Date of service: Waiver? l Patient name: Insurance: Subscriber name: Address: Group #: Previous balance: Copay: Today’s charges: Phone: Account #: Today’s payment: check# DOB: Age: Sex: Physician name: Balance due: RANK Office visit New Est RANK Office procedures RANK Laboratory Minimal 99211 Anoscopy 46600 Venipuncture 36415 Problem focused 99201 99212 Audiometry 92551 Blood glucose, monitoring device 82962 Expanded problem focused 99202 99213 Cerumen removal 69210 Blood glucose, visual dipstick 82948 Detailed 99203 99214 Colposcopy 57452 CBC, w/ auto differential 85025 Comprehensive 99204 99215 Colposcopy w/biopsy 57455 CBC, w/o auto differential 85027 Comprehensive (new patient) 99205 ECG, w/interpretation 93000 Cholesterol 82465 Significant, separate service -25 -25 ECG, rhythm strip 93040 Hemoccult, guaiac 82270 Well visit New Est Endometrial biopsy 58100 Hemoccult, immunoassay 82274 < 1 y 99381 99391 Flexible sigmoidoscopy 45330 Hemoglobin A1C 85018 1-4 y 99382 99392 Flexible sigmoidoscopy w/biopsy 45331 Lipid panel 80061 5-11 y 99383 99393 Fracture care, cast/splint 29_____ Liver panel 80076 12-17 y 99384 99394 Site: ____________________ KOH prep (skin, hair, nails) 87220 18-39 y 99385 99395 Nebulizer 94640 Metabolic panel, basic 80048 40-64 y 99386 99396 Nebulizer demo 94664 Metabolic panel, comprehensive 80053 65 y + 99387 99397 Spirometry 94010 Mononucleosis 86308 Medicare preventive services Spirometry, pre and post 94060 Pregnancy, blood 84703 Pap Q0091 Tympanometry 92567 Pregnancy, urine 81025 Pelvic & breast G0101 Vasectomy 55250 Renal panel 80069 Prostate/PSA G0103 Skin procedures Units Sedimentation rate 85651 Tobacco counseling/3-10 min 99406 Burn care, initial 16000 Strep, rapid 86403 Tobacco counseling/>10 min 99407 Foreign body, skin, simple 10120 Strep culture 87081 Welcome to Medicare exam G0344 Foreign body, skin, complex 10121 Strep A 87880 ECG w/Welcome to Medicare exam G0366 I&D, abscess 10060 TB 86580 Flexible sigmoidoscopy G0104 I&D, hematoma/seroma 10140 UA, complete, non-automated 81000 Hemoccult, guaiac G0107 Laceration repair, simple 120____ UA, w/o micro, non-automated 81002 Flu shot G0008 Site: __________ Size: _____ UA, w/ micro, non-automated 81003 Pneumonia shot G0009 Laceration repair, layered 120____ Urine colony count 87086 Consultation/preop clearance Site: __________ Size: _____ Urine culture, presumptive 87088 Expanded problem focused 99242 Lesion, biopsy, one 11100 Wet mount/KOH 87210 Detailed 99243 Lesion, biopsy, each add’l 11101 Vaccines Comprehensive/mod complexity 99244 Lesion, destruct., benign, 1-14 17110 DT, <7 y 90702 Comprehensive/high complexity 99245 Lesion, destruct., premal., single 17000 DTP 90701 Other services Lesion, destruct., premal., ea. add’l 17003 DtaP, <7 y 90700 After posted hours 99050 Lesion, excision, benign 114____ Flu, 6-35 months 90657 Evening/weekend appointment 99051 Site: __________ Size: _____ Flu, 3 y + 90658 Home health certification G0180 Lesion, excision, malignant 116____ Hep A, adult 90632 Home health recertification G0179 Site: __________ Size: _____ Hep A, ped/adol, 2 dose 90633 Post-op follow-up 99024 Lesion, paring/cutting, one 11055 Hep B, adult 90746 Prolonged/30-74 min 99354 Lesion, paring/cutting, 2-4 11056 Hep B, ped/adol 3 dose 90744 Special reports/forms 99080 Lesion, shave 113____ Hep B-Hib 90748 Disability/Workers comp 99455 Site: __________ Size: _____ Hib, 4 dose 90645 Radiology Nail removal, partial 11730 HPV 90649 Nail removal, w/matrix 11750 IPV 90713 Skin tag, 1-15 11200 MMR 90707 Diagnoses Medications Units Pneumonia, >2 y 90732 1 Ampicillin, up to 500mg J0290 Pneumonia conjugate, <5 y 90669 2 B-12, up to 1,000 mcg J3420 Td, >7 y 90718 3 Epinephrine, up to 1ml J0170 Varicella 90716 4 Kenalog, 10mg J3301 Immunizations & Injections Units Next office visit Lidocaine, 10mg J2001 Allergen, one 95115 Recheck Prev PRN _______ D W M Y Normal saline, 1000cc J7030 Allergen, multiple 95117 Instructions: Phenergan, up to 50mg J2550 Imm admin, one 90471 Progesterone, 150mg J1055 Imm admin, each add’l 90472 Rocephin, 250mg J0696 Imm admin, intranasal, one 90473 Testosterone, 200mg J1080 Imm admin, intranasal, each add’l 90474 Referral Tigan, up to 200 mg J3250 Injection, joint, small 20600 To: Toradol, 15mg J1885 Injection, joint, intermediate 20605 Miscellaneous services Injection, joint, major 20610 Instructions: Injection, ther/proph/diag 90772 Injection, trigger point 20552 Physician signature Supplies X ____________________________________________________ Infectious & Parasitic Diseases Mental Disorders H66.006 Acute suppurative otitis media without B00.9 Herpesviral infection, unspecified F41.9 Anxiety disorder, unspecified spontaneous rupture of ear drum, A60.9 Anogenital herpesviral infection F90.0 Attention-deficit