Medical professionals are always looking for ways to improve the quality and accuracy of patient care. One way to do this is by using a superbill template form. A superbill is a document that helps track services provided to a patient, as well as payments received from insurance companies. Superbill templates can help ensure that all required information is included on the bill, reducing the chances of errors and improving billing efficiency. There are many different types of superbill templates available online, so medical professionals can choose the one that best meets their needs.Creating a superbill template can be a great way to improve the accuracy and efficiency of your practice's billing process. There are many different templates available online, so you can find one that best suits your needs.
Before you decide to fill in superbill template, you will want to understand more in regards to the type of form you will work with.
| Question | Answer |
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| Form Name | Superbill Template |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | sample superbill for mental health, mental health psychotherapy superbill template, superbill template mental health, printable psychotherapy superbill template |
Family Practice Management Superbill Template |
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From the American Academy of Family Practice (AAFP) Family Practice Management Toolkit |
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(http://www.aafp.org/fpm/20060900/43inse.html) |
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Date of service: |
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Waiver? l |
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Patient name: |
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Insurance: |
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Subscriber name: |
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Address: |
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Group #: |
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Previous balance: |
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Copay: |
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Today’s charges: |
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Phone: |
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Account #: |
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Today’s payment: check# |
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DOB: |
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Age: |
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Sex: |
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Physician name: |
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Balance due: |
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RANK |
Office visit |
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New |
Est |
RANK |
Office procedures |
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RANK |
Laboratory |
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Minimal |
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99211 |
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Anoscopy |
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46600 |
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Venipuncture |
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36415 |
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Problem focused |
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99201 |
99212 |
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Audiometry |
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92551 |
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Blood glucose, monitoring device |
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82962 |
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Expanded problem focused |
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99202 |
99213 |
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Cerumen removal |
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69210 |
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Blood glucose, visual dipstick |
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82948 |
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Detailed |
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99203 |
99214 |
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Colposcopy |
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57452 |
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CBC, w/ auto differential |
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85025 |
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Comprehensive |
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99204 |
99215 |
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Colposcopy w/biopsy |
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57455 |
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CBC, w/o auto differential |
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85027 |
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Comprehensive (new patient) |
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99205 |
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ECG, w/interpretation |
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93000 |
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Cholesterol |
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82465 |
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Significant, separate service |
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ECG, rhythm strip |
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93040 |
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Hemoccult, guaiac |
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82270 |
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Well visit |
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New |
Est |
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Endometrial biopsy |
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58100 |
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Hemoccult, immunoassay |
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82274 |
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< 1 y |
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99381 |
99391 |
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Flexible sigmoidoscopy |
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45330 |
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Hemoglobin A1C |
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85018 |
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99382 |
99392 |
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Flexible sigmoidoscopy w/biopsy |
45331 |
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Lipid panel |
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80061 |
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99383 |
99393 |
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Fracture care, cast/splint |
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29_____ |
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Liver panel |
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80076 |
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99384 |
99394 |
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Site: ____________________ |
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KOH prep (skin, hair, nails) |
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87220 |
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99385 |
99395 |
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Nebulizer |
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94640 |
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Metabolic panel, basic |
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80048 |
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99386 |
99396 |
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Nebulizer demo |
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94664 |
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Metabolic panel, comprehensive |
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80053 |
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65 y + |
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99387 |
99397 |
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Spirometry |
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94010 |
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Mononucleosis |
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86308 |
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Medicare preventive services |
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Spirometry, pre and post |
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94060 |
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Pregnancy, blood |
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84703 |
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Pap |
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Q0091 |
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Tympanometry |
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92567 |
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Pregnancy, urine |
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81025 |
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Pelvic & breast |
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G0101 |
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Vasectomy |
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55250 |
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Renal panel |
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80069 |
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Prostate/PSA |
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G0103 |
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Skin procedures |
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Units |
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Sedimentation rate |
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85651 |
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Tobacco |
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99406 |
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Burn care, initial |
16000 |
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Strep, rapid |
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86403 |
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Tobacco counseling/>10 min |
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99407 |
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Foreign body, skin, simple |
10120 |
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Strep culture |
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87081 |
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Welcome to Medicare exam |
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G0344 |
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Foreign body, skin, complex |
10121 |
