SCAN Health Plan

Pain Assessment – Category II Codes

Medication Management Medication reconciliation post discharge

Pain Assessment – Category II Codes

Pain severity quantified, no pain present

Reliant UC- Santa Fe Springs Telegraph Rd. (310) 491-7060 Mon-Fri 8:30am-8pm

Care of Older Adults Advance care plan (document) present in medical records

Advance care planning discussion documented in records

Medication Reconcilliation – CPT Codes: , , Category II Codes

Medication Reconcilliation – CPT Codes: , , Category II Codes

Current Level of Function (Compare to initial assessment.) Category II Codes

Dusk to Dawn Urgent Care Paramount Blvd. (562) 808-2273 M-F 9am-12am

Studebaker Road

Dilated retinal eye exam documented/reviewed

7 standard filed stereoscopic photo documented/reviewed

Eye imaging validated to match dx documented/reviewed

Adult BMI BMI Documented *See below for dx codes*

Comprehensive Diabetes Most recent HbA1c level less than 7.0%

Most recent HbA1c level between 7.0-9.0%

Most recent HbA1c level greater than 9.0%

Cholesterol Mgmt. Most recent LDL-C <100 mg/dL

Most recent LDL-C 100-129 mg/dL

Most recent LDL-C >=130 mg/dL

HbA1c Control (≤ 9.0) : >9 : 7-7.9

8-9

Positive microalbuminuria test documented/reviewed

Negative microalbuminuria test documented/reviewed

Positive microalbuminuria test confirmed with lab result

Documentation of tx for nephropathy

Low risk for retinopathy

Controlling Blood Pressure Most recent systolic blood pressure <130 mmHg

Most recent systolic blood pressure 130-139 mm Hg

Most recent systolic blood pressure >=140 mm Hg

Most recent diastolic blood pressure <80 mm Hg

Most recent diastolic blood pressure 80-89 mmHg

Most recent diastolic blood pressure >=90 mm Hg

ACEI or ARB therapy prescribed or currently taking

 - Skull <4V  -Spine Cervical 2 or 3V  - Shoulder min  - Hip unilateral min

 -CT Sinus Survey 2V 2V

 –1V  -Pelvis 1V  - Wrist 2V  - Knee 1 or 2V

 –2V  -Sacrum & coccyx min 2V  - Hand 2V  - Tibia & Fibula 2V

 - Ribs Uni 2V  - Fingers min 2V  - Ankle 2V

 - Sternum Min 2V MAMMOGRAPHY  - Foot 2V

 - Skull <4V  -Spine Cervical 2 or 3V  - Shoulder min  - Hip unilateral min

 -Spine Thoracic 2V  - Elbow 2V  - Hip bilateral min 2V

CHEST  -Spine Lumbosacral 2-3V  - Forearm 2V  – Femur 2V

 –1V  -Pelvis 1V  - Wrist 2V  - Knee 1 or 2V

 –2V  -Sacrum & coccyx min 2V  - Hand 2V  - Tibia & Fibula 2V

 - Skull <4V  -Spine Cervical 2 or 3V  - Shoulder min  - Hip unilateral min

 -Spine Thoracic 2V  - Elbow 2V  - Hip bilateral min 2V

CHEST  -Spine Lumbosacral 2-3V  - Forearm 2V  – Femur 2V

 –1V  -Pelvis 1V  - Wrist 2V  - Knee 1 or 2V

 –2V  -Sacrum & coccyx min 2V  - Hand 2V  - Tibia & Fibula 2V

 - Ribs Uni 2V  - Fingers min 2V  - Ankle 2V

 - Skull <4V  -Spine Cervical 2 or 3V  - Shoulder min  - Hip unilateral min

 -Spine Thoracic 2V  - Elbow 2V  - Hip bilateral min 2V

CHEST  -Spine Lumbosacral 2-3V  - Forearm 2V  – Femur 2V

 –1V  -Pelvis 1V  - Wrist 2V  - Knee 1 or 2V

 –2V  -Sacrum & coccyx min 2V  - Hand 2V  - Tibia & Fibula 2V

 - Ribs Uni 2V  - Fingers min 2V  - Ankle 2V

 - Sternum Min 2V MAMMOGRAPHY  - Foot 2V

 Mammography ABDOMEN  - Calcaneus min 2V

Screening, Digital (age 40+)  -anteroposterior  - Toes min 2V

Screening, Digital (age 40+)  -anteroposterior  - Toes min 2V

 Mammography ABDOMEN  - Calcaneus min 2V

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Skin test; tuberculosis, intradermal $10.00 (Fluvirin) $25.00

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Females 21-65 yrs and 67+ Every 3 years (

Females 21-65 yrs and 67+ Every 3 years (

Females 21-65 yrs and 67+ Every 3 years (

Females 21-65 yrs and 67+ Every 3 years (

Females 21-65 yrs and 67+ Every 3 years (

Females 21-65 yrs and 67+ Every 3 years (

Females 21-65 yrs and 67+ Every 3 years (

Females 21-65 yrs and 67+ Every 3 years (

Females 21-65 yrs and 67+ Every 3 years (

Females 21-65 yrs and 67+ Every 3 years (

Females 21-65 yrs and 67+ Every 3 years (

1 Pap test: females 21-65 yrs w/ no hysterectomyAND an

1 Pap test: females 21-65 yrs w/ no hysterectomyAND an

1 Pap test: females 21-65 yrs w/ no hysterectomyAND an

Los Angeles, CA Sat 8am-2pm

Tel: 818-480-7234 Los Angeles, CA Tel: 323-375-3945 Los Angeles, CA

Los Angeles, CA

Los Angeles, CA

Los Angeles, CA

(formerly Silver Lake Urgent Care) Los Angeles, CA

Los Angeles, CA , USA

Los Angeles, CA Sat 9am-3pm

Los Angeles, CA Sat-Sun 9am-6pm

Los Angeles, CA

123456-01 Doe John 1/1/1960 M 1/1/2012 Blue Shield 123 Main St. Angeles 213-555-5555

Tel: 323-375-3940 Beverly Hills, CA Beverly Hills, CA

Tel: 323-375-3940 Beverly Hills, CA Beverly Hills, CA

Gardena, CA Sat-Sun 9am-2pm

Huntington Park , CA Sat-Sun 10am-5pm

Lynwood, CA Sat-Sun 9am-2pm

Los Angeles, CA 0017 CA 2680 Saturn Ave. Ste. 100

Inglewood, CA Sat-Sun 9am-2pm

8540 s Sepulveda Blvd. #105 Inglewood, CA Torrance, CA Los Angeles, CA

Vaqyta) $75.00 Administration of influenza virus vaccine $25.00

schedule, for intramuscular use (Harvix, Vaqta) $32.03 for intramuscular use (FLUZONE high-dose) $45.00

schedule, for intramuscular use (Harvix) $30.00 intramuscular use (Prevnar13) $195.00

Montebello, CA Sat-Sun 10am-5pm

CHILDHOOD IMMUNIZATION STATUS (CIS) 3 HiB

CHILDHOOD IMMUNIZATION STATUS (CIS) 3 HiB

dose schedule), for intramuscular use (Pedvax HIB) $50.00 mL dosage, for intramuscular use. (FLucelvax) $24.05

schedule), for intramuscular use (ActHIB, Hiberix) $45.00 live, for oral use (RotaTeq) $92.00

(GARDASIL) $146.95 schedule, live, for oral use (Rotarix) $92.00

( or )

intramuscular use $204.86 (Fluzone Quadrivalent) $23.00

intramuscular use $41.80 vial]) $25.00

Flu Shots (FSO) Males and Females Annually Flu Vaccine

no preservative) $25.00 $51.66

[5ml vial 0.25 ml dose]) $25.00 (Pentacel) $89.99

Flu Shots (FSO) Males and Females Annually Flu Vaccine

Flu Shots (FSO) Males and Females Annually Flu Vaccine

schedule, for intramuscular use (Harvix, Vaqta) $32.03 for intramuscular use (FLUZONE high-dose) $45.00

4 PCV or

Santa Fe Springs, CA Sat-Sun 10am-5pm

dose schedule), for intramuscular use (Pedvax HIB) $50.00 mL dosage, for intramuscular use. (FLucelvax) $24.05

schedule), for intramuscular use (ActHIB, Hiberix) $45.00 live, for oral use (RotaTeq) $92.00

(GARDASIL) $146.95 schedule, live, for oral use (Rotarix) $92.00

intramuscular use $204.86 (Fluzone Quadrivalent) $23.00

intramuscular use $41.80 vial]) $25.00

no preservative) $25.00 $51.66

[5ml vial 0.25 ml dose]) $25.00 (Pentacel) $89.99

for intramuscular use (Daptacel, Infanrix) $30.00 injection $200.00

USP [For Pediatric Use]) $20.00 (Recombivax dialysis) $70.00

Cerritos, CA

subcutaneous use (M-M-R II) $75.00 intramuscular use (Energix-B, Recombivax HB) $35.00

subcutaneous use (ProQuad) $202.40 Recombivax HB) $35.00

intramuscular use (IPOL) $30.00 REQUIRED $70.00

adult) $25.00 (Energix-B, RECOMBIVAX dialysis)-AUTH REQUIRED $70.00

intramuscular use (Adacel, Boostrix) $48.00 Hib), for intramuscular use (COMVAX) $45.00

(Varivax) $122.02 Shingrix. Adult dose 0.5 mL $169.99

IMMUNIZATIONS FOR ADOLESCENTS (IMA) Males and Females who turn 13 in 2015 yrs Td ( , )

4 DTaP

Paramount, CA Sat-Sun 9am-6pm

use (Pneumovax23) $95.00 REQUIRED $15.00

A/C/Y/W-135) $100.00 REQUIRED $30.00

(Menactra, Menveo) $125.00 REQUIRED $45.00

for intramuscular use (Daptacel, Infanrix) $30.00 injection $200.00

USP [For Pediatric Use]) $20.00 (Recombivax dialysis) $70.00

subcutaneous use (M-M-R II) $75.00 intramuscular use (Energix-B, Recombivax HB) $35.00

subcutaneous use (ProQuad) $202.40 Recombivax HB) $35.00

intramuscular use (IPOL) $30.00 REQUIRED $70.00

adult) $25.00 (Energix-B, RECOMBIVAX dialysis)-AUTH REQUIRED $70.00

intramuscular use (Adacel, Boostrix) $48.00 Hib), for intramuscular use (COMVAX) $45.00

(Varivax) $122.02 Shingrix. Adult dose 0.5 mL $169.99

intramuscular use (PEDIARIX) $50.00 intramuscular use $25.00

Medication Reconcilliation – CPT Codes: , , Category II Codes

Glendale, CA Sat-Sun 9am-5pm

Glendale, CA 205 2ND Floor CA 150

Oceanside, CA

Vista, CA

 –OB/GYN Consult  - Well W omen Exam (Annual) – Age 18-39  - Well W omen Exam (Annual) – Age >65

 - OB/GYN Follow-up  - Well W omen Exam (Annual) – Age 40-64

 –OB/GYN Consult  - Well W omen Exam (Annual) – Age 18-39  - Well W omen Exam (Annual) – Age >65

 - OB/GYN Follow-up  - Well W omen Exam (Annual) – Age 40-64

 –OB/GYN Consult  - Well W omen Exam (Annual) – Age 18-39  - Well W omen Exam (Annual) – Age >65

Medication Reconcilliation – CPT Codes: , , Category II Codes

Medication Reconcilliation – CPT Codes: , , Category II Codes

Vaqyta) $75.00 Administration of influenza virus vaccine $25.00

use (Pneumovax23) $95.00 REQUIRED $15.00

Flu Shots (FSO) Males and Females Annually Flu Vaccine

Skin test; tuberculosis, intradermal $10.00 (Fluvirin) $25.00

Pain Screening or pain management