Unique Plan Description: UROGYN General Clinic
Plan Selection Display: UROGYN General Clinic
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2012-03-04 21:22:41
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2024-03-04 14:48:27
Available at all facilities: Yes

UROGYN General Clinic
Laboratory
	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 Straight Cath, spec type = Urine
	CBC with Diff
		T;N, Routine, spec type = Blood
	Hemogram (CBC no Diff)
		T;N, Routine, spec type = Blood
	CA 125
		T;N, Routine, spec type = Blood
	Basic Metabolic Panel
		T;N, Routine, spec type = Blood
	Comprehensive Metabolic Panel
		T;N, Routine, spec type = Blood
	Wet Prep - PC/FH
		T;N, Routine, spec type = Genital
		T;N, Routine, spec type = Scrapings
		T;N, Routine, spec type = Skin
		T;N, Routine, spec type = Wound
	Herpes Simplex Virus 1/2 PCR. Other than blood
		T;N, Routine, spec type = Genital
	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
	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 CV & 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
	Wet Mt Physician Perform
		
Point of Care
	Urine Dipstick POC - PC
		T;N, Urine
Diagnostic Tests
Diagnostics
	Cystogram
		T;N, Routine
	Cystourethrogram Retrograde
		T;N, Routine
	Fluoro <1hr Urology
		T;N, Routine
	Hysterosalpingogram
		T;N, Routine
	IVP
		T;N, Routine
CT
	CT Urogram
		T;N, Routine
Ultrasound
	US Pelvis Complete Non OB
		T;N, Routine
	US Pelvis Limited
		T;N, Routine
	US Renal Retro Complete
		T;N, Routine
	US Renal Retro Limited
		T;N, Routine
	US Transvaginal
		T;N, Routine
MRI
	MRI Pelvis w&w/o Contrast
		T;N, Routine
Medications

	HEParin 10,000 units/mL (In Office)
		30,000 units, Solution, Catheter, Once, NOW
			Comment: Into bladder.
	triamcinolone 40mg/mL (Kenalog-40)(In Office)
		40 mg, Injection, Catheter, Once, NOW
	gentamicin (In Office)
		mg, Injection, IM-Intramuscular, Once, NOW
	bupivacaine 0.5% (Marcaine/Sensorcaine) 50 mL vial (In Office)
		5 mL, Injection, Catheter, Once, NOW
	lidocaine 1% (5 mL) (Xylocaine) (In Office)
		10 mL, Injection, IM-Intramuscular, Once, NOW
			Comment: Into pelvic area (trigger points)
		10 mL, Injection, MISC, Once, NOW
			Comment: Into pelvic area (trigger points)
	sodium bicarbonate (In Office)
		10 mL, Injection, Catheter, Once, NOW
			Comment: bladder instillation
	Coaptite (In Office)
		1 mL, Injection, MISC, Once, NOW
			Comment: per scope depending on urethral size.
		2 mL, Injection, MISC, Once, NOW
			Comment: per scope depending on urethral size.
	Macroplastique (In Office)
		1 mL, Injection, MISC, Once, NOW
			Comment: per scope depending on urethral size.
	cefTRIAXone 250mg IM (Rocephin) (In Office)
		1,000 mg, Injection, IM-Intramuscular, Once, NOW
			Comment: Inject deep into Muscle
	lidocaine 2% Jelly Urojet (In Office)
		1 appl, Gel, TOPICAL, Once, T;N
Patient Care
	51701 Insert Non-Indwell bladder catheter
		
	51700 Bladder irrigation simple lav/instillation
		
	51798 Post-voiding residual/bladder capacity US
		
	51702 Insert temp indwelling bladder cath simp (foley)
		
Consults/Follow-up
	Follow-up Appointment
		Follow Up Visit, PRN
		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
Charges/Supplies
	A4562 CLS-PESSARY NON-RUBBER, ANY TYPE
		
	zz99354 EVM - Prolonged Care, Outpatient, 1 Hr
		T;N
	99355 EVM - Prolonged Care, Outpatient, Ea Addl 30 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 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
No Charge / Follow Up
	99213C EVM - MPC CLINIC AUDIT BY CODER
		T;N
	99211n EVM - No Charge Professional Service
		T;N
	99024 EVM - Post Op Visit
		T;N
Procedures in Office
	56605 Biopsy vulva or perineum, 1 lesion
		
	56606 Biopsy vulva or perineum, ea addl
		
	58100 Endometrial bx wo cervical dilation
		
	51715 Endoscopic Injection Urethra and/or Bladder Neck
		
	77002 Fluoroscopy Guidance for Needle Placement
		
	58340 Injection for HSG or SIS
		
	74740 HSG radiologic S&I
		
	76831 SIS US S&I
		
	57160 Insert Pessary
		
	51702 Insert temp indwelling bladder cath simp (foley)
		
	51785 Needle EMG Anal or Urethral Sphincter
		
	20552 Trigger point inj sing or mult, 1-2 musc
		
	20553 Trigger point inj sing or mult, >/= 3 musc
		
	53660 Urethral Dilation, Initial
		
	53661 Urethral Dilatation, Subsequent
		
		Urodynamics(NOTE)*
	51729 Complex Cystometrogram w/Voiding Pressure Study
		
	51741 Complex Uroflowmetry
		
	52000 Cystoscopy
		
	51726 Cystometrogram, Complex
		
	51727 Cystometrogram w/Urethal Pressure Profile
		
	51728 Cystometrogram w/Voiding Pressure Study
		
	51784 EMG, Urethral or Anal Sphincter
		
	51600 Injection For Cystography
		
	51797 Voiding Pressure Studies, Intra-abdominal
		
		InterStim(NOTE)*
	95972 Analyze neurostimulator, w/ program, 1st hr
		
	97032 Apply electrical stimulation/15min
		
	97014 Apply electrical stimulation (unattended)
		
	58536 Endometrial Cryoablation
		
	64590 Insert/Repair  Peripheral Neurostimulator Receiver/Generator
		
	64561 Percutaenous Implant Neurostimulator, Sacral Nerve
		
Supplies
	A4290 CLS-INSTERSTIM TX TEST KIT, 2 UNITS

*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