Unique Plan Description: ENT General Clinic
Plan Selection Display: ENT General Clinic
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2012-04-16 15:32:41
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2023-02-21 09:00:03
Available at all facilities: Yes

ENT General Clinic
Laboratory
	CBC with Diff
		T;N, Routine, spec type = Blood
	Hemogram (CBC no Diff)
		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
	Sed Rate
		T;N, Routine, spec type = Blood
	ANA Screen
		T;N, Routine, spec type = Blood
	BUN
		T;N, Routine, spec type = Blood
	Creatinine
		T;N, Routine, spec type = Blood
	Ferritin
		T;N, Routine, spec type = Blood
	Folate
		T;N, Routine, spec type = Blood
	Iron
		T;N, Routine, spec type = Blood
	Iron Panel - MH/WH/JE
		T;N, Routine, spec type = Blood
	Transferrin Profile
		T;N, Routine, spec type = Blood
	Magnesium Level
		T;N, Routine, spec type = Blood
	Potassium Level
		T;N, Routine, spec type = Blood
	Thyroxine Total T4 (not for screening)
		T;N, Routine, spec type = Blood
	Free T4
		T;N, Routine, spec type = Blood
	TSH
		T;N, Routine, spec type = Blood
	Vitamin B12 Level
		T;N, Routine, spec type = Blood
	Sputum Culture
		T;N, Routine, spec type = Sputum
	Culture Anaerobic
		T;N, Routine
	Basic Metabolic Panel
		T;N, Routine, spec type = Blood
	Infectious Mononucleosis Screen
		T;N, Routine, spec type = Blood
Point of Care
	Coumadin POC - PC
		T;N, Blood
	INR POC
		T;N, Blood
Diagnostic Tests

	MRA Head w Contrast
		T;N, Routine
	Neck Soft Tissue
		T;N, Routine
	Sinus <3 View
		T;N, Routine
Ultrasound
	US Thyroid Neck Soft Tissue
		T;N, Routine
CT
	CT Neck w Contrast
		T;N, Routine
	CT Sinus w/o Contrast
		T;N, Routine
	CT Temporal Bones w Contrast
		T;N, Routine
	CT Temporal Bones w/o Contrast
		T;N, Routine
	CTA Neck
		T;N, Routine
	CT Facial Bones w/o Contrast
		T;N, Routine
MRI
	MRI IACs w & w/o Contrast
		T;N, Routine
			Comment: with and without Gadolinium (contrast)
	MRI Neck Soft Tissue w/o Contrast
		T;N, Routine
	MRI Neck Soft Tissue w & w/o Contrast
		T;N, Routine
			Comment: with and without Gadolinium (contrast)
	MRI Brain w & w/o Contrast
		T;N, Routine
Medications

	triamcinolone 40mg/mL (Kenalog-40)(In Office)
		40 mg, Injection, IM-Intramuscular, Once, NOW
		60 mg, Injection, IM-Intramuscular, Once, NOW
		80 mg, Injection, IM-Intramuscular, Once, NOW
	methylPREDNISolone (Solu-Medrol 40 mg) (In Office)
		40 mg, Injection, IM-Intramuscular, Once, NOW
	dexamethasone (Decadron) 4mg/mL  (In Office)
		mg, Injection, IM-IntraMUSCULAR, Once, NOW
			Comment: Dosage Depending upon weight
Consults/Follow-up
	Follow-up Appointment
		Follow Up Visit, 2 weeks
		Follow Up Visit, 1 week
		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
		Follow Up Visit, PRN
	Communication to CLINIC Nurse
		Send patient to JE lab for Connexin 26 with pre-cert forms.
	Consult Oral Surgeon
		
	Consult Ear Nose and Throat
		Refer to/Consult with: UNMC
	Consult Neurologist
		
	Consult Gastroenterologist
		Refer to/Consult with: Midwest GI
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
	31579 DIAG LARYNGOSCOPY w/STROBOSCOPY
		
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
	99213C EVM - MPC CLINIC AUDIT BY CODER
		T;N
	99211n EVM - No Charge Professional Service
		T;N
	99024 EVM - Post Op Visit
		T;N
Procedures in Office
	92568 Acoustic reflex
		
	92570 Acoustic reflex decay
		
	30100 Biopsy, Intranasal
		
	zz11100 Biopsy of skin, subcu tissue; single
		
	42800 Biopsy Oroopharynx
		
	41100 Bx of tongue anterior 2/3
		
	41105 Biopsy Tongue Posterior One-Third
		
	40808 Biopsy vestibule of mouth
		
	92585 Brainstem evoked response
		
	95992 Canalith repositioning
		
	17250 Chem cauter of granulation tissue
		
	92557 Comprehensive Audiometry
		
	92582 Conditioning play audiometry
		
	30903 Control nasal hem anterior complex
		
	30901 Control nasal hem anterior simple
		
	30905 Control Nasal Hemorrhage, Posterior Initial
		
	42960  Control Oropharyngeal Hemorrhage
		
	69220 Debride Mastoidectomy Cavity, Simple
		
	31579 DIAG LARYNGOSCOPY w/STROBOSCOPY
		
	69005 Drainage External Ear Abscess, Complicated
		
	92504 EAR MICROSCOPY EXAM
		
	11440 Exc ben les face ear nose </= 0.5cm
		
	11420 Exc ben les scalp neck hand feet </= 0.5cm
		
	11640 Exc mal les face ears nose lips </= 0.5cm
		
	11620 Exc mal les scalp neck hand feet </= 0.5cm
		
	30110 Excise, Nasal Polyp(s), Simple
		
	10021 Fine Needle Asp
		
	42700 I&D Abscess, Peritonsillar
		
	10060 I&D abscess simple/single
		
	69000 Incise & Drain External Ear
		
	10140 I&D hematoma seroma
		
	11900 Injection, intralesional, </= 7 lesions
		
	42999 Injection snoreplasty
		
	31575 Laryngoscopy flex diagnostic
		
	69420 Myringotomy w/Aspiration &/or Tube Inflation bilateral
		
	31238 Nasal Endoscopy, Surgical
		
	31231 Nasal endoscopy diag uni/bilat
		
	92512 Nasal Function Study
		
	31237 Nasal/sinus endoscopy w bx/polyp

	92511 Nasopharynoscopy w/Enodoscope
		
	92588 OAE comprehensive
		
	92587 OAE limited
		
	10160 Puncture aspirat abscess hematoma cyst
		
	92551 Pure tone screening air only
		
	92552 Pure tone threshold, air only
		
	92553 Pure tone threshold, air and bone
		
	69210 Remove Cerumen Impaction
		
	69200 Remove FB, External Auditory Canal
		
	30300 Remove FB Intranasal
		
	42809 Remove FB pharynx
		
	12011 Rep wound sim face ears nose </= 2.5cm
		
	92583 Select picture audiometry
		
	42330 Sialolithotomy
		
	92555 Speech Audiometry threshold
		
	92556 Speech Audiometry threshold w/ speech recognition
		
	92565 Stenger test, pure tone
		
	92577 Stenger test, speech
		
	92563 Tone decay test
		
	92567 Tympanometry
		
	69433 Tympanostomy w/Tube, Local or Topical Anesthesia bilateral
		
	69610 Tympanic Membrane Repair
		
	30200 Injection Turbinate(s), Therapuetic
		
	30801 Ablate Turbinates Inferior Uni or Bilateral Any Method
		
	92579 VRA ( visual reinforcement audiometry)

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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
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