Unique Plan Description: OB Prenatal Care Clinic
Plan Selection Display: OB Prenatal Care Clinic
PlanType: Medical                                 
Version: 2          
Begin Effective Date: 2015-08-31 08:26:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2025-05-01 10:30:12
Available at all facilities: Yes

Initial Visit Clinic
Laboratory
	UA
		T;N, Routine, Routine, spec type = Urine
	URINE Culture
		T;N, Routine, Urine Midstream, spec type = Urine
	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
	Trichomonas PCR
		T;N, Routine, spec type = Urine
		T;N, Routine, spec type = Genital
	Varicella Zoster Virus IgG
		T;N, Routine, spec type = Blood
General Labs
	Hemogram (CBC no Diff)
		T;N, Routine, spec type = Blood
	TSH
		T;N, Routine, spec type = Blood
	Free T4
		T;N, Routine, spec type = Blood
	Hemoglobin A1C
		T;N, Routine, spec type = Blood
	Comprehensive Metabolic Panel
		T;N, Routine, spec type = Blood
	Hepatic Function Panel
		T;N, Routine, spec type = Blood
	Beta-HCG Quantitative - Pregnancy
		T;N, Routine, spec type = Blood
	Progesterone Level
		T;N, Routine, spec type = Blood
	Cystic Fibrosis (CFTR) Variant Panel (PreAuth Req)-2013661
		T;N, Routine, spec type = Blood
	Early Screen NT - PC
		T;N, Routine, spec type = Blood
	Myriad NIPT
		T;N, Routine, spec type = Blood
	Myriad Carrier Screen
		T;N, Routine, spec type = Blood
	AFP Maternal
		T;N, Routine, spec type = Blood
	CMV Antibodies IgG and IgM
		T;N, Routine, spec type = Blood
	Toxoplasma IgG and IgM
		T;N, Routine, spec type = Blood
	Hgb Eval Rflx EP/RBC Solubility
		T;N, Routine, spec type = Blood
		Collect Quad Screen between 15-21 weeks of gestation(NOTE)*
	QUAD Screen
		T;N, Routine, spec type = Blood
Urine Studies
	UA (Culture if Positive)
		T;N, Routine, Routine, spec type = Urine
	Protein Urine Timed Set
		T;N, Routine, Routine, spec type = Urine
	Protein Creatinine Ratio Urine
		T;N, Routine, Urine Random, spec type = Urine
Cervical/Vaginal Specimens
	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 CV & 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
	Vaginitis Panel PCR
		T;N, Routine, spec type = Genital
	Wet Prep - PC/FH
		T;N, Routine, spec type = Genital
	Q0111 Wet Mt Physician Perform
		
	Q0112 KOH Prep Physician Perform
		
	Group B Strep by PCR
		T;N, Routine, spec type = Vaginal/Rectal
Diagnostic Tests

	US Amniocentesis
		T;N, Pregnant, Routine
	US OB Complete 1st Trimester
		T;N, Routine
	US OB Transvaginal 1st Trimester
		T;N, Routine
	US OB 2nd 3rd Trimester
		T;N, Pregnant, Routine
	US OB Limited
		T;N, Pregnant, Routine
	US OB Transvaginal
		T;N, Pregnant, Routine
	US Fetal Nuchal w Measurement
		T;N, Pregnant, Routine
Medications
Immunizations
	tetanus/diphth/pertuss (Tdap/Adacel) (In Office)
		0.5 mL, Suspension-Injection, 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
	influenza vaccine, TRIvalent (*FluLaval) (In Office)
		0.5 mL, Suspension, IM-Intramuscular, Once, T;N, Encounter for immunization
Consults/Follow-up

	Return to Clinic Women's
		Future Order In Approximately 1 month(s) Grace Period (+/-) 7 Day(s), 7, Day(s), 1, month(s), In Approximately
		Future Order In Approximately 1 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 1, week(s), In Approximately
		Future Order In Approximately 2 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 2, week(s), In Approximately
		Future Order In Approximately 3 week(s) Grace Period (+/-) 3 Day(s), 3, Day(s), 3, week(s), In Approximately
		Future Order In Approximately 6 week(s) Grace Period (+/-) 7 Day(s), 7, Day(s), 6, week(s), In Approximately
	Follow-up Appointment
		Follow Up Visit, 1 month
		Follow Up Visit, 1 week
		Follow Up Visit, 2 weeks
		Follow Up Visit, 3 weeks
		Follow Up Visit, 5 weeks
		Follow Up Visit, See Special Instructions
	Consult Perinatologist
		
Charges/Supplies
Procedures in Office
	76801 US Abdominal <14 Wks (in office)
		
	76815 US OB Limited (in office)
		
	76816 US OB Follow-up (in office)
		
	76817 US OB Transvaginal (in office)
		
	76805 Level 1 U/S (in office)
		
	76811 Level 2 U/S (in office)
		
Initial Pt Visit
	594008 TOTAL OBSTETRICAL CARE
		
	595108 TOTAL C-SECTION CARE
		
	596108 VBAC CARE

Visit 10-14 week Clinic
Laboratory
Point of Care
	Urine Dipstick POC OB
		T;N, Urine
General Labs
	Hemogram (CBC no Diff)
		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
	Hepatic Function Panel
		T;N, Routine, spec type = Blood
	Glucose 1h p Glucose Challenge
		T;N, Routine, spec type = Blood
Urine Studies
	Urinalysis
		T;N, Routine, Routine, spec type = Urine
	Culture Urine
		T;N, Routine, Urine Midstream, spec type = Urine
	UA (Culture Pos)
		T;N, Routine, Routine, spec type = Urine
	Protein Creatinine Ratio Urine
		T;N, Routine, Urine Random, spec type = Urine
Cervical/Vaginal Specimens
	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
	Vaginitis Panel PCR
		T;N, Routine, spec type = Genital
	Wet Prep - PC/FH
		T;N, Routine, spec type = Genital
	Q0111 Wet Mt Physician Perform
		
