Unique Plan Description: PMC Low Back Pain Clinic
Plan Selection Display: PMC Low Back Pain Clinic
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2012-03-08 12:42:43
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2021-12-06 10:45:19
Available at all facilities: No

PMC Low Back Pain Clinic
Laboratory
	INR - MH/WH/JE
		T;N, Routine, spec type = Blood
	Prothrombin Time (PT) - FH
		T;N, Routine
	Platelet Count
		T;N, Routine, spec type = Blood
	BUN
		T;N, Routine, spec type = Blood
	Creatinine
		T;N, Routine, spec type = Blood
	Pain Management Drug Pnl Urine
		T;N, Routine, Routine, spec type = Urine
	Pain Management Drug Scn w/ Interp Urine
		T;N, Routine, Routine, spec type = Urine
Diagnostic Tests
	EMG & NCV
		T;N
	EMG
		T;N
	CT Spine Lumbar w & w/o Contrast
		T;N, Routine
	CT Spine Lumbar w Contrast
		T;N, Routine
	CT Spine Lumbar w/o Contrast
		T;N, Routine
	MRI Lumbar w Contrast
		T;N, Routine
	MRI Lumbar w/o Contrast
		T;N, Routine
	Spine Lumbar AP & Lat
		T;N, Routine
	Spine Lumbar Lat Only
		T;N, Routine
	Spine Lumbar w Obl
		T;N, Routine
Medications
	Lyrica  25 mg oral capsule
		1 CAP, BY MOUTH, BID, # 60 CAP, 0 Refill(s)
	Lyrica  50 mg oral capsule
		1 CAP, BY MOUTH, QHS, # 30 CAP, 0 Refill(s)
Consults/Follow-up
	Communication to CLINIC Nurse
		Obtain Narcotic Agreement
	Follow-up Appointment
		Follow Up Visit, 2 weeks
		Follow Up Visit, 1 month
		Follow Up Visit, 1 week
		Follow Up Visit, 1 year
		Follow Up Visit, 3 months
		Follow Up Visit, 3 weeks
		Follow Up Visit, 6 months
		Follow Up Visit, See Special Instructions
	Procedure to Schedule
		Water Therapy
			Comment: Procare 3 or Alegent Health
	Consult Physical Therapy
		Reason for Referral: Tens Application-PT (1X)
	Consult Neurologist
		
	Consult Psychiatrist
		
	Consult Orthopedics
		
Charges/Supplies
	99221 EVM - Initial Hosp Care, per day,Low; 40 min -PF
		T;N
	99222 EVM - Initial Hosp Care, per day, Mod; 55 min -PF
		T;N
	99223 EVM - Initial Hosp Care, per day, High; 75m
		T;N
	99231 EVM - PF Subseq Hsp Care, per Day, Low; 25 Min -PF
		T;N
	99232 EVM - PF Subseq Hsp Care, per Day, Moderate; 35min PF
		T;N
	99233 EVM - Subseq inpt visit, High; 50 m
		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
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
Supplies
	Back Brace
		T;N
Procedures in Office
	62311 Epidural Steroid Inj Lumbar/Sacral
		
		Cervical
		Lumbar
		Thoracic
	64493 INJECT PARAVERTEBRAL FACET JOINT
		
	77002 Fluoroscopy Guidance for Needle Placement
		C-arm at office
	20552 Trigger point inj sing or mult, 1-2 musc
		
	20553 Trigger point inj sing or mult, >/= 3 musc

*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