Unique Plan Description: ID General Clinic
Plan Selection Display: ID General Clinic
PlanType: Medical                                 
Version: 2          
Begin Effective Date: 2020-11-01 07:39:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2022-09-06 11:19:36
Available at all facilities: Yes

ID General Clinic
Laboratory
	Acute Hepatitis Panel with Rflx to Hepatitis C Confirm
		T;N, Routine
	ANA Screen
		T;N, Routine, spec type = Blood
	ANA Reflexive Panel
		T;N, Routine, spec type = Blood
	ANCA Vasculitis (ANCA/MPO/PR3) (3003745)
		T;N, Routine, spec type = Blood
	Basic Metabolic Panel
		T;N, Routine, spec type = Blood
	CBC with Diff
		T;N, Routine, Once, spec type = Blood
	CD4 Percent
		T;N, Routine, spec type = Blood
	CMV Antibody IgM
		T;N, Routine, spec type = Blood
	zzCytomegalovirus (CMV) by Quantitative PCR
		T;N, Routine, spec type = Blood
	Comprehensive Metabolic Panel
		T;N, Routine, Once, spec type = Blood
	Culture AFB
		T;N, Routine
	Culture Fungus
		T;N, Routine
	Sputum Culture
		T;N, Routine, spec type = Sputum
	Culture Routine
		T;N, Routine, spec type = Wound
	Culture Urine
		T;N, Routine, Urine, spec type = Urine
	Epstein Barr Virus Antibody Panel
		T;N, Routine, spec type = Blood
	Ehrlichia chaffeensis Antibodies IgG and IgM
		T;N, Routine, spec type = Blood
	ESR
		T;N, Routine, spec type = Blood
	Free T4
		T;N, Routine, spec type = Blood
	GC/Chlamydia PCR-MH/WH/PC
		T;N, Routine, spec type = Cervix
		T;N, Routine, spec type = Vaginal
	Urine GC/Chlamydia PCR - MH/WH/PC
		T;N, Routine, spec type = Urine
	GC/Chlamydia(Rapid) DNA - FH/JE
		T;N, Routine, spec type = Cervix
		T;N, Routine, spec type = Urine
		T;N, Routine, spec type = Vaginal
	Hepatitis C Genotyping
		T;N, Routine, spec type = Blood
	Hepatitis C Virus RNA Quant PCR
		T;N, Routine, spec type = Blood
	Hemoglobin A1C
		T;N, Routine, spec type = Blood
	HIV-1/2 Ag/Ab Combo - MH/WH/JE
		T;N, Routine, spec type = Blood
	HIV 1 by Quantitative NAAT
		T;N, Routine, spec type = Blood
	Histoplasma Antigen Quantitative
		T;N, Routine, spec type = Urine
		T;N, Routine, spec type = Blood
	hsCRP
		T;N, Routine, Once, spec type = Blood
	Immunoglobulins (GAM)
		T;N, Routine, spec type = Blood
	Infectious Mononucleosis Screen
		T;N, Routine, spec type = Blood
	Influenza A and B Screen PCR
		T;N, Routine, spec type = Nasopharynx
	Lipid Panel
		T;N, Routine, spec type = Blood
	Rapid RSV Ag - PC
		T;N, Routine, spec type = Nasopharynx
	Rheumatoid Factor Quantitative
		T;N, Routine, spec type = Blood
	Syphilis Total Antibodies
		T;N, Routine, spec type = Blood
	T. pallidum Ab by TP-PA
		T;N, Routine, spec type = Blood
	Stool Pathogen Panel (PCR)
		T;N, Routine, spec type = Stool
		Includes targets for: Campylobacter, Salmonella, Shigella, Vibrio, Yersinia enterocolitica, Shiga Toxins 1 and 2, Norovirus and Rotavirus.(NOTE)*
	Strep Group A PCR
		T;N, Routine, spec type = Throat
	Respiratory Syncytial Virus (RSV) PCR
		T;N, Routine, spec type = Nasopharynx
	TSH
		T;N, Routine, spec type = Blood
	UA (Culture if Positive)
		T;N, Routine, Routine, spec type = Urine
	Uric Acid
		T;N, Routine, spec type = Blood
	West Nile Virus Ab Panel
		T;N, Routine, spec type = Blood
	West Nile Virus Ab Panel CSF
		T;N, Routine, spec type = Cerebrospinal Fluid
	Histoplasma Antibody (CF/ID)
		T;N, Routine, spec type = Blood
Diagnostic Tests
Diagnostics
	Venous Duplex Unilat Upper or Lower
		T;N
	Venous Duplex Bil Upper or Lower
		T;N
	Echo w Doppler resting
		T;N
			Comment: Dr Salfity to read
	ECG
		T;N
	Chest 2 View
		T;N, Routine
CT
	CT Chest w Contrast
		T;N, Routine
	CT Chest w/o Contrast
		T;N, Routine
	CT Abd Pelvis w Contrast
		T;N, Routine
Ultrasound
	US Abd Complete
		T;N, Routine
	US Abd Limited
		T;N, Routine
MRI
	MRI Foot Lt w Contrast
		T;N, Routine
	MRI Foot Lt w/o Contrast
		T;N, Routine
	MRI Foot Rt w Contrast
		T;N, Routine
	MRI Foot Rt w/o Contrast
		T;N, Routine
Medications

