Unique Plan Description: MFM Primary OB Management Clinic
Plan Selection Display: MFM Primary OB Management Clinic
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2012-03-20 14:46:49
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2025-05-01 10:25:58
Available at all facilities: Yes

MFM OB Initial Visit
Laboratory
	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
	Hgb Eval Rflx EP/RBC Solubility
		T;N, Routine, spec type = Blood
	TSH
		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
	QUAD Screen
		T;N, Routine, spec type = Blood
	Glucose 1h p Glucose Challenge
		T;N, Routine, spec type = Blood
	AFP Maternal
		T;N, Routine, spec type = Blood
	Cystic Fibrosis (CFTR) Variant Panel (PreAuth Req)-2013661
		T;N, Routine, spec type = Blood
	Comprehensive Metabolic Panel
		T;N, Routine, spec type = Blood
	UA (Culture if Positive)
		T;N, Routine, Routine, spec type = Urine
Medications
	ondansetron  4 mg oral tablet
		1 TAB, BY MOUTH, Q6H, PRN nausea, # 30 TAB, 0 Refill(s), Hard Stop
	ondansetron  8 mg oral tablet
		1 TAB, BY MOUTH, Q6H, PRN nausea, # 30 TAB, 0 Refill(s), Hard Stop
	folic acid 1 mg oral tablet
		1 TAB BY MOUTH DAILY, # 90 TAB, 3 Refill(s), Soft Stop
		4 TAB, BY MOUTH, DAILY, # 360 TAB, 3 Refill(s), Soft Stop
		5 TAB, BY MOUTH, DAILY, # 450 TAB, 3 Refill(s), Soft Stop
	Prenate DHA oral capsule
		1 CAP BY MOUTH DAILY, # 90 CAP, 3 Refill(s)
Immunizations
	tetanus/diphth/pertuss (Tdap/Adacel) (In Office)
		0.5 mL, Suspension-Injection, IM-Intramuscular, Once, T;N, Encounter for immunization
	influenza vaccine, TRIvalent (*FluLaval) (In Office)
		0.5 mL, Suspension, IM-Intramuscular, Once, T;N, 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, 2x per week
	Request for Service
		T;N
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
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
	76817 US OB Transvaginal (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
	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 OB Visit up to 24 Weeks
Laboratory

	CBC with Diff
		T;N, Routine, spec type = Blood
	Hematocrit
		T;N, Routine, spec type = Blood
	Hemoglobin
		T;N, Routine, spec type = Blood
	Antibody Titer
		T;N, Routine, spec type = Blood
		Collect Quad Screen between 15-21 weeks of gestation(NOTE)*
	QUAD Screen
		T;N, Routine, spec type = Blood
	AFP Maternal
		T;N, Routine, spec type = Blood
Point of Care
	Urine Dipstick POC OB
		T;N, Urine
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, 2x per week
	Request for Service
		T;N
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
Procedures in Office
	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
	76817 US OB Transvaginal (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
	76816 US OB Follow-up (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	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
	76801 US Abdominal <14 Wks (in office)

MFM OB Visit 24-28 Weeks
Laboratory

	Hematocrit
		T;N, Routine, spec type = Blood
	Hemoglobin
		T;N, Routine, spec type = Blood
	TSH
		T;N, Routine, spec type = Blood
	Free T4
		T;N, Routine, spec type = Blood
	Glucose 1h p Glucose Challenge
		T;N, Routine, spec type = Blood
	OB 3 Hour Glucose Tolerance Panel
		T;N, Routine, spec type = Blood
	Fetal Fibronectin
		T;N, Routine, spec type = Swab
	Antibody Titer
		T;N, Routine, spec type = Blood
Point of Care
	Urine Dipstick POC OB
		T;N, Urine
Medications

