Unique Plan Description: Peds 15 Month Check Clinic
Plan Selection Display: Peds 15 Month Check Clinic
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2020-11-01 07:47:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2025-03-25 16:07:46
Available at all facilities: Yes

Peds 15 Month Check Clinic
Laboratory
	Hemogram (CBC no Diff)
		T;N, Routine, spec type = Blood
	CBC with Diff
		T;N, Routine, spec type = Blood
	Hemoglobin
		T;N, Routine, spec type = Blood
	Hematocrit
		T;N, Routine, spec type = Blood
	Lead Screen - PC
		T;N, Routine, spec type = Capillary Blood
	Lead Capillary (0020745)
		T;N, Routine, spec type = Blood
	Lead (0020098)
		T;N, Routine, spec type = Blood
Point of Care
	Hemoglobin POC - PC (lab)
		T;N, spec type = Blood
Medications
Immunizations
	diphth/haemophil/pertussis/tetanus/polio (Pentacel) (In Office)
		0.5 mL, Solution-Injection, IM-Intramuscular, Once, NOW, Encounter for immunization
	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
	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, NOW, Encounter for immunization
	pneumococcal 20-valent conjugate vaccine (Prevnar 20) (In Office)
		0.5 mL, Suspension, IM-Intramuscular, Once, NOW, Encounter for immunization
	varicella virus vaccine (Varivax) (In Office)
		0.5 mL, Injection, SUBCUTANEOUS, Once, T;N, Encounter for immunization
	90460 Adm Imm w/Counsel First
		
	90461 Adm Imm w/Counsel Ea Add
		
Patient Care

	94640 Inhalation treatment
		
	92567 Tympanometry
		
	51701 Insert Non-Indwell bladder catheter
		
	Vision Screening - PC
		
	94760 Pulse Oximetry- Single
		
	92552 Pure tone threshold, air only
		
Consults/Follow-up
	Return to Clinic Primary Care
		Future Order, 2, Day(s), 1, week(s), In Approximately
		Future Order, 2, Day(s), 2, week(s), In Approximately
		Future Order, 3, Day(s), 3, week(s), In Approximately
		Future Order, 7, Day(s), 6, week(s), In Approximately
		Future Order, 7, Day(s), 1, month(s), In Approximately
		Future Order, 7, Day(s), 2, month(s), In Approximately
		Future Order, 7, Day(s), 3, month(s), In Approximately
		Future Order, 7, Day(s), 4, month(s), In Approximately
		Future Order, 7, Day(s), 6, month(s), In Approximately
		Future Order, 14, Day(s), 12, month(s), In Approximately
	Follow-up Appointment
		Follow Up Visit, 3 months
		Follow Up Visit, 1 week
		Follow Up Visit, 2 weeks
		Follow Up Visit, 3 weeks
		Follow Up Visit, 6 weeks
		Follow Up Visit, 1 month
		Follow Up Visit, 6 months
		Follow Up Visit, 1 year
		Follow Up Visit, See Special Instructions
		Follow Up Visit, PRN
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
Est Pt Preventive Med
	99391 EVM - Prev Med Estab Patient Less Than 1 yr
		T;N
	99392 EVM - Prev Med Estab Patient 1-4 yrs
		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
New Pt Preventive Med
	99381 EVM -  Prev Med New Patient Less Than 1 yr
		T;N
	99382 EVM - Prev Med New Patient 1-4 yrs
		T;N
No Charge / Follow Up
	99024 EVM - Post Op Visit
		
	99211n EVM - No Charge Professional Service
		T;N
	99213C EVM - MPC CLINIC AUDIT BY CODER
		T;N
Procedures in Office
	69210 Remove Cerumen Impaction
		
	17110 Des ben les up to 14
		
	17111 Des ben les 15 or more
		
	10120 Incise remove foreign body subcu simple
		
	69200 Remove FB, External Auditory Canal
		
	30300 Remove FB Intranasal
		
	10060 I&D abscess simple/single
		
	96110 Development testing, limited

*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