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Practice Name Practice Name PatientName: Date of Service: Date of Birth: SSN: Place of Service: Payment Amount: $ CA CC CK Insurance: PCP/Attending MD: Date Last Seen (must be w/in last 6 months): Dx Codes 800.00-995.0: Auto Employment Other Date of InJury: New Patient Office Established Patient Office New Patient Rest Home Established Pt. Rest Home Prolonged Services/Post Op [ ] 99202 20 min [ ] 99212 10 min [ ] 99324 Low [ ] 99334 Straightforward [ ] 99354 First Hour [ ] 99203 30 min [ ] 99213 15 min [ ] 99325 Straightforward [ ] 99335 Low [ ] 99355 Each addtl 30 min [ ] 99204 45 min [ ] 99214 25 min [ ] 99024 POST OP VISIT Incision & Drainage Orthotics Continued Diagnosis Codes [ ] 10060 I & D Abscess [ ] L3260 Surgical shoe 078.19 Oth Spcfd viral warts 726.72 Tibialis tendinitis [ ] 10061 Complicated/multiple [ ] L4386 Walking boot 110.1 Dermatophytosis nail 726.79 Ankle enthesopathy [ ] 10080 Drain pilonidal cyst Diabetic Shoes 110.4 Dermatophytosis foot 726.91 Exostosis, site NOS [ ] 10120 Remove FB [ ] A5500 Shoe Fitting 216.7 Benign neoplasm leg 727.06 Tenosynovitis foot/an [ ] 10160 Puncture drainage [ ] A5513 Multi Density Insert 238.1 Neoplasm soft tissue 727.1 Bunion [ ] 10140 Drain Hematoma Cast Application/Strapping 274.0 Gouty arthropathy 727.40 Synovial cyst NOS Debridement [ ] 29405 Appl short leg cast 355.0 Sciatic nerve lesion 728.71 Plantar fibromatosis [ ] 11040 Skin partial thickness [ ] 29515 Appl LE splint 355.5 Tarsal tunnel synd 729.5 Pain in limb [ ] 11041 Skin full thickness [ ] 29540 Strapping ankle/foot 355.6 Plantar nerve lesion 733.93 Stress fx tibia/fibula [ ] 97597 Wound care [ ] 29580 Unna boot 355.8 Mononeuritis leg nos 733.94 Stress fx metatarsals Pair/Cut Corn & Callus X-Ray 459.9 Circulatory disease 734 Flat foot [ ] 11055 One [ ] 73600 Ankle 2 views 692.4 Chemical dermatitis 735.0 Hallux valgus [ ] 11056 2-4 [ ] 73620 Foot op & lateral 700 Corns & callosities 735.2 Hallux rigidus [ ] 11057 4+ Surgical Procedures 701.1 Keratoderma Acq 735.4 Other hammer toe Excision Benign Lesions [ ] 20924 Rem tendon-graft 701.4 Keloid scar 736.70 Acq ankle-foot def NOS [ ] 11420 0.5 cm or less [ ] 27695 Repair ankle ligament 703.0 Ingrowing nail 736.79 Acq ankle-foot def NEC [ ] 11421 0.6 - 1.0 cm [ ] 28002 I & D infection 703.8 Disease of nail NEC 736.81 Unequal leg length [ ] 11422 1.1 - 2 cm [ ] 28008 Faciotomy foot/toe 707.13 Ulcer of ankle 780.8 Gen hyperhidrosis [ ] 11423 2.1 - 3 cm [ ] 28011 Tenotomy 707.15 Ulcer other part foot 782.3 Edema Nail Care [ ] 28060 Part rem foot fascia 709.8 Skin disorders NEC 824.2 Fx lateral malleolus-cl [ ] 11720 Debride 5 or less [ ] 28080 Exc Morton neuroma 714.0 Rheumatoid arthritis 826.0 Fx phalanx foot-closed [ ] 11721 Debride 6 or more [ ] 28090 Rem foot lesion 716.17 Arthropathy ankle trau 844.9 Sprain knee & leg Wart /Benign LesionRemoval [ ] 28110 Part rem metatarsal 718.20 Path dislocat-unspec 845.00 Sprain ankle [ ] 17110 Wart Dest to 14 [ ] 28124 Part removal toe 719.47 Joint pain - Ankle 845.10 Sprain foot NOS Nail Removal [ ] 28208 Repair foot tendon 719.67 Joint symptom ankle 924.10 Contusion lower leg [ ] 11730 Avul nail plate, 1 [ ] 28285 Repair hammertoe 726.70 Ankle enthesopathy 928.3 Crushing injury toe [ ] 11732 Each addtl plate [ ] 28288 Part rem foot bone 726.71 Achilles tendinitis V72.84 Preop exam unspec [ ] 11750 Exc nail matrix [ ] 28289 Cheilectomy Systemic Diagnosis Codes- Bold requires DLS & Ref MD [ ] 11765 Exc nail fold, toe [ ] 28292 Keller/McBride 250._____ DM II w/o Comp 459.81 Venous insufficiency Layer Closure Wound [ ] 28296 Austin bunionectomy 337.1 Aut neuropathy other 459.9 Circulatory disease [ ] 12041 2.5 cm or less [ ] 28298 Correction bunion 356.4 Idio prog polyneurop 681.10 Cellulitis toe nos [ ] 12042 2.6 - 7.5 cm [ ] 28308 Osteotomy MTH 451.2 Thromb L.E. 681.11 Onychia toe Injection/Aspiration Other Procedure(s) Other Diagnosis Codes [ ] 20600 Inj sm jnt bursa [ ] [ ] 20605 Inj interm jnt/bursa [ ] [ ] 20612 Inj ganglion cyst [ ] Class Findings [ ] 20550 Inj plantar fascia [ ] Class A Findings: [ ] 20551 Inj single tendon Toe Modifiers 1) Nontraumatic amputation of foot or integral skeletal portion [ ] 64450 N block other peripheral Digit Left Foot Right Foot Class B Findings: Drugs Hallux TA T5 1) Absent posterior tibial pulse [ ] J3301 Kenalog _____ mg 2nd Digit T1 T6 2) Advanced trophic changes as: hair growth, nail changes, [ ] J1110 D.H.E. _____ mg 3rd Digit T2 T7 pigmentary changes, skin texture, skin color. (3 REQUIRED) Orthotics 4th Digit T3 T8 3) Absent dorsalis pedis pulse [ ] 97760 Orthotic fitting 5th Digit T4 T9 Class C Findings: [ ] 97762 C/O for orthotic Q-Codes 1) Claudication, 2) Temperature changes, 3) Edema, [ ] L1901 Ankle, elastic [ ] Q7 - 1 Class A Finding 4) Paresthesias, 5) Burning [ ] L1902 Ankle gauntlet [ ] Q8 - 2 Class B Findings Notes to Billing Office: [ ] L1906 Ankle brace/support [ ] Q9 - 1 Class B & 2 Class C Findings [ ] L3020 Foot insrt long/met.
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