	Q0112 KOH Prep Physician Perform
		
Diagnostic Tests

	US Amniocentesis
		T;N, Routine
	US OB Transvaginal 1st Trimester
		T;N, Routine
	US OB 2nd 3rd Trimester
		T;N, Pregnant, Routine
	US OB Limited
		T;N, Pregnant, Routine
	US OB Transvaginal
		T;N, Routine
	US OB Followup
		T;N, Pregnant, Routine
Medications
	RHo (D) immune globulin 300 mcg (In Office)
		1,500 intl_units, Solution, IM-Intramuscular, Once, NOW
			Comment: 1500intl units=300mcg=1vial/syringe
Immunizations
	tetanus/diphth/pertuss (Tdap/Adacel) (In Office)
		0.5 mL, Suspension-Injection, 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
	influenza vaccine, TRIvalent (*FluLaval) (In Office)
		0.5 mL, Suspension, IM-Intramuscular, Once, T;N, Encounter for immunization
Consults/Follow-up

	Return to Clinic Women's
		Future Order In Approximately 1 month(s) Grace Period (+/-) 7 Day(s), 7, Day(s), 1, month(s), In Approximately
		Future Order In Approximately 1 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 1, week(s), In Approximately
		Future Order In Approximately 2 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 2, week(s), In Approximately
		Future Order In Approximately 3 week(s) Grace Period (+/-) 3 Day(s), 3, Day(s), 3, week(s), In Approximately
		Future Order In Approximately 6 week(s) Grace Period (+/-) 7 Day(s), 7, Day(s), 6, week(s), In Approximately
	Follow-up Appointment
		Follow Up Visit, 1 month
		Follow Up Visit, 1 week
		Follow Up Visit, 2 weeks
		Follow Up Visit, 3 weeks
		Follow Up Visit, 5 weeks
		Follow Up Visit, See Special Instructions
	Consult Perinatologist
		
	Patient Education
		T;N, EMMI Education
Charges/Supplies
Procedures in Office
	76801 US Abdominal <14 Wks (in office)
		
	76815 US OB Limited (in office)
		
	76816 US OB Follow-up (in office)
		
	76817 US OB Transvaginal (in office)
		
	76805 Level 1 U/S (in office)
		
	76811 Level 2 U/S (in office)
		
Est. Pt Visit
	0502F EVM - Prenatal Care Visit - Subsequent

Visit 15-19 week Clinic
Laboratory
Point of Care
	Urine Dipstick POC OB
		T;N, Urine
General Labs
	Hemogram (CBC no Diff)
		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
	Hepatic Function Panel
		T;N, Routine, spec type = Blood
	Glucose 1h p Glucose Challenge
		T;N, Routine, spec type = Blood
	Antibody Screen
		T;N, Routine, spec type = Blood
	Antibody Titer
		T;N, Routine, spec type = Blood
	AFP Maternal
		T;N, Routine, spec type = Blood
		Collect Quad Screen between 15-21 weeks of gestation(NOTE)*
	QUAD Screen
		T;N, Routine, spec type = Blood
Urine Studies
	Urinalysis
		T;N, Routine, Routine, spec type = Urine
	Culture Urine
		T;N, Routine, Urine Midstream, spec type = Urine
	UA (Culture Pos)
		T;N, Routine, Routine, spec type = Urine
	Protein Creatinine Ratio Urine
		T;N, Routine, Urine Random, spec type = Urine
Cervical/Vaginal Specimens
	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
	Vaginitis Panel PCR
		T;N, Routine, spec type = Genital
	Wet Prep - PC/FH
		T;N, Routine, spec type = Genital
	Q0111 Wet Mt Physician Perform
		
	Q0112 KOH Prep Physician Perform
		
Diagnostic Tests

	US Amniocentesis
		T;N, Routine
	US OB 2nd 3rd Trimester
		T;N, Pregnant, Routine
	US OB Limited
		T;N, Pregnant, Routine
	US OB Transvaginal
		T;N, Routine
	US OB Followup
		T;N, Pregnant, Routine
Medications
Immunizations
	tetanus/diphth/pertuss (Tdap/Adacel) (In Office)
		0.5 mL, Suspension-Injection, 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
	influenza vaccine, TRIvalent (*FluLaval) (In Office)
		0.5 mL, Suspension, IM-Intramuscular, Once, T;N, Encounter for immunization
Consults/Follow-up

	Return to Clinic Women's
		Future Order In Approximately 1 month(s) Grace Period (+/-) 7 Day(s), 7, Day(s), 1, month(s), In Approximately
		Future Order In Approximately 1 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 1, week(s), In Approximately
		Future Order In Approximately 2 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 2, week(s), In Approximately
		Future Order In Approximately 3 week(s) Grace Period (+/-) 3 Day(s), 3, Day(s), 3, week(s), In Approximately
		Future Order In Approximately 6 week(s) Grace Period (+/-) 7 Day(s), 7, Day(s), 6, week(s), In Approximately
	Follow-up Appointment
		Follow Up Visit, 1 month
		Follow Up Visit, 1 week
		Follow Up Visit, 2 weeks
		Follow Up Visit, 3 weeks
		Follow Up Visit, 5 weeks
		Follow Up Visit, See Special Instructions
	Consult Perinatologist
		
	Patient Education
		T;N, EMMI Education
Charges/Supplies
Procedures in Office
	Q0114 FERN TEST
		
