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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