Unique Plan Description: OBGYN Methotrexate Therapy Clinic
Plan Selection Display: OBGYN Methotrexate Therapy Clinic
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2012-03-02 13:41:02
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2025-10-22 12:00:46
Available at all facilities: Yes

OBGYN Methotrexate Therapy Clinic
Laboratory
	Beta-HCG Quantitative - Pregnancy
		T;N, Routine, spec type = Blood
		T+4; 0400, Routine, spec type = Blood
		T+7; 0400, Routine, spec type = Blood
	Hemogram (CBC no Diff)
		T;N, Routine, spec type = Blood
	CBC with Diff
		T;N, Routine, spec type = Blood
		T+7; 0400, Routine, spec type = Blood
	Comprehensive Metabolic Panel
		T;N, Routine, spec type = Blood
		T+7; 0400, Routine, spec type = Blood
	ABORh Patient Type
		T;N, Routine, spec type = Blood
Medications
	methotrexate (In Office)
		50 mg/m2, Injection, IM-Intramuscular, Once, NOW
			Comment: If total volume to be administered is over 2.5mL, dose will be split into two separate syringes by pharmacy. Extremely Hazardous Drug / Antineoplastic /  PPE Requirements: Dispensed From Pharmacy In Rx Crush Bag, Double Gloves, Gown, Face Shield If Tube Admin Or Splashing Risk.
	RHo (D) immune globulin 300 mcg (In Office)
		1,500 intl_units, Solution, IM-Intramuscular, Once, NOW
Consults/Follow-up
	Follow-up Appointment
		For lab tests and office visit., 1 week
		See Special Instructions
		In 3 days for lab tests.
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
No Charge / Follow Up
	99213C EVM - MPC CLINIC AUDIT BY CODER

*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