	76815 US OB Limited (in office)
		
	76816 US OB Follow-up (in office)
		
	76817 US OB Transvaginal (in office)
		
	76805 Level 1 U/S (in office)
		
	76811 Level 2 U/S (in office)
		
Est. Pt Visit
	0502F EVM - Prenatal Care Visit - Subsequent

Visit 20 - 23 week Clinic
Laboratory
Point of Care
	Urine Dipstick POC OB
		T;N, Urine
General Labs
	Hemogram (CBC no Diff)
		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
	Hepatic Function Panel
		T;N, Routine, spec type = Blood
	Glucose 1h p Glucose Challenge
		T;N, Routine, spec type = Blood
	Antibody Screen
		T;N, Routine, spec type = Blood
	Antibody Titer
		T;N, Routine, spec type = Blood
	AFP Maternal
		T;N, Routine, spec type = Blood
		Collect Quad Screen between 15-21 weeks of gestation(NOTE)*
	QUAD Screen
		T;N, Routine, spec type = Blood
Urine Studies
	Urinalysis
		T;N, Routine, Routine, spec type = Urine
	Culture Urine
		T;N, Routine, Urine Midstream, spec type = Urine
	UA (Culture Pos)
		T;N, Routine, Routine, spec type = Urine
	Protein Creatinine Ratio Urine
		T;N, Routine, Urine Random, spec type = Urine
Cervical/Vaginal Specimens
	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
	Vaginitis Panel PCR
		T;N, Routine, spec type = Genital
	Wet Prep - PC/FH
		T;N, Routine, spec type = Genital
	Q0111 Wet Mt Physician Perform
		
	Q0112 KOH Prep Physician Perform
		
Diagnostic Tests

	US Amniocentesis
		T;N, Routine
	US OB 2nd 3rd Trimester
		T;N, Pregnant, Routine
	US OB Limited
		T;N, Pregnant, Routine
	US OB Transvaginal
		T;N, Routine
		T;N, Routine, Check Cervix Length
	US OB Followup
		T;N, Pregnant, Routine
Medications
	RHo (D) immune globulin 300 mcg (In Office)
		1,500 intl_units, Solution, IM-Intramuscular, Once, NOW
			Comment: 1500intl units=300mcg=1vial/syringe
Immunizations
	tetanus/diphth/pertuss (Tdap/Adacel) (In Office)
		0.5 mL, Suspension-Injection, 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
	influenza vaccine, TRIvalent (*FluLaval) (In Office)
		0.5 mL, Suspension, IM-Intramuscular, Once, T;N, Encounter for immunization
Consults/Follow-up

	Return to Clinic Women's
		Future Order In Approximately 1 month(s) Grace Period (+/-) 7 Day(s), 7, Day(s), 1, month(s), In Approximately
		Future Order In Approximately 1 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 1, week(s), In Approximately
		Future Order In Approximately 2 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 2, week(s), In Approximately
		Future Order In Approximately 3 week(s) Grace Period (+/-) 3 Day(s), 3, Day(s), 3, week(s), In Approximately
	Follow-up Appointment
		Follow Up Visit, 1 month
		Follow Up Visit, 1 week
		Follow Up Visit, 2 weeks
		Follow Up Visit, 3 weeks
		Follow Up Visit, See Special Instructions
	Consult Perinatologist
		
	Patient Education
		T;N, EMMI Education
Charges/Supplies
Procedures in Office
	Q0114 FERN TEST
		
	76815 US OB Limited (in office)
		
	76816 US OB Follow-up (in office)
		
	76817 US OB Transvaginal (in office)
		
	76805 Level 1 U/S (in office)
		
	76811 Level 2 U/S (in office)
		
Est. Pt Visit
	0502F EVM - Prenatal Care Visit - Subsequent

Visit 26 - 28 week Clinic
Laboratory
General Labs
	Hemogram (CBC no Diff)
		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
	Hepatic Function Panel
		T;N, Routine, spec type = Blood
	Glucose 1h p Glucose Challenge
		T;N, Routine, spec type = Blood
	Syphilis Total Antibodies
		T;N, Routine, spec type = Blood
	Antibody Screen
		T;N, Routine, spec type = Blood
	Antibody Titer
		T;N, Routine, spec type = Blood
Urine Studies
	Urinalysis
		T;N, Routine, Routine, spec type = Urine
	Culture Urine
		T;N, Routine, Urine Midstream, spec type = Urine
	UA (Culture Pos)
		T;N, Routine, Routine, spec type = Urine
	Protein Urine Timed Set
		T;N, Routine, Routine, spec type = Urine
	Protein Creatinine Ratio Urine
		T;N, Routine, Urine Random, spec type = Urine
Cervical/Vaginal Specimens
	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
	Vaginitis Panel PCR
		T;N, Routine, spec type = Genital
	Wet Prep - PC/FH
		T;N, Routine, spec type = Genital
	Q0111 Wet Mt Physician Perform
		
	Q0112 KOH Prep Physician Perform
		
	Fetal Fibronectin
		T;N, Routine, spec type = Swab
Point of Care
	Urine Dipstick POC OB
		T;N, Urine
Diagnostic Tests

	US OB Limited
		T;N, Pregnant, Routine
	US OB Transvaginal
		T;N, Routine
		T;N, Routine, Check Cervix Length
	US OB Followup
		T;N, Pregnant, Routine
	US Fetal Biophysical w/o Stress
		T;N, Routine
	US Fetal Biophysical w Stress
		T;N, Routine
Medications
	RHo (D) immune globulin 300 mcg (In Office)
		1,500 intl_units, Solution, IM-Intramuscular, Once, NOW
			Comment: 1500intl units=300mcg=1vial/syringe
Immunizations
	tetanus/diphth/pertuss (Tdap/Adacel) (In Office)
		0.5 mL, Suspension-Injection, 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
	influenza vaccine, TRIvalent (*FluLaval) (In Office)
		0.5 mL, Suspension, IM-Intramuscular, Once, T;N, Encounter for immunization
Consults/Follow-up

