Unique Plan Description: Breast Ctr Male Clinic (JE)
Plan Selection Display: Breast Ctr Male Clinic (JE)
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2012-03-01 14:42:32
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2023-02-21 08:59:17
Available at all facilities: Yes

Breast Ctr Male Clinic (JE)
Laboratory
	CBC with Diff
		T;N, Routine, spec type = Blood
	Comprehensive Metabolic Panel
		T;N, Routine, spec type = Blood
	Testosterone Total and Free (Adult Male)
		T;N, Routine, spec type = Blood
	Estradiol Level
		T;N, Routine, spec type = Blood
	LH
		T;N, Routine, spec type = Blood
	TSH
		T;N, Routine, spec type = Blood
	Thyroxine Total T4 (not for screening)
		T;N, Routine, spec type = Blood
	Beta-HCG Quantitative - Pregnancy
		T;N, Routine, spec type = Blood
	CEA
		T;N, Routine, spec type = Blood
	CA 15-3
		T;N, Routine, spec type = Blood
	DHEA
		T;N, Routine, spec type = Blood
Diagnostic Tests
Diagnostics
	Chest 2 View
		T;N, Routine
	Mammo Bil Diag Male
		T;N, Routine
	Mammo Unilat Diag Lt
		T;N, Routine
	Mammo Unilat Diag Rt
		T;N, Routine
Ultrasound
	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

	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
	Cleocin HCl 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 pain, # 20 TAB, 0 Refill(s), Hard Stop
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
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
No Charge / Follow Up
	99211n EVM - No Charge Professional Service
		T;N
	99024 EVM - Post Op Visit
		T;N
Procedures in Office
	19100 Breast bx percu needle core

*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