Unique Plan Description: Pelvic Pain General Clinic
Plan Selection Display: Pelvic Pain General Clinic
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2012-03-14 14:32:46
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2025-02-19 11:17:40
Available at all facilities: Yes

Pelvic Pain General Clinic
Laboratory
General Labs
	CBC with Diff
		T;N, Routine, spec type = Blood
	Hematocrit
		T;N, Routine, spec type = Blood
	Hemoglobin
		T;N, Routine, spec type = Blood
	HCG Qualitative Serum - PC/FH
		T;N, Routine, spec type = Blood
	Hemoglobin A1C
		T;N, Routine, spec type = Blood
	Sex Hormone Binding Globulin
		T;N, Routine, spec type = Blood
	Estradiol Level
		T;N, Routine, spec type = Blood
	Follicle Stimulating Hormone
		T;N, Routine, spec type = Blood
	PSA
		T;N, Routine, spec type = Blood
	Free T4
		T;N, Routine, spec type = Blood
	Testosterone Total/Free (Female/Child)
		T;N, Routine, spec type = Blood
	TSH
		T;N, Routine, spec type = Blood
	Vitamin D 25-Hydroxy Level (preferred for deficiency)
		T;N, Routine, spec type = Blood
	Basic Metabolic Panel
		T;N, Routine, spec type = Blood
	Comprehensive Metabolic Panel
		T;N, Routine, spec type = Blood
	Hepatic Function Panel
		T;N, Routine, spec type = Blood
	Lipid Panel
		T;N, Routine, spec type = Blood
	T3 Free
		T;N, Routine, spec type = Blood
	DHEA
		T;N, Routine, spec type = Blood
	Cholesterol
		T;N, Routine, spec type = Blood
	Thyroid Panel
		T;N, Routine, spec type = Blood
	LH
		T;N, Routine, spec type = Blood
	Prolactin Level
		T;N, Routine, spec type = Blood
	Anti Mullerian Hormone
		T;N, Routine, spec type = Blood
STD Screening
	Hepatitis B Core Antibody IgM (Acute)
		T;N, Routine, spec type = Blood
	Hepatitis C Virus (HCV) Antibody with Rflx to PCR Confirmation
		T;N, Routine, spec type = Blood
	Syphilis Total Antibodies
		T;N, Routine, spec type = Blood
	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
	Hepatitis B Surface Antibody
		T;N, Routine, spec type = Blood
	Herpes Simplex Virus Ab IgG w/ Reflex Typing
		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
	Culture Routine
		T;N, Routine, Micro Swab, spec type = Genital
	Herpes Simplex Virus 1/2 PCR. Other than blood
		T;N, Routine, spec type = Genital
Cervical/Vaginal Specimens
	Wet Prep - PC/FH
		T;N, Routine, spec type = Genital
	KOH Prep Physician Perform
		
	Wet Mt Physician Perform
		
Anatomic Pathology
	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 CERV & 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
	Tissue Request
		T;N, Routine, Tissue, Labia Majora, Routine
		T;N, Routine, Tissue, Labia Minora, Routine
		T;N, Routine, Tissue, Vaginal, Routine
		T;N, Routine, Tissue, Cervical, Routine
		T;N, Routine, Tissue, Endometrium, Routine
		T;N, Routine, Tissue, Endocervix, Routine
Urine Studies
	Toxicology Screen DAU - MH/WH/JE
		T;N, Routine, Urine Random, spec type = Urine
	Drug Screen Urine - FH
		T;N, Routine, Urine Random, spec type = Urine
	NMP 22 Bladder Check - PC
		T;N, Routine, Routine, spec type = Urine
	HCG Urine Qualitative
		T;N, Routine, Routine, spec type = Urine
	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, Urine, spec type = Urine
	Urine Dipstick POC - PC
		T;N, Urine
Diagnostic Tests

	zzDXA Scan
		T;N
Ultrasound
	US Abd Limited
		T;N, Routine
	US Transvaginal
		T;N, Routine
	US Pelvis Complete Non OB
		T;N, Routine
	US Breast Bil Complete
		T;N, Routine
	US Breast Bil Limited
		T;N, Routine
	US Breast Lt Complete
		T;N, Routine
	US Breast Lt Limited
		T;N, Routine
	US Breast Rt Complete
		T;N, Routine
	US Breast Rt Limited
		T;N, Routine
CT
	CT Abd w/o Contrast
		T;N, Routine
	CT Abd Pelvis w & w/o Cont
		T;N, Routine
	CT Abd w Contrast
		T;N, Routine
Diagnostics
	Chest 2 View
		T;N, Routine
	Mammo Bil Screen
		T;N, Routine, Encounter for screening mammogram for malignant neoplasm of breast
		T;N, Routine, Personal history of malignant neoplasm of breast | Encounter for screening mammogram for malignant neoplasm of breast
	Mammo Implants Screen
		T;N, Routine, Encounter for screening mammogram for malignant neoplasm of breast
		T;N, Routine, Personal history of malignant neoplasm of breast | Encounter for screening mammogram for malignant neoplasm of breast
Medications