	Return to Clinic Women's
		Future Order In Approximately 2 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 2, week(s), In Approximately
		Future Order In Approximately 1 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 1, week(s), In Approximately
		Future Order In Approximately 3 week(s) Grace Period (+/-) 3 Day(s), 3, Day(s), 3, week(s), In Approximately
		Future Order In Approximately 1 month(s) Grace Period (+/-) 7 Day(s), 7, Day(s), 1, month(s), In Approximately
	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, See Special Instructions
	Consult Perinatologist
		
	Patient Education
		T;N, EMMI Education
Charges/Supplies
Procedures in Office
	Fetal Non-Stress Test
		
	Q0114 FERN TEST
		
	76815 US OB Limited (in office)
		
	76816 US OB Follow-up (in office)
		
	76818 US Fetal Biophysical Profile (in office)
		
	76819 US Fetal Biophys w/o Stress (in office)
		
	76805 Level 1 U/S (in office)
		
	76811 Level 2 U/S (in office)
		
Est. Pt Visit
	0502F EVM - Prenatal Care Visit - Subsequent

Visit 29 - 30 week Clinic
Laboratory
Point of Care
	Urine Dipstick POC OB
		T;N, Urine
General Labs
	Hemogram (CBC no Diff)
		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
	Hepatic Function Panel
		T;N, Routine, spec type = Blood
	Glucose 1h p Glucose Challenge
		T;N, Routine, spec type = Blood
	Antibody Screen
		T;N, Routine, spec type = Blood
	Antibody Titer
		T;N, Routine, spec type = Blood
Urine Studies
	Urinalysis
		T;N, Routine, Routine, spec type = Urine
	Culture Urine
		T;N, Routine, Urine Midstream, spec type = Urine
	UA (Culture Pos)
		T;N, Routine, Routine, spec type = Urine
	Protein Urine Timed Set
		T;N, Routine, Routine, spec type = Urine
	Protein Creatinine Ratio Urine
		T;N, Routine, Urine Random, spec type = Urine
Cervical/Vaginal Specimens
	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
	Group B Strep by PCR
		T;N, Routine, spec type = Vaginal/Rectal
	Vaginitis Panel PCR
		T;N, Routine, spec type = Genital
	Wet Prep - PC/FH
		T;N, Routine, spec type = Genital
	Q0111 Wet Mt Physician Perform
		
	Q0112 KOH Prep Physician Perform
		
	Fetal Fibronectin
		T;N, Routine, spec type = Swab
Diagnostic Tests

	US OB Limited
		T;N, Pregnant, Routine
	US OB Transvaginal
		T;N, Routine
		T;N, Routine, Check Cervix Length
	US OB Followup
		T;N, Pregnant, Routine
	US Fetal Biophysical w/o Stress
		T;N, Routine
	US Fetal Biophysical w Stress
		T;N, Routine
Medications
	RHo (D) immune globulin 300 mcg (In Office)
		1,500 intl_units, Solution, IM-Intramuscular, Once, NOW
			Comment: 1500intl units=300mcg=1vial/syringe
Immunizations
	tetanus/diphth/pertuss (Tdap/Adacel) (In Office)
		0.5 mL, Suspension-Injection, 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
	influenza vaccine, TRIvalent (*FluLaval) (In Office)
		0.5 mL, Suspension, IM-Intramuscular, Once, T;N, Encounter for immunization
Consults/Follow-up

	Return to Clinic Women's
		Future Order In Approximately 2 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 2, week(s), In Approximately
		Future Order In Approximately 1 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 1, week(s), In Approximately
		Future Order In Approximately 3 week(s) Grace Period (+/-) 3 Day(s), 3, Day(s), 3, week(s), In Approximately
		Future Order In Approximately 1 month(s) Grace Period (+/-) 7 Day(s), 7, Day(s), 1, month(s), In Approximately
	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, See Special Instructions
	Consult Perinatologist
		
	Patient Education
		T;N, EMMI Education
Charges/Supplies
Procedures in Office
	Fetal Non-Stress Test
		
	Q0114 FERN TEST
		
	76815 US OB Limited (in office)
		
	76816 US OB Follow-up (in office)
		
	76818 US Fetal Biophysical Profile (in office)
		
	76819 US Fetal Biophys w/o Stress (in office)
		
	76805 Level 1 U/S (in office)
		
	76811 Level 2 U/S (in office)
		
Est. Pt Visit
	0502F EVM - Prenatal Care Visit - Subsequent

Visit 31 - 32 week Clinic
Laboratory
Point of Care
	Urine Dipstick POC OB
		T;N, Urine
General Labs
	Hemogram (CBC no Diff)
		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
	Hepatic Function Panel
		T;N, Routine, spec type = Blood
	Antibody Screen
		T;N, Routine, spec type = Blood
	Antibody Titer
		T;N, Routine, spec type = Blood
Urine Studies
	Urinalysis
		T;N, Routine, Routine, spec type = Urine
	Culture Urine
		T;N, Routine, Urine Midstream, spec type = Urine
	UA (Culture Pos)
		T;N, Routine, Routine, spec type = Urine
	Protein Urine Timed Set
		T;N, Routine, Routine, spec type = Urine
	Protein Creatinine Ratio Urine
		T;N, Routine, Urine Random, spec type = Urine
Cervical/Vaginal Specimens
	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
	Group B Strep by PCR
		T;N, Routine, spec type = Vaginal/Rectal
	Vaginitis Panel PCR
		T;N, Routine, spec type = Genital
	Wet Prep - PC/FH
		T;N, Routine, spec type = Genital
	Q0111 Wet Mt Physician Perform
		
