Unique Plan Description: Peds 12 Year 7th Grade Physical Clinic
Plan Selection Display: Peds 12 Year 7th Grade Physical Clinic
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2020-11-01 08:29:21
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2025-10-22 12:57:56
Available at all facilities: Yes

Peds 12 Year 7th Grade Physical Clinic
Laboratory
	CBC with Diff
		T;N, Routine, spec type = Blood
	Hemogram (CBC no Diff)
		T;N, Routine, spec type = Blood
	Urogram
		T;N, Routine, Routine, spec type = Urine
	UA
		T;N, Routine, Routine, spec type = Urine
	UA (Culture Pos)
		T;N, Routine, Routine, spec type = Urine
	Culture Urine
		T;N, Routine, spec type = Urine
	Lead Screen - PC
		T;N, Routine, spec type = Capillary Blood
	Lead (0020098)
		T;N, Routine, spec type = Blood
	Cholesterol
		T;N, Routine, spec type = Blood
	Lipid Panel
		T;N, Routine, spec type = Blood
	Strep Group A PCR
		T;N, Routine, spec type = Throat
Point of Care
	Hemoglobin POC - PC (lab)
		T;N, Routine, spec type = Blood
	Cholesterol POC-PC
		T;N, Routine, spec type = Blood
Medications
Immunizations
	hepatitis A pediatric vaccine (Vaqta Pediatric) (In Office)
		0.5 mL, Injection, IM-Intramuscular, Once, NOW, Encounter for immunization
	hepatitis B pediatric vaccine (Recombivax Pediatric) (In Office)
		0.5 mL, Solution-Injection, IM-Intramuscular, Once, T;N, Encounter for immunization
	human papillomavirus vaccine (Gardasil 9) (In Office)
		0.5 mL, Solution, 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
	meningococcal conjugate vaccine (MenQuadfi) (In Office)
		0.5 mL, Solution, IM-Intramuscular, Once, T;N, Encounter for immunization
	pneumococcal 20-valent conjugate vaccine (Prevnar 20) (In Office)
		0.5 mL, Suspension, IM-Intramuscular, Once, NOW, Encounter for immunization
	tetanus/diphth/pertuss (Tdap/Adacel) (In Office)
		0.5 mL, Suspension-Injection, IM-Intramuscular, Once, T;N, Encounter for immunization
	measles/mumps/rubella/varicella virus vaccine (MMRV) (ProQuad) (In Office)
		0.5 mL, Injection, SUBCUTANEOUS, Once, NOW, duration: 1 Dose(s)/Time(s), Encounter for immunization
	90460 Adm Imm w/Counsel First
		
	90461 Adm Imm w/Counsel Ea Add
		
Patient Care

	Vision Screening - PC
		
	92552 Pure tone threshold, air only
		
	94760 Pulse Oximetry- Single
		
	94640 Inhalation treatment
		
	51701 Insert Non-Indwell bladder catheter
		
	92567 Tympanometry
		
	92583 Select picture audiometry
		
Consults/Follow-up
	Return to Clinic Primary Care
		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
		1 year
		1 week
		2 weeks
		3 weeks
		6 weeks
		1 month
		3 months
		6 months
		See Special Instructions
		PRN
	Consult Allergist
		
	Consult Ear Nose and Throat
		
	Consult Otolaryngologist
		
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
Est Pt Preventive Med
	99394 EVM - Prev Med Estab Patient 12-17 yrs
		T;N
	99395 EVM - Prev Med Estab Patient 18-39 yrs
		T;N
New Pt Preventive Med
	99384 EVM - Prev Med New Patient 12-17 yrs
		T;N
	99385 EVM - Prev Med New Patient 18-39 yrs
		T;N
No Charge / Follow Up
	99024 EVM - Post Op Visit
		T;N
	99211n EVM - No Charge Professional Service
		T;N
	99213C EVM - MPC CLINIC AUDIT BY CODER
		T;N
Procedures in Office
	96110 Development testing, limited

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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