	methylPREDNISolone (Depo-Medrol 40 mg/mL) (In Office)
		20 mg, Suspension-Injection, IM-Intramuscular, Once, NOW
		40 mg, Suspension-Injection, IM-Intramuscular, Once, NOW
	leuprolide 3.75mg 1-month depot (Lupron Depot) (In Office)
		3.75 mg, Injection, IM-Intramuscular, Once, NOW
			Comment: Extremely Hazardous Drug | Antineoplastic |  PPE Requirements: Chemotherapy Gown, Double Gloves.
	leuprolide 11.25mg 3-month depot (Lupron Depot) (In Office)
		11.25 mg, Injection, IM-Intramuscular, Once, NOW
			Comment: Extremely Hazardous Drug | Antineoplastic |  PPE Requirements: Chemotherapy Gown, Double Gloves.
	medroxyPROGESTERone (Depo-Provera) (In Office)
		150 mg, Injection, IM-Intramuscular, Once, NOW
	onabotulinumtoxinA (Botox) (In Office)
		units, Injection, IM-Intramuscular, Once, NOW
		100 units, Injection, IM-Intramuscular, Once, NOW
		200 units, Injection, IM-Intramuscular, Once, NOW
	levonorgestrel (Mirena) (In Office)
		52 mg, Insert, IntraUterine, Once, NOW
	ParaGard (In Office)
		1 EA, Insert, IntraUterine, Once, NOW
	cefTRIAXone 250mg IM (Rocephin) (In Office)
		0 mg, Injection, IM-Intramuscular, Once, NOW
			Comment: Inject deep into Muscle
		2,000 mg, Injection, IM-Intramuscular, Once, NOW
			Comment: Inject deep into Muscle
		1,000 mg, Injection, IM-Intramuscular, Once, NOW
			Comment: Inject deep into Muscle
	human papillomavirus vaccine (Gardasil 9) (In Office)
		0.5 mL, Solution, IM-Intramuscular, Once, NOW, Encounter for immunization
	triamcinolone 40mg/mL (Kenalog-40)(In Office)
		mg, Injection, IM-Intramuscular, Once, NOW
		10 mg, Injection, IM-Intramuscular, Once, NOW
		20 mg, Injection, IM-Intramuscular, Once, NOW
		40 mg, Injection, IM-Intramuscular, Once, NOW
		80 mg, Injection, IM-Intramuscular, Once, NOW
		40 mg, Injection, Catheter, Once, NOW
	bupivacaine 0.25% (Marcaine/Sensorcaine) (In Office)
		mL, Injection, IM-Intramuscular, Once, NOW
			Comment: into vestibular glands
	bupivacaine 0.5% (Marcaine/Sensorcaine) 50 mL vial (In Office)
		mL, Injection, IM-Intramuscular, Once, NOW
			Comment: into vestibular glands
		5 mL, Injection, Catheter, Once, NOW
	lidocaine 1% (5 mL) (Xylocaine) (In Office)
		mL, Injection, IM-Intramuscular, Once, NOW
			Comment: into vestibular glands
	lidocaine 1% (2 mL) (Xylocaine) (In Office)
		mL, Injection, IM-Intramuscular, Once, NOW
			Comment: into vestibular glands
	lidocaine 2% in 5mL Vial (Xylocaine) (In Office)
		mL, Injection, IM-Intramuscular, Once, NOW
			Comment: into vestibular glands
Patient Care
	Straight Catheter
		
Consults/Follow-up
	Follow-up Appointment
		Follow Up Visit, 6 weeks
		Follow Up Visit, 1 week
		Follow Up Visit, 2 weeks
		Follow Up Visit, 3 weeks
		Follow Up Visit, 1 month
		Follow Up Visit, 3 months
		Follow Up Visit, 6 months
		Follow Up Visit, 1 year
		Follow Up Visit, See Special Instructions
		Follow Up Visit, PRN
	Consult Uro/Gyn
		
	Consult Physical Therapy
		
	Consult OB/GYN
		
	Consult Gastroenterologist
		
	Consult Sexual Medicine
		
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
	99396 EVM - Prev Med Estab Patient 40-64 yrs
		T;N
	99397 EVM - Prev Med Estab Patient > 65 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
	99386 EVM - Prev Med New Patient 40-64 yrs
		T;N
	99387 EVM - Prev Med New Patient > 65 yrs
		T;N
No Charge / Follow Up
	99211n EVM - No Charge Professional Service
		T;N
	99024 EVM - Post Op Visit
		T;N
	99213C EVM - MPC CLINIC AUDIT BY CODER
		T;N
Procedures in Office
	58100 Endometrial bx wo cervical dilation
		
	57100 Biopsy vaginal mucosa simple
		
	56605 Biopsy vulva or perineum, 1 lesion
		
	56606 Biopsy vulva or perineum, ea addl
		
	56821 Colposcopy  Vulva , Biopsy
		
	57455 Colposcopy  Cervix , Biopsy
		
	57456 Colposcopy  Cervix, w/ endocervical curettage
		
	57420 Colposcopy, Vagina
		
	56420 I&D Bartholin Gland Abscess
		
	56405 I&D Vulva or Perineal Abscess
		
	53060 I&D Skenes cyst
		
	11980 Implant hormone pellet subcu
		
	58300 Insert IUD
		
	58301 IUD removal
		
	zz96372 Injection Ther/Proph/Diag   SC/IM
		
	20552 Trigger point inj sing or mult, 1-2 musc
		
	20553 Trigger point inj sing or mult, >/= 3 musc
		
	76830 US Transvaginal non OB (in office)
		
	51700 Bladder irrigation simple lav/instillation
		
			Comment: with potassium instillation

*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