Name:______________________________                                   Date of Service:_____________________

DOB:_______________________________                                     Follow Up Visit: _____________________

                                                                                                                            Referral: ___________________________ 

 

                                                                                                                             Height:__________________________

                                                                                                                             Weight: _________________________  

 

E&M/Office Visit Level:

 

 

 Office/Other Outpatient Visit

New Pt

Established Pt

 

Level 1: Problem Focused

99201 (retiring in 2021)

99211

 

Level 2: Expanded problem focused

99202

99212

 

Level 3: Detailed

99203

99213

 

Level 4: Comprehensive, moderate

99204

99214

 

Level 5: Comprehensive, high

99205

99215

Blood pressure:

Systolic:

Diastolic:

 

3074F:   <130

 

3078F:  <80

 

3075F:  130-139

 

3079F:  80-89

 

3077F:  >140

 

3080F:  >90

 

BMI (3008F):

 

Z68.1: 19.9 or less

 

Z68.24: 24.0-24.9

 

Z68.29: 29.0-29.9

 

Z68.34: 34.0-34.9

 

Z68.39: 39.0-39.9

 

 

Z68.45: 70 or greater

 

 

 

 

 

Z68.20: 20.0-20.9

 

Z68.25: 25.0-25.9

 

Z68.30: 30.0-30.9

 

Z68.35: 35.0-35.9

 

Z68.41: 40.0-44.9

 

Z68.21: 21.0-21.9

 

Z68.26: 26.0-26.9

 

Z68.31: 31.0-31.9

 

Z68.36: 36.0-36.9

 

Z68.42: 45.0-49.9

 

Z68.22: 22.0-22.9

 

Z68.27: 27.0-27.9

 

Z68.32: 32.0-32.9

 

Z68.37: 37.0-37.9

 

Z68.43: 50.0-59.9

 

Z68.23: 23.0-23.9

 

Z68.28: 28.0-28.9

 

Z68.33: 33.0-33.9

 

Z68.38: 38.0-38.9

 

Z68.44: 60.0-69.9

 

Diabetic Care:

HbA1c:

3044F: <7.0%

3051F:

 >7.0%-<8.0%

3052F:

>8.0%-<9.0%

3046F: >9.0%

 

Nephropathy:

 

3060F: positive microalbumin test result (30-300)

 

3062F: positive microalbumin test result documented/reviewed (>30)

 

3061F: negative microalbumin tests documented/reviewed

 

3066F: receiving dialysis, ESRD treatment, CRF, ARF, renal insufficiency

4010F: ACE inhibitor/ARB therapy

 

 

*review diabetic eye exam need, name of provider/practice:_________________________________ (obtain signed release of information)

 

 

 

Preventive Screenings/Exclusions:

 

Colorectal Cancer:

Breast Cancer:

Osteoporosis:

 

 

Z85.038: Cancer, personal history, other malignant neoplasm of large intestine

 

Z90.13: History of bilateral mastectomy

G0130: Bone mineral density test

 

 

Z90.12: Absence of left breast

 

 

Z85.048: Cancer, personal history, other malignant neoplasm of rectum, rectosigmoid junction, anus

 

Z90.11: Absence of right breast

 

 

 

 

 

Vaccinations:

 

G8482: Flu vaccine ordered & administered

 

4040F: Pneumonia vaccine administered or previously given

 

G8483: Flu vaccine not given for documented reason

 

4040F-1P: Pneumonia vaccine not administered for medical reasons

Medication Reconciliation Post-Discharge:

1111F: Discharge medications reconciled w/ current medication in the outpatient record

 

99495: Transition of care

99496: Transition of care

 

 

Annual Wellness/Initial Preventive Physical Exam:

G0438: Initial annual wellness

G0439: Subsequent annual wellness

G0402: Initial Preventive Physical Exam – IPPE (Welcome); once in a patient’s lifetime; billed in first 12 months of joining Medicare

*If you’re a federally-qualified health center (FQHC) you must bill G0468 along with one of the 3 codes listed above (G0438, G0439, G0402)

Fall Risks:

 

1100F: screening, 2 or more falls in past year or any fall with injury in the past year

 

1101F: screening, no falls in the past year or only 1 fall without injury in the past year

 

1100F-1P: patient not screened, medical reasons

 

1101F-1P: patient not screened, medical reasons

Advanced Directive:

1157F: Advance care planning or similar legal document in record

1158F: Advance care planning discussion notated in record

 

S0257: Counseling/discussion regarding advanced directive/end of life care with patient and/or surrogate

Medication List & Review (need to bill both):

 

1159F: Medication list documented in record

 

1160F: Review of all medications by provider & documented in record

Functional Status:

Pain Assessment:

1170F: Functional status assessed

 

 

1125F: Pain severity quantified, present

 

1126F: Pain severity quantified, no pain present

Tobacco Cessation:

1034F: Current tobacco smoker

1035F: Current smokeless tobacco user

1036F: Current non-smoker

Depression Screening: G0444 (annual depression screening)

 

G8431: Screening for depression documented as positive and follow up plan is documented

 

96160: Pre-natal/Post-partum health risk assessment with scoring and documentation

 

G850: Screening for depression documented as negative, follow up plan is not required

 

96127: Brief emotional/behavioral assessment (ADD/ADHD) with scoring and documentation

Improving Bladder Control:

1090F: Presence or absence of urinary incontinence

0509F: Urinary incontinence plan of care documented

Monitoring Physical Activity:

Z71.82: Exercise counseling

1003F: Level of activity assessed

 

 

Frequent LAB Studies

 

CBC

 

Lipid

 

Microalbumin (protein)

 

BMP

 

HbA1c

 

UA C/S

 

CMP

 

TSH

 

Urinalysis

 

PT/INR

 

PSA

 

eGFR

 

36415:  Venipuncture

 

Hepatic/LFTs

 

UACR (urine-creatinine ration)

 

 

Frequently Ordered Tests

 

Mammogram

 

Other:

 

Colonoscopy

 

Other:

 

1.28.2021

April 2023 Bulletin

April 2023 BulletinHere is what your PACN Team and Member colleagues have been up to as we begin 2023:PACN-ACO education session was held on February 24th for Quality Reporting (MIPS) submission tips. Thanks to all our PACN-ACO participants for your engagement to...

read more

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