Unique Plan Description: Srg Onc Melanoma Clinic
Plan Selection Display: Srg Onc Melanoma Clinic
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2012-03-04 16:03:11
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2023-02-09 14:37:17
Available at all facilities: Yes

Srg Onc Melanoma Clinic
Laboratory
	CBC with Diff
		T;N, Routine, spec type = Blood
	Comprehensive Metabolic Panel
		T;N, Routine, spec type = Blood
	INR - MH/WH/JE
		T;N, Routine, spec type = Blood
	Prothrombin Time (PT) - FH
		T;N, Routine
	PTT - MH/WH/JE
		T;N, Routine, spec type = Blood
	Partial Thromboplastin Time (PTT) - FH
		T;N, Routine, spec type = Diagnostic Blood
	LD
		T;N, Routine, spec type = Blood
Diagnostic Tests
Diagnostics
	Chest 2 View
		T;N, Routine
Ultrasound
	US Leg NonVascular Lt
		T;N, Routine
			Comment: Groin
	US Leg NonVascular Rt
		T;N, Routine
			Comment: Groin
	US Pelvis Limited
		T;N, Routine
			Comment: Groin
	US Breast Lt Complete
		T;N, Routine
	US Breast Lt Limited
		T;N, Routine
	US Breast Rt Complete
		T;N, Routine
	US Breast Rt Limited
		T;N, Routine
CT
	CT Abd Pelvis w & w/o Cont
		T;N, Routine
	CT Abd Pelvis w Contrast
		T;N, Routine
	CT Abd Pelvis w/o Contrast
		T;N, Routine
	CT Chest w & w/o Contrast
		T;N, Routine
	CT Chest w Contrast
		T;N, Routine
	CT Chest w/o Contrast
		T;N, Routine
MRI
	MRI Brain w & w/o Contrast
		T;N, Routine
	MRI Brain w Contrast
		T;N, Routine
	MRI Brain w/o Contrast
		T;N, Routine
PET/CT
	PET CT Whole Body Study
		T;N, Routine
	PET CT Skull Base Thigh Study
		T;N, Routine
Medications

	acetaminophen-hydrocodone 325 mg-5 mg oral tablet
		1 or 2 TAB, BY MOUTH, Q4H, PRN for pain, # 40 TAB, 0 Refill(s), Hard Stop
	Percocet 5 mg-325 mg oral tablet
		1 or 2 TAB, BY MOUTH, Q4H, PRN for pain, # 20 TAB, 0 Refill(s), Hard Stop
	Protonix 40 mg oral delayed release tablet
		1 TAB, BY MOUTH, BID, # 30 TAB, 1 Refill(s), Soft Stop
	Carafate 1 g oral tablet
		1 TAB, BY MOUTH, QID, X 10 Day(s), # 30 TAB, 1 Refill(s), Soft Stop
	Colace 100 mg oral capsule
		1 CAP BY MOUTH BID, PRN for constipation, # 180 CAP, 3 Refill(s)
Consults/Follow-up
	Follow-up Appointment
		Follow Up Visit, 1 month
	Request for Service
		
	Surgery to Schedule
		
	Consult Oncologist
		
	Consult Primary Care Provider
		Reason for Referral: Pre-Op H&P
	Consult Radiation Oncologist
		
	Consult Gastroenterologist
		
	Consult Pulmonologist
		
Charges/Supplies
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
No Charge / Follow Up
	99211n EVM - No Charge Professional Service
		T;N
	99024 EVM - Post Op Visit
		T;N
Procedures in Office
	zz11100 Biopsy of skin, subcu tissue; single
		
	11621 Exc mal les scalp neck hand feet 0.6-1.0cm
		
	11622 Exc mal les scalp neck hand feet 1.1-2.0cm
		
	11623 Exc mal les scalp neck hand feet 2.1-3.0cm
		
	11624 Exc mal les scalp neck hand feet 3.1-4.0cm
		
	11620 Exc mal les scalp neck hand feet </= 0.5cm
		
	11626 Exc mal les scalp neck hand feet > 4.0cm
		
	11601 Exc mal les trunk arm leg 0.6-1.0cm
		
	11602 Exc mal les trunk arm leg 1.1-2.0cm
		
	11603 Exc mal les trunk arm leg 2.1-3.0cm
		
	11604 Exc mal les trunk arm leg 3.1-4.0cm
		
	11606 Exc mal les trunk arm leg 4.1cm or larger
		
	11600 Exc mal les trunk arm leg </= 0.5cm
		
	10060 I&D abscess simple/single
		
	36590 Rem Central Vein Device Non-tunneled
		
	13152 Rep cmplx eyelid nose ear 2.6-7.5cm
		
	13131 Rep cmplx frhd chck chin neck h/f 1.1-2.5cm
		
	13132 Rep cmplx frhd chck chin neck h/f 2.6-7.5cm
		
	13133 Rep cmplx frhd chck chin neck h/f ea add 5cm
		
	13120 Rep cmplx scalp arm leg 1.1-2.5 cm
		
	13121 Rep cmplx scalp arm leg 2.6-7.5 cm
		
	13122 Rep cmplx scalp arm leg ea add 5cm/less
		
	13101 Rep cmplx trunk 2.6-7.5cm
		
	13102 Rep cmplx trunk ea add 5cm/ less
		
	12011 Rep wound sim face ears nose </= 2.5cm
		
	12013 Rep wound sim face ears nose 2.6-5.0cm
		
	12014 Repair Wound, Simple, Face, Mucous Membranes, 5.1-7.5 cm or Less
		
	12001 Rep wound sim scalp neck trunk ext </= 2.5cm
		
	12002 Rep wound sim scalp neck trunk ext 2.6-7.5cm
		
	12004 Rep wound sim scalp neck trunk ext 7.6-12.5cm
		
	12005 Rep wound sim scalp neck trunk ext 12.6-20cm

*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