	Q0112 KOH Prep Physician Perform
		
	Fetal Fibronectin
		T;N, Routine, spec type = Swab
Diagnostic Tests

	US OB Limited
		T;N, Pregnant, Routine
	US OB Transvaginal
		T;N, Routine
		T;N, Routine, Check Cervix Length
	US OB Followup
		T;N, Pregnant, Routine
	US Fetal Biophysical w/o Stress
		T;N, Routine
	US Fetal Biophysical w Stress
		T;N, Routine
Medications
Immunizations
	tetanus/diphth/pertuss (Tdap/Adacel) (In Office)
		0.5 mL, Suspension-Injection, 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
	influenza vaccine, TRIvalent (*FluLaval) (In Office)
		0.5 mL, Suspension, IM-Intramuscular, Once, T;N, Encounter for immunization
	RSV vaccine, preF A-B, recombinant (Abrysvo) (In Office)
		0.5 mL, Solution-Injection, IM-Intramuscular, Once, T;N, Encounter for immunization
Consults/Follow-up

	Return to Clinic Women's
		Future Order In Approximately 2 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 2, week(s), In Approximately
		Future Order In Approximately 1 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 1, week(s), In Approximately
		Future Order In Approximately 3 week(s) Grace Period (+/-) 3 Day(s), 3, Day(s), 3, week(s), In Approximately
		Future Order In Approximately 1 month(s) Grace Period (+/-) 7 Day(s), 7, Day(s), 1, month(s), In Approximately
	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, See Special Instructions
	Consult Perinatologist
		
	Patient Education
		T;N, EMMI Education
Charges/Supplies
Procedures in Office
	Fetal Non-Stress Test
		
	Q0114 FERN TEST
		
	76815 US OB Limited (in office)
		
	76816 US OB Follow-up (in office)
		
	76818 US Fetal Biophysical Profile (in office)
		
	76819 US Fetal Biophys w/o Stress (in office)
		
	76805 Level 1 U/S (in office)
		
	76811 Level 2 U/S (in office)
		
Est. Pt Visit
	0502F EVM - Prenatal Care Visit - Subsequent

Visit 33 - 34 week Clinic
Laboratory
Point of Care
	Urine Dipstick POC OB
		T;N, Urine
General Labs
	Hemogram (CBC no Diff)
		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
	Hepatic Function Panel
		T;N, Routine, spec type = Blood
	Antibody Screen
		T;N, Routine, spec type = Blood
	Antibody Titer
		T;N, Routine, spec type = Blood
Urine Studies
	Urinalysis
		T;N, Routine, Routine, spec type = Urine
	Culture Urine
		T;N, Routine, Urine Midstream, spec type = Urine
	UA (Culture Pos)
		T;N, Routine, Routine, spec type = Urine
	Protein Urine Timed Set
		T;N, Routine, Routine, spec type = Urine
	Protein Creatinine Ratio Urine
		T;N, Routine, Urine Random, spec type = Urine
Cervical/Vaginal Specimens
	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
	Group B Strep by PCR
		T;N, Routine, spec type = Vaginal/Rectal
	Vaginitis Panel PCR
		T;N, Routine, spec type = Genital
	Wet Prep - PC/FH
		T;N, Routine, spec type = Genital
	Q0111 Wet Mt Physician Perform
		
	Q0112 KOH Prep Physician Perform
		
	Fetal Fibronectin
		T;N, Routine, spec type = Swab
Diagnostic Tests

	US OB Limited
		T;N, Pregnant, Routine
	US OB Transvaginal
		T;N, Routine
		T;N, Routine, Check Cervix Length
	US OB Followup
		T;N, Pregnant, Routine
	US Fetal Biophysical w/o Stress
		T;N, Routine
	US Fetal Biophysical w Stress
		T;N, Routine
Medications
Immunizations
	tetanus/diphth/pertuss (Tdap/Adacel) (In Office)
		0.5 mL, Suspension-Injection, 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
	influenza vaccine, TRIvalent (*FluLaval) (In Office)
		0.5 mL, Suspension, IM-Intramuscular, Once, T;N, Encounter for immunization
	RSV vaccine, preF A-B, recombinant (Abrysvo) (In Office)
		0.5 mL, Solution-Injection, IM-Intramuscular, Once, T;N, Encounter for immunization
Consults/Follow-up

	Return to Clinic Women's
		Future Order In Approximately 2 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 2, week(s), In Approximately
		Future Order In Approximately 1 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 1, week(s), In Approximately
		Future Order In Approximately 3 week(s) Grace Period (+/-) 3 Day(s), 3, Day(s), 3, week(s), In Approximately
		Future Order In Approximately 1 month(s) Grace Period (+/-) 7 Day(s), 7, Day(s), 1, month(s), In Approximately
	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, See Special Instructions
	Consult Perinatologist
		
	Patient Education
		T;N, EMMI Education
Charges/Supplies
Procedures in Office
	Fetal Non-Stress Test
		
	Q0114 FERN TEST
		
	76815 US OB Limited (in office)
		
	76816 US OB Follow-up (in office)
		
	76818 US Fetal Biophysical Profile (in office)
		
	76819 US Fetal Biophys w/o Stress (in office)
		
	76805 Level 1 U/S (in office)
		
	76811 Level 2 U/S (in office)
		
Est. Pt Visit
	0502F EVM - Prenatal Care Visit - Subsequent

Visit 35-36 week Clinic
Laboratory
Point of Care
	Urine Dipstick POC OB
		T;N, Urine
General Labs
	Hemogram (CBC no Diff)
		T;N, Routine, spec type = Blood
	TSH
		T;N, Routine, spec type = Blood
	Free T4
		T;N, Routine, spec type = Blood
	Hepatic Function Panel
		T;N, Routine, spec type = Blood
	Comprehensive Metabolic Panel
		T;N, Routine, spec type = Blood
	Antibody Screen
		T;N, Routine, spec type = Blood
	Antibody Titer
		T;N, Routine, spec type = Blood
Urine Studies
	Urinalysis
		T;N, Routine, Routine, spec type = Urine
	Culture Urine
		T;N, Routine, Urine Midstream, spec type = Urine
	UA (Culture Pos)
		T;N, Routine, Routine, spec type = Urine
	Protein Urine Timed Set
		T;N, Routine, Routine, spec type = Urine
	Protein Creatinine Ratio Urine
		T;N, Routine, Urine Random, spec type = Urine
Cervical/Vaginal Specimens
	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
	Group B Strep by PCR
		T;N, Routine, spec type = Vaginal/Rectal
	Vaginitis Panel PCR
		T;N, Routine, spec type = Genital
	Wet Prep - PC/FH
		T;N, Routine, spec type = Genital
	Q0111 Wet Mt Physician Perform
		
