Medical Administration Mod 3

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Outpatient_Encounter_Form1.doc

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Outpatient Encounter Form

Patient Information		Billing Information		Visit Information
Patient ID number		Primary		Visit date
Patient name		Primary ID number		Visit number
Address		Primary group number		Rendering physician
City/State		Secondary		Referring physician
Social Security number		Secondary ID number		Reason for visit
Phone number		Secondary group no.
Date of birth		Cash/credit card
Age		Other billing

E/M Modifiers	Procedure Modifiers	Other Modifiers
24 — Unrelated E/M service during postop.	22 — Unusual, excessive procedure
25 — Significant, separately identifiable E/M	50 — Bilateral procedure
57 — Decision for surgery	51 — Multiple surgical procedures in same day
	52 — Reduced/incomplete procedure
	55 — Postop. management only
	59 — Distinct multiple procedures

CATEGORY	CODE	MOD	FEE	CATEGORY	CODE	MOD	FEE
Office Visit — New Patient				Wound Care
Minimal office visit	99201			Debride partial thick burn	11040
20 minutes	99202			Debride full thickness burn	11041
30 minutes	99203			Debride wound, not a burn	11000
45 minutes	99204			Unna boot application	29580
60 minutes	99205			Unna boot removal	29700
Other				Other
Office Visit — Established				Supplies
Minimal office visit	99211			Ace bandage, 2”	A6448
10 minutes	99212			Ace bandage, 3"-4”	A6449
15 minutes	99213			Ace bandage, 6”	A6450
25 minutes	99214			Cast, fiberglass	A4590
40 minutes	99215			Coban wrap	A6454
Other				Foley catheter	A4338
General Procedures				Immobilizer	L3670
Anascopy	46600			Kerlix roll	A6220
Audiometry	92551			Oxygen mask/cannula	A4620
Breast aspiration	19000			Sleeve, elbow	E0191
Cerumen removal	69210			Sling	A4565
Circumcision	54150			Splint, ready-made	A4570
DDST	96110			Splint, wrist	S8451
Flex sigmoidoscopy	45330			Sterile packing	A6407
Flex sig. w/ biopsy	45331			Surgical tray	A4550
Foreign body removal—foot	28190			Other
Nail removal	11730			OB Care
Nail removal/phenol	11750			Routine OB care	59400
Trigger point injection	20552			OB call	59422
Tympanometry	92567			Ante partum 4–6 visits	59425
Visual acuity	99173			Ante partum 7 or more visits	59426
Other				Other

Other Visit Information: Fees:

Lab Work to Order: Total Charges: $

Referral to: Copay Received: $

Provider Signature: Other Payment: $

Next Appointment: Total Due: $

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