Unique Plan Description: Breast Ctr Female Clinic (JE)
Plan Selection Display: Breast Ctr Female Clinic (JE)
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2012-03-02 11:55:25
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2025-02-19 09:57:49
Available at all facilities: Yes

Breast Ctr Female Clinic (JE)
Laboratory
	CBC with Diff
		T;N, Routine, spec type = Blood
	Comprehensive Metabolic Panel
		T;N, Routine, spec type = Blood
	Thyroxine Total T4 (not for screening)
		T;N, Routine, spec type = Blood
	TSH
		T;N, Routine, spec type = Blood
	Beta-HCG Quantitative - Pregnancy
		T;N, Routine, spec type = Blood
	Pregnancy Test Urine
		T;N, Routine, Routine, spec type = Urine
	CA 15-3
		T;N, Routine, spec type = Blood
	CEA
		T;N, Routine, spec type = Blood
	MRSA Nasal Screen Rapid - JE
		T;N, Routine, spec type = Swab
	Culture Routine
		T;N, Routine, Micro Swab, spec type = Abscess, Breast
Diagnostic Tests
Diagnostics
	ECG
		T;N
	Bone Imaging Whole Body
		T;N, Routine
	Chest 2 View
		T;N, Routine
	Mammary Ductogram Single Duct
		T;N, Routine
	Mammary Ductogram Multi Ducts
		T;N, Routine
Mammo
	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
	Mammo Bil Diag
		T;N, Routine
	Mammo Implants Diag
		T;N, Routine
	Mammo Unilat Diag Lt
		T;N, Routine
	Mammo Implant Diag Lt
		T;N, Routine
	Mammo Unilat Diag Rt
		T;N, Routine
	Mammo Implant Diag Rt
		T;N, Routine
	Stereotactic Breast Bx Lt
		T;N, Routine
	Stereotactic Breast Bx Rt
		T;N, Routine
	Tumor Loc Multiple
		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
CT
	CT Abd w & w/o Contrast
		T;N, Routine
	CT Chest w Contrast
		T;N, Routine
	CT Pelvis w Contrast
		T;N, Routine
MRI
	MRI Breast w/o Contrast Lt
		T;N, Routine
	MRI Breast w & w/o Contrast Lt
		
	MRI Breast w/o Contrast Rt
		T;N, Routine
	MRI Breast w & w/o Contrast Rt
		
	MRI Breast w/o Contrast Bil
		
	MRI Breast w & w/o Contrast Bil
		T;N, Routine
	MRI Brain w & w/o Contrast
		T;N, Routine
Ultrasound
	US Breast Asp Guided Lt
		T;N, Routine
	US Breast Asp Guided Rt
		T;N, Routine
	US Breast Bx Lt
		T;N, Routine
	US Breast Bx Rt
		T;N, Routine
	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
Medications

	lidocaine-EPINEPHrine 2%-1:100000 (In Office)
		20 mL, Injection, IM-Intramuscular, Once, T;N
	lidocaine 1% (5 mL) (Xylocaine) (In Office)
		5 mL, Injection, SUBCUTANEOUS, Once, T;N
	sodium bicarbonate (In Office)
		50 mL, Injection, SUBCUTANEOUS, Once, T;N
			Comment: Mix with lidocaine as directed.
Prescriptions
	amoxicillin-clavulanate  875 mg-125 mg oral tablet
		1 TAB BY MOUTH BID, X 10 Day(s), # 20 TAB, 0 Refill(s), Hard Stop
	Avelox 400 mg oral tablet
		1 TAB BY MOUTH DAILY, X 10 Day(s), # 10 TAB, 0 Refill(s), Hard Stop
	clindamycin 300 mg oral capsule
		1 CAP BY MOUTH QID, X 10 Day(s), # 40 CAP, 0 Refill(s), Hard Stop
	metroNIDAZOLE 500 mg oral tablet
		1 TAB BY MOUTH TID, X 10 Day(s), # 30 TAB, 0 Refill(s), Hard Stop
	cephalexin 500 mg oral capsule
		1 CAP BY MOUTH TID, X 10 Day(s), # 30 CAP, 0 Refill(s), Hard Stop
	acetaminophen-hydrocodone 325 mg-5 mg oral tablet
		1 or 2 TAB, BY MOUTH, Q4-6H, PRN pain, # 20 TAB, 0 Refill(s), Hard Stop
	Percocet 5 mg-325 mg oral tablet
		1 or 2 TAB, BY MOUTH, Q4H, PRN pain, # 20 TAB, 0 Refill(s), Hard Stop
	Ultram 50 mg oral tablet
		1 or 2 TAB, BY MOUTH, Q6H, PRN for pain, # 20 TAB, Hard Stop
	tamoxifen 20 mg oral tablet
		1 TAB BY MOUTH DAILY, # 30 TAB, 3 Refill(s)
			Comment: Extremely Hazardous Drug | Antineoplastic |  PPE Requirements: Dispensed From Pharmacy In Rx Crush Bag, Double Gloves, Gown, Face Shield If Tube Admin Or Splashing Risk.
	Evista 60 mg oral tablet
		1 TAB, BY MOUTH, DAILY, # 30 TAB, 3 Refill(s)
Patient Care

	Patient Instructions
		Patient to shower with chlorhexadine gluconate evening before surgery
		Patient to shower with chlorhexadine gluconate morning of surgery
		NPO 8 hours before surgery
Consults/Follow-up
	Follow-up Appointment
		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, 1 year
		Follow Up Visit, See Special Instructions
	Request for Service
		BCR Gene Rearrangement, Contact the hospital laboratory
		BCR-ABL Quantitative, Contact the hospital laboratory
		Oncotype Dx, Contact the hospital laboratory
	Consult Oncologist
		
	Consult Radiation Oncologist
		
	Consult Primary Care Provider
		
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
	Multidisciplinary Conference
		
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
		
	19100 Breast bx percu needle core
		
	19000 BCF- Breast Aspiration
		
	10021 Fine Needle Asp
		
	10060 I&D abscess simple/single
		
	10140 I&D hematoma seroma
		
	19020 Mastotomy w/ Exploration Drain Abscess
		
	19000 Puncture asp breast cyst
		
	19001 Puncture asp breast cyst ea additional
		
	10160 Puncture aspirat abscess hematoma cyst
		
	11201 Removal of skin tags, each additional ten
		
	11200 Removal of skin tags, up to and inc 15

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NOTE - This component is a note
Rx - This component is a prescription
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