Unique Plan Description: MFM Clinic
Plan Selection Display: MFM Clinic
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2012-03-05 20:02:40
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2025-05-01 10:24:59
Available at all facilities: Yes

MFM Clinic
Laboratory
Amniotic Fluid Testing
	UNMC Reproductive Chromosome Rflx to FISH
		T;N, Routine, spec type = Amniotic Fld
	FISH Studies with Reflex - WH/MFM/Repro
		T;N, Routine, spec type = Amniotic Fld
	Amniotic Fluid Screen (ROM)
		T;N, Stat, spec type = Vaginal
General Labs
	AFP Maternal
		T;N, Routine, spec type = Blood
	ANA Screen
		T;N, Routine, spec type = Blood
	Heparin Anti-Xa Heparin
		T;N, Routine, spec type = Blood
	Anti-Factor Xa LMWH Lovenox
		T;N, Routine, spec type = Blood
	Beta-HCG Quantitative - Pregnancy
		T;N, Routine, spec type = Blood
	CBC with Diff
		T;N, Routine, spec type = Blood
	UNMC Reproductive Chromosome Rflx to FISH
		T;N, Routine, spec type = Blood
	Comprehensive Metabolic Panel
		T;N, Routine, spec type = Blood
	Cystic Fibrosis (CFTR) Variant Panel (PreAuth Req)-2013661
		T;N, Routine, spec type = Blood
	GYN Request (PAP)
		T;N, Routine TL PAP CERVICAL, Routine
		T;N, Routine TL PAP CV & VAG, Routine
		T;N, Routine TL PAP VAGINAL, Routine
		T;N, Routine PAP CERVICAL, Routine
		T;N, Routine PAP CERV & VAG, Routine
		T;N, Routine PAP VAGINAL, Routine
	GYN Pap with HPV High Risk Co-Test
		T;N, Routine TL PAP CERVICAL, Routine
		T;N, Routine TL PAP CV & VAG, Routine
		T;N, Routine TL PAP VAGINAL, Routine
	GYN Pap with Reflex to HPV High Risk
		T;N, Routine TL PAP CERVICAL, Routine
		T;N, Routine TL PAP CV & VAG, Routine
		T;N, Routine TL PAP VAGINAL, Routine
	HPV High Risk with 16 and 18 Genotyping
		T;N, Routine, spec type = Cervix
		T;N, Routine, spec type = Vaginal
	Hemoglobin A1C
		T;N, Routine, spec type = Blood
	Hepatic Function Panel
		T;N, Routine, spec type = Blood
	HIV-1/2 Ag/Ab Combo - MH/WH/JE
		T;N, Routine, spec type = Blood
	HIV 1/2 Screen w/ p24 Antigen - FH
		T;N, Routine, spec type = Blood
	Parvovirus B19 Ab IgG and IgM
		T;N, Routine, spec type = Blood
	Postnatal High Density SNP Array with Reflex (PreAuth Req)
		T;N, Routine, spec type = Blood
	CMV Antibodies IgG and IgM
		T;N, Routine, spec type = Blood
	QUAD Screen
		T;N, Routine, spec type = Blood
	Thyroid Panel
		T;N, Routine, spec type = Blood
	Toxoplasma IgG and IgM
		T;N, Routine, spec type = Blood
	Vaginitis Panel PCR
		T;N, Routine, spec type = Genital
	Bacterial Vaginosis Screen - MH/WH/FH
		T;N, Routine, spec type = Genital
	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
		T;N, Routine, spec type = Urine
	Group B Strep by PCR
		T;N, Routine, spec type = Vaginal/Rectal
	Yeast and Trich Wet Prep (Trich PCR if Neg) - MH/WH
		T;N, Routine, spec type = Genital
	Wet Prep - PC/FH
		T;N, Routine, spec type = Genital
	Fetal Fibronectin
		T;N, Stat, spec type = Swab
	SNP Array with Reflex
		T;N, Routine, spec type = Blood
	Pregnancy Loss UNMC Microarray (PreAuth Req)
		T;N, Routine, spec type = Tissue/Blood
Bariatric Baseline Nutritional Status
Glucose Studies
	Glucose 1h p Glucose Challenge
		T;N, Routine, spec type = Blood
	Glucose Tolerance Testing Panel (0hr, 2hr)
		T;N, Routine, spec type = Blood
	OB 3 Hour Glucose Tolerance Panel
		T;N, Routine, spec type = Blood
Coagulation
Urine Studies
	UA (Culture if Positive)
		T;N, Routine, Routine, spec type = Urine
	Protein Urine Timed Set
		
