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Office visit New Minimal Problem focused 99201 Exp problem focused 99202 Detailed 99203 Comp 99204 Comp (new patient) 99205 Significant, sep serv -25 Well visit New <1y 99381 1-4 y 99382 5-11 y 99383 12-17 y 99384 18-39 y 99385 40-64 y 99386 65 y + 99387 Medicare preventive services Pap Pelvic & breast Prostate/PSA Tobacco couns/3-10 min Tobacco couns/>10 min Welcome to Medicare exam ECG w/Welcome to Medicare Flexible sigmoidoscopy Hemoccult, guaiac Flu shot Pneumonia shot Consultation/preop clearance Exp problem focused Detailed Comp/mod complex Comp/high complex Other services After posted hours Evening/weekend appointment Home health certification Home health recertification Post-op follow-up Prolonged/30-74 min Special reports/forms Disability/Workers comp Radiology Diagnoses 1 2 3 4 Next office visit Recheck • Prev • PRN Instructions: Est 99211 99212 99213 99214 99215 -25 Est 99391 99392 99393 99394 99395 99396 99397 Q0091 G0101 G0103 G0375 G0376 G0344 G0366 G0104 G0107 G0008 G0009 99242 99243 99244 99245 99050 99051 G0180 G0179 99024 99354 99080 99455 _____ D W M Y Referral To: Instructions: Physician signature X___________________________________ Office procedures Anoscopy Audiometry Cerumen removal Colposcopy Colposcopy w/biopsy ECG, w/interpretation ECG, rhythm strip Endometrial biopsy Flexible sigmoidoscopy Flexible sigmoidoscopy w/biopsy Fracture care, cast/splint Site: __________________ Nebulizer Nebulizer demo Peak flow monitoring Spirometry Spirometry, pre and post Tympanometry Vasectomy Skin procedures Burn care, initial 16000 Foreign body, skin, simple 10120 Foreign body, skin, cmplx 10121 I&D, abscess 10060 I&D, hematoma/seroma 10140 Laceration repair, simple 120__ Site: _______ Size: _____ Laceration repair, layered 120__ Site: _______ Size: _____ Lesion, biopsy, one 11100 Lesion, biopsy, each add’l 11101 Lesion, excision, benign 114__ Site: _______ Size: _____ Lesion, excision, malignant 116__ Site: _______ Size: _____ Lesion, paring/cutting, one 11055 Lesion, paring/cutting, 2-4 11056 Lesion, shave 113__ Site: _______ Size: _____ Nail removal, partial 11730 Nail removal, w/matrix 11750 Skin tag, 1-15 11200 Wart, flat, 1-14 17110 Wart, plantar, single 17000 Wart, plantar, each add’l 17003 Medications Ampicillin, up to 500mg J0290 B-12, up to 1,000 mcg J3420 Epinephrine, up to 1ml J0170 Kenalog, 10mg J3301 Lidocaine, 10mg J2001 Normal saline, 1000cc J7030 Phenergan, up to 50mg J2550 Progesterone, 150mg J1055 Rocephin, 250mg J0696 Testosterone, 200mg J1080 Tigan, up to 200 mg J3250 Toradol, 15mg J1885 Miscellaneous services 46600 92551 69210 57452 57455 93000 93040 58100 45330 45331 29___ 94640 94664 94150 94010 94060 92567 55250 Units Units Laboratory Venipuncture Blood glucose, monitoring device Blood glucose, visual dipstick CBC, w/ auto differential CBC, w/o auto differential Cholesterol Hemoccult, guaiac Hemoccult, immunoassay Hemoglobin A1C Lipid panel Liver panel KOH prep (skin, hair, nails) Metabolic panel, basic Metabolic panel, comprehensive Mononucleosis Pregnancy, blood Pregnancy, urine Renal panel Sedimentation rate Strep, rapid Strep culture Strep A TB UA, complete, non-automated UA, w/o micro, non-automated UA, w/ micro, non-automated Urine colony count Urine culture, presumptive Wet mount/KOH Vaccines