/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/order-sets/,/clinical/cckm-tools/content/order-sets/ambulatory/,/clinical/cckm-tools/content/order-sets/ambulatory/vascular-surgery/,

/clinical/cckm-tools/content/order-sets/ambulatory/vascular-surgery/name-98510-en.cckm

201710291

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Ambulatory,Vascular Surgery

FDS - Vascular Surgery - Adult - Preoperative [2795]

FDS - Vascular Surgery - Adult - Preoperative [2795] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Vascular Surgery


FDS - Vascular Surgery - Adult - Preoperative [2795]
for Adult Patients OnlyIntended
Carotid Stent or Carotid Endarterectomy Preprocedure orders use one of the For
following order sets:
[5292]Preprocedure -Adult -Carotid Endarterectomy -FDS
[5295] Preprocedure -Adult -Carotid Stent Placement (Neuro Suite/OR) -FDS
[5322]Preprocedure -Adult -Carotid Stent Placement (Cath Lab) -FDS
Pre-Day of Procedure
Non-Categorized Patient Care Orders [111679]
chlorhexidine gluconate (HIBICLENS) 4 % topical
liquid [64730]
237 mL, , starting 10/11/17, Normal
Medications-MRSA/MSSA Positive [138973]
Note: Please select the orders below if patient is MRSA or MSSA positive
mupirocin (BACTROBAN) 2 % ointment [45826] 1 Tube, 0, starting 10/11/17, E-Prescribe
chlorhexidine gluconate (HIBICLENS) 4 % topical
liquid [64730]
237 mL, , starting 10/11/17, E-Prescribe
Labs - MRSA and MSSA Screening [138594]
MRSA/MSSA BY PCR [HCMSSA] Status: Standing, Expires:2/10/18 Manual,Count:1,
Office collect, Routine, A Pre-Surgical screen consists
of one culturette swab from both left and right nares.
This assay cannot detect MSSA when MRSA is
present.
Laboratory [86963]
CBC WITH DIFFERENTIAL [CBC] Status: Standing, Expires:11/25/17 MANUAL,Count:1,
Normal, Routine
ELECTROLYTES [LYTE] Status: Standing, Expires:11/25/17 MANUAL,Count:1,
Normal, Routine
BUN [BUN] Status: Standing, Expires:11/25/17 MANUAL,Count:1,
Normal, Routine
CREATININE [CRET] Status: Standing, Expires:11/25/17 MANUAL,Count:1,
Normal, Routine
CALCIUM [CA] Status: Standing, Expires:11/25/17 MANUAL,Count:1,
Normal, Routine
MAGNESIUM [MAG] Status: Standing, Expires:11/25/17 MANUAL,Count:1,
Normal, Routine
PHOSPHATE [PHOS] Status: Standing, Expires:11/25/17 MANUAL,Count:1,
Normal, Routine
GLUCOSE [GLU] Status: Standing, Expires:11/25/17 MANUAL,Count:1,
Normal, Routine
PROTHROMBIN TIME/INR [PT] Status: Standing, Expires:11/25/17 MANUAL,Count:1,
Normal, Routine
PTT [PTT] Status: Standing, Expires:11/25/17 MANUAL,Count:1,
Normal, Routine
URINALYSIS WITH MICROSCOPY AND
CULTURE IF >5 WBC/HPF [HCUACULT]
Status: Standing, Expires:11/25/17 MANUAL,Count:1,
Normal, Routine
Laboratory - Pregnancy Test [87226]
surgery is pelvic, renal, pregnancy test if female between menarche & menopause and any of: (1) Obtain
intercourse, (3) patient missed menses, (4) patient says abdominal, (2) patient had unprotected -or intra
pregnant. she "could" be
Page 1 of 11
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10/2017CCKM@uwhealth.org

