Unique Plan Description: GEM General Clinic
Plan Selection Display: GEM General Clinic
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2011-11-18 07:30:08
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2023-03-14 08:43:22
Available at all facilities: Yes

GEM General Clinic
Laboratory
	Urinalysis
		T;N, Routine, Routine, spec type = Urine
	UA (Culture if Positive)
		T;N, Routine, Routine, spec type = Urine
	CBC with Diff
		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
	Ferritin
		T;N, Routine, spec type = Blood
	TSH
		T;N, Routine, spec type = Blood
	Free T4
		T;N, Routine, spec type = Blood
	Comprehensive Metabolic Panel
		T;N, Routine, spec type = Blood
	Basic Metabolic Panel
		T;N, Routine, spec type = Blood
	Hepatic Function Panel
		T;N, Routine, spec type = Blood
	Sed Rate
		T;N, Routine, spec type = Blood
	Syphilis Total Antibodies
		T;N, Routine, spec type = Blood
	Hemoglobin A1C
		T;N, Routine, spec type = Blood
	Vitamin D 25-Hydroxy Level (preferred for deficiency)
		T;N, Routine, spec type = Blood
	Cholesterol
		T;N, Routine, spec type = Blood
	Lipid Panel
		T;N, Routine, spec type = Blood
	Vitamin B12 Level
		T;N, Routine, spec type = Blood
	Folate
		T;N, Routine, spec type = Blood
	PSA (For Screening Only)
		T;N, Routine, spec type = Blood
	PSA Diagnostic
		T;N, Routine, spec type = Blood
	INR - MH/WH/JE
		T;N, Routine, spec type = Blood
	Prothrombin Time (PT) - FH
		T;N, Routine
	Phenytoin Level
		T;N, Routine, spec type = Blood
	Phenobarbital Level
		T;N, Routine, spec type = Blood
	Rheumatoid Factor Quantitative
		T;N, Routine, spec type = Blood
Diagnostic Tests
Diagnostics
	Echo w Doppler resting
		T;N
	Venous Duplex Unilat Upper or Lower
		T;N
	Venous Duplex Bil Upper or Lower
		T;N
	Chest 2 View
		T;N, Routine
	Hip Min 2 View Lt
		T;N, Routine
	Hip Min 2 View Rt
		T;N, Routine
	Spine Lumbar AP & Lat
		T;N, Routine
	Spine Thoracic 3 View
		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
	zzDXA Scan
		T;N
CT
	CT Head w Contrast
		T;N, Routine
	CT Head w/o Contrast
		T;N, Routine
MRI
	MRI Brain w & w/o Contrast
		T;N, Routine
Ultrasound
	US Abd Limited
		T;N, Routine
	US Abd Complete
		T;N, Routine
	US Pelvis Complete Non OB
		T;N, Routine
	US Pelvis Limited
		T;N, Routine
Medications

	triamcinolone 40mg/mL (Kenalog-40)(In Office)
		40 mg, Injection, IM-Intramuscular, Once, NOW
	cyanocobalamin (Vit B12) (In Office)
		1,000 mcg, Injection, IM-Intramuscular, Once, NOW
Immunizations
	influenza vaccine, TRIvalent (*FluLaval) (In Office)
		0.5 mL, Suspension, IM-Intramuscular, Once, T;N, Encounter for immunization
	pneumococcal 20-valent conjugate vaccine (Prevnar 20) (In Office)
		0.5 mL, Suspension, IM-Intramuscular, Once, T;N, Encounter for immunization
Consults/Follow-up

	Follow-up Appointment
		Follow Up Visit, 3 months
		Follow Up Visit, 1 week
		Follow Up Visit, 2 weeks
		Follow Up Visit, 3 weeks
		Follow Up Visit, 1 month
		Follow Up Visit, 6 months
		Follow Up Visit, 1 year
		Follow Up Visit, See Special Instructions
	Procedure to Schedule
		
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
		
	99347 EVM - Home Visit, Estab Patient, 15 Min
		
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
	99024 EVM - Post Op Visit
		T;N
	99211n EVM - No Charge Professional Service
		T;N
	99213C EVM - MPC CLINIC AUDIT BY CODER
		T;N
Procedures in Office
	69210 Remove Cerumen Impaction
		
Prolonged Care
	zz99354 EVM - Prolonged care office 1 hr
		T;N
	99355 EVM - Prolonged care office ea add 30m
		T;N
	99358 EVM - Prolonged Care, Before/After Pt Seen 1 HR
		T;N
	99359 EVM - Prolonged Care, Before/After Pt Seen Ea Addtl 30 Min
		T;N

Electrophoresis
Laboratory

	Protein Electrophoresis Serum w/Reflex to Immunofixation
		
	Protein Electrophoresis Serum with Immunofixation
		
	Protein Electrophoresis Serum
		
	Kappa Lambda Free Light Chains Quant w/ Ratio
		
	Bence Jones Urine (Immunofixation).
		
	Protein Electrophoresis CSF
		
	Hgb Eval Rflx EP/RBC Solubility
		
Chemistry
		Recommended screening orders are Serum Protein Electrophoresis with Immunofixation and the Kappa Lambda Free Light Chains Quant with Ratio.(NOTE)*
		Serum Electrophoresis orderables include orders with Immunofixation, Reflexing to Immunofixation (if a suspicious band is detected), and without Immunofixation.(NOTE)*
		Urine Electrophoresis Order Bence Jones (Preferred sample is a 24 Hour Urine)(NOTE)*

*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