DT, <7 y DTP DtaP, <7 y Flu, 6-35 months Flu, 3 y + Hep A, adult Hep A, ped/adol, 2 dose Hep B, adult Hep B, ped/adol 3 dose Hep B-Hib Hib, 4 dose HPV IPV MMR Pneumonia, >2 y Pneumonia conjugate, <5 y Td, >7 y Varicella Immunizations & Injections Allergen, one 95115 Allergen, multiple 95117 Imm admin, one 90471 Imm admin, each add’l 90472 Imm admin, intranasal, one 90473 Imm admin, intranasal, add’l 90474 Injection, joint, small 20600 Injection, joint, intermediate 20605 Injection, joint, major 20610 Injection, ther/proph/diag 90772 Injection, tendon sheath 20552 Supplies 36415 82962 82948 85025 85027 82465 82270 82274 85018 80061 80076 87220 80048 80053 86308 84703 81025 80069 85651 86403 87081 87880 86580 81000 81002 81003 87086 87088 87210 90702 90701 90700 90657 90658 90632 90633 90746 90744 90748 90645 90649 90713 90707 90732 90669 90718 90716 Units Infectious & Parasitic Diseases 053.9 Herpes zoster, NOS 054.9 Herpetic disease, uncomplicated 075 Mononucleosis 034.0 Strep throat 079.99 Viral infection, unspec. 078.10 Warts, all sites Neoplasms Benign Neoplasms 239.2 Skin, soft tissue neoplasm, unspec. 216.9 Skin, unspec. Endocrine, Nutritional & Metabolic Disorders Endocrine 250.01 Diabetes I, uncomplicated 250.91 Diabetes I, w/ unspec. complications Diabetes II/unspec., w/o comp, not 250.00 uncontrolled 250.90 Diabetes II, w/ unspec. complications 242.90 Hyperthyroidism, NOS 244.9 Hypothyroidism, unspec. Metabolic/Other 274.9 Gout, unspec. 272.0 Hypercholesterolemia 272.2 Hyperlipidemia, mixed 272.1 Hypertriglyceridemia 278.01 Obesity, morbid 278.00 Obesity, NOS 278.02 Overweight Blood Diseases 285.9 Anemia, other, unspec. Mental Disorders 300.00 Anxiety state, unspec. 314.00 Attention deficit, w/o hyperactivity 290.00 Dementia, senile, NOS 311 Depression, NOS Nervous System & Sense Organ Disorders Nervous System Diseases 354.0 Carpal tunnel 345.90 Epilepsy, unspec., w/o status 346.90 Migraine, unspec., not intractable Eye Diseases 372.30 Conjunctivitis, unspec. 368.10 Visual disturbance, unspec. Ear Diseases 380.4 Cerumen impaction 389.9 Hearing loss, unspec. 380.10 Otitis externa, unspec. 382.00 Otitis media, acute Circulatory System Arrythmias 427.31 Atrial fibrillation Cardiac 413.9 Angina pectoris, NOS 428.0 Heart failure, congestive, unspec. 414.9 Ischemic heart disease, chronic, unsp. 424.1 Valvular disorder, aortic, NOS Vascular 796.2 Elevated BP w/o hypertension 401.1 Hypertension, benign 458.0 Hypotension, orthostatic 443.9 Peripheral vascular disease, unspec. 451.9 Thrombophlebitis, unspec. 459.81 Venous insufficiency, unspec. Respiratory System Lower Respiratory Tract 493.90 Asthma, unspec. 466.0 Bronchitis, acute 496 COPD, NOS 486 Pneumonia, unspec. Upper Respiratory Tract 462 Pharyngitis, acute 477.9 Rhinitis, allergic, cause unspec. 461.9 Sinusitis, acute, NOS 465.9 Upper respiratory infection, acute, NOS Digestive System 564.00 Constipation, unspec. 562.10 Diverticulosis of colon 562.11 Diverticulitis of colon, NOS 535.50 Gastritis, unspec. w/o hemorrhage 558.9 Gastroenteritis, noninfectious, unspec. 530.81 GERD, no esophagitis 455.6 Hemorrhoids, NOS 564.1 Irritable bowel syndrome 578.1 Melena Lower Extremity 729.5 Pain in limb 728.71 Plantar fascitis Spine/Torso 724.4 Back pain w/ radiation, unspec. 