Urine, Pregnancy Test [UPREG] Status: Standing, Expires:11/25/17 MANUAL,Count:1,
Normal, Routine
Labs - Blood Bank [154611]
Antibody Screen
Use to prescreen patient for alloantibodies to red blood cell components. Order if specimen collection will
be greater than 72 hours prior to surgery. Blood products cannot be issued on the basis of this test.
ABO and Rh Typing
Use to determine patient blood type. Order if specimen collection will be greater than 72 hours prior to
surgery. Blood products cannot be issued on the basis of this test.
Type and Screen
Order if specimen collection will be less than 72 hours prior to surgery.
ANTIBODY SCREEN [ABSCR] Status: Standing, Expires:11/25/17 MANUAL,Count:1,
Normal, Routine
Diagnostic Tests and Imaging [87134]
ECG - 12 Lead [EKG0008] Status: Future, Expires: 11/11/2018, Normal, Routine
Routine EEG [EEG0004] Status: Future, Expires: 4/14/2019, Normal, Routine
X-RAY CHEST PA & LAT VIEWS [R71020] Status: Future, Expires: 12/11/2018, Normal, Routine
X-Ray Chest PA & LAT Views Dual Energy
[R71020A]
Status: Future, Expires: 12/11/2018, Normal, Routine
Pulmonary Lab Testing [999992] Routine
Reason for Exam:
Specify Test:
Specify location (if desired):
NM Rest & Stress Test [117124]
Stress Test order. Nuclear routine This panel is the OP Level II Chest Pain and
Both orders are required for stress testing. Do not remove the orders.
NM MYOCARDIAL PERFUSION REST &
STRESS (SPECT) W WALL MOTION &
EJECTION FRACTION [R78452]
Status: Future, Expires: 12/11/2018, Normal,
Routine
Exercise or Drug Stress Test (with Nuclear
Medicine) [EKG0007]
Status: Future, Expires: 11/11/2018, Normal,
Routine
MRA SPINAL CANAL W OR W/ O CONTRAST
[R72159]
Status: Future, Expires: 12/11/2018, Normal, Routine
Pre-Op Day of Procedure
Isolation Status [97372]
Isolation - Enhanced Contact - Clostridium
Difficile [ISO0010]
CONTINUOUS, Separate order must be placed for
isolation cart., Pre-Op Day Of Procedure
Isolation - Contact - MRSA [ISO0039] CONTINUOUS, Separate order must be placed for
isolation cart., Pre-Op Day Of Procedure
Isolation - Contact - VRE [ISO0051] CONTINUOUS, Separate order must be placed for
isolation cart., Pre-Op Day Of Procedure
Isolation - Protective Precautions - Panel
[116356]
Protective Precautions [ISO0001] CONTINUOUS
Reason for Protective Precautions:
Pre-Op Day Of Procedure
Protective - Positive Pressure Room
[NURCOM0109]
CONTINUOUS, Pre-Op Day Of Procedure
Isolation - Contact - Multidrug Resistant
Organism - Panel [116335]
Page 2 of 11
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Isolation - Contact - Multidrug Resistant
Organism (MDR) [ISO0006]
CONTINUOUS, Pre-Op Day Of Procedure
Isolation Cart [EQP0016] CONTINUOUS, Routine, Pre-Op Day Of Procedure
Isolation - Contact - Extensively Resistant
Organism (XDR) - Panel [193206]
Isolation - Contact - Extensively Drug Resistant
Organism (XDR) [ISO0320]
CONTINUOUS, Pre-Op Day Of Procedure
Isolation Cart [EQP0016] CONTINUOUS, Routine, Pre-Op Day Of Procedure
Perioperative Normogyclemia Management - For First Day Surgery Patients Only (Single Response)
[216835]
equal to 6.4%diabetes history includes prediabetes and patients with A1C less than or No
Patients withOUT Diabetes [216834]
Glucose, POC [IPGLUCOSE] ONCE For 1 Occurrences, Routine, Glucose, POC
should always be ordered in conjunction with orders
for hypoglycemia management and monitoring as
indicated in the Hypoglycemia Management (Adult)
panel.
If Conditional, What Condition?
Pre-Op Day Of Procedure
Glucose, POC [IPGLUCOSE] EVERY 2 HOURS, Routine, Glucose, POC should
always be ordered in conjunction with orders for
hypoglycemia management and monitoring as
indicated in the Hypoglycemia Management (Adult)
panel.
If Conditional, What Condition?
Repeat POC glucose if previous reading greater
than or equal to 180 mg/dL. No recheck for reading
< 180 mg/dL, Pre-Op Day Of Procedure
Notify Provider [NURCOM0001] Provider to Notify: Other (Comment)
Notify based on: Blood Glucose
If blood glucose > (mg/dL): 179
If blood glucose < (mg/dL):
Pre-Op Day Of Procedure
Patients WITH Diabetes [216834]
Glucose, POC [IPGLUCOSE] ONCE For 1 Occurrences, Routine, Glucose, POC
should always be ordered in conjunction with orders
for hypoglycemia management and monitoring as
indicated in the Hypoglycemia Management (Adult)
panel.
If Conditional, What Condition?
Pre-Op Day Of Procedure
Glucose, POC [IPGLUCOSE] EVERY 2 HOURS, Routine, Glucose, POC should
always be ordered in conjunction with orders for
hypoglycemia management and monitoring as
indicated in the Hypoglycemia Management (Adult)
panel.
If Conditional, What Condition?
Repeat POC glucose if previous reading greater
than or equal to 180 mg/dL. No recheck for reading
< 180 mg/dL, Pre-Op Day Of Procedure
Notify Provider [NURCOM0001] Provider to Notify: Other (Comment)
Notify based on: Blood Glucose
If blood glucose > (mg/dL): 179
If blood glucose < (mg/dL):
Pre-Op Day Of Procedure
Non-Categorized Patient Care Orders [92390]
Page 3 of 11
Printed by STRAKA, KEVIN F [KFS1] at 10/11/2017 7:13:16 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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10/2017CCKM@uwhealth.org

