UWHEALTH GASTROENTEROLOGY HOSPITAL Doctor Name MD # Sched Dept/Specialty # NAME: 16045-666 Insurance ______PLACE INPATIENT HOSPITAL 86 Special Billing Instructions

Date of Injury D.O.B. OUTPATIENT HOSPITAL 16000 Type of Injury: ÿ Auto ÿ Work ÿ Other ADMISSION DATE: DISCHARGE DATE: Date of Service HISTORY# REFERRING PHYSICIAN RESIDENT PRESENT: o YES o NO

FEE WAIVERS/ REDUCTIONS ( PRO FESSIONA L FEES ONLY) Community Care Write- Offs (100%) Fee Overrides o o Check here to request consideration for community care. PBS Discretionary (7)not to be used if patient has insurance Please indicate fee to be will evaluate & reduce or write-off fees for qualifying pts. o Fee Dispute (8) charged next to the CPT code. CODE ü PROCEDURES CODE P PROCEDURES ESOPHAGOSCOPY COLONOSCOPY 43200 Esophagoscopy, rigid or flexible; diagnostic 45378 Colonoscopy, flexible, proximal to splenic flexure: diagnostic 43201 w/ directed submucosal injection(s), any substance 45380 w/biopsy, single or multiple 43202 w/ biopsy, single or multiple 45381 w/ directed submucosal injection(s), any substance 43204 w/ injection sclerosis of 45382 w/control of bleeding 43205 w/ band ligation of esophageal varicies 45383 w/ablation of tumor(s)/(s)/lesion(s) 43215 w/ removal of foreign body 45384 w/removal of tumor(s)/polyp(s)/lesion(s)by hot bx forceps 43216 w/ removal of tumor (s) polyp (s) / Lesions (s) hot biopsy 45385 w/removal of tumor(s)/polyp(s)/lesion(s) by snare technique 43217 w/ removal of tumor (s) polyp (s) / Lesions (s) by share 45386 w/ balloon, one or more strictures 43219 w/ insertion of plastic tube or stent 45387 w/transendoscopic stent placement (includes predilation) 43220 w/ balloon dilation, (less than 30 mm diameter) Hemorrhoidectomy, internal by rubber band ligation 43226 w/ insertion of guide wire follow by dilation over guide wire 46221 43227 w/ control of bleeding FLEXIBLE SIGMOIDOSCOPY 43228 w/ ablation of tumor (s) / polyp (s) / Lesion (s) 45330 Sigmodioscopy, flexible; diagnostic 43232 w/ transendoscopic unltrasound- guided intramural or transmural fine 45331 w/ biopsy, single or multiple needle aspiration / biopsy (s) 45332 w/ removal of foreign body ESOPHAGOGASTRODUODENOSCOPY 45333 w/ removal of tumor(s)/polyp(s) /lesion(s) by hot bx forceps 43235 Upper gastrointestinal endoscopy; diagnostic 45334 w/ control of bleeding 43236 w/ directed submucosal injection(s), any substance 45335 w/ direct submucosal injection(s), any substance 43239 w/ biopsy, single or multiple 45337 w/ decompression of , any method 43240 w/ transmural drainage of pseudocyst 45338 w/ removal of tumor(s)/ polyp(s)/ lesion(s) by snare technique 43241 w/ transendoscopic intraluminal tube or catheter placement 45339 w/ ablation of tumor(s) polyp(s) or other lesion(s) not 43243 w/ injection sclerosis esophageal / Amenable to removal by hot biopsy 43244 w/ band ligation of esophageal and/or gastric varices 45340 w/ balloon, one or more strictures 43245 w/ dilation of gastric outlet for obstruction 45341 w/ endoscopic ultrasound