Urget Care Superbill

URGENT CARE LOCATION (CIRCLE ONE) CPT 99201 99202 99203 99204 99205 99025 90025 99211 99212 99213 99214 99215 99354 99355 46600 11730* 16030* 16025* 16020* 53670 30903 30901 10060* 10140* 10120* 65222* 07008 12001* 12002* 12004* 12011* 12013* 12031* 12032* 12041* 12042* 29505 29515

Provider # 13 15

DESCRIPTION FEE DESCRIPTION FEE CPT NEW PATIENTS X-RAY; (cont'd) LEVEL 1, BRIEF; 10 min 73060 HUMERUS; 2+ VIEWS LEVEL 2, LIMITED: 20 min 73560 KNEE; AP & LAT LEVEL 3, EXPANDED; 30 min 72110 LS SPINE; COMPLETE W/OBLIQUES LEVEL 4, COMPREHENSIVE; 45 min 70110 MANDIBLE; COMPLETE LEVEL 5, COMPREHENSIVE; 60 min 70160 NASAL BONES; COMPLETE NEW PT. INITIAL VISIT W/*PROC. 72190 PELVIS; 3+VIEWS ESTABLISHED PATIENTS 04209 POST REDUCTION OFFICE VISIT, NO CHARGE N/C 71100 RIB, UNILATERAL, 2 VIEWS LEVEL 1, BRIEF: 72220 SACRUM & COCCYX; 2+ VIEWS LEVEL 2, LIMITED: 73050 SHOULDER AC JTS; BILATERAL LEVEL 3, EXPANDED: 73030 SHOULDER; COMPLETE LEVEL 4, COMPREHENSIVE: 70360 SOFT TISSUE LEVEL 5, COMPREHENSIVE: 72070 THORACIC SPINE; AP&LAT PROLONGED SERVICE 1st HOUR 73590 TIB-FIB; AP&LAT PROLONGED SERV. EA ADD'L 30min 73110 WRIST; COMPLETE LAB (POST CHARGES FROM LAB TICKET ONLY) PROCEDURES ANOSCOPY 36415 VENIPUNCTURE AVULSION NAIL, SIMPLE 86308 MONO SCREEN (HETEROPHILE) BURN CARE; LG, NO ANEST 81025 PREGNANCY TEST - URINE BURN CARE, MED, NO ANEST 87880 RAPID STREP ANTIGEN BURN CARE, SMALL, NO ANEST 81001 UA COMPLETE CATHETERIZATION (ADD TRAY) 80100 Urine Drug Screen EPISTAXIS CONTROL; COMPLEX SUPPLIES (SENT HOME WITH PATIENT) EPISTAXIS CONTROL, SIMPLE I&D ABSCESS; SIMPLE 02074 ACE WRAP 4" I&D HEMATOMA/SEROMA/FLUID 02075 ACE WRAP 6" REM. FB SUB Q; SIMPLE 02786 ADAPTIC DRESSING REM. FB CORNEA W/SLIT LAMP 02019 ANKLE BRACE REMOVE CONSTRICTING RING 02620 ANKLE BRACE: AIR CAST LACERATION REPAIRS 02604 ANKLE, E-Z WRAP; RIGID REP LAC 2.5cm OR LESS 02686 BURN DRESSING, LARGE REP LAC 2.6 - 7.5cm 02685 BURN DRESSING, SMALL REP LAC 7.6 - 12.5cm 02066 CERVICAL COLLAR FACIAL LAC 2.5cm OR LESS 02007 CLAVICLE STRAP FACIAL LAC 2.6 - 5.0 cm 02077 DRESSINGS; LARGE LAYER CLOS. SCALP/AXILLA/TRUNK ; <2.5CM 03201 DRESSINGS; MEDIUM LAYER CLOS.SCALP/AXILLA/TRUNK 2.6-7.5CM 02076 DRESSINGS; SMALL LAYER CLOSURE; NECK/HANDS/FEET <2.5CM 02011 ELBOW SUPPORT LAYER CLOSURE;NECK/HANDS/ FEET 2.6-7.5CM 02082 FINGER SPLINT SPLINTS / SUPPLIES 02013 KNEE IMMOBILIZER APPLY LONG LEG SPLINT 02087 KNEE SLEEVE APPLY SHORT LEG SPLINT 02387 KWIK COLD

Fed

29125 29105 02222 02223 74000 74022 73610 72052 71020 73000 73080 70150 73630 73090 73130 73510