Glucose, POC [IPGLUCOSE] ONCE, Starting today For 1 Occurrences, Routine,
Glucose, POC should always be ordered in
conjunction with orders for hypoglycemia management
and monitoring as indicated in the Hypoglycemia
Management (Adult) panel.
If Conditional, What Condition?
Pre-Op Day Of Procedure
Premedications for Needle Insertion [106313]
Use lidocaine topical dressing kit for stable patient, no lidocaine allergies, have at least 30
minutes time prior to needing to use IV
Sodium chloride (bacteriostatic) 0.9% intradermal: Useful for patients requiring urgent IV
access; onset is within 1 minute. Choice of medication should be based on patient’s previous
experience/preference, history of lidocaine allergy and ease of access.
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Pre-Op Day Of Procedure
lidocaine (LMX) 4% topical dressing kit [66882] Topical, EVERY 1 HOUR PRN, peripheral line
insertion - see Admin Instructions
Do NOT apply to area greater than 200 square
centimeters (maximum 2.5 g/site; maximum 4 sites
per hour, 6 times per day). Do NOT leave on longer
than 2 hours. Use for stable patient, no allergies to
lidocaine, with at least 30 minutes time prior to IV use
Pre-Op Day Of Procedure
lidocaine (XYLOCAINE) 1% injection [39034] 0.1-0.4 mL, Intradermal, PRN, peripheral line insertion
- see Admin Instructions
Use an insulin or TB syringe with a 25-30 gauge
needle to inject solution and create a wheal. Wait 30
seconds to 1 minute then insert IV catheter into center
of wheal. Use if IV is needed within 30 minutes.
Choice of medication should be based on patient’s
previous experience/preference, history of lidocaine
allergy and ease of access
Pre-Op Day Of Procedure
sodium chloride (bacteriostatic) 0.9 % injection
[50585]
0.05-0.1 mL, Intradermal, PRN, peripheral line
insertion - see Admin Instructions
Use an insulin or TB syringe with a 25-30 gauge
needle to inject solution and create a wheal. Wait 30
seconds to 1 minute then insert IV catheter into center
of wheal. Use if IV is needed within 30 minutes.
Choice of medication should be based on patient’s
previous experience/preference, history of lidocaine
allergy and ease of access
Pre-Op Day Of Procedure
Laboratory [87177]
CBC WITH DIFFERENTIAL [CBC] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
Page 4 of 11
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CBC WITHOUT DIFFERENTIAL [HEMO] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
ELECTROLYTES [LYTE] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
BUN [BUN] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
CREATININE [CRET] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
GLUCOSE [GLU] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
CALCIUM [CA] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
PROTHROMBIN TIME/INR [PT] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
PTT [PTT] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
Laboratory - Pregnancy Test [81397]
surgery is pelvic, renal, pregnancy test if female between menarche & menopause and any of: (1) Obtain
intercourse, (3) patient missed menses, (4) patient says abdominal, (2) patient had unprotected -or intra
pregnant. she "could" be
Urine, Pregnancy Test [UPREG] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
Tests [127550]
Page 5 of 11
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TYPE AND SCREEN [HCTS] STAT, Starting today For 1 Occurrences, Routine, As
good clinical practice and for patient safety, the
Transfusion Service will automatically crossmatch 2
packed RBCs on all patients with antibodies to ensure
blood would be available in the event it is needed. If
you would like to opt out of this automatic order for this
patient please contact the UWHC Blood Bank at (608)
263-8367 or The American Center Lab at (608) 234-
6600 as appropriate., Pre-Op Day Of Procedure
Blood Products [83983]
Red Blood Cells (Adult) [BLB0006] 1 UNIT, Starting today For 1 Occurrences, Routine
Reason for Order: R1 Life-threatening hemorrhage or
anticipated/ongoing surgical blood loss
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): SURGICAL USE
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates
up to 4 Months Only) (May be pre-selected based on
history):
Consent Status:
Pre-Op Day Of Procedure
Plasma (Adult) [BLB0003] Starting today, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): SURGICAL USE
Date Product Needed:
Consent Status:
Pre-Op Day Of Procedure
Platelets (Adult) [BLB0004] 1 SINGLE, Starting today For 1 Occurrences, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): SURGICAL USE
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates
up to 4 Months Only) (May be pre-selected based on
history):
Consent Status:
Pre-Op Day Of Procedure
Page 6 of 11
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Cryoprecipitate (Adult) [BLB0005] Starting today, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): SURGICAL USE
Date Product Needed:
Consent Status:
Fibrin Glue, mLs Needed:
Pre-Op Day Of Procedure
Blood Products [83984]
Red Blood Cells (Pediatric) [BLB0013] 1 UNIT, Starting today For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR5 Acute blood loss or anticipated
surgical blood loss
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): SURGICAL USE
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates
up to 4 Months Only) (May be pre-selected based on
history):
Volume-Reduced (May be pre-selected based on
history):
Consent Status:
Pre-Op Day Of Procedure
Plasma (Pediatric) [BLB0010] Starting today, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): SURGICAL USE
Date Product Needed:
Consent Status:
Pre-Op Day Of Procedure
Page 7 of 11
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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10/2017CCKM@uwhealth.org