723.9 Cervical disorder, NOS Upper Extremity 726.32 Lateral epicondylitis 726.10 Rotator cuff syndrome, NOS Perinatal (Infant) 779.3 Feeding problem, newborn Signs & Symptoms 789.00 Abdominal pain, unspec. 795.01 Abnormal Pap, ASC-US 719.40 Arthralgia, unspec. Genitourinary System 569.3 Bleeding, rectal Urinary System Diseases 592.9 Calculus, urinary, unspec. 595.0 Cystitis, acute 599.7 Hematuria 593.9 Renal insufficiency, acute 599.0 Urinary tract infection, unspec./pyuria Male Genital Organ Dieases 607.84 Impotence, organic 302.72 Impotence, psychosexual dysfunction 601.9 Prostatitis, NOS 257.2 Testicular hypofunction Breast Diseases 611.72 Breast lump Female Genital Organ Diseases 616.0 Cervicitis 622.10 Dysplasia, cervix, unspec. 625.9 Pelvic pain, unspec. female disease 616.10 Vaginitis/vulvitis, unspec. Disorders of Menstruation 626.0 Amenorrhea 627.9 Menopausal disorders, unspec. 626.2 Menstruation, excessive/frequent 625.3 Menstruation, painful 626.6 Metrorrhagia Pregnancy, Childbirth 641.90 Hemorrhage in preg., unspec. V24.2 Postpartum follow-up, routine V22.2 Pregnant state, incidental V22.0 Prenatal care, normal, first pregnancy V22.1 Prenatal care, normal, other pregnancy 786.50 786.2 787.91 780.4 787.2 788.1 782.3 783.3 780.6 271.9 784.0 788.30 782.2 785.6 780.79 787.02 787.01 719.46 724.2 785.1 788.42 782.1 782.0 786.05 780.2 788.41 787.03 783.21 Chest pain, unspec. Cough Diarrhea, NOS Dizziness/vertigo, NOS Dysphagia Dysuria Edema, localized, NOS Feeding problem, infant/elderly Fever, nonperinatal Glucose intolerance Headache, unspec. Incontinence/enuresis, NOS Localized swelling/mass, superficial Lymph nodes, enlarged Malaise and fatigue, other Nausea, alone Nausea w/ vomiting Pain, knee Pain, low back Palpitations Polyuria Rash, nonvesicular, unspec. Sensory disturbance skin Shortness of breath Syncope Urinary frequency Vomiting, alone Weight loss Skin, Subcutaneous Tissue 706.1 Acne 702.0 Actinic keratosis 682.9 Cellulitis/abscess, unspec. 692.9 Contact dermatitis, NOS 691.8 Eczema, atopic dermatitis 703.0 Ingrown nail 110.1 Onychomycosis 709.9 Other skin disease, unspec. 696.1 Psoriasis, other 695.3 Rosacea 706.2 Sebaceous cyst 702.19 Seborrheic keratosis, NOS 707.9 Ulcer, skin, chronic, unspec. 708.9 Urticaria, unspec. Musculoskeletal & Connective Tissue General 716.90 Arthropathy, unspec. 729.1 Fibromyositis 715.90 Osteoarthrosis, unspec. 733.00 Osteoporosis, unspec. 714.0 Rheumatoid arthritis 727.00 Synovitis/tenosynovitis, unspec. Injuries & Adverse Effects Dislocations, Sprains & Strains 845.00 Sprain/strain: ankle, unspec. 845.10 Sprain/strain: foot, unspec. 842.1 Sprain/strain: hand, unspec. 844.9 Sprain/strain: knee/leg, unspec. 847.0 Sprain/strain: neck, unspec. 840.9 Sprain/strain: shoulder/arm, unspec. 842.00 Sprain/strain: wrist, unspec. Other Trauma, Adverse Effects 919.0 Abrasion, unspec. 924.9 Contusion, unspec. 919.4 Insect bite 894.0 Open wound, lower limb, unspec. 884.0 Open wound, upper limb, unspec. Supplemental Classification V72.32 Confirm norm Pap after initial abn V25.01 Contraception, oral V25.02 Contraception, other (diaphragm, etc.) V25.2 Contraception, sterilization V58.30 Dressing change, nonsurgical V01.9 Exposure, infectious disease, unspec. V72.31 Gynecological exam V06.8 Immunization, combination, other V06.1 Immunization, DTP V04.81 Immunization, influenza V70.0 Well adult check V20.2 Well child check