examination 43246 w/ directed placement of percutaneous gastrostomy tube 45345 w/ transendoscopic stent placement (includes predilation) 43247 w/ removal of foreign body COLONOSCOPY THRU STOMA 43248 w/ insert guide wire follow by dilation of over guide wire 44388 Colonoscopy thru stoma; diagnostic 43249 w/ balloon dilation of esophagus (less than 30mm diameter) 43250 w/ removal tumor(s)/polyp(s)/lesions(s) by hot biopsy forceps 44389 w/ biopsy; single or multiple 43251 w/ removal of tumor (s)/ polyp (s) / lesion (s) by snare 44391 w/ control of bleeding 43255 w/ control of bleeding 44392 w/removal of tumor (s)/polyp (s)/ lesion (s) by hot bx forceps 43256 w/ transendoscopic stent placement ( include predilation) 44393 w/ ablation of tumor (s) /polyp (s) /lesions (s) 43258 w/ ablation of tumor(s), polyp(s), or other lesion(s) not amenable to hot 44394 w/ removal tumor(s)/plyp(s)/lesion(s) by snare technique biopsy forceps, bipolar cautery or snare 44397 w/ transendoscopic stent placement (includes predilation) ENDOSCOPY 44380 Ileoscopy thru stoma; diagnostic 44360 Small intestinal endoscopy, enteroscopy beyond 2nd part of , 44382 w/ biopsy, single or multiple not including ; diagnostic DILATION W /O ENDOSCOPY, SENGSTAAKEN 44361 w/ biopsy, single or multiple 43450 Dilation of esophagus; by unguided sound/bougie, sngl/mult passes 44364 w/ removal of tumor (s)/ polyp (s)/ or other lesions (s) by snare 43453 Over guide wire or string 44365 w/ removal of tumor (s)/ polyp (s)lesion(s) by hot bx forceps 43458 w/ balloon (30mm diameter or larger) for achalasia 44366 w/ control of bleeding MANOMETRY 44370 w/ transendoscopic stent placement (includes predilation) 91122-26 Anorectal manometry 44373 w/ conversion of percutan. gastrostomy tube to percutan jejunostomy tube Esopth function test impedance, 1 hour or less 44385 Endoscopic eval of small intestinal (abdomen or pelvic) pouch w /wo collect 91037-26 specimen by brush or wash 91038-26 Esopth function test impedance, greater than 1 hour ERCP 91010-26 Esophageal motility 43260 Endoscopic retrograde cholangiopancreatography ; diagnostic PH LEVEL 43261 w/ biopsy, single or multiple 91034-26 24 hour PH test impedance 43262 w/ sphincterotomy / papillotomy 91035-26 Bravo capsule placement (for PH) 43264 w/ removal of stone (s) from biliarty / pancreatic ducts MISCELLANEOUS 43265 w/ endo destruction, lithotripsy, calc, any method 49082 Abdmnl paracentesis (diag or theraput) w/o image & guidance 43267 w/ insertion nasobiliary or nasopancreatic drainage tube 43761 Repositioning of the gastric feeding tube for enteric nutrition 43268 w/ insertion tube / stent into bile / pancreatic duct 43760 Change of gastrostomy tube 43269 w/ removal foreign body / change of tube or stent 43273 Endoscopic cannulation of papilla w /direct visual of CBD(s) 43271 w/ balloon dilation ampulla / biliray / pancreatic duct (s) &/or panc duct(s) list in addit. to code for prim proced. ADDITIONAL PROCEDURES DOM/GI/Meriter/1 2/15/2012 91110-26 Gastro Tract imaging, intralum. (eg. capsule) esoph thru ileum w/phys. interp & report CODE DIAGNOSIS CODE DIAGNOSIS CODE DIAGNOSIS SYMPTOMS DUODENAL ULCERS COLON / continued 789.30 Abdominal Mass (5th digit 0 = w/o obstr., 1 = with obstr.) 