Unique Plan Description: OBGYN Adolescent Clinic
Plan Selection Display: OBGYN Adolescent Clinic
PlanType: Medical                                 
Version: 2          
Begin Effective Date: 2020-11-01 07:43:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2025-01-07 10:36:17
Available at all facilities: Yes

OBGYN Adolescent Clinic
Laboratory
	Hemogram (CBC no Diff)
		T;N, Routine, spec type = Blood
	Glucose Level
		T;N, Routine, spec type = Blood
	TSH
		T;N, Routine, spec type = Blood
	Free T4
		T;N, Routine, spec type = Blood
	Free T3
		T;N, Routine, spec type = Blood
	FSH
		T;N, Routine, spec type = Blood
	LH
		T;N, Routine, spec type = Blood
	Sex Hormone Binding Globulin
		T;N, Routine, spec type = Blood
	Estradiol Level
		T;N, Routine, spec type = Blood
	Comprehensive Metabolic Panel
		T;N, Routine, spec type = Blood
	Prolactin Level
		T;N, Routine, spec type = Blood
	Beta-HCG Quantitative - Pregnancy
		T;N, Routine, spec type = Blood
	Testosterone Total/Free (Female/Child)
		T;N, Routine, spec type = Blood
	Vitamin D 25-Hydroxy Level (preferred for deficiency)
		T;N, Routine, spec type = Blood
	Von Willebrand Panel
		T;N, Routine, spec type = Blood
	Lipid Panel
		T;N, Routine, spec type = Blood
	DHEA Sulfate
		T;N, Routine, spec type = Blood
	Anti Mullerian Hormone
		T;N, Routine, spec type = Blood
	17-Hydroxypregnenolone Quant
		T;N, Routine, spec type = Blood
	HCG Qualitative Serum - PC/FH
		T;N, Routine, spec type = Blood
Urine Studies
	HCG Urine Qualitative
		T;N, Routine, Routine, Urine Random, spec type = Urine
	UA (Culture Pos)
		T;N, Routine, Routine, spec type = Urine
	Culture Urine
		T;N, Routine, Urine Midstream, 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 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
	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
	Vaginitis Panel PCR
		T;N, Routine, spec type = Genital
	Wet Prep - PC/FH
		T;N, Routine, spec type = Genital
	Trichomonas PCR
		T;N, Routine, spec type = Genital
	Candida Screen
		T;N, Routine, spec type = Vaginal
	Herpes Simplex Virus 1/2 PCR. Other than blood
		T;N, Routine, spec type = Genital
	Yeast and Trich Wet Prep (Trich PCR if Neg) - MH/WH
		T;N, Routine, spec type = Genital
	Tissue Request
		T;N, Routine, Tissue, Cervical, Routine
Diagnostic Tests
Radiology
	US Pelvis Complete Non OB
		T;N, Routine
	Transvaginal US
		T;N, Routine
	US Abd Complete
		T;N, Routine
	US Breast Bil Complete
		T;N, Routine
	US Breast Lt Complete
		T;N, Routine
	US Breast Rt Complete
		T;N, Routine
	US Renal Retro Complete
		T;N, Routine
Medications

	medroxyPROGESTERone (Depo-Provera) (In Office)
		150 mg, Injection, IM-Intramuscular, Once, T;N
	levonorgestrel (Liletta) (In Office)
		52 mg, Insert, IntraUterine, Once, T;N
	levonorgestrel (Mirena) (In Office)
		52 mg, Insert, IntraUterine, Once, T;N
	levonorgestrel (Skyla) (In Office)
		13.5 mg, Insert, IntraUterine, Once, T;N
	levonorgestrel (Kyleena) (In Office)
		19.5 mg, Insert, IntraUterine, Once, T;N
	ParaGard (In Office)
		1 EA, Insert, IntraUterine, Once, T;N
	etonogestrel (Nexplanon) (In Office)
		68 mg, Implant, SUBCUTANEOUS, Once, T;N
Immunizations
	human papillomavirus vaccine (Gardasil 9) (In Office)
		0.5 mL, Solution, IM-Intramuscular, Once, T;N, Encounter for immunization
	tetanus-diphth toxoids adult/adol (Td-Tenivac)(In Office)
		0.5 mL, Injection, IM-Intramuscular, Once, T;N
	tetanus/diphth/pertuss (Tdap/Adacel) (In Office)
		0.5 mL, Suspension-Injection, IM-Intramuscular, Once, T;N, Encounter for immunization
	hepatitis A adult vaccine (Vaqta) (In Office)
		1 mL, Injection, IM-Intramuscular, Once, T;N, Encounter for immunization
	hepatitis B adult vaccine (Engerix) (In Office)
		1 mL, Suspension-Injection, IM-Intramuscular, Once, T;N, Encounter for immunization
	hepatitis B adult vaccine (Recombivax HB) (In Office)
		1 mL, Solution-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
	measles/mumps/rubella virus vaccine (MMR) (In Office)
		0.5 mL, Injection, SUBCUTANEOUS, 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
	varicella virus vaccine (Varivax) (In Office)
		0.5 mL, Injection, SUBCUTANEOUS, Once, T;N, Encounter for immunization
	meningococcal conjugate vaccine (MenQuadfi) (In Office)
		0.5 mL, Solution, 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
		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
		Future Order In Approximately 1 month(s) Grace Period (+/-) 7 Day(s), 7, Day(s), 1, month(s), In Approximately
		Future Order In Approximately 2 month(s) Grace Period (+/-) 7 Day(s), 7, Day(s), 2, month(s), In Approximately
		Future Order In Approximately 3 month(s) Grace Period (+/-) 7 Day(s), 7, Day(s), 3, month(s), In Approximately
		Future Order In Approximately 4 month(s) Grace Period (+/-) 7 Day(s), 7, Day(s), 4, month(s), In Approximately
		Future Order In Approximately 6 month(s) Grace Period (+/-) 7 Day(s), 7, Day(s), 6, month(s), In Approximately
		Future Order In Approximately 12 month(s) Grace Period (+/-) 14 Day(s), 14, Day(s), 12, month(s), In Approximately
	Follow-up Appointment
		Follow Up Visit, 1 year
		Follow Up Visit, 1 month
		Follow Up Visit, 2 weeks
		Follow Up Visit, 2 months
		Follow Up Visit, 6 months
		Follow Up Visit, PRN
		Follow Up Visit, See Special Instructions
Charges/Supplies
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
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 Preventive Med
	99384 EVM - Prev Med NP FULL 12-17yrs
		T;N
	99385 EVM - Prev Med NP FULL 18-39yrs
		T;N
Est Pt Preventive Med
	99394 EVM - Prev Med EP FULL 12-17yrs
		T;N
	99395 EVM - Prev Med EP FULL 18-39yrs
		T;N
No Charge / Follow Up
	99211n EVM - No Charge Professional Service
		T;N
	Audit by Coder
		T;N
	99024 EVM - Post Op Visit
		T;N
Procedures in Office
	58300 Insert IUD
		
	58301 IUD removal
		
	Q0111 Wet Mt Physician Perform
		
	Q0112 KOH Prep Physician Perform
		
	11981 Insert Drug Implant Device
		Implanon or Nexplanon
	11982 Remove Implant; Implanon
		Implanon or Nexplanon
	11983 Remove/Reinsert Non Bio Drug Deliv
		Implanon or Nexplanon

*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