APPLY SHORT ARM SPLINT APPLY LONG ARM SPLINT ORTHOGLASS; ARM ORTHOGLASS; LEG X-RAY ABDOMEN (1 VIEW) ABDOMINAL SERIES ANKLE; COMPLETE CERVICAL SPINE; COMPLETE CHEST PA & LAT CLAVICLE; COMPLELTE ELBOW; COMPLETE FACIAL BONES; COMPLETE FOOT; COMPLETE FOREARM; AP&LAT HAND; 3+ VIEWS HIP; COMPLETE, UNILATERAL

02200 MALLET FINGER SPLINT 02127 ORTHO SHOE 02129 RIB BELT

Provider #

Federal ID #

INJURY DATE: CPT DESCRIPTION FEE SUPPLIES (SENT HOME WITH PATIENT) 02110 SLING, ARM 02084 UNIVERSAL THUMB SPLINT 02150 WRIST BRACE, LIBERTY 02010 WRIST SPLINT TRAYS AND OTHER SUPPLIES 02534 EYE TRAY 02111 SIMPLE TRAY 02097 SMALL SUTURE TRAY W/ANES 02033 SUTURE REMOVAL KIT 02094 TRAY, PELVIC / SMALL W/ANESTHESIA 02795 TRAY, SMALL W/O ANESTHESIA 02101 INSERTION TRAY W/FOLEY W/O BAG 02389 STRAIGHT TIP CATHETER 02027 IV SUPPLIES 02795 I&D TRAY J7030 INFUSION NORMAL SALINE: 1000 cc J7040 INFUSION N/S, STERILE; 500ml = 1 UNIT J7120 LACTATED RINGERS; 1000cc MISCELLANEOUS 93000 EKG; COMPLETE 99291 CRITICAL CARE; 1ST HOUR 99292 CRITICAL CARE; EA ADD'L 30 MIN TOTAL TIME:________ to __________

02474 DISPOSABLE CAUTERY UNIT 69210 EAR IRRIGATION 94640 NEBULIZER TREATMENT 02026 OXYGEN SUPPLIES 94760 OXIMETRY INJECTIONS AND ADMINISTRATIONS 90780 IV INFUSION; UP TO 1 HOUR 90781 IV INFUSION; EA ADD'L HR TO 8 HRS 90782 THERAP/ DIAG INJECTION; SUB Q/ IM 90784 THERAP/ DIAG INJECTION; IV 90788 IM INJECTION OF ANTIBIOTIC J0150 J1200 03524 J0702 J2175 J1030 J1160

ADENOSINE; 6mg X _____ BENADRYL; 50mg CARDIAZEM PER 25MG X ______

CELESTONE; 3mg/ml X ______ DEMEROL; PER 100mg X _____ DEPOMEDROL 40mg X ______ DIGOXIN UP TO 0.5mg

J0170 J3030 J1940 J2550 J0696 J2930 J1885

EPINEPHRIN/SUSPHRINE; 1ml amp

IMITREX 6mg LASIX UP TO 20mg X ______ PHENERGAN 50mg X _____ ROCEPHIN PER 250mg: X _________

SOLUMEDROL; 125MG X _______ TORADOL; PER 15mg: X ________

OTHER: 99211 ADMINISTER PPD W/NO MD VISIT 86580 PPD 90718 TETANUS; Td (V06.5 or Injury code)

FAMILY PRACTICE CODE MOD DESCRIPTION OFFICE VISITS - NEW PATIENTS 99201 LEVEL 1, BRIEF; 10 min 99202 LEVEL 2, LIMITED: 20 min 99203 LEVEL 3, EXPANDED; 30 min 99204 LEVEL 4, COMPREHENSIVE; 45 min 99205 LEVEL 5, COMPREHENSIVE; 60 min 99025 NEW PT. INITIAL VISIT W/*PROC. PREVENTIVE EXAM - NEW PATIENTS 99381 PREVENTIVE MEDICINE < 1 YEAR 99382 PREVENTIVE MEDICINE, 1 - 4 99383 PREVENTIVE MEDICINE, 5-11 99384 PREVENTIVE MEDICINE, 12-17 99385 PREVENTIVE MEDICINE, 18-39 99386 PREVENTIVE MEDICINE, 40-64 99387 PREVENTIVE MEDICINE, 65+ OFFICE VISITS - EST. PATIENTS 99211 LEVEL 1, BRIEF: 5 min 99212 LEVEL 2, LIMITED: 10 min 99213 LEVEL 3, EXPANDED: 15 min 99214 LEVEL 4, COMPREHENSIVE: 25 min 99215 LEVEL 5, COMPREHENSIVE: 40min PREVENTIVE EXAM - EST. PATIENTS 99391 PREVENTIVE MEDICINE < 1 YEAR 99392 PREVENTIVE MEDICINE, 1 - 4 99393 PREVENTIVE MEDICINE, 5-11 99394 PREVENTIVE MEDICINE, 12-17 99395 PREVENTIVE MEDICINE, 18-39 99396 PREVENTIVE MEDICINE, 40-64 99397 PREVENTIVE MEDICINE, 65+ INITIAL NURSING FACILITY CARE 99301 LEVEL 1 , ANNUAL ASSESSMENT 99302 LEVEL 2, NEW PROBLEM 99303 LEVEL 3, INITIAL ADMIT TO NH SUBSEQUENT NURSING FACILITY CARE 99311 LEVEL 1, STABLE NH VISIT 99312 LEVEL 2, MINOR PROBLEM 99313 LEVEL 3, MAJOR PROBLEM PROCEDURES 94640 AIRWAY INHALATION TREATMENT 46600 ANOSCOPY;DIAGNOSTIC 92551 AUDIOMETRY AIR ONLY