Platelets (Pediatric) [BLB0011] Starting today, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): SURGICAL USE
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates
up to 4 Months Only) (May be pre-selected based on
history):
Volume-Reduced (May be pre-selected based on
history):
Consent Status:
Pre-Op Day Of Procedure
Cryoprecipitate (Pediatric) [BLB0012] Starting today, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): SURGICAL USE
Date Product Needed:
Consent Status:
Pre-Op Day Of Procedure
VTE Prophylaxis
VTE Prophylaxis [109260]
• If low risk for development of VTE - select VTE Prophylaxis - Reason Not Ordered
• If requires VTE prophylaxis AND
◦ LOW bleed risk - select pharmacologic agent only
◦ ABSOLUTE bleed risk - select mechanical agents only
◦ HIGH bleed risk - weigh risk of bleed vs risk of VTE development and select drug OR
mechanical agent
NOTE: Mechanical and pharmacologic agents should only be used together in patients
with a very high risk of VTE development
VTE Risk Factor Assessment Tool URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
Sequential Compression Device (SCD) Panel
(TREATMENT AND SUPPLY) [206111]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
IntraOp
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
IntraOp
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
Pre-Op Day Of Procedure
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, ON CALL For 1 Doses
If patient scheduled for block, give after block placed
IntraOp
Page 8 of 11
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VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE For 1 Occurrences, Routine
Reason Not Ordered:
Pre-Op Day Of Procedure
Surgical Prophylaxis
First Line (Single Response) [138608]
cefuroxime (ZINACEF) intraVENOUS - NOTE:
Patients who are 40-159 kg [800030]
1.5 g, Intravenous, ON CALL For 1 Doses, IntraOp
cefuroxime (ZINACEF) intraVENOUS - NOTE:
Patients who are 160 kg or greater [800030]
3 g, Intravenous, ON CALL For 1 Doses, IntraOp
Patients with MRSA or High Risk for MRSA/MRSE (Implanted Device) (Single Response) [138609]
Patients who are 40-159 kg [231400]
cefuroxime (ZINACEF) intraVENOUS [800030] 1.5 g, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS
[800084]
Intravenous, ON CALL For 1 Doses, Pre-Op Day Of
Procedure
Patients who are 160 kg or greater [231403]
cefuroxime (ZINACEF) intraVENOUS [800030] 3 g, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS - Note:
Vancomycin should be dosed with a total weight
greater than or equal to 120 kg (Maximum Dose
= 2 g) [800084]
2 g, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies (Single Response) [138634]
Patients who are 40-159 kg [231708]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
vancomycin (VANCOCIN) intraVENOUS
[800084]
15 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are 160 kg or greater [231711]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses
Administer over 2 hours
Pre-Op Day Of Procedure
vancomycin (VANCOCIN) intraVENOUS