	Q0112 KOH Prep Physician Perform
		
Diagnostic Tests

	US OB Limited
		T;N, Pregnant, Routine
	US OB Transvaginal
		T;N, Routine
		T;N, Routine, Check Cervix Length
	US OB Followup
		T;N, Pregnant, Routine
	US Fetal Biophysical w/o Stress
		T;N, Routine
	US Fetal Biophysical w Stress
		T;N, Routine
Medications
Immunizations
	tetanus/diphth/pertuss (Tdap/Adacel) (In Office)
		0.5 mL, Suspension-Injection, 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
	influenza vaccine, TRIvalent (*FluLaval) (In Office)
		0.5 mL, Suspension, IM-Intramuscular, Once, T;N, Encounter for immunization
	RSV vaccine, preF A-B, recombinant (Abrysvo) (In Office)
		0.5 mL, Solution-Injection, IM-Intramuscular, Once, T;N, Encounter for immunization
Consults/Follow-up

	Return to Clinic Women's
		Future Order In Approximately 1 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 1, week(s), In Approximately
		Future Order In Approximately 2 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 2, week(s), In Approximately
	Follow-up Appointment
		Follow Up Visit, 1 week
		Follow Up Visit, 2 weeks
		Follow Up Visit, See Special Instructions
	Consult Perinatologist
		
	Patient Education
		T;N, EMMI Education
Charges/Supplies
Procedures in Office
	Fetal Non-Stress Test
		
	Q0114 FERN TEST
		
	76815 US OB Limited (in office)
		
	76816 US OB Follow-up (in office)
		
	76818 US Fetal Biophysical Profile (in office)
		
	76819 US Fetal Biophys w/o Stress (in office)
		
	76805 Level 1 U/S (in office)
		
	76811 Level 2 U/S (in office)
		
Est. Pt Visit
	0502F EVM - Prenatal Care Visit - Subsequent

Visit 37 week Clinic
Laboratory
Point of Care
	Urine Dipstick POC OB
		T;N, Urine
General Labs
	Hemogram (CBC no Diff)
		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
	Hepatic Function Panel
		T;N, Routine, spec type = Blood
	Antibody Titer
		T;N, Routine, spec type = Blood
Urine Studies
	Urinalysis
		T;N, Routine, Routine, spec type = Urine
	Culture Urine
		T;N, Routine, Urine Midstream, spec type = Urine
	UA (Culture Pos)
		T;N, Routine, Routine, spec type = Urine
	Protein Urine Timed Set
		T;N, Routine, Routine, spec type = Urine
	Protein Creatinine Ratio Urine
		T;N, Routine, Urine Random, spec type = Urine
Cervical/Vaginal Specimens
	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
	Group B Strep by PCR
		T;N, Routine, spec type = Vaginal/Rectal
	Vaginitis Panel PCR
		T;N, Routine, spec type = Genital
	Wet Prep - PC/FH
		T;N, Routine, spec type = Genital
	Q0111 Wet Mt Physician Perform
		
	Q0112 KOH Prep Physician Perform
		
Diagnostic Tests

	US OB Limited
		T;N, Pregnant, Routine
	US OB Followup
		T;N, Pregnant, Routine
	US OB Transvaginal
		T;N, Routine
	US Fetal Biophysical w/o Stress
		T;N, Routine
	US Fetal Biophysical w Stress
		T;N, Routine
Medications
Immunizations
	tetanus/diphth/pertuss (Tdap/Adacel) (In Office)
		0.5 mL, Suspension-Injection, 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
	influenza vaccine, TRIvalent (*FluLaval) (In Office)
		0.5 mL, Suspension, IM-Intramuscular, Once, T;N, Encounter for immunization
Consults/Follow-up

	Return to Clinic Women's
		Future Order In Approximately 1 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 1, week(s), In Approximately
		Future Order In Approximately 2 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 2, week(s), In Approximately
	Follow-up Appointment
		Follow Up Visit, 1 week
		Follow Up Visit, 2 weeks
		Follow Up Visit, See Special Instructions
	Consult Perinatologist
		
	Patient Education
		T;N, EMMI Education
Charges/Supplies
Procedures in Office
	Fetal Non-Stress Test
		
	Q0114 FERN TEST
		
	76815 US OB Limited (in office)
		
	76816 US OB Follow-up (in office)
		
	76818 US Fetal Biophysical Profile (in office)
		
	76819 US Fetal Biophys w/o Stress (in office)
		
	76805 Level 1 U/S (in office)
		
	76811 Level 2 U/S (in office)
		
Est. Pt Visit
	0502F EVM - Prenatal Care Visit - Subsequent

Visit 24 - 25 week Clinic
Laboratory
Point of Care
	Urine Dipstick POC OB
		T;N, Urine
General Labs
	Hemogram (CBC no Diff)
		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
	Hepatic Function Panel
		T;N, Routine, spec type = Blood
	Glucose 1h p Glucose Challenge
		T;N, Routine, spec type = Blood
	Antibody Screen
		T;N, Routine, spec type = Blood
	Antibody Titer
		T;N, Routine, spec type = Blood
	AFP Maternal
		T;N, Routine, spec type = Blood
		Collect Quad Screen between 15-21 weeks of gestation(NOTE)*
	QUAD Screen
		T;N, Routine, spec type = Blood
Urine Studies
	Urinalysis
		T;N, Routine, Routine, spec type = Urine
	Culture Urine
		T;N, Routine, Urine Midstream, spec type = Urine
	UA (Culture Pos)
		T;N, Routine, Routine, spec type = Urine
	Protein Creatinine Ratio Urine
		T;N, Routine, Urine Random, spec type = Urine
Cervical/Vaginal Specimens
	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
	Vaginitis Panel PCR
		T;N, Routine, spec type = Genital
	Wet Prep - PC/FH
		T;N, Routine, spec type = Genital
	Q0111 Wet Mt Physician Perform
		