hyperactivity disorder, recurrent, bilateral B02.9 Zoster without complications predominantly inattentive type H66.007 Acute suppurative otitis media without B27.00 Gammaherpesviral mononucleosis F90.9 Attention-deficit hyperactivity disorder, spontaneous rupture of ear drum, without complication unspecified type recurrent, unspecified ear B27.01 Gammaherpesviral mononucleosis with F03 Unspecified dementia H66.009 Acute suppurative otitis media without polyneuropathy F33.9 Major depressive disorder, recurrent, spontaneous rupture of ear drum, B27.02 Gammaherpesviral mononucleosis with unspecified unspecified ear meningitis Nervous System & Sense Organ Disorders B27.09 Gammaherpesviral mononucleosis with Circulatory System other complications Nervous System Diseases Arrythmias B27.10 Cytomegaloviral mononucleosis without G56.00 Carpal tunnel syndrome, unspecified I48.0 Atrial fibrillation complications side B27.11 Cytomegaloviral mononucleosis with G56.01 Carpal tunnel syndrome, right side Cardiac polyneuropathy G56.02 Carpal tunnel syndrome, left side I20.8 Other forms of angina pectoris B27.12 Cytomegaloviral mononucleosis with G40.90 Epilepsy, unspecified, not intractable I20.9 Angina pectoris, unspecified meningitis G40.901 Epilepsy, unspecified, not intractable, I25.701 Atherosclerosis of coronary artery B27.19 Cytomegaloviral mononucleosis with with status epilepticus bypass graft(s), unspecified, with other complication G40.909 Epilepsy, unspecified, not intractable, angina pectoris with documented B27.80 Other infectious mononucleosis without without status epilepticus spasm complication G43.90 Migraine, unspecified, not intractable I25.111 Atherosclerotic heart disease of native B27.81 Other infectious mononucleosis with G44.039 Episodic paroxysmal hemicrania, not coronary artery with angina pectoris polyneuropathy intractable Episodic paroxysmal with documented spasm B27.82 Other infectious mononucleosis with hemicrania NOS I25.118 Atherosclerotic heart disease of native meningitis G44.049 Chronic paroxysmal hemicrania, not coronary artery with other forms of B27.89 Other infectious mononucleosis with intractable Chronic paroxysmal angina pectoris other complication hemicrania NOS I25.119 Atherosclerotic heart disease of native B27.90 Infectious mononucleosis, unspecified coronary artery with unspecified angina without complication Eye Diseases pectoris B27.91 Infectious mononucleosis, unspecified H10.9 Unspecified conjunctivitis I25.708 Atherosclerosis of coronary artery with polyneuropathy H53.10 Unspecified subjective visual bypass graft(s), unspecified, with other B27.92 Infectious mononucleosis, unspecified disturbances forms of angina pectoris with meningitis H53.11 Day blindness I25.709 Atherosclerosis of coronary artery B27.99 Infectious mononucleosis, unspecified bypass graft(s), unspecified, with with other complication Ear Diseases unspecified angina pectoris J02.0 Streptococcal pharyngitis H61.20 Impacted cerumen, unspecified ear I25.711 Atherosclerosis of autologous vein J03.00 Acute streptococcal tonsillitis, H61.21 Impacted cerumen, right ear coronary artery bypass graft(s) with unspecified H61.22 Impacted cerumen, left ear angina pectoris with documented J03.01 Acute recurrent streptococcal tonsillitis H61.23 Impacted cerumen, bilateral spasm J02.0 Streptococcal sore throat H60.00 Abscess of external ear, unspecified I25.718 Atherosclerosis of autologous vein B97.8 Other viral agents as the cause of ear coronary artery bypass graft(s) with diseases classified elsewhere H60.01 Abscess of right external ear other forms of angina pectoris B07 Viral warts H60.02 Abscess of left external ear I25.719 Atherosclerosis of autologous vein H60.03 Abscess of external ear, bilateral coronary artery bypass graft(s) with Neoplasms H60.10 Cellulitis of external ear, unspecified unspecified angina pectoris Benign Neoplasms ear I25.721 Atherosclerosis of autologous artery D49.2 Neoplasm of unspecified behavior of H60.11 Cellulitis of right external ear coronary artery bypass graft(s) with bone, soft tissue, and skin H60.12 Cellulitis of left external ear angina pectoris with documented D23.9 Other benign neoplasm of skin, H60.13 Cellulitis of external ear, bilateral spasm unspecified H60.311 Diffuse otitis externa, right ear I25.728 Atherosclerosis of autologous artery H60.312 Diffuse otitis externa, left ear coronary artery bypass graft(s) with Endocrine, Nutritional & Metabolic Disorders H60.313 Diffuse otitis externa, bilateral other forms of angina pectoris H60.319 Diffuse otitis externa, unspecified ear I25.729 Atherosclerosis of autologous artery Endocrine H60.32 Hemorrhagic otitis externa coronary artery bypass graft(s) with E10.8 Type 1 diabetes mellitus with H60.321 Hemorrhagic otitis externa,