569.41 Solitary Rectal Ulcer 789.04 Abdominal , lt. Lower quad. 532.3__ Acute w/o hemrhg or perf. 556.2 Ulcerative , chronic 789.02 Abdominal pain, lt. Upper quad. 532.2__ Acute w/ hemrhg & perf. 556.9 Ulcerative , unspec. 556.5 - Left sided, chronic 789.05 Abdominal pain, periumbilic 532.7__ Chrnc w/o hemrhg or perf. 789.03 Abdominal pain, rt. Lower quad. 556.6 Ulcerative Colitis - universal, chronic 532.6__ Chrnc w/ hemrhg or perf. 789.01 Abdominal pain, rt. Upper quad. 560.2 Volvulus 532.9__ Unspec, w/o hemrhg or perf. 789.06 Abdominal pain, epigastric V76.51 Screening colonoscopy GASTRIC ULCERS PANCREASE / BILE DUCTS 789.07 Abdominal pain, generalized (5th digit 0 = w/o obstr., 1 = with obstr.) 793.6 Abnormal findings radiological, abn & retroperit 577.0 Acute 531.3__ Acute w/o hemrhg or perf. 783.0 Anorexia 576.2 Obstruction 531.2__ Acute w/ hemrhg & perf. 493.90 Asthma 575.8 __ 787.99 Change in Bowel Habits 531.7 Chrnc w/o hemhg or perf. 576.1 Cholangitis 786.2 Cough 531.6__ Chrnc w/ hemrhg & perf. 574.50 Choledocholithiasis w/o obstr. 787.91 531.9__ Unspc, w/o hemrhg or perf. 574.20 Cholelithiasis NOS w/o obstr. 536.8 Dyspepsia GASTROJEJUNAL ULCERS 577.1 th 787.20 Dysphagia unspecified (5 digit 0 = w/o obstr., 1 = with obstr.) 577.2 Pancreatic Cyst / Pseudocyst 787.21 Dysphagia oral phase 534.3__ Acute w/o hemrhg or perf. 576.5 Sphincter of Oddi Spasm 787.29 Other dysphagia 534.2__ Acute w/ hemrhg & perf. LIVER 790.5 Abnormal LFT’s - Alk Phos 783.3 Feeding Problem 534.7__ Chrnc w/o hemrhg or perf. 790.4 Abnormal LFT’s - Transaminase 787.3 Flatulence 534.6__ Chrnc w/ hemrhg & perf. 573.9 Abnormal LFT’s -Unspec. Dis. Liver 787.1 Heartburn 534.9__ Unspc w/o hemrhg or perf. 571.3 Alcoholic 782.4 Jaundice, NOS PEPTIC ULCERS 277.6 Alpha 1- Antitrypsin Def. 787.01 & Vomiting (5th digit 0 = w/o obstr., 1 = with obstr.) 571.6 - Biliary 787.02 Nausea alone 533.3__ Acute w/o hemrhg or perf. 571.5 Cirrhosis - Non Alcoholic __ 536.2 Persistent Vomiting 533.2 Acute w/ hemrhg & perf. 796.4 Elevated Ferritin 462 533.7__ Chrnc w/o hemrhg or perf. 571.40 - Chronic , Unspec. 784.99 Throat clearing 533.6__ Chrnc w/ hemrhg & perf. 070.9 Hepatitis - Viral NOS w/o hep. coma 787.03 Vomiting alone 533.9__ Unspc w/o hemrhg or perf. 070.30 Hepatitis B, w/o Hepatitis Delta ESOPHAGUS AND 070.51 w/o Hepatic Coma 530.12 Acute (5th digit 0 = w/o mention of hemorrhage, 070.54 Hepatitis C, Chronic, w/o Hepatic Coma 530.0 Achalasia 1 = with hemorrhage) 789.1 Hepatomegaly 530.85 Barretts Esophagus 535.0__ acute 782.4 Jaundice - Unspec. 530.5 Dyskinesia of Esophagus 535.3__ alcoholic 789.51 Malignant ascites 530.3 535.1__ Chronic (atrophic) 789.59 Other ascites 530.20 Esophageal ulcer, w/o bleeding 535.5__ unspec. 