Allied Clinic 12345 Allied Avenue, Suite: A Laguna Hills, CA 92653 Tel: 123-456-7890; Fax: 987-654-3210

PATIENT NAME: ______DATE: ______

SSN#: ______DOB: ______

VISITS New Established 99201 99203 99211 Brief 99213 Expanded 99202 99204 99212 Problem focused 99214 Detailed 99205 99215 Comprehensive

PROCEDURES 59000 Amniocentesis 56501 Destruction, Vulvar Lesion 58611 Ligation of fallopian tube(s) 19000 Aspiration Breast Cyst 57170 Diaphragm Fitting 57160 Pessary Fitting 57500 Cervical Biopsy 57505 Endocervical Curettage 81025 Pregnancy Test 59514 Cesarean Delivery 58100 Endometrial Biopsy 81000 Urinalysis 57452 Colposcopy 10060 I&D Abscess 57100 Vaginal Biopsy 57454 Colposcopy w/ Biopsy 10140 I&D Hematoma 36415 Venipuncture 57511 Cryosurgery 10180 I&D PostOp Wound 56605 Vulvar Biopsy 59020 CST 58300 IUD Insertion 87210 Wet Mount 11043 Debridement 58301 IUD Removal 57061 Destruction, Vaginal Lesion ______Other

Urodynamics CPT Urodynamics ICD-10 51726 Complete Cystometrogram 51727 Urethral Pressure Profile N39.3 (625.6) Stress Incontinence 51728 Bladder Voiding Pressure 51741 Complex Uroflowmetry N39.41 (788.31) Urge incontinence 51797 Intraabdominal Voiding Pressure 51784 EMG R35.1 (788.43) Nocturia R32 (788.30) Incontinence of urine

OB - DIAGNOSIS GYN - DIAGNOSIS O28.9 (796.5) AFP Abnormality R19.0 (789.30) Abdominal Mass A60.9 (054.10) Herpes Simplex Virus O46.90 (641.90) Antepartum Bleed R10 (789.00) Abdominal Pain N88.3 (622.5) Incompetent Cervix 034.21 (654.21) Cesarean Delivery R87.619 (795.0) Abnormal Pap N97.9 (628.9) Infertility O36.8190 (655.7) Decreased Fetal N93.8 (626.8) Abnormal Uterine N92.6 (626.4) Irregular menses Mvmt Bleed C80.1 (199.1) Malignant neoplasm Z37.0 (V27.0) Delivery of single, D39.9 (236.3) Adnexal Mass N95.1 (627.2) Menopause liveborn N91.2 (626.0) Amenorrhea N92.0 (626.2) Menorrhagia O00 (633.1) Ectopic Pregnancy Z01.419 (V72.31) Annual Exam N83.20 (620.2) Ovarian Cyst O24.4 (648.8) Gest. Diabetes N95.2 (627.3) Atrophic Vaginitis N73.6 (614.6) Pelvic Adhesions O21.0 (643.0) Hypermesis N75.0 (616.2) Bartholin Cyst R.19.00 (789.3) Pelvic Mass O02.1 (632) Missed Abortion Z30.49 (V25.49) Birth Control R10.2 (625.9) Pelvic Pain O41.0 (658.0) Oligohydramnios O02.0 (631.8) Blighted Ovum N95.0 (627.1) Post Menopausal 040 (657.00) Polyhydramnios N63 (611.72) Breast Lump Bleeding Z34.80 (V22.2) Prenatal Care N64.4 (611.71) Breast Pain N73.9 (614.9) PID O09.90 (V23.9) Prenatal High Risk N87.1 622.12) Cervical Dysplasia N81.9 (618.00) Rectocele O86.89 (670.00) Puerperal N84.1 (622.7) Cervical Polyp C79.82 (198.82) Secondary malignant Injection N72 (616.0) Cervicitis neoplasm O26.85 (641.9) Spotting N30.90 (595.9) Cystocele N39.0 (599.0) UTI Z30.2 (V25.2) Sterilization N92.5 (626.8) DUB N89.8 (623.8) Vaginal Bleeding O20.0 (640.0) Threatened Abortion N94.6 (625.3) Dysmenorrhea N89.8(623.5) Vaginal Discharge ______Other N80.9 (617.9) Endometriosis N81.4 (618.4) Vaginal Prolapse D25.9 (218.9) Fibroid Uterus N76.0 (616.10) Vaginitis N64.3 (611.6) Galactorrhea D28.0 (221.2) Vulvar Lesion B07.9 (078.10) HPV B37.9 (112.9) Yeast Infection ______Other Note: ICD-9 codes are noted in parentheses.

Physician’s Signature: Dr. MacTap______Date: 4/10/2014______