Birthwithlove Midwifery Services

Kelley Faulkner, DEM For BILLING QUESTIONS, please call Signature______New Life Midwifery Services 508-429-6663 19 West Walnut Street Bio Lab, Inc., Milford, MA Milford, MA 01757 Need Referral Referral#______508-478-6226 508-429-6663 Diagnosis:______Evaluation & Mgmt. Code Fee ______ New Patient, Minimal 99201 33 Laboratory Code Fee   New Patient, Problem 99202 67 ______Pap Smear 88150 12   New Patient, Low Complex 99203 94 Specimen Prep 99000 19   New Patient, Mod Compl 99204 136 Diagnostic Codes Code AFP Triscreen 82105 see Lab st   New Pt, High Complexity 99205 153  1 Pregnancy V22.0 Antibody Screen 86850 39   Established Pt, Minimal 99211 26  Other Pregnancy-add # V22.1 Beta Strep Screen 86403 13   Establish Pt, Problem 99212 43  Late Onset of Care V23.9 Beta HCG, Qualitative 84703 17   Establish Pt, Low Compl 99213 86  Spontaneous abortion 634.9 Beta HCG, Quantitative 84702 35   Establish Pt, Detailed 99214 122  Breech/Version 652.1 CBC w/differentia 85022 19   Est Pat, Comprehensive 99215 148  Premature Labor 644.0 Chlamydia Culture 87110 45   Home Visit/new/20 min 99341 42  PROM 658.1 Estradiol 82670 45   Home Visit/new/30 min 99342 62  Threatened Labor 644.13 Fasting Blood Sugar 82947 11   Home Visit/New/60 min 99344 130  Nausea/vomiting 643.0 FSH 83001 38   Home Visit/new/75 min 99345 165  Anemia 648.2 GC Culture 87070 48   Home visit/est/15 min 99347 39  Mild Preeclampsia 642.4 Gestational Glucose 82950 11   Home visit/est/25 min 99348 59  Edema 646.1 HCG-urine 81025 5   Home Visit/est/40 min 99349 87  Mastitis 611.0 Hemacult 82270 see Lab   Home Visit/est/60 min 99350 126  UTI 599.0 Hematocrit 85014 6  New Estab  Delivery 650 Hemoglobin 85018 6   Well Woman 12-17 99384 99394  Grand Multip delivered 659.41 Hepatitis B 87340 see Lab  136  Post-term Delivered Herpes Culture 87274 see Lab   Well Woman 18-39 99385 99395 645.01 HIV 86701 see Lab  136  Vaginal Birth OOH V27.0 LH 83002 see Lab   Well Woman 40-64 99386 99396  Baby Born OOH V30.20 Obstetric Profile 80055 134  Immediate Postpartum V24.0 144   Postpartum visit 59430 125  Post Partum V24.2 PKU Screening 84030   Post operative visit 99024  PKU-NB Screening V77.3 Post Coital Test 89300 see Lab  116  Well-Baby Care V20.1 RPR 86592 see Lab   Maternity Global Fee 59400  Lactation V24.1 Serum Progesterone 84144 see Lab  4310  Fertility 628.9 Three Hour GTT 82951  Vaginal Delivery 59409 29  Thyroid Profile 80091 see Lab 2040 Surgeries/Procedures Code Fee   UCG 81025 see Lab Vaginal Delivery- VBAC 59612 2080  Placenta Delivery 59414 89   Urinalysis 81000 see Lab Newborn Exam <6 wks 99432 150  Vit K J3430 10   Urinalysis Dip 81002 5 Preconception- New 99241 123  Doula Care/labor supp. 99499 479   Urine Culture 87086 15 Preconception- Est 99241 70  Erythromycin J3490.03 10  Wet Mount 87210 see Lab Place of Service: Office____ other_____  Attendance at birth/ 99436 179  Blood Draw 36415 11 Client’s home______Stabilization of infant  Fetal Non-Stress Test 59025 Medication/Comments:______ Injection 90782 10 105  Contraception advice V25.09 36 ______  Lactation Consult ______Blood Handling Fee 99000 9  Rhogam J2790 9 Patient Name: Account No.:  Supplies/materials 99070 Midwife Signature: ______I hereby authorize my insurance Date:______benefits to be paid directly to the Today’s Payment New Balance physician and acknowledge that I am Return in ______weeks______months financially responsible for any unpaid Date : Check [ ] #______balance. I also authorize the physician Cash [ ] MC/VISA [ ] to release any information requested by the insurance company. $______copay Next Appointment______, 200__ At ______AM/PM