	Q0112 KOH Prep Physician Perform
		
Diagnostic Tests

	US Amniocentesis
		T;N, Routine
	US OB 2nd 3rd Trimester
		T;N, Pregnant, Routine
	US OB Limited
		T;N, Pregnant, Routine
	US OB Transvaginal
		T;N, Routine
		T;N, Routine, Check Cervix Length
	US OB Followup
		T;N, Pregnant, Routine
Medications
	RHo (D) immune globulin 300 mcg (In Office)
		1,500 intl_units, Solution, IM-Intramuscular, Once, NOW
			Comment: 1500intl units=300mcg=1vial/syringe
Immunizations
	tetanus/diphth/pertuss (Tdap/Adacel) (In Office)
		0.5 mL, Suspension-Injection, 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
	influenza vaccine, TRIvalent (*FluLaval) (In Office)
		0.5 mL, Suspension, IM-Intramuscular, Once, T;N, Encounter for immunization
Consults/Follow-up

	Return to Clinic Women's
		Future Order In Approximately 1 month(s) Grace Period (+/-) 7 Day(s), 7, Day(s), 1, month(s), In Approximately
		Future Order In Approximately 1 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 1, week(s), In Approximately
		Future Order In Approximately 2 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 2, week(s), In Approximately
		Future Order In Approximately 3 week(s) Grace Period (+/-) 3 Day(s), 3, Day(s), 3, week(s), In Approximately
	Follow-up Appointment
		Follow Up Visit, 1 month
		Follow Up Visit, 1 week
		Follow Up Visit, 2 weeks
		Follow Up Visit, 3 weeks
		Follow Up Visit, See Special Instructions
	Consult Perinatologist
		
	Patient Education
		T;N, EMMI Education
Charges/Supplies
Procedures in Office
	Q0114 FERN TEST
		
	76815 US OB Limited (in office)
		
	76816 US OB Follow-up (in office)
		
	76817 US OB Transvaginal (in office)
		
	76805 Level 1 U/S (in office)
		
	76811 Level 2 U/S (in office)
		
Est. Pt Visit
	0502F EVM - Prenatal Care Visit - Subsequent

Visit 38 week Clinic
Laboratory
Point of Care
	Urine Dipstick POC OB
		T;N, Urine
General Labs
	Hemogram (CBC no Diff)
		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
	Hepatic Function Panel
		T;N, Routine, spec type = Blood
	Antibody Titer
		T;N, Routine, spec type = Blood
Urine Studies
	Urinalysis
		T;N, Routine, Routine, spec type = Urine
	Culture Urine
		T;N, Routine, Urine Midstream, spec type = Urine
	UA (Culture Pos)
		T;N, Routine, Routine, spec type = Urine
	Protein Urine Timed Set
		T;N, Routine, Routine, spec type = Urine
	Protein Creatinine Ratio Urine
		T;N, Routine, Urine Random, spec type = Urine
Cervical/Vaginal Specimens
	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
	Group B Strep by PCR
		T;N, Routine, spec type = Vaginal/Rectal
	Vaginitis Panel PCR
		T;N, Routine, spec type = Genital
	Wet Prep - PC/FH
		T;N, Routine, spec type = Genital
	Q0111 Wet Mt Physician Perform
		
	Q0112 KOH Prep Physician Perform
		
Diagnostic Tests

	US OB Limited
		T;N, Pregnant, Routine
	US OB Followup
		T;N, Pregnant, Routine
	US OB Transvaginal
		T;N, Routine
	US Fetal Biophysical w/o Stress
		T;N, Routine
	US Fetal Biophysical w Stress
		T;N, Routine
Medications
Immunizations
	tetanus/diphth/pertuss (Tdap/Adacel) (In Office)
		0.5 mL, Suspension-Injection, 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
	influenza vaccine, TRIvalent (*FluLaval) (In Office)
		0.5 mL, Suspension, IM-Intramuscular, Once, T;N, Encounter for immunization
Consults/Follow-up

	Return to Clinic Women's
		Future Order In Approximately 1 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 1, week(s), In Approximately
		Future Order In Approximately 2 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 2, week(s), In Approximately
	Follow-up Appointment
		Follow Up Visit, 1 week
		Follow Up Visit, 2 weeks
		Follow Up Visit, See Special Instructions
	Consult Perinatologist
		
	Patient Education
		T;N, EMMI Education
Charges/Supplies
Procedures in Office
	Fetal Non-Stress Test
		
