Unique Plan Description: MFM Targeted Ultrasound Consult Clinic
Plan Selection Display: MFM Targeted Ultrasound Consult Clinic
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2012-03-30 17:02:42
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2022-08-30 08:45:53
Available at all facilities: No

MFM Targeted Ultrasound Consult Clinic
Medications
	RHo (D) immune globulin 300 mcg (In Office)
		1,500 intl_units, Solution, IM-Intramuscular, Once, NOW
Consults/Follow-up
	Follow-up Appointment
		2 weeks
		2 months
		1 week
		3 weeks
		1 month
		3 months
		See Special Instructions
		PRN
	Request for Service
		T;N
	Surgery to Schedule
		
	Consult Other
		
Charges/Supplies
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 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
Procedures in Office
	59000 CP Amniocentesis, diagnostic MFM
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	Level 1 U/S (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76811 Level II U/S  -MFM
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76816 US OB Follow-up (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76817 US OB Transvaginal (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76827 Doppler (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76828 Doppler F/U (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	93770 Ductus Venosus (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76825 Doppler Echo, Fetal, 2D (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76826 Doppler Echo, Fetal F/U (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76820 Doppler Umb Artery (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76821 Doppler Mid-Cerebral Artery (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	93976 Doppler Uterine Artery (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3

*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