follow-up
	Return to Clinic Primary Care
		Future Order In Approximately 1 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 1, week(s), In Approximately
		Future Order In Approximately 2 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 2, week(s), In Approximately
		Future Order In Approximately 3 week(s) Grace Period (+/-) 3 Day(s), 3, Day(s), 3, week(s), In Approximately
		Future Order In Approximately 6 week(s) Grace Period (+/-) 7 Day(s), 7, Day(s), 6, week(s), In Approximately
		Future Order In Approximately 1 month(s) Grace Period (+/-) 7 Day(s), 7, Day(s), 1, month(s), In Approximately
		Future Order In Approximately 2 month(s) Grace Period (+/-) 7 Day(s), 7, Day(s), 2, month(s), In Approximately
		Future Order In Approximately 3 month(s) Grace Period (+/-) 7 Day(s), 7, Day(s), 3, month(s), In Approximately
		Future Order In Approximately 4 month(s) Grace Period (+/-) 7 Day(s), 7, Day(s), 4, month(s), In Approximately
		Future Order In Approximately 6 month(s) Grace Period (+/-) 7 Day(s), 7, Day(s), 6, month(s), In Approximately
		Future Order In Approximately 12 month(s) Grace Period (+/-) 14 Day(s), 14, Day(s), 12, month(s), In Approximately
	Follow-up Appointment
		Follow Up Visit, 1 year
		Follow Up Visit, 1 week
		Follow Up Visit, 2 weeks
		Follow Up Visit, 3 weeks
		Follow Up Visit, 1 month
		Follow Up Visit, 3 months
		Follow Up Visit, 6 months
		Follow Up Visit, See Special Instructions
	Colonoscopy to Schedule
		
	Consult OB/GYN
		
Charges/Supplies
	G0438 EVM - ANNUAL WELLNESS VISIT; 1ST
		T;N
	G0439 EVM - ANNUAL WELLNESS VISIT; SUB
		T;N
	G0402 EVM - WELCOME TO MEDICARE PHYS,,
		T;N
New Pt Visit
	zz99201 EVM-New Pt Visit Problem focused 10m
		T;N
	99202 EVM - OP VISIT NEW PATIENT, STRAIGHTFORWARD 15 MIN
		T;N
	99203 EVM - OP VISIT NEW PATIENT, LOW LEVEL 30 MIN
		T;N
	99204 EVM - OP VISIT NEW PATIENT, MODERATE LEVEL 45 MIN
		T;N
	99205 EVM - OP VISIT NEW PATIENT, HIGH LEVEL 60 MIN
		T;N
Est. Pt Visit
	99211 EVM - OP visit estab patient, minimal care < 10 min
		T;N
	99212 EVM - OP VISIT ESTAB PATIENT, STRAIGHTFORWARD 10 MIN
		T;N
	99213 EVM - OP VISIT ESTAB PATIENT, LOW LEVEL 20 MIN
		T;N
	99214 EVM - OP VISIT ESTAB PATIENT, MODERATE 30 MIN
		T;N
	99215 EVM - OP VISIT ESTAB PATIENT, HIGH LEVEL 40 MIN
		T;N
New Pt Preventive Med
	99384 EVM - Prev Med New Patient 12-17 yrs
		T;N
	99385 EVM - Prev Med New Patient 18-39 yrs
		T;N
	99386 EVM - Prev Med New Patient 40-64 yrs
		T;N
	99387 EVM - Prev Med New Patient > 65 yrs
		T;N
Est Pt Preventive Med
	99394 EVM - Prev Med Estab Patient 12-17 yrs
		T;N
	99395 EVM - Prev Med Estab Patient 18-39 yrs
		T;N
	99396 EVM - Prev Med Estab Patient 40-64 yrs
		T;N
	99397 EVM - Prev Med Estab Patient > 65 yrs
		T;N
No Charge / Follow Up
	99024 EVM - Post Op Visit
		T;N
	99211n EVM - No Charge Professional Service
		T;N
	99213C EVM - MPC CLINIC AUDIT BY CODER
		T;N

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase