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Download austin radiological association medication charge form (exam)
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AUSTIN RADIOLOGICAL ASSOCIATION MEDICATION CHARGE FORM (EXAM) Patient Name: CODES Accession: MEDICATION DESCRIPTIONS QTY. Insurance: CODES MEDICATION DESCRIPTIONS QTY. 99070DX 50% DEXTROSE (25GM) PREFILL SYR J0696 ROCEPHIN PER 250MG, INJECTION J0152 ADENOSINE UP TO 30MG, INJECTION 99070RF ROMAZICON 0.5MG/5ML VIAL P9045 ALBUMIN INFUSION 5% 250ML 99070S2 SODIUM BICARB 4.2% 5ML VIAL J2997 ALTEPLASE RECOMBINANT 99070S1 SODIUM BICARB 50MEQ/50ML SYRINGE J0282 AMIODARONE PER 30MG, INJECTION 99070S3 SODIUM BICARB 8.4% 50ML VIAL J0690 ANCEF (CEFAZOLIN) PER 500MG, INJ J1720 SOLU CORTEF PER 100MG, INJECTION J0461 ATROPINE PER 0.01MG, INJECTION J2930 SOLU MEDROL PER 125MG, INJECTION J1200 BENADRYL UP TO 50 MG, INJECTION J3250 TIGAN UP TO 200 MG, INJECTION J0610 CALCIUM GLUCONATE PER 10ML, IN 99070VP VERAPAMIL 5MG/2ML AMPULE J0744 CIPRO PER 200MG, INJECTION J3410 VISTARIL UP TO 25 MG, INJECTION 99070CM CLINDAMYCIN 600MG/4ML VIAL J2405 ZOFRAN PER 1 MG, INJECTION J1265 DOPAMINE PER 40MG, INJECTION 99070EP EPINEPHRINE 1MG/10ML SYRINGE CODES IV FLUID DESCRIPTIONS 99070EA EPINEPHRINE UP TO 1 ML AMPULE, INJ J7070 D5W, INFUSION, 1000ML J1580 GENTAMIACIN UP TO 80MG, INJECTION J7120 LACTATED RINGERS, 1000ML *J1610 GLUCAGON PER 1 MG, INJECTION 99070SM SODIUM CHLORIDE 0.45%, 1000ML J1642 HEPARIN SODIUM LOCK FLUSH 10 UNITS J7030 SODIUM CHLORIDE 0.9%, 1000ML J1815 INSULIN PER 5 UNITS, INJECTION J7050 SODIUM CHLORIDE 0.9%, 250ML J3301 KENALOG 40MG/ML, 1ML VIAL J1940 LASIX UP TO 20 MG, INJECTION J1956 LEVAQUIN PER 250MG, INJECTION J2001 LIDOCAINE HCI FOR IV INFUSION 10MG J3475 MAGNESIUM SULFATE PER 500MG J1040 METHYLPREDNISOLONE ACETATE 80MG 99070MI METOPROLOL 5 ML VIAL, INJECTION J2310 NARCAN PER 1 MG, INJECTION CODES IV HYDRATION QTY. 96365 IV Hydration w/medication infusion, initial, up to one hour 96366 IV Hydration w/medication infusion, each additional hour. 99070PE PEPCID PER 20MG, INJECTION J2550 QTY. 96367 Additional sequential infusion, up to one hour. PHENERGAN UP TO 50 MG, INJECTION *Not allowed to charge for Medicare patients at IDTF sites 96360 IV Hydration, initial, 31 min to 1 hour. 96361 IV Hydration, each additional hour. Primary reason staff administered medication: PARAMEDIC/RN, PRINT NAME: Aid in diagnostic Imaging Abnormal Blood Chemistry (Dx Code 790.6) PSR, PRINT NAME: Nausea/Vomiting (Dx Code 787.01) Hypoglycemia (Dx Code 251.2) Allergic Reaction (Dx Code 708.0) Other, description: . Dx Code used: . 08/03/11TR AUSTIN RADIOLOGICAL ASSOCIATION MEDICATION CHARGE FORM (SEDATION/PAIN MGMT) Patient Name: CODES Accession: MEDICATION DESCRIPTIONS QTY. Insurance: CODES IV FLUID DESCRIPTIONS J1200 BENADRYL UP TO 50 MG, INJECTION J7070 D5W, INFUSION, 1000ML J2175 DEMEROL UP TO 100 MG, INJECTION J7120 LACTATED RINGERS, 1000ML J1170 DILAUDID UP TO 4MG, INJECTION 99070SM SODIUM CHLORIDE 0.45%, 1000ML J1790 DROPERIDOL 5MG, INJECTION J7030 SODIUM CHLORIDE 0.9%, 1000ML J3010 FENTANYL PER 100 MCG, INJECTION J7050 SODIUM CHLORIDE 0.9%, 250ML J2270 MORPHINE PER 10 MG, INJECTION J2310 NARCAN PER 1 MG, INJECTION J2300 NUBAIN PER 10MG, INJECTION J2550 PHENERGAN UP TO 50 MG, INJECTION 99070RF ROMAZICON 0.5MG/5ML VIAL J3230 THORAZINE PER 50 MG, INJECTION J3250 TIGAN UP TO 200 MG, INJECTION J1885 TORADOL PER 15MG, INJECTION J3360 VALIUM PER 5MG, INJECTION J2250 VERSED PER 1 MG, INJECTION J3410 VISTARIL UP TO 25 MG, INJECTION J2405 ZOFRAN PER 1 MG, INJECTION QTY. Nurse/Paramedic Section Primary reason patient (guardian) requested medication to complete exam: Claustrophobia/Anxiety/Pediatric Patient Relief of Muscle Spasms (motion disorder) BEGIN IV SEDATION INTRA-SERVICE TIME : Pain END IV SEDATION INTRA-SERVICE TIME: Charge for IV Sedation Charge for IM Sedation TOTAL IV SEDATION INTRA-SERVICE TIME: Charge for IM Pain Management PARAMEDIC/RN, PRINT NAME: Charge for IV Pain Management charge for each additional (new) pain medication given (IV). # . PSR Section No Charge for Medicare IV/IM sedations or medications. CPT Code charged to . PSR, PRINT NAME: *Please verify that insurance is current* 08/03/11TR
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