	RHo (D) immune globulin 300 mcg (In Office)
		1,500 intl_units, Solution, IM-Intramuscular, Once, NOW
	Prometrium 100 mg oral capsule
		1 CAP VAGINAL QHS, # 30 CAP, 1 Refill(s), Soft Stop
Consults/Follow-up
	Follow-up Appointment
		Follow Up Visit, 2 weeks
		Follow Up Visit, 2 months
		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
	Request for Service
		T;N
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
Procedures in Office
	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
	76817 US OB Transvaginal (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76819 US Fetal Biophys w/o Stress (in office)
		Fetal Complications, Additional Fetus 0
		Potential non-reassuring fetal status, Additional Fetus 0
		Maternal disorder, Additional Fetus 0
		Fetal disorder, Additional Fetus 0
	76818 US Fetal Biophysical Profile (in office)
		Fetal Complications, Additional Fetus 0
	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
	59001 Amniocentesis Therapeutic (in office)
		
	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

MFM OB Visit 29-37 Weeks
Laboratory

	CBC with Diff
		T;N, Routine, spec type = Blood
	TSH
		T;N, Routine, spec type = Blood
	Free T4
		T;N, Routine, spec type = Blood
	Antibody Titer
		T;N, Routine, spec type = Blood
	Fetal Fibronectin
		T;N, Routine, spec type = Swab
	Group B Strep by PCR
		T;N, Routine, spec type = Vaginal/Rectal
	Glucose 1h p Glucose Challenge
		T;N, Routine, spec type = Blood
	OB 3 Hour Glucose Tolerance Panel
		T;N, Routine, spec type = Blood
Point of Care
	Urine Dipstick POC OB
		T;N, Urine
Medications

	Prometrium 100 mg oral capsule
		1 CAP VAGINAL QHS, # 30 CAP, 1 Refill(s), Soft 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, 2x per week
	Request for Service
		T;N
	Surgery 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
		T;N
Procedures in Office
	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
	76817 US OB Transvaginal (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
	59000 CP Amniocentesis, diagnostic MFM
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	59001 Amniocentesis Therapeutic (in office)
		
	76816 US OB Follow-up (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	Fetal Non-Stress Test
		
	76819 US Fetal Biophys w/o Stress (in office)
		Fetal Complications, Additional Fetus 0
		Potential non-reassuring fetal status, Additional Fetus 0
		Maternal disorder, Additional Fetus 0
		Fetal disorder, Additional Fetus 0
	76818 US Fetal Biophysical Profile (in office)
		Fetal Complications, Additional Fetus 0
		Potential non-reassuring fetal status, Additional Fetus 0
		Maternal disorder, Additional Fetus 0
		Fetal disorder, Additional Fetus 0
	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

MFM OB Visit 37 Weeks-Post Dates
Laboratory

	CBC with Diff
		T;N, Routine, spec type = Blood
	Group B Strep by PCR
		T;N, Routine, spec type = Vaginal/Rectal
Point of Care
	Urine Dipstick POC OB
		T;N, Urine
Consults/Follow-up

	Follow-up Appointment
		Follow Up Visit, 1 week
		Follow Up Visit, 2x per week
	Request for Service
		T;N
	Surgery 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
		T;N
Procedures in Office
	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
	76815 US OB Limited (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	59000 CP Amniocentesis, diagnostic 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
	Fetal Non-Stress Test
		
	76819 US Fetal Biophys w/o Stress (in office)
		Fetal Complications, Additional Fetus 0
		Potential non-reassuring fetal status, Additional Fetus 0
		Maternal disorder, Additional Fetus 0
		Fetal disorder, Additional Fetus 0
	76818 US Fetal Biophysical Profile (in office)
		Fetal Complications, Additional Fetus 0
		Potential non-reassuring fetal status, Additional Fetus 0
		Maternal disorder, Additional Fetus 0
		Fetal disorder, Additional Fetus 0
	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

Prenatal Panel
Laboratory

	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

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

Ultrascreen Ambulatory
Laboratory
	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

PIH Panel
Laboratory
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

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

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