	Q0114 FERN TEST
		
	76815 US OB Limited (in office)
		
	76816 US OB Follow-up (in office)
		
	76818 US Fetal Biophysical Profile (in office)
		
	76819 US Fetal Biophys w/o Stress (in office)
		
	76805 Level 1 U/S (in office)
		
	76811 Level 2 U/S (in office)
		
Est. Pt Visit
	0502F EVM - Prenatal Care Visit - Subsequent

Visit 39 week Clinic
Laboratory
Point of Care
	Urine Dipstick POC OB
		T;N, Urine
General Labs
	Hemogram (CBC no Diff)
		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
	Hepatic Function Panel
		T;N, Routine, spec type = Blood
	Antibody Titer
		T;N, Routine, spec type = Blood
Urine Studies
	Urinalysis
		T;N, Routine, Routine, spec type = Urine
	Culture Urine
		T;N, Routine, Urine Midstream, spec type = Urine
	UA (Culture Pos)
		T;N, Routine, Routine, spec type = Urine
	Protein Urine Timed Set
		T;N, Routine, Routine, spec type = Urine
	Protein Creatinine Ratio Urine
		T;N, Routine, Urine Random, spec type = Urine
Cervical/Vaginal Specimens
	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
	Group B Strep by PCR
		T;N, Routine, spec type = Vaginal/Rectal
	Vaginitis Panel PCR
		T;N, Routine, spec type = Genital
	Wet Prep - PC/FH
		T;N, Routine, spec type = Genital
	Q0111 Wet Mt Physician Perform
		
	Q0112 KOH Prep Physician Perform
		
Diagnostic Tests

	US OB Limited
		T;N, Pregnant, Routine
	US OB Followup
		T;N, Pregnant, Routine
	US OB Transvaginal
		T;N, Routine
	US Fetal Biophysical w/o Stress
		T;N, Routine
	US Fetal Biophysical w Stress
		T;N, Routine
Medications
Immunizations
	tetanus/diphth/pertuss (Tdap/Adacel) (In Office)
		0.5 mL, Suspension-Injection, 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
	influenza vaccine, TRIvalent (*FluLaval) (In Office)
		0.5 mL, Suspension, IM-Intramuscular, Once, T;N, Encounter for immunization
Consults/Follow-up

	Return to Clinic Women's
		Future Order In Approximately 1 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 1, week(s), In Approximately
		Future Order In Approximately 2 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 2, week(s), In Approximately
	Follow-up Appointment
		Follow Up Visit, 1 week
		Follow Up Visit, 2 weeks
		Follow Up Visit, See Special Instructions
	Consult Perinatologist
		
	Patient Education
		T;N, EMMI Education
Charges/Supplies
Procedures in Office
	Fetal Non-Stress Test
		
	Q0114 FERN TEST
		
	76815 US OB Limited (in office)
		
	76816 US OB Follow-up (in office)
		
	76818 US Fetal Biophysical Profile (in office)
		
	76819 US Fetal Biophys w/o Stress (in office)
		
	76805 Level 1 U/S (in office)
		
	76811 Level 2 U/S (in office)
		
Est. Pt Visit
	0502F EVM - Prenatal Care Visit - Subsequent

Visit 40 week Clinic
Laboratory
Point of Care
	Urine Dipstick POC OB
		T;N, Urine
General Labs
	Hemogram (CBC no Diff)
		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
	Hepatic Function Panel
		T;N, Routine, spec type = Blood
	Antibody Titer
		T;N, Routine, spec type = Blood
Urine Studies
	Urinalysis
		T;N, Routine, Routine, spec type = Urine
	Culture Urine
		T;N, Routine, Urine Midstream, spec type = Urine
	UA (Culture Pos)
		T;N, Routine, Routine, spec type = Urine
	Protein Urine Timed Set
		T;N, Routine, Routine, spec type = Urine
	Protein Creatinine Ratio Urine
		T;N, Routine, Urine Random, spec type = Urine
Cervical/Vaginal Specimens
	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
	Group B Strep by PCR
		T;N, Routine, spec type = Vaginal/Rectal
	Vaginitis Panel PCR
		T;N, Routine, spec type = Genital
	Wet Prep - PC/FH
		T;N, Routine, spec type = Genital
	Q0111 Wet Mt Physician Perform
		
	Q0112 KOH Prep Physician Perform
		
Diagnostic Tests

	US OB Limited
		T;N, Pregnant, Routine
	US OB Followup
		T;N, Pregnant, Routine
	US OB Transvaginal
		T;N, Routine
	US Fetal Biophysical w/o Stress
		T;N, Routine
	US Fetal Biophysical w Stress
		T;N, Routine
Medications
Immunizations
	tetanus/diphth/pertuss (Tdap/Adacel) (In Office)
		0.5 mL, Suspension-Injection, 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
	influenza vaccine, TRIvalent (*FluLaval) (In Office)
		0.5 mL, Suspension, IM-Intramuscular, Once, T;N, Encounter for immunization
Consults/Follow-up

	Return to Clinic Women's
		Future Order In Approximately 1 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 1, week(s), In Approximately
		Future Order In Approximately 2 week(s) Grace Period (+/-) 2 Day(s), 2, Day(s), 2, week(s), In Approximately
	Follow-up Appointment
		Follow Up Visit, 1 week
		Follow Up Visit, 2 weeks
		Follow Up Visit, See Special Instructions
	Consult Perinatologist
		
	Patient Education
		T;N, EMMI Education
Charges/Supplies
Procedures in Office
	Fetal Non-Stress Test
		
	Q0114 FERN TEST
		
	76815 US OB Limited (in office)
		
	76816 US OB Follow-up (in office)
		
	76818 US Fetal Biophysical Profile (in office)
		
	76819 US Fetal Biophys w/o Stress (in office)
		
	76805 Level 1 U/S (in office)
		
	76811 Level 2 U/S (in office)
		
Est. Pt Visit
	0502F EVM - Prenatal Care Visit - Subsequent

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

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

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

Creatinine Clearance Set

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

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

Creatinine Clearance Set

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

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

Creatinine Clearance Set

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

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

Creatinine Clearance Set

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

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

Creatinine Clearance Set

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

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

Creatinine Clearance Set

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

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

Creatinine Clearance Set

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

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

Creatinine Clearance Set

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

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

Creatinine Clearance Set

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

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