[800084]
2 g, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
IntraOp
Laboratory [118366]
ACTIVATED CLOTTING TIME, POC
[HCACTPOC]
CONDITIONAL For 1 Days, Routine
If Conditional, What Condition? Monitor heparin
IntraOp
IntraOp
Diagnostic Tests and Imaging [87228]
Imaging in OR [R10000] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
IntraOp
Patient Care Orders [151162]
Lateral Transfer Device - Hovermatt
[NURCOM0022]
ONCE, Starting today For 1 Occurrences, After patient
is transferrred to the OR table place the Hovermatt on
the postoperative bed., IntraOp
Counseling - Smoking Cessation
Smoking Cessation Counseling [4763]
Page 9 of 11
Printed by STRAKA, KEVIN F [KFS1] at 10/11/2017 7:13:16 PM
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Smoking Cessation Counseling, 3 -10 minutes
[99406]
Normal, Routine
Smoking Cessation Counseling, >10 minutes
[99407]
Normal, Routine
Diagnosis
Diagnosis - Pre Op [711]
Pre-operative general physical examination
[255759]
Other specified pre-operative examination
Diagnosis - Smoking Cessation [134767]
Tobacco use disorder [305.1.ICD-9-CM] Tobacco use disorder
Personal history of tobacco use, presenting
hazards to health [V15.82.ICD-9-CM]
Personal history of tobacco use, presenting hazards to
health
Level of Service
Office Visit - Established Patients [30779]
99211 - Level I LOS Code
99212 - Level II LOS Code
99213 - Level III LOS Code
99214 - Level IV LOS Code
99215 - Level V LOS Code
99211 - w/ Resident (GC) - Level I LOS Code
99212 - w/ Resident (GC) - Level II LOS Code
99213 - w/ Resident (GC) - Level III LOS Code
99214 - w/ Resident (GC) - Level IV LOS Code
99215 - w/ Resident (GC) - Level V LOS Code
Office visit - New Patients [30778]
99201- Level I LOS Code
99202- Level II LOS Code
99203- Level III LOS Code
99204- Level IV LOS Code
99205 - Level V LOS Code
99201- w/ Resident (GC) - Level I LOS Code
99202- w/ Resident (GC) - Level II LOS Code
99203- w/ Resident (GC) - Level III LOS Code
99204- w/ Resident (GC) - Level IV LOS Code
99205- w/ Resident (GC) - Level V LOS Code
Consults - New or Established [30780]
If Medicare patient, do not use Consult LOS. Choose an Established or New Patient LOS. Add the
appropriate additional E/M Code of 99354-99359 for prolonged office consultations in the LOS
section of the Visit Navigator.
99241 - Level I LOS Code
99242 - Level II LOS Code
99243 - Level III LOS Code
99244 - Level IV LOS Code
99245 - Level V LOS Code
99241- w/ Resident (GC) - Level I LOS Code
99242 - w/ Resident (GC)- Level II LOS Code
99243 - w/ Resident (GC) - Level III LOS Code
Page 10 of 11
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

99244 - w/ Resident (GC) - Level IV LOS Code
99245 - w/ Resident (GC) - Level V LOS Code
Preoperative Exam (Global) [1265]
Preoperative H&P, No Charge, Surgical Package LOS Code
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Printed by STRAKA, KEVIN F [KFS1] at 10/11/2017 7:13:16 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org