	Creatinine Urine Timed Set
		
Stool Studies
	Toxigenic Clostridioides Difficile by EIA Reflex to PCR
		T;N, Routine, spec type = Stool
	Giardia/Cryptosporidium Antigen Screen
		T;N, Routine, spec type = Stool
Medications

	betamethasone acet-betamethasone na phosphate (Celestone Soluspan) (In Office)
		12 mg, Injection, IM-Intramuscular, Once, NOW
	RHo (D) immune globulin 300 mcg (In Office)
		1,500 intl_units, Solution, IM-Intramuscular, Once, NOW
	medroxyPROGESTERone (Depo-Provera) (In Office)
		150 mg, 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
	Lantus Solostar Pen 100 units/mL subcutaneous solution
		10 units, SUBCUTANEOUS, DAILY, 1 EA, 6 Refill(s), Soft Stop
	Levemir FlexTouch 100 units/mL subcutaneous solution
		10 units, SUBCUTANEOUS, DAILY, 1 EA, 6 Refill(s)
	HumuLIN N KwikPen 100 units/mL subcutaneous suspension
		units, SUBCUTANEOUS, BID, 1 EA, 6 Refill(s)
	NovoLOG FlexPen 100 units/mL injectable solution
		units, SUBCUTANEOUS, TIDAC, 1 EA, 6 Refill(s)
	HumaLOG KwikPen 100 units/mL injectable solution
		units, SUBCUTANEOUS, TIDAC, 1 EA, 6 Refill(s)
	glyBURIDE 2.5 mg oral tablet
		1 TAB, BY MOUTH, BIDAC, # 60 TAB, 3 Refill(s)
	metFORMIN  500 mg oral tablet
		1 TAB, BY MOUTH, BIDWM, # 60 TAB, 3 Refill(s)
	HEParin 10000 units/ml injectable solution
		5,000 units, SUBCUTANEOUS, BID, 10 mL, 6 Refill(s), Soft Stop
		7,500 units, SUBCUTANEOUS, BID, 10 mL, 6 Refill(s), Soft Stop
		10,000 units, SUBCUTANEOUS, BID, 10 mL, 6 Refill(s), Soft Stop
	Lovenox  30 mg/0.3 mL subcutaneous solution
		30 mg, SUBCUTANEOUS, DAILY, 30 syringes, 6 Refill(s), Soft Stop
	Lovenox  40 mg/0.4 mL subcutaneous solution
		40 mg, SUBCUTANEOUS, DAILY, 30 syringes, 6 Refill(s), Soft Stop
	Lovenox  60 mg/0.6 mL subcutaneous solution
		60 mg, SUBCUTANEOUS, DAILY, 30 syringes, 6 Refill(s), Soft Stop
	Lovenox  80 mg/0.8 mL subcutaneous solution
		80 mg, SUBCUTANEOUS, DAILY, 30 syringes, 6 Refill(s), Soft Stop
	Lovenox 100 mg/mL injectable solution
		100 mg, SUBCUTANEOUS, DAILY, 30 syringes, 6 Refill(s), Soft Stop
	Lovenox 120 mg/0.8 mL injectable solution
		120 mg, SUBCUTANEOUS, DAILY, 30 syringes, 6 Refill(s), Soft Stop
	Lovenox 150 mg/mL injectable solution
		150 mg, SUBCUTANEOUS, DAILY, 30 syringes, 6 Refill(s), Soft Stop
Consults/Follow-up
	Follow-up Appointment
		Follow Up Visit, 2 weeks
		Follow Up Visit, Today
		Follow Up Visit, 1 month
		Follow Up Visit, 3 months
		Follow Up Visit, 6 months
		Follow Up Visit, 1 week
		Follow Up Visit, 3 weeks
		Follow Up Visit, 6 weeks
		Follow Up Visit, PRN
		Follow Up Visit, See Special Instructions
	Request for Service
		
