FAMILY PRACTICE

Provider # Federal ID #

#
REFERRING MD: (PLEASE PRINT FULL NAME)
(AREA CODE):

PHONE NUMBER ( IF NON CMG PROVIDER)

ICD9 CODE 1 ICD9 CODE 2 ICD9 CODE 3 ICD9 CODE 4

AUTHORIZATION NUMBER: DATE OF INJURY: CHANGE DATE TO

CODE MOD

DESCRIPTION

CODE MOD

DESCRIPTION

CODE MOD

DESCRIPTION

99201 99202 99203 99204 99205 99025 99381 99382 99383 99384 99385 99386 99387 99211 99212 99213 99214 99215 99391 99392 99393 99394 99395 99396 99397 99301 99302 99303 99311 99312 99313 94640 46600 92551

OFFICE VISITS - NEW PATIENTS LEVEL 1, BRIEF; 10 min LEVEL 2, LIMITED: 20 min LEVEL 3, EXPANDED; 30 min LEVEL 4, COMPREHENSIVE; 45 min LEVEL 5, COMPREHENSIVE; 60 min NEW PT. INITIAL VISIT W/*PROC. PREVENTIVE EXAM - NEW PATIENTS PREVENTIVE MEDICINE < 1 YEAR PREVENTIVE MEDICINE, 1 - 4 PREVENTIVE MEDICINE, 5-11 PREVENTIVE MEDICINE, 12-17 PREVENTIVE MEDICINE, 18-39 PREVENTIVE MEDICINE, 40-64 PREVENTIVE MEDICINE, 65+ OFFICE VISITS - EST. PATIENTS LEVEL 1, BRIEF: 5 min LEVEL 2, LIMITED: 10 min LEVEL 3, EXPANDED: 15 min LEVEL 4, COMPREHENSIVE: 25 min LEVEL 5, COMPREHENSIVE: 40min PREVENTIVE EXAM - EST. PATIENTS PREVENTIVE MEDICINE < 1 YEAR PREVENTIVE MEDICINE, 1 - 4 PREVENTIVE MEDICINE, 5-11 PREVENTIVE MEDICINE, 12-17 PREVENTIVE MEDICINE, 18-39 PREVENTIVE MEDICINE, 40-64 PREVENTIVE MEDICINE, 65+ INITIAL NURSING FACILITY CARE LEVEL 1 , ANNUAL ASSESSMENT LEVEL 2, NEW PROBLEM LEVEL 3, INITIAL ADMIT TO NH SUBSEQUENT NURSING FACILITY CARE LEVEL 1, STABLE NH VISIT LEVEL 2, MINOR PROBLEM LEVEL 3, MAJOR PROBLEM PROCEDURES AIRWAY INHALATION TREATMENT ANOSCOPY;DIAGNOSTIC AUDIOMETRY AIR ONLY

10060 10061* 11200 11201 17000 17003 17004 93000 93005 20550 20600* 20605* 20610* 94150 69210 45330 94010 87220 82270 Q0091 86580 81000 87210 86588 90782 J3420 J0702 J2175 J1460 J2000 J2550 J0696 J3030 J1055 J1070 J1080 J9215 J3301

TRAYS (ADD TO SURGICAL PROCEDURES) I&D ABSCESS/CYST, SIMPLE TRAY, SMALL W/ANESTHESIA I&D ABSCESS, COMPL. OR MULT. 02094 02097 SUTURE TRAY W/ANESTHESIA SKIN TAG REMOVAL, UP TO 15 TRAY, MEDIUM W/SPEC. ROOM(SIG) 02098 SKIN TAG REMOVAL, EA ADDL 10 TRAY, LARGE + RM + SPEC. EQUIP DEST.BEN LESION,ANY METHD, 1st 02095 SUPPLIES 2nd THROUGH 14th LESIONS EA DEST BEN LES. ANY METH. > 15 02113 CANVAS KNEE BRACE EKG, COMPLETE 02010 CANVAS WRIST SUPPORT 02112 ELASTIC ANKLE WRAP EKG, TRACING ONLY INJ TENDON/LIGAMENT/CYST/TRIGGER PT 02018 ELASTIC ANKLET INJECT.SMALL JT/BURSA/CYST 02579 FINGER SPLING INJECT. INT. JOINT/BURSA/CYST 02129 RIB BELT INJECT.MAJOR JOINT/BURSA/CYST 02525 SLING VITAL CAPACITY; SEPARATE PROC 02488 STERI-STRIPS REMOVAL IMPACTED CERUMEN 02033 SUTURE REMOVAL KIT SIGMOIDOSCOPY; FLEXIBLE 02011 TENNIS ELBOW SUPPORT SPIROMETRY W/GRAPHIC RECORD 02084 UNIVERSAL THUMB SPLINT OTHER: SPECIFY DIAGNOSTICS KOH OCCULT BLOOD PAP SMEAR HANDLING CASTS/SPLINTS PPD URINALYSIS, ROUTINE 29065 LONG ARM CAST 29075 WET MOUNT SHORT ARM CAST 29105 LONG ARM SPLINT QUICK STREP UNITS 29125 INJECTIONS SHORT ARM SPLINT SUB Q OR IM INJECTION OF MED 29405 SHORT LEG CAST 29515 B-12 ; up to 1000 mcg SHORT LEG SPLINT CELESTONE SOLUSPAN 1cc 02220 CAST MATERIAL, PLASTER, ARM DEMEROL PER 100mg 02221 CAST MATERIAL, PLASTER, LEG GAMMA GLOBULIN; IM 1cc 02222 CAST MATERIAL, FIBERG, ARM LIDOCAINE 02223 CAST MATERIAL, FIBERG, LEG PHENERGAN UP TO 50 mg ROCEPHIN 250 mg X ____ UNITS IMITREX 6mg X _____ UNITS
DEPO-PROVERA 150mg (CONTRACEPTIVE)

DEPO-TESTOSTERONE 100mg DEPO-TESTOSTERONE 200mg INTERFERON .05cc KENALOG, PER 10mg

FRACTURE MANAGEMENT: INITIAL

FOLLOW-UP 99024 (NO CHARGE VISIT) V54.8

SPECIAL INSTRUCTIONS: ACCIDENT COORDINATION OF BENEFITS NON-COVERED SERVICE THIRD PARTY LIEN OTHER: (SPECIFY)

MODIFIERS: -22 UNUSUAL SERVICE (NEED REPORT!) -43 -25 SEPARATELY IDENTIFIABLE E/M SERVICE -52 BY SAME MD ON DAY OF PROC. -55 -50 BILATERAL PROCEDURE -56 -51 MULTIPLE PROCEDURES

CHARGE REDUCED BY MD REDUCED SERVICES POST-OPERATIVE MANAGEMENT ONLY PREOPERATIVE MANAGEMENT ONLY

FEES SUBJECT TO CHANGE WITHOUT NOTICE