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Strep A |
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87880 |
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ECG w/Welcome to Medicare exam |
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G0366 |
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I&D, abscess |
10060 |
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TB |
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86580 |
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Flexible sigmoidoscopy |
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G0104 |
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I&D, hematoma/seroma |
10140 |
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UA, complete, |
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81000 |
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Hemoccult, guaiac |
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G0107 |
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Laceration repair, simple |
120____ |
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UA, w/o micro, |
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81002 |
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Flu shot |
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G0008 |
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Site: __________ Size: _____ |
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UA, w/ micro, |
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81003 |
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Pneumonia shot |
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G0009 |
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Laceration repair, layered |
120____ |
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Urine colony count |
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87086 |
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Consultation/preop clearance |
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Site: __________ Size: _____ |
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Urine culture, presumptive |
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87088 |
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Expanded problem focused |
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99242 |
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Lesion, biopsy, one |
11100 |
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Wet mount/KOH |
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87210 |
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Detailed |
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99243 |
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Lesion, biopsy, each add’l |
11101 |
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Vaccines |
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Comprehensive/mod complexity |
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99244 |
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Lesion, destruct., benign, |
17110 |
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DT, <7 y |
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90702 |
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Comprehensive/high complexity |
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99245 |
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Lesion, destruct., premal., single |
17000 |
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DTP |
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90701 |
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Other services |
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Lesion, destruct., premal., ea. add’l |
17003 |
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DtaP, <7 y |
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90700 |
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After posted hours |
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99050 |
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Lesion, excision, benign |
114____ |
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Flu, |
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90657 |
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Evening/weekend appointment |
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99051 |
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Site: __________ Size: _____ |
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Flu, 3 y + |
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90658 |
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Home health certification |
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G0180 |
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Lesion, excision, malignant |
116____ |
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Hep A, adult |
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90632 |
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Home health recertification |
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G0179 |
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Site: __________ Size: _____ |
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Hep A, ped/adol, 2 dose |
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90633 |
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99024 |
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Lesion, paring/cutting, one |
11055 |
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Hep B, adult |
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90746 |
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99354 |
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Lesion, paring/cutting, |
11056 |
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Hep B, ped/adol 3 dose |
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90744 |
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Special reports/forms |
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99080 |
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Lesion, shave |
113____ |
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Hep |
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90748 |
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Disability/Workers comp |
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99455 |
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Site: __________ Size: _____ |
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Hib, 4 dose |
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90645 |
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Radiology |
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Nail removal, partial |
11730 |
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HPV |
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90649 |
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Nail removal, w/matrix |
11750 |
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IPV |
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90713 |
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Skin tag, |
11200 |
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MMR |
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90707 |
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Diagnoses |
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Medications |
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Units |
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Pneumonia, >2 y |
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90732 |
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1 |
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Ampicillin, up to 500mg |
J0290 |
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Pneumonia conjugate, <5 y |
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90669 |
2 |
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J3420 |
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Td, >7 y |
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90718 |
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3 |
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Epinephrine, up to 1ml |
J0170 |
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Varicella |
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90716 |
4 |
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Kenalog, 10mg |
J3301 |
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Immunizations & Injections |
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Units |
Next office visit |
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Lidocaine, 10mg |
J2001 |
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Allergen, one |
95115 |
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Recheck |
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Prev |
PRN |
_______ D W |
M Y |
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Normal saline, 1000cc |
J7030 |
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Allergen, multiple |
95117 |
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Instructions: |
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Phenergan, up to 50mg |
J2550 |
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Imm admin, one |
90471 |
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Progesterone, 150mg |
J1055 |
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Imm admin, each add’l |
90472 |
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Rocephin, 250mg |
J0696 |
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Imm admin, intranasal, one |
90473 |
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Testosterone, 200mg |
J1080 |
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Imm admin, intranasal, each add’l |
90474 |
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Referral |
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Tigan, up to 200 mg |
J3250 |
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Injection, joint, small |
20600 |
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To: |
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Toradol, 15mg |
J1885 |
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Injection, joint, intermediate |
20605 |
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Instructions: |
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Miscellaneous services |
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Injection, joint, major |
20610 |
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Injection, ther/proph/diag |
90772 |
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Injection, trigger point |
20552 |
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Physician signature |
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Supplies |
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X ____________________________________________________ |
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Infectious & Parasitic Diseases
054.9Herpes simplex, any site
053.9Herpes zoster, NOS
075 Infectious mononucleosis
034.0Strep throat
079.99Viral infection, unspec.
