Unique Plan Description: PMR General Clinic
Plan Selection Display: PMR General Clinic
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2012-03-27 18:43:39
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2024-09-23 00:37:27
Available at all facilities: Yes

PMR General Clinic
Laboratory
	CBC with Diff
		T;N, Routine, spec type = Blood
	Hemogram (CBC no Diff)
		T;N, Routine, spec type = Blood
	Comprehensive Metabolic Panel
		T;N, Routine, spec type = Blood
	Hepatic Function Panel
		T;N, Routine, spec type = Blood
	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
	Urinalysis
		T;N, Routine, Routine, spec type = Urine
Urine Studies
	UA (Culture if Positive)
		T;N, Routine, Routine, spec type = Urine
Diagnostic Tests
Diagnostics
	Hip Min 2 View Lt
		T;N, Routine
	Hip Min 2 View Rt
		T;N, Routine
	Knee 1 or 2 View Lt
		T;N, Routine
	Knee 1 or 2 View Rt
		T;N, Routine
	Knee 3 View Lt
		T;N, Routine
	Knee 3 View Rt
		T;N, Routine
	Knee Min 4 View Lt
		T;N, Routine
	Knee Min 4 View Rt
		T;N, Routine
	Spine Cervical Lat w Flex & Ext
		T;N, Routine
	Spine Lumbar Lat w Flex & Ext
		T;N, Routine
	Spine Thoracic AP & Lat
		T;N, Routine
	Shoulder Min 2 View Lt
		T;N, Routine
	Shoulder Min 2 View Rt
		T;N, Routine
	Wrist Min 3 View Lt
		T;N, Routine
	Wrist Min 3 View Rt
		T;N, Routine
	Spine Lumbar AP & Lat
		T;N, Routine
	Spine Lumbar w Obl
		T;N, Routine
	Spine Cervical 2 or 3 View
		T;N, Routine
	Spine Cervical w Obl
		T;N, Routine
CT
	CT Spine Cervical w Contrast
		T;N, Routine
	CT Spine Thoracic w/o Contrast
		T;N, Routine
	CT Spine Lumbar w/o Contrast
		T;N, Routine
	CT Head w/o Contrast
		T;N, Routine
MRI
	MRI Cervical w Contrast
		T;N, Routine
	MRI Thoracic w/o Contrast
		T;N, Routine
	MRI Lumbar w/o Contrast
		T;N, Routine
	MRI Pelvis w/o Contrast
		T;N, Routine
	MRI Brain w/o Contrast
		T;N, Routine
Medications

	Baclofen (Gablofen Intrathecal) 40mg/20mL (2000mcg/mL) (In Office)
		10 mg, Kit, IntraThecal, Once, NOW
	Baclofen (Gablofen Intrathecal) 10mg/20mL (500mcg/mL)  (In Office)
		10 mg, Kit, IntraThecal, Once, NOW
	Baclofen (Gablofen Intrathecal) 20mg/20mL (1000mcg/mL) (In Office)
		20 mg, Injection, IntraThecal, Once, NOW
	Baclofen (Gablofen Intrathecal) 40mg/20mL (2000mcg/mL) (In Office)
		40 mg, Kit, IntraThecal, Once, NOW
	betamethasone acet-betamethasone na phosphate (Celestone Soluspan) (In Office)
		0 mg, Injection, IntraArticular, Once, NOW
	triamcinolone 40mg/mL (Kenalog-40)(In Office)
		mg, Injection, IntraArticular, Once, NOW
	onabotulinumtoxinA (Botox) (In Office)
		units, Injection, SUBCUTANEOUS, Once, NOW
	dexamethasone (Decadron) 4mg/mL  (In Office)
		mg, Injection, IM-IntraMUSCULAR, Once, NOW
			Comment: Dosage Depending upon weight
	lidocaine 1% (5 mL) (Xylocaine) (In Office)
		10 mL, Injection, SUBCUTANEOUS, Once, NOW
		10 mL, Injection, IM-Intramuscular, Once, NOW
	lidocaine 1% (2 mL) (Xylocaine) (In Office)
		2 mL, IM-Intramuscular, Once, NOW
		2 mL, SUBCUTANEOUS, Once, NOW
	bupivacaine 0.25% (Marcaine/Sensorcaine) (In Office)
		10 mL, Injection, SUBCUTANEOUS, Once, NOW
		10 mL, Injection, IM-Intramuscular, Once, NOW
	bupivacaine 0.5% (Marcaine/Sensorcaine) 50 mL vial (In Office)
		30 mL, Injection, SUBCUTANEOUS, Once, NOW
		30 mL, Injection, IM-Intramuscular, Once, NOW
	zzethanol (Dehydrated Alcohol 98% injectable soln) (In Office)
		1 EA, Injection, INJ Soft Tissue, Once, NOW
		2 EA, Injection, INJ Soft Tissue, Once, NOW
		3 EA, Injection, INJ Soft Tissue, Once, NOW
		4 EA, Injection, INJ Soft Tissue, Once, NOW
		5 EA, Injection, INJ Soft Tissue, Once, NOW
	incobotulinumtoxinA (Xeomin) (In Office)
		50 units, Injection, SUBCUTANEOUS, Once, NOW
		100 units, Injection, SUBCUTANEOUS, Once, NOW
	methylPREDNISolone (Depo-Medrol 40 mg/mL) (In Office)
		40 mg, Suspension-Injection, IM-Intramuscular, Once, NOW
		40 mg, Suspension-Injection, IntraSynovial, Once, NOW
		40 mg, Suspension-Injection
	lidocaine 2% in 5mL Vial (Xylocaine) (In Office)
		5 mL, Injection, IM-Intramuscular, Once, NOW
		5 mL, Injection, SUBCUTANEOUS, Once, NOW
	zzlidocaine 1% (Xylocaine) (In Office)
		2 mL, Injection
	lidocaine 2% in 5mL Vial (Xylocaine) (In Office)
		5 mL, Injection
	ziconotide (Prialt) 25mcg/ml intrathecal solution (In Office)
		500 mcg, Injection, IntraThecal, Once, NOW
			Comment: To fill Medtronic pump
	Anti-Embolism Stockings Script
		
