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 |
|
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Level 4: Comprehensive, moderate |
99204 |
99214 |
|
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Level 5: Comprehensive, high |
99205 |
99215 |
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Blood pressure: |
|||
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Systolic: |
Diastolic: |
||
|
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3074F: <130 |
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3078F: <80 |
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3075F: 130-139 |
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3079F: 80-89 |
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3077F: >140 |
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3080F: >90 |
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BMI (3008F): |
|||||||||||
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Z68.1: 19.9 or less |
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Z68.24: 24.0-24.9 |
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Z68.29: 29.0-29.9 |
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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% |
||||
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Nephropathy: |
|||
|
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3060F: positive microalbumin test result (30-300) |
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3062F: positive microalbumin test result documented/reviewed (>30) |
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|
3061F: negative microalbumin tests documented/reviewed |
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3066F: receiving dialysis, ESRD treatment, CRF, ARF, renal insufficiency |
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4010F: ACE inhibitor/ARB therapy |
|||
*review diabetic eye exam need, name of provider/practice:_________________________________ (obtain signed release of information)
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Preventive Screenings/Exclusions: |
|
|||||||||||
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Colorectal Cancer: |
Breast Cancer: |
Osteoporosis: |
|
|||||||||
|
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Z85.038: Cancer, personal history, other malignant neoplasm of large intestine |
|
Z90.13: History of bilateral mastectomy |
G0130: Bone mineral density test |
|
|||||||
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Z90.12: Absence of left breast |
|
||||||||||
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Z85.048: Cancer, personal history, other malignant neoplasm of rectum, rectosigmoid junction, anus |
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Z90.11: Absence of right breast |
|
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Vaccinations: |
||||||
|
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G8482: Flu vaccine ordered & administered |
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4040F: Pneumonia vaccine administered or previously given |
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|
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G8483: Flu vaccine not given for documented reason |
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4040F-1P: Pneumonia vaccine not administered for medical reasons |
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Medication Reconciliation Post-Discharge: |
||||||
|
1111F: Discharge medications reconciled w/ current medication in the outpatient record |
|
99495: Transition of care |
99496: Transition of care |
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Annual Wellness/Initial Preventive Physical Exam: |
||||||||
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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 |
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*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) |
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Fall Risks: |
||||||||
|
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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 |
|||||
|
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1100F-1P: patient not screened, medical reasons |
|
1101F-1P: patient not screened, medical reasons |
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Advanced Directive: |
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1157F: Advance care planning or similar legal document in record |
1158F: Advance care planning discussion notated in record |
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|
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S0257: Counseling/discussion regarding advanced directive/end of life care with patient and/or surrogate |
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Medication List & Review (need to bill both): |
||||||||
|
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1159F: Medication list documented in record |
|||||||
|
|
1160F: Review of all medications by provider & documented in record |
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Functional Status: |
Pain Assessment: |
|||||||
|
1170F: Functional status assessed
|
|
1125F: Pain severity quantified, present |
||||||
|
|
1126F: Pain severity quantified, no pain present |
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|
Tobacco Cessation: |
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|
1034F: Current tobacco smoker |
1035F: Current smokeless tobacco user |
|||||||
|
1036F: Current non-smoker |
||||||||
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Depression Screening: G0444 (annual depression screening) |
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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 |
|||||
|
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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 |
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Lipid |
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Microalbumin (protein) |
|
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BMP |
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HbA1c |
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UA C/S |
|
|
CMP |
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TSH |
|
Urinalysis |
|
|
PT/INR |
|
PSA |
|
eGFR |
|
|
36415: Venipuncture |
|
Hepatic/LFTs |
|
UACR (urine-creatinine ration) |
|
Frequently Ordered Tests |
|||
|
|
Mammogram |
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Other: |
|
|
Colonoscopy |
|
Other: |
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