	Surgery to Schedule
		
	Consult Cardiologist
		
	Consult General Surgery
		
	Consult Pulmonologist
		
	Consult GI
		
	Consult Endocrinologist
		
	Consult Dentist
		
	Consult Psychiatrist
		
	Consult Diabetes Educator
		
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
Procedures in Office
	76801 US Abdominal <14 Wks (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	Level 1 U/S (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76811 Level II U/S  -MFM
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76816 US OB Follow-up (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76815 US OB Limited (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76819 US Fetal Biophys w/o Stress (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76818 US Fetal Biophysical Profile (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76817 US OB Transvaginal (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76813 US Fetal 1st Tri Nuchal Meas (in office)
		Nuchal Translucency, Additional Fetus 0
		Nuchal Translucency, Additional Fetus 1
		Nuchal Translucency, Additional Fetus 2
		Nuchal Translucency, Additional Fetus 3
	76827 Doppler (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76828 Doppler F/U (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	93770 Ductus Venosus (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76825 Doppler Echo, Fetal, 2D (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76826 Doppler Echo, Fetal F/U (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76820 Doppler Umb Artery (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76821 Doppler Mid-Cerebral Artery (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	93976 Doppler Uterine Artery (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	Fetal Non-Stress Test
		
	59000 CP Amniocentesis, diagnostic MFM
		Genetic Testing, Additional Fetus 0
		Genetic Testing, Additional Fetus 1
		Genetic Testing, Additional Fetus 2
		Genetic Testing, Additional Fetus 3

MFM Bariatric Baseline Nutritional Panel
Laboratory

	Glucose Level
		T;N, Routine, spec type = Blood
	CBC with Diff
		T;N, Routine, spec type = Blood
	Iron Panel - MH/WH/JE
		T;N, Routine, spec type = Blood
	Ferritin
		T;N, Routine, spec type = Blood
	Albumin
		T;N, Routine, spec type = Blood
	Vitamin B12 Level
		T;N, Routine, spec type = Blood
	Calcium Level
		T;N, Routine, spec type = Blood
	Phosphorus
		T;N, Routine, spec type = Blood
	Vitamin D 25-Hydroxy Level (preferred for deficiency)
		T;N, Routine, spec type = Blood

Prenatal Panel
	CBC with Diff
		T;N, Routine, spec type = Blood
	Rubella Ab IgG Screen - MH/WH/JE
		T;N, Routine, spec type = Blood
	Rubella IgG Ab Quantitative - FH
		T;N, Routine, spec type = Blood
	RPR
		T;N, Routine, spec type = Blood
	Hepatitis B Surface Antigen
		T;N, Routine, spec type = Blood
	Type and Screen (No Product on hold)
		T;N, Routine, spec type = Blood
	HIV-1/2 Ag/Ab Combo - MH/WH/JE
		T;N, Routine, spec type = Blood
	HIV 1/2 Screen w/ p24 Antigen - FH
		T;N, Routine, spec type = Blood
	Hepatitis C Virus (HCV) Antibody with Rflx to PCR Confirmation
		T;N, Routine, spec type = Blood

Creatinine Clearance Set
	.Urine Time and Volume
		T;N, Routine, Routine, spec type = Urine
	.Creatinine
		
	.Cclr

Ultrascreen Ambulatory
	Early Screen NT - PC
		T;N, Routine, spec type = Blood
	Myriad NIPT
		T;N, Routine, spec type = Blood
Diagnostic Tests
	US Fetal Nuchal w Measurement
		T;N, Pregnant, Routine

OB Thrombophilia Work Up
Laboratory
	Cardiolipin Antibodies IgG and IgM
		T;N, Routine, spec type = Blood
	Homocysteine Total
		T;N, Routine, spec type = Blood
	Immunoglobulin G
		T;N, Routine, spec type = Blood
	Immunoglobulin M
		T;N, Routine, spec type = Blood
	Factor V Leiden Mutation  (PreAuth Req)
		T;N, Routine, spec type = Blood
	Lupus Anticoagulant Panel
		T;N, Routine, spec type = Blood
	MTHFR PCR  (PreAuth Req)
		T;N, Routine, spec type = Blood
	Prothrombin (F2) G20210A Pathogenic Variant (PreAuth Req)
		T;N, Routine, spec type = Blood
	Anti-Thrombin III Enzymatic (Activity)
		T;N, Routine, spec type = Blood
	Protein C Functional
		T;N, Routine, spec type = Blood
	Protein S Free Antigen
		T;N, Routine, spec type = Blood
	Protein S Functional
		T;N, Routine, spec type = Blood

PIH Panel
Urine Studies
	Creatinine Clearance
		T;N, Routine, Routine, Urine Timed, spec type = Urine
	C. Clearance Serum
		T;N, Routine, spec type = Blood
	Protein Urine Timed Set
		T;N, Routine, Routine, spec type = Urine
	Protein Creatinine Ratio Urine
		T;N, Routine, Routine, Urine Random, spec type = Urine
General Labs
	CBC with Diff
		T;N, Routine, spec type = Blood
	Comprehensive Metabolic Panel
		T;N, 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