Unique Plan Description: Sex Med General Clinic
Plan Selection Display: Sex Med General Clinic
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2012-03-28 14:46:31
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2024-08-19 16:56:09
Available at all facilities: Yes

Sex Med General Clinic
Laboratory
	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
	Beta-HCG Quantitative - Pregnancy
		T;N, Routine, spec type = Blood
	Hemoglobin A1C
		T;N, Routine, spec type = Blood
	Sex Hormone Binding Globulin
		T;N, Routine, spec type = Blood
	Prolactin Level
		T;N, Routine, spec type = Blood
	Vitamin B12 Level
		T;N, Routine, spec type = Blood
	PSA
		T;N, Routine, spec type = Blood
	Testosterone Total and Free (Adult Male)
		T;N, Routine, spec type = Blood
	Testosterone Total/Free (Female/Child)
		T;N, Routine, spec type = Blood
	Iron Panel - MH/WH/JE
		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
	Estradiol Level
		T;N, Routine, spec type = Blood
	TSH
		T;N, Routine, spec type = Blood
	Free T4
		T;N, Routine, spec type = Blood
	T3 Free
		T;N, Routine, spec type = Blood
	Thyroid Panel
		T;N, Routine, spec type = Blood
	Culture Routine
		T;N, Routine, Vagina
	DHEA Sulfate
		T;N, Routine, spec type = Blood
	HIV-1/2 Ag/Ab Combo - MH/WH/JE
		T;N, Routine, spec type = Blood
	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
	Herpes Simplex Virus Ab IgG w/ Reflex Typing
		T;N, Routine, spec type = Blood
	Hepatitis B Surface Antibody
		T;N, Routine
	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
	Hepatitis B Surface Antibody
		T;N, Routine, spec type = Blood
	Herpes Simplex Virus Ab IgG w/ Reflex Typing
		T;N, Routine, spec type = Blood
Urine Studies
	Pregnancy Test Urine
		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
Cervical/Vaginal Specimens
	Varicella Zoster DNA Detection Swab
		T;N, Routine, spec type = Swab
	Varicella Zoster DNA Detection other than blood
		T;N, Routine, spec type = Swab
	Wet Prep - PC/FH
		T;N, Routine, spec type = Genital
	Wet Mt Physician Perform
		
	KOH Prep Physician Perform
		
	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
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

	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
	lidocaine 1% (5 mL) (Xylocaine) (In Office)
		mL, Injection, IM-Intramuscular, Once, NOW
		4 mL, Injection, IM-Intramuscular, Once, NOW
			Comment: into Vestibular glands
		5 mL, Injection, IM-Intramuscular, Once, NOW
			Comment: to iliococcyges left or right
		5 mL, Injection, IM-Intramuscular, Once, NOW
			Comment: to levator ani left or right
	lidocaine 2% in 5mL Vial (Xylocaine) (In Office)
		mL, Injection, IM-Intramuscular, Once, NOW
		4 mL, Injection, IM-Intramuscular, Once, NOW
			Comment: to Vestibular glands
		5 mL, Injection, IM-Intramuscular, Once, NOW
			Comment: to iliococcyges left or right
		5 mL, Injection, IM-Intramuscular, Once, NOW
			Comment: to levator ani left or right
	onabotulinumtoxinA (Botox) (In Office)
		100 units, Injection, IM-Intramuscular, Once, NOW
			Comment: into vestibular glands.
	triamcinolone 40mg/mL (Kenalog-40)(In Office)
		20 mg, Injection, IM-Intramuscular, Once, NOW
			Comment: to vestibular glands x4
		40 mg, Injection, IM-Intramuscular, Once, NOW
			Comment: to iliococcygeus  Left
		40 mg, Injection, IM-Intramuscular, Once, NOW
			Comment: to iliococcygeus Right
		40 mg, Injection, IM-Intramuscular, Once, NOW
			Comment: to levator ani        Left
		40 mg, Injection, IM-Intramuscular, Once, NOW
			Comment: to levator ani        Right
		40 mg, Injection, IM-Intramuscular, Once, NOW
			Comment: to posterior fourchette
		20 mg, Injection, IM-Intramuscular, Once, NOW
			Comment: to posterior fourchette
	lidocaine-EPINEPHrine 2%-1:100000 (In Office)
		mL, Injection, IM-Intramuscular, Once, NOW
		mL, Injection, SUBCUTANEOUS, Once, NOW
		5 mL, Injection, SUBCUTANEOUS, Once, NOW
		10 mL, Injection, SUBCUTANEOUS, Once, NOW
		15 mL, Injection, SUBCUTANEOUS, Once, NOW
Patient Care
	Straight Catheter
		
Consults/Follow-up
	Follow-up Appointment
		Follow Up Visit, 1 month
		Follow Up Visit, 1 week
		Follow Up Visit, 2 weeks
		Follow Up Visit, 3 weeks
		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 Physical Therapy
		
	Consult Urogynecologic
		
	Consult OB/GYN
		
	Consult Gastroenterologist
		
Charges/Supplies
Procedures in Office
	56420 I&D Bartholin Gland Abscess
		
	58301 IUD removal
		
	56405 I&D Vulva or Perineal Abscess
		
	20553 Trigger point inj sing or mult, >/= 3 musc
		
	zz96372 Injection Ther/Proph/Diag   SC/IM
		
	20552 Trigger point inj sing or mult, 1-2 musc
		
	56605 Biopsy vulva or perineum, 1 lesion
		
	56606 Biopsy vulva or perineum, ea addl
		
	56821 Colposcopy  Vulva , Biopsy
		
	57420 Colposcopy, Vagina
		
	11980 Implant hormone pellet subcu
		
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
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
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
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

Female Testopel Panel Clinic
Laboratory

	Lipid Panel
		T;N, Routine, spec type = Blood
	Hemoglobin
		T;N, Routine, spec type = Blood
	Hematocrit
		T;N, Routine, spec type = Blood
	Hemoglobin and Hematocrit
		T;N, Routine, spec type = Blood
	Hepatic Function Panel
		T;N, Routine, spec type = Blood
	Testosterone Total/Free (Female/Child)
		T;N, Routine, spec type = Blood
Consults/Follow-up
	Follow-up Appointment
		Follow Up Visit, 3-4 months
		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

Male Testopel Panel Clinic
Laboratory
	Lipid Panel
		T;N, Routine, spec type = Blood
	Hemoglobin
		T;N, Routine, spec type = Blood
	Hematocrit
		T;N, Routine, spec type = Blood
	Hemoglobin and Hematocrit
		T;N, Routine, spec type = Blood
	Hepatic Function Panel
		T;N, Routine, spec type = Blood
	Testosterone Total and Free (Adult Male)
		T;N, Routine, spec type = Blood
	PSA
		T;N, Routine, spec type = Blood
Consults/Follow-up
	Follow-up Appointment
		Follow Up Visit, 3-4 months
		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

Menopause Panel Clinic
Laboratory
	LH
		T;N, Routine, spec type = Blood
	FSH
		T;N, Routine, spec type = Blood
	Estradiol Level
		T;N, Routine, spec type = Blood
Consults/Follow-up
	Follow-up Appointment
		Follow Up Visit, 1 month
		Follow Up Visit, 1 week
		Follow Up Visit, 2 weeks
		Follow Up Visit, 3 weeks
		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

*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