078.10Warts, all sites
Neoplasms
Benign Neoplasms
239.2Skin, soft tissue neoplasm, unspec.
216.9Skin, unspec.
Endocrine, Nutritional & Metabolic Disorders
Endocrine
250.01Diabetes I, uncomplicated
250.91Diabetes, I, w/ unspec. complications
250.00Diabetes II, uncomplicated
250.90Diabetes II, w/ unspec. complications
242.90Hyperthyroidism, NOS
244.9Hypothyroidism, unspec.
Metabolic/Other
274.9Gout, unspec.
272.0Hypercholesterolemia, pure
272.2Hyperlipidemia, mixed
278.00Obesity, NOS
278.02Overweight
Blood Diseases
285.9Anemia, other, unspec.
Mental Disorders
300.00Anxiety state, unspec.
314.00Attention deficit, w/o hyperactivity
290.0Dementia, senile, uncomplicated
311 |
Depressive disorder, NOS |
Nervous System & Sense Organ Disorders
Nervous System Diseases
354.0Carpal tunnel
345.90Epilepsy, unspec., not intractable
346.90Migraine, unspec., not intractable
Eye Diseases
372.30Conjunctivitis, unspec.
368.10Visual disturbance, unspec.
Ear Diseases
380.4Cerumen impaction
389.9Hearing loss, unspec.
380.10Otitis externa, unspec.
382.00Otitis media, acute
Circulatory System
Arrythmias
427.31Atrial fibrillation
Cardiac
413.9Angina pectoris, NOS
428.0Heart failure, congestive, unspec.
424.1Heart valve, aortic, not rheum.
414.9Ischemic heart disease, chronic, unspec.
Vascular
796.2Elevated BP w/o hypertension
401.1Hypertension, benign
458.0Hypotension, orthostatic
443.9Peripheral vascular disease, unspec.
451.9Thrombophlebitis, unspec.
459.81Venous insufficiency, unspec.
Respiratory System
Lower Respiratory Tract
493.90Asthma, unspec.
466.0Bronchitis, acute
496 |
COPD, NOS |
486 |
Pneumonia, unspec. |
Upper Respiratory Tract
462 Pharyngitis, acute
477.9Rhinitis, allergic, cause unspec.
461.9Sinusitis, acute, NOS
465.9Upper respiratory infection, acute, NOS
Digestive System
578.1Blood in stool
564.00Constipation, unspec.
562.10Diverticulosis of colon
562.11Diverticulitis of colon, NOS
535.50Gastritis, unspec., w/o hemorrhage
558.9Gastroenteritis, noninfectious, unspec.
530.81Gastroesophageal reflux, no esophagitis
455.6Hemorrhoids, NOS
564.1Irritable bowel syndrome
Genitourinary System
Urinary System Diseases
592.9Calculus, urinary, unspec.
595.0Cystitis, acute
599.70Hematuria, unspec.
593.9Renal insufficiency, acute
599.0Urinary tract infection, unspec. /pyuria
Male Genital Organ Dieases
607.84Impotence, organic
302.72Impotence, psychosexual dysfunction
601.9Prostatitis, NOS
Breast Diseases
611.72Breast lump
Female Genital Organ Diseases
V13.22 Cervical dysplasia, past history
616.0Cervicitis
622.10Dysplasia, cervix, unspec.
