Form 030268 is a document used to calculate the amount of workers' compensation benefits an injured worker is entitled to. This form can be confusing, so here we will provide an overview of how to complete it. First, you will need to know the date of injury and the type of injury. Then you will need to find the corresponding code for that injury. Finally, you will need to calculate the total wages earned by the injured worker in the previous year. Once you have all this information, you can fill out Form 030268 and send it to your employer's workers' compensation insurance company.
| Question | Answer |
|---|---|
| Form Name | Form 030268 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | UPIN, virginia, FSC, MUSCULOSKELETAL |
Orthopaedic Surgery Encounter Form
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CHARGE CONTROL NO. |
DIV. NO. |
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DIV. NAME |
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INVOICE NO. |
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MULT. SURG.? |
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FSC LIST |
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MRN |
PATIENT NAME |
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ADMIT DATE |
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DISCHARGE |
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DATE |
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CASE |
PROVIDER |
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FSC OVERRIDE |
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DISC |
DISC |
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TYPE |
% |
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REFERRING PHYSICIAN |
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UPIN |
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INJURY DATE |
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ADJ. AMT. |
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SVC. CTR. |
RESIDENT |
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TIME |
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THRU DATE |
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REFERRAL # |
LMP |
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ONSET |
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TREATMENT TIME |
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TYPE |
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BILLING AREA |
LOCATION |
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SERVICE DATE |
AUTHORIZATION |
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HOSPITAL |
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COMMERCIAL LAB |
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I |
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CHIEF COMPLAINT: |
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II |
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HISTORY OF PRESENT ILLNESS (HPI) |
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Was this an accident? If yes, what was the date and approximate hour of the day? |
_____/_____/_____ |
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Hour:___________ |
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Work related? |
οYes |
ο No |
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Location Quality Severity |
Duration |
Timing |
Context Modifying Factors |
Associated Signs & Symptoms |
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PAST MEDICAL, SOCIAL, FAMILY HISTORY (PFSH) |
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III |
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MEDICAL (Illness, Operations, Injuries and Treatment) |
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IV |
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SOCIAL (Review of Past & Current Activities) |
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οTOBACCO________________________ οETOH_________________________ |
οLIVING ARRANGEMENTS_____________________________ |
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V |
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FAMILY (Review of Medical Events in Patient’s Family) |
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οCAD |
οIDDM |
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οARTHRITIS |
οCA |
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VI |
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REVIEW OF SYSTEMS (ROS) |
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CONSTITUTIONAL |
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NO COMPLAINT ο |
CARDIOVASCULAR |
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NO COMPLAINT ο |
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HEMATOLOGICAL/LYMPHATIC |
NO COMPLAINT ο |
RESPIRATORY |
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NO COMPLAINT ο |
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INTEGUMENTARY |
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NO COMPLAINT ο |
PSYCHIATRIC |
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NO COMPLAINT ο |
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NEUROLOGICAL |
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NO COMPLAINT ο |
MUSCULOSKELETAL |
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NO COMPLAINT ο |
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EARS/NOSE/THROAT/MOUTH |
NO COMPLAINT ο |
ALLERGIC/IMMUNOLOGIC |
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NO COMPLAINT ο |
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GASTROINTESTINAL |
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NO COMPLAINT ο |
ENDOCRINE |
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NO COMPLAINT ο |
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EYES |
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NO COMPLAINT ο |
GENITOURINARY |
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NO COMPLAINT ο |
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(2) Problem Focused: CC; |
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SCORE |
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(3) Expanded problem: CC; |
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(4) Detailed: CC; ³ 4 HPI elements (acute) or ³ 3 HPI elements (chronic); |
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(5) Comprehensive: CC; ³ HPI elements (acute) or ³ 3 HPI elements (chronic); 10+ ROS; 3 PFSH |
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elements (new or consult) or 2 PFSH elements (established) |
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Form # 030268 To reorder, log onto: http://www.virginia.edu/uvaprint/HSC/hs_forms.pl
VII
VIII
IX
PHYSICAL EXAM
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CONSTITUTIONAL – θMeasure any three of following vital signs |
(2) Problem Focused: One to five elements identified by bullet |
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(3) Expanded problem: At least six elements identified by bullet |
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Height________________________________ Weight__________________ |
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BP Supine_________________ |
BP Sitting/Standing__________ |
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(4) |
Detailed: At least twelve elements identified |
SCORE |
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by bullet |
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Pulse Rate_________________ |
Respiration _________________ |
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Temperature________________ |
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(5) Comprehensive: All elements identified below |
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CARDIOVASCULAR ο Observation and palpation of peripheral vascular system |
NEUROLOGICAL/PSYCHIATRIC |
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LYMPHATIC ο Palpation of lymph nodes in neck, axilae, groin/or other |
ο Examination of Sensation |
ο Examination of deep tendon reflexes |
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ο Test Coordination |
ο Orientation |
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MUSCULOSKELETAL ο Examination of gait and station |
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ο Mood and affect |
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JOINT EXAMINATION |
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SKIN |
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INSPECT 4 OF 6 AREAS |
• Inspection, percussion, and/or palpation |
• |
Stability |
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Inspection, or |
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• Range of motion |
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Muscle strength, tone |
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Palpation |
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ο Head and Neck |
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ο Spine, Ribs & Pelvis |
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ο L |
upper extremity |
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ο R |
upper extremity |
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ο L |
lower extremity |
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ο R |
lower extremity |
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MEDICAL DECISION MAKING: Circle the appropriate value in each column. Two of the three elements must be met or exceeded to achieve the level.