Consults/Follow-up
	Procedure to Schedule
		
	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, 1 month
		Follow Up Visit, 4 months
		Follow Up Visit, 6 months
		Follow Up Visit, 1 year
		Follow Up Visit, See Special Instructions
		Follow Up Visit, PRN
	Consult Family medicine
		
	Consult Internal Medicine
		
	Consult Neurologist
		
	Consult Neurosurgery
		
	Consult Orthopedics
		
	Consult Physical Therapy
		
	Consult Psychiatrist
		
	Consult Speech Therapy
		
	Consult Other
		
Charges/Supplies
	99211n EVM - No Charge Professional Service
		
Est. Pt Visit
	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
	99366 EVM - Medical Team Conf with Patient
		T;N
	99367 EVM - Medical team conference wo pt
		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
Procedures in Office
	20600 Arthrocentesis asp/inj small joint/bursa
		
	20605 Arthrocentesis asp/inj intermediate joint/bursa
		
	20610 Arthrocentesis asp/inj major joint/bursa
		
	U2369 Nurse Refill w/ Reprogramming
		
	U5990 Nurse Refill w/o Reprogramming
		
	62367 Electronic analysis of pump w/o reprogramming or refill
		
	U2367 Pump w/o Programming
		
	62368 Electronic analysis of pump w/ reprogramming
		
	U2368 Pump with Reprogramming
		
	62370 MD Refill with reprogramming of pump
		
	U2370 Physician Refill with Reprogramming
		
	95991 MD Refill w/o reprogramming of pump
		
	U5991 Physician Refill w/o Reprogramming
		
	64612 Chemodenervation, Muscles(s), Facial Nerves
		
	64616 CHEMODENERV MUSC NECK DYSTON
		
	64642 CHEMODENERV 1 EXTREMITY 1-4
		
	64643 Chemodenervation, 1 Extremity 1-4, EA
		
	64644 CHEMODENERV 1 EXTREM 5/> MUS
		
	64645 Chemodenervation, 1 Extremity 5/>, EA
		
	64646 CHEMODENERV TRUNK MUSC 1-5
		
	64647 CHEMODENERV TRUNK MUSC 6/>
		
	64653 Destruct Other Scalp,Neck,Face Neurolytic Agent
		
	64640 Destruct Peripheral/Branch Nerve Neurolytic Agent
		
	95873 E-Stim for guidance during chemodenervation
		
	95874 EMG for guidance during chemodenervation
		
	zz96372 Injection Ther/Proph/Diag   SC/IM
		
	20550 Tendon sheath/ligament inj single
		
	20551 Tendon sheath origin inj single
		
	20552 Trigger point inj sing or mult, 1-2 musc
		
	20553 Trigger point inj sing or mult, >/= 3 musc
		
Prolonged Care
	zz99354 EVM - Prolonged Care, Outpatient, 1 Hr
		T;N
	99355 ES-OP Prolonged Services; Each Addl 30 Min
		T;N

*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