22022197.xls FAMILY PRACTICE 09/13/2009

CODE 10060 10061* 11200 11201 17000 17003 17004 93000 93005 20550 20600* 20605* 20610* 94150 69210 45330 94010 87220 82270 Q0091 86580 81000 87210 87880 90782 J3420 J0702 J2175 J1460 J2000 J2550 J0696 J3030 J1055 J1070 J1080 J9215 J3301

MOD

DESCRIPTION CODE MOD DESCRIPTION I&D ABSCESS/CYST, SIMPLE TRAYS (ADD TO SURGICAL PROCEDURES) I&D ABSCESS, COMPL. OR MULT. 02094 TRAY, SMALL W/ANESTHESIA 02097 SUTURE TRAY W/ANESTHESIA SKIN TAG REMOVAL, UP TO 15 02098 TRAY, MEDIUM W/SPEC. ROOM(SIG) SKIN TAG REMOVAL, EA ADDL 10 DEST.BEN LESION,ANY METHD, 1st 02095 TRAY, LARGE + RM + SPEC. EQUIP SUPPLIES 2nd THROUGH 14th LESIONS EA DEST BEN LES. ANY METH. > 15 02113 CANVAS KNEE BRACE EKG, COMPLETE 02010 CANVAS WRIST SUPPORT 02112 ELASTIC ANKLE WRAP EKG, TRACING ONLY INJ TENDON/LIGAMENT/CYST/TRIGGER PT 02018 ELASTIC ANKLET INJECT.SMALL JT/BURSA/CYST 02579 FINGER SPLING INJECT. INT. JOINT/BURSA/CYST 02129 RIB BELT INJECT.MAJOR JOINT/BURSA/CYST 02525 SLING VITAL CAPACITY; SEPARATE PROC 02488 STERI-STRIPS REMOVAL IMPACTED CERUMEN 02033 SUTURE REMOVAL KIT SIGMOIDOSCOPY; FLEXIBLE 02011 TENNIS ELBOW SUPPORT SPIROMETRY W/GRAPHIC RECORD 02084 UNIVERSAL THUMB SPLINT OTHER: SPECIFY DIAGNOSTICS KOH OCCULT BLOOD PAP SMEAR HANDLING CASTS/SPLINTS PPD URINALYSIS, ROUTINE 29065 LONG ARM CAST 29075 WET MOUNT SHORT ARM CAST 29105 LONG ARM SPLINT QUICK STREP 29125 INJECTIONS UNITS SHORT ARM SPLINT SUB Q OR IM INJECTION OF MED 29405 SHORT LEG CAST 29515 B-12 ; up to 1000 mcg SHORT LEG SPLINT CELESTONE SOLUSPAN 1cc 02220 CAST MATERIAL, PLASTER, ARM DEMEROL PER 100mg 02221 CAST MATERIAL, PLASTER, LEG GAMMA GLOBULIN; IM 1cc 02222 CAST MATERIAL, FIBERG, ARM LIDOCAINE 02223 CAST MATERIAL, FIBERG, LEG PHENERGAN UP TO 50 mg ROCEPHIN 250 mg X ____ UNITS IMITREX 6mg X _____ UNITS DEPO-PROVERA 150mg (CONTRACEPTIVE) DEPO-TESTOSTERONE 100mg DEPO-TESTOSTERONE 200mg INTERFERON .05cc KENALOG, PER 10mg

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