Unique Plan Description: PMC Spinal Stenosis Clinic
Plan Selection Display: PMC Spinal Stenosis Clinic
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2012-03-09 12:29:01
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2023-05-17 15:14:33
Available at all facilities: No

PMC Spinal Stenosis Clinic
Laboratory
	INR - MH/WH/JE
		T;N, Routine, spec type = Blood
	Platelet Count
		T;N, Routine, spec type = Blood
	BUN
		T;N, Routine, spec type = Blood
	Creatinine
		T;N, Routine, spec type = Blood
	Urinalysis
		T;N, Routine, Routine, spec type = Urine
	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
Diagnostics
	Bone Imaging Whole Body
		T;N, Routine
	Spine Cervical 2 or 3 View
		T;N, Routine
	Spine Cervical Lat Only
		T;N, Routine
	Spine Lumbar AP & Lat
		T;N, Routine
	Spine Lumbar Lat Only
		T;N, Routine
	Spine Lumbar w Obl
		T;N, Routine
	Spine Thoracic 3 View
		T;N, Routine
	Spine Thoracic AP & Lat
		T;N, Routine
	Spine Thoracic Lat Only
		T;N, Routine
CT
	CT Spine Cervical w & w/o Contrast
		T;N, Routine
	CT Spine Cervical w Contrast
		T;N, Routine
	CT Spine Cervical w/o Contrast
		T;N, Routine
	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
	CT Spine Thoracic w & w/o Contrast
		T;N, Routine
	CT Spine Thoracic w Contrast
		T;N, Routine
	CT Spine Thoracic w/o Contrast
		T;N, Routine
MRI
	MRI Cervical w Contrast
		T;N, Routine
	MRI Cervical w/o Contrast
		T;N, Routine
	MRI Lumbar w Contrast
		T;N, Routine
	MRI Lumbar w/o Contrast
		T;N, Routine
	MRI Thoracic w Contrast
		T;N, Routine
	MRI Thoracic w/o Contrast
		T;N, Routine
Medications

	Mobic 7.5 mg oral tablet
		1 TAB, BY MOUTH, DAILY, # 30 TAB, 0 Refill(s)
	naproxen 500 mg oral tablet
		1 TAB, BY MOUTH, BID, # 60 TAB, 0 Refill(s), Hard Stop
	CeleBREX 200 mg oral capsule
		1 CAP, BY MOUTH, DAILY, # 30 CAP, 0 Refill(s)
	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)
	Neurontin 300 mg oral capsule
		1 CAP, BY MOUTH, QHS, # 30 CAP, 0 Refill(s), Soft Stop
	Topamax  25 mg oral tablet
		1 TAB, BY MOUTH, DAILY, # 30 TAB, 0 Refill(s)
	Zonegran 100 mg oral capsule
		1 CAP, BY MOUTH, DAILY, # 30 CAP, 0 Refill(s)
	Cymbalta 60 mg oral delayed release capsule
		1 CAP, BY MOUTH, DAILY, (do not crush or chew), # 30 CAP, 0 Refill(s)
	amitriptyline 10 mg oral tablet
		1 TAB, BY MOUTH, QHS, # 30 TAB, 0 Refill(s)
	Lidoderm 5% topical film
		See instructions, Apply patch to affected area 12 hours on, 12 hours off, # 1 pkg, 0 Refill(s), Hard Stop
	acetaminophen-hydrocodone 325 mg-5 mg oral tablet
		1 TAB, BY MOUTH, Q6H, PRN pain, # 60 TAB, 0 Refill(s), Hard Stop
	acetaminophen-hydrocodone 325 mg-7.5 mg oral tablet
		1 TAB, BY MOUTH, Q6H, PRN pain, # 60 TAB, 0 Refill(s), Hard Stop
	Percocet 5 mg-325 mg oral tablet
		1 TAB, BY MOUTH, Q6H, PRN pain, # 60 TAB, 0 Refill(s), Hard Stop
	Percocet 7.5 mg-325 mg oral tablet
		1 TAB, BY MOUTH, Q6H, PRN pain, # 30 TAB, 0 Refill(s), Hard Stop
	Percocet 10 mg-325 mg oral tablet
		1 TAB, BY MOUTH, Q6H, PRN pain, # 30 TAB, 0 Refill(s), Hard Stop
	morphine 30 mg/24 hours oral capsule, extended release
		1 CAP, By Mouth, Q24H, # 30 CAP, 0 Refill(s)
	Dilaudid 4 mg oral tablet
		1 TAB, BY MOUTH, Q6H, # 60 TAB, 0 Refill(s), Hard Stop
	diclofenac 1% topical gel
		1 appl, TOPICAL, TID, # 100 gm, 5 Refill(s)
	cyclobenzaprine  5 mg oral tablet
		1 TAB, BY MOUTH, Q8H, PRN muscle spasms, # 30 TAB, 0 Refill(s), Hard Stop
	Skelaxin 800 mg oral tablet
		1 TAB, BY MOUTH, Q8H, PRN muscle spasms, # 30 TAB, 0 Refill(s), Hard Stop
	Ultram 50 mg oral tablet
		1 TAB, BY MOUTH, Q6H, PRN muscle spasms, # 30 TAB, 0 Refill(s), Hard Stop
	traMADol 100 mg/24 hours oral capsule, extended release
		1 TAB, BY MOUTH, Q24H, PRN muscle spasms, # 30 TAB, 0 Refill(s), Soft Stop
Consults/Follow-up
	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
	Request for Service
		Water Therapy
			Comment: Pro Care 3, Alegent Health
	Consult Physical Therapy
		Reason for Referral: Evaluation and Screen, Special Instructions Tens Application-PT (1X)
	Consult Neurologist
		
	Consult Neurosurgery
		
	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
	27096 INJECTION SI JOINT, W/ FLUORO GUIDANCE

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NOTE - This component is a note
Rx - This component is a prescription
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