576.1 Primary Sclerosing Cholangitis 530.21 Esophageal ulcer, w/ bleeding COLON / RECTUM MALIGNANT TUMORS 456.0 Esophageal Varices w/ Hemorrhage 565.0 156.9 CA , part unspec. 530.11 Esophagitis Reflux 565.1 150.9 CA Esophagus, unspec 935.1 Foreign Body Esophagus 009.1 Colitis - Micro / Collagenous 155.2 CA Liver, not spec. As primary or secondary 530.81 GERD 157.9 CA Pancreas, part unspec. 530.7 Mallory - Weiss 211.3 Colon Adenomatous Polyp - Benign 151.9 CA Stomach - Unspec. STOMACH 564.00 , Unspecified 536.8 Dyspepsia 564.01 Constipation, Slow Transit 153.9 CA Colon - Unspec. 535.00 Gastritis - Acute w/o hemorrhage 564.02 Constipation, Outlet Dysfunction 152.9 CA , unpsec. 535.30 Gastritis - Alcoholic w/o hemorrhage 564.09 Constipation, Other BENIGN TUMORS 535.10 Gastritis - Chronic w/o hemorrhage 555.1 Crohns Colon 211.3 Colon 535.50 Gastroduodenitis w/o hemorrhage V12.72 Disease of digestive system colon polyps 211.0 Esophagus 536.3 562.11 - Colon 211.5 Liver & Bile Ducts 041.86 Helicobacter pylori (H.pylori) 562.10 - Colon 211.6 Pancreas, except islet of longerhans 578.0 455.3 External w/o complications 211.1 Stomach 553.3 Hiatal 455.4 External thrombosed hemorrhoids MISCELLANEOUS 643.00 Hyperemesis Gravidarum 455.5 Extrnl hemorrhoids w /other complications 793.4 Abnorm Ct Scan radiological GI 533.90 Peptic Ulcer- Unspec., w/o hemorrhage, w/o obstr. V16.0 Family Hx. Colon Cancer 285.9 Anemia - Unspec. 564.2 Post Gastrectomy Syndrome SMALL BOWEL 792.1 Heme Positive Stools 437.9 Cerebrovascular Disease, NOS 579.8 Bile Salt Diarrhea 787.60 Full Incontinence of Feces 780.94 Early satiety 579.0 Celiac Disease 787.61 Incomplete defecation V18.51 Fam Hx. Colonic Polyps 555.2 Crohns - Small / Large Bowel 560.32 V18.59 Fam. hx GI disorder 555.0 Crohns - Small Bowel 787.63 Fecal urgency V76.49 Flex Screening, other sites 562.00 Diverticulosis - Small Bowel 455.0 Internal Hemorrhoids w/o complications 784.0 - Unspec. 537.3 Duodenal Stenosis 455.1 Internal thrombosed hemorrhoids 242.90 Hyperthyroid w/o thyrotoxic crisis or storm 535.60 Duodenitis w/o Hemorrhage 455.2 Intrnl hemorrhoids w /other complications 244.9 Hypothyroid, unspec 535.61 Duodenitis w/Hemorrhage 560.9 Intestinal Obstruction, unspec. 280.9 Iron def. anemia, unspecified 005.9 Food poisoning, unspec. 564.1 780.79 Malaise & Fatigue, Other 009.1 - Infectious presumed 564.7 715.90 Osteoarthritis, Unspec. 558.9 Gastroenteritis - other & unspec., noninfections 578.1 / 007.1 Giardiasis 438.82 Other late effects of Cerebrovascular 569.79 Other complications of intestinal pouch 560.1 Disease, Dysphagia V10.05 Personal hx malig. neoplasm-lrg intestine 557.1 Ischemic Bowel - Chronic 281.0 569.71 Pernicious Anemia 557.0 Ischemic Bowel - Acute 780.2 Syncope 579.9 - Unspec. 564.6 Proctalgia Fugax 465.9 URI, NOS (Acute) 537.0 698.0 599.0 Urinary Tract Infection, site not specified 003.0 Salmonella Gastroenteritis 558.1 Radiation 004.9 Shigella, unspec. 569.3 Rectal Bleeding 079.99 Viral Infection NOS 579.3 569.0 Rectal Polyps 783.21 Weight Loss ADDITIONAL PROCEDURES

# = Please Rank Diagnoses DOM/GI/Meriter/1 2/15/2012