Number of possible Diagnoses or |
Amount and/or complexity |
Risk of Complications and/or |
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Type of Decision Making |
Score |
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Minimal (1) |
Minimal or None (<1) |
Minimal |
3 |
Straightforward |
2 |
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Limited (2) |
Limited (2) |
Low |
3 |
Low Complexity |
3 |
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Multiple (3) |
Moderate (3) |
Moderate |
3 |
Moderate Complexity |
4 |
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Extensive (4+) |
Extensive (4+) |
High |
3 |
High Complexity |
5 |
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LEVEL OF CARE CALCULATION: Initial visit or consultation: |
History |
Orthopaedic |
Medical Decision |
LEVEL OF |
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score. |
Examination |
Making |
CARE |
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X
CIRCLE LEVEL OF VISIT |
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LEVEL 1 |
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LEVEL 2 |
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LEVEL 3 |
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LEVEL 4 |
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LEVEL 5 |
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CONSULTATIONS |
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99241 (63110308) |
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99242 (63110316) |
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99243 (63110324) |
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99244 (63110332) |
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99245 (63110340) |
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CONFIRM CONSULT. |
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99271 (63110456) |
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99272 (63110464) |
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99273 (63110472) |
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99274 (63110480) |
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99275 (63110498) |
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NEW PT VISIT |
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99201 (63110357) |
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99202 (63110365) |
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99203 (63110373) |
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99204 (63110381) |
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99205 (63011399) |
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ESTAB. PT VISIT |
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99211 (63110407) |
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99212 (63110415) |
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99213 (63110423) |
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99214 (63110431) |
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99215 (63110449 |
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PROCEDURES (CIRCLE, CHECK OR COMPLETE) |
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ASPIRATION/INJECTION |
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20600 (63121693) |
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20605 (63121685) |
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20610 (63121677) |
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20550 (63120042) |
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SMALL JOINT BURSA OR |
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INTERMEDIATE JOINT, BURSA OR |
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MAJOR JOINT |
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TENDON SHEATH, LIGAMENT, |
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GANGLION CYST |
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GANGLION |
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OR BURSA |
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TRIGGER POINTS OR CYST |
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INJECTABLE |
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99499 (63110118) |
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99024 (63110506) |
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DRUG TYPE:___________________________ AMOUNT_____________________________ |
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HCPCS Code:___________________________ SMS CODE:___________________________ |
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FRACTURE CARE (Check and/or complete) |
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SITE_______________________________________________________ |
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_____Without manipulation |
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_____ With manipulation |
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_____Initial Treatment Only |
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_____Open Treatment |
CPT Code:___________________ |
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SMS Code:___________________ Recasting (specify type)_______________________________________ |
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Casting Material: |
_____Plaster (A4580) |
_____Fiberglass (A4590) |
CPT Code:______________________ |
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SMS Code:______________________ |
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DIAGNOSIS |
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DX Code |
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Description |
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1 |
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2 |
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3 |
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MISCELLANEOUS (Complete) |
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Description:___________________________________________________________ |
HCPCS CPT Code:___________________________________________________________ |
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RETURN APPOINTMENT (SPECIFY): |
WITHIN_______(WEEKS) |
WITHIN_______(MONTHS) |
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OTHER_______ |
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ATTENDING PHYSICIAN SIGNATURE:____________________________________________ |
RESIDENT FELLOW SIGNATURE: |
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