	tuberculin purified protein derivative (PPD) (In Office)
		0.1 mL, Injection, IntraDermal, Once, NOW
	penicillin G benzathine (Bicillin LA) (In Office)
		2,400,000 units, Suspension-Injection, IM-Intramuscular, Once, NOW
	cefTRIAXone 250mg IM (Rocephin) (In Office)
		mg, Injection, IM-Intramuscular, Once, NOW
			Comment: Inject deep into Muscle
		1,000 mg, Injection, IM-Intramuscular, Once, NOW
			Comment: Inject deep into Muscle
		2,000 mg, Injection, IM-Intramuscular, Once, NOW
			Comment: Inject deep into Muscle
	ceftriaxone IVPB (Rocephin) duplex bag (In Office)
		2,000 mg, Injection, IVPB, Once, T;N
		1,000 mg, Injection, IVPB, Once, T;N
	ertapenem (Invanz)/NS (In Office)
		1,000 mg, INT, IVPB, Once, T;N
	vancomycin/NS (In Office)
		1,000 mg, INT, IVPB, Once, T;N
		1,500 mg, INT, IVPB, Once, T;N
	DAPTOmycin (Cubicin) (In Office)
		mg, INT, IVPB, Once, T;N
Immunizations
	hepatitis B adult vaccine (Recombivax HB) (In Office)
		1 mL, Solution-Injection, IM-Intramuscular, Once, T;N, Encounter for immunization
	hepatitis B pediatric vaccine (Recombivax Pediatric) (In Office)
		0.5 mL, Solution-Injection, IM-Intramuscular, Once, T;N, Encounter for immunization
	hepatitis A adult vaccine (Vaqta) (In Office)
		1 mL, Injection, IM-Intramuscular, Once, NOW, Encounter for immunization
	hepatitis A pediatric vaccine (Vaqta Pediatric) (In Office)
		0.5 mL, Injection, IM-Intramuscular, Once, NOW, Encounter for immunization
	human papillomavirus vaccine (Gardasil 9) (In Office)
		0.5 mL, Solution, IM-Intramuscular, Once, T;N, Encounter for immunization
	influenza virus vaccine (*QUADrivalent) (In Office)
		0.5 mL, Suspension, IM-Intramuscular, Once, T;N, Encounter for immunization
	Influenza virus vaccine (Flublok) (In Office)
		0.5 mL, Solution, IM-Intramuscular, Once, T;N, Encounter for immunization
	Japanese encephalitis (Ixiaro) (In Office)
		0.5 mL, Suspension, IM-Intramuscular, Once, T;N, Encounter for immunization
	meningococcal conjugate vaccine (MenQuadfi) (In Office)
		0.5 mL, Solution, IM-Intramuscular, Once, T;N, Encounter for immunization
	measles/mumps/rubella virus vaccine (MMR) (In Office)
		0.5 mL, Injection, SUBCUTANEOUS, Once, NOW, Encounter for immunization
	pneumococcal 20-valent conjugate vaccine (Prevnar 20) (In Office)
		0.5 mL, Suspension, IM-Intramuscular, Once, T;N, Encounter for immunization
	poliovirus vaccine, inactivated (Ipol) (In Office)
		0.5 mL, Solution-Injection, IM-Intramuscular, Once, NOW, Encounter for immunization
		0.5 mL, Solution-Injection, SUBCUTANEOUS, Once, NOW, Encounter for immunization
	rabies vaccine, purified chick embryo cell (RabAvert) (In Office)
		2.5 intl_units, Injection, IM-Intramuscular, Once, NOW, Encounter for immunization
			Comment: Inject deep into Muscle
	tetanus-diphth toxoids adult/adol (Td-Tenivac)(In Office)
		0.5 mL, Injection, IM-Intramuscular, Once, NOW
	tetanus/diphth/pertuss (Tdap/Adacel) (In Office)
		0.5 mL, Suspension-Injection, IM-Intramuscular, Once, T;N, Encounter for immunization
	typhoid vaccine, inactivated (Typhim) (In Office)
		0.5 mL, Solution, IM-Intramuscular, Once, T;N, Encounter for immunization
	varicella virus vaccine (Varivax) (In Office)
		0.5 mL, Injection, SUBCUTANEOUS, Once, NOW, Encounter for immunization
	yellow fever vaccine (YF-Vax) (In Office)
		0.5 mL, Injection, SUBCUTANEOUS, Once, NOW, Encounter for immunization
	zoster vaccine, recomb, adjuv (Shingrix)(In Office)
		0.5 mL, Suspension, IM-Intramuscular, Once, NOW, Encounter for immunization
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
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
Prolonged Care
	99354 EVM - Prolonged Care, Outpatient, 1 Hr
		T;N
	99355 EVM - Prolonged Care, Outpatient, Ea Addl 30 Min
		T;N
Procedures in Office
	10140 I&D hematoma seroma
		
	11042 Debride subcu tissue </= 20 sq cm

Blood Culture Set
Laboratory

	.Blood Culture.
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
		Timed, spec type = Blood
		T+1;0400, Routine, spec type = Blood
	.Blood Culture
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
		Timed, spec type = Blood
		T+1;0400, Routine, spec type = Blood

*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