616.10Vaginitis/vulvitis, unspec.
Disorders of Menstruation
626.0Amenorrhea
627.9Menopausal disorders, unspec.
626.2Menstruation, excessive/frequent
625.3Menstruation, painful
626.6Metrorrhagia
Pregnancy, Childbirth
641.90Bleeding in preg., unspec.
V24.2 Postpartum
V22.2 Pregnancy
V22.0 Prenatal care, normal, first pregnancy
V22.1 Prenatal care, normal, other pregnancy
Skin, Subcutaneous Tissue
706.1Acne, other
702.0Actinic keratosis
682.9Cellulitis/abscess, unspec.
692.9Contact dermatitis, NOS
691.8Eczema, atopic dermatitis
703.0Ingrown nail
110.1Onychomycosis
709.9Other skin disease, unspec.
696.1Psoriasis
695.3Rosacea
706.2Sebaceous cyst
702.19Seborrheic keratosis, NOS
707.9Ulcer, skin, chronic, unspec.
708.9Urticaria, unspec.
Musculoskeletal & Connective Tissue
General
716.90Arthropathy, unspec.
729.1Myalgia/myositis, unspec.
715.90Osteoarthrosis, unspec.
733.00Osteoporosis, unspec.
714.0Rheumatoid arthritis (not JRA)
727.00Synovitis/tenosynovitis, unspec.
Lower Extremity
729.5Pain in limb
Spine/Torso
724.4Back pain w/ radiation, unspec.
723.9Cervical disorder, NOS
Upper Extremity
726.10Shoulder syndrome, unspec.
Perinatal (Infant)
779.3Feeding problem, newborn
Signs & Symptoms
789.00Abdominal pain, unspec.
795.01Abnormal Pap,
719.40Arthralgia, unspec.
569.3Bleeding, rectal
786.50Chest pain, unspec.
786.2Cough
787.91Diarrhea, NOS
780.4Dizziness/vertigo, NOS
787.20Dysphagia, unspec.
788.1Dysuria
782.3Edema, localized, NOS
783.3Feeding problem, infant/elderly
780.60Fever, unspec.
271.9Glucose intolerance
784.0Headache, unspec.
788.30Incontinence/enuresis, NOS
782.2Localized swelling/mass, superficial
785.6Lymph nodes, enlarged
780.79Malaise and fatigue, other
787.02Nausea, alone
787.01Nausea w/ vomiting
719.46Pain, knee
724.2Pain, low back
785.1Palpitations
788.42Polyuria
782.1Rash, nonvesicular, unspec.
782.0Sensory disturbance skin
786.05Shortness of breath
780.2Syncope
788.41Urinary frequency
787.03Vomiting, alone
783.21Weight loss
Injuries & Adverse Effects
Dislocations, Sprains & Strains
845.00Sprain/strain: ankle, unspec.
845.10Sprain/strain: foot, unspec.
842.10Sprain/strain: hand, unspec.
844.9Sprain/strain: knee/leg, unspec.
847.0Sprain/strain: neck, unspec.
840.9Sprain/strain: shoulder/upper arm, unspec.
842.00Sprain/strain: wrist, unspec.
Other Trauma, Adverse Effects
919.0Abrasion, unspec.
924.9Contusion, unspec.
919.4Insect bite
894.0Open wound, lower limb, unspec.
884.0Open wound, upper limb, unspec.
Supplemental Classification
V25.01 |
Contraception, oral |
V25.02 |
Contraception, other (diaphragm, etc.) |
V58.31 |
Dressing, surgical wound |
V01.9 |
Exposure, infectious disease, unspec. |
V72.31 |
Gynecological exam |
V06.8 |
Immunization, combination, other |
V06.1 |
Immunization, DTP |
V04.81 |
Immunization, influenza |
V25.2 |
Sterilization |
V70.0 |
Well adult check |
V20.2 |
Well child check |
updated 9/08