Patient name: $PLAST, $PFIRST, $PMIXGearLorenzo Bright512007-06-05T13:09:00Z2012-08-07T17:13:00Z2012-08-07T17:51:00Z17724407XGear3610516912Patient name: @PNAME1Physician name: @PRVNAMEDate of service: @TODAYAddress: @PADDR1Insurance: @INS1Copay: @PCOP@PADDR2Subscriber name: @INAME1Previous balance: @PBAL@PCITY,@PSTATE @PZIPGroup #: @INS1GRPToday's charges: @TODCHGSPhone:@PHOMEMember #: @INS1MEMToday's payment:DOB: @PDOB Age:@PAGE Sex: @PSEXAccount #: @PACCTBalance due:Office visitNewEstOffice procedures Laboratory Minimal 99211 Anoscopy 46600 Venipuncture 36415 Problem focused9920199212 Audiometry 92551 Blood glucose, monitoring device82962 Exp problem focused9920299213 Cerumen removal 69210 Blood glucose, visual dipstick82948 Detailed9920399214 Colposcopy 57452 CBC, w/ auto differential85025 Comp9920499215 Colposcopy w/biopsy 57455 CBC, w/o auto differential85027 Comp (new patient)99205 ECG, w/interpretation 93000 Cholesterol82465 Significant, sep serv-25-25 ECG, rhythm strip 93040 Hemoccult, guaiac82270 Well visitNewEst Endometrial biopsy 58100 Hemoccult, immunoassay82274 < 1 y9938199391 Flexible sigmoidoscopy 45330 Hemoglobin A1C85018 1-4 y9938299392 Flexible sigmoidoscopy w/biopsy45331 Lipid panel80061 5-11 y9938399393 Fracture care, cast/splint 29___ Liver panel80076 12-17 y9938499394 Site: __________________ KOH prep (skin, hair, nails)87220 18-39 y9938599395 Nebulizer 94640 Metabolic panel, basic80048 40-64 y9938699396 Nebulizer demo 94664 Metabolic panel, comprehensive80053 65 y +9938799397 Peak flow monitoring 94150 Mononucleosis86308 Medicare preventive services Spirometry 94010 Pregnancy, blood84703 PapQ0091 Spirometry, pre and post 94060 Pregnancy, urine 81025 Pelvic & breastG0101 Tympanometry 92567 Renal panel 80069 Prostate/PSAG0103 Vasectomy 55250 Sedimentation rate 85651 Tobacco couns/3-10 minG0375 Skin procedures Units Strep, rapid 86403 Tobacco couns/>10 minG0376 Burn care, initial16000 Strep culture 87081 Welcome to Medicare examG0344 Foreign body, skin, simple10120 Strep A 87880 ECG w/Welcome to MedicareG0366 Foreign body, skin, cmplx10121 TB 86580 Flexible sigmoidoscopyG0104 I&D, abscess10060 UA, complete, non-automated81000 Hemoccult, guaiacG0107 I&D, hematoma/seroma10140 UA, w/o micro, non-automated81002 Flu shotG0008 Laceration repair, simple120__ UA, w/ micro, non-automated81003 Pneumonia shotG0009 Site: _______ Size: _____ Urine colony count87086 Consultation/preop clearance Laceration repair, layered120__ Urine culture, presumptive87088 Exp problem focused99242 Site: _______ Size: _____ Wet mount/KOH87210 Detailed99243 Lesion, biopsy, one11100 Vaccines Comp/mod complex99244 Lesion, biopsy, each add’l11101 DT, <7 y 90702 Comp/high complex99245 Lesion, excision, benign114__ DTP 90701 Other services Site: _______ Size: _____ DtaP, <7 y 90700 After posted hours99050 Lesion, excision, malignant116__ Flu, 6-35 months 90657 Evening/weekend appointment99051 Site: _______ Size: _____ Flu, 3 y + 90658 Home health certificationG0180 Lesion, paring/cutting, one11055 Hep A, adult 90632 Home health recertificationG0179 Lesion, paring/cutting, 2-411056 Hep A, ped/adol, 2 dose 90633 Post-op follow-up99024 Lesion, shave113__ Hep B, adult 90746 Prolonged/30-74 min99354 Site: _______ Size: _____ Hep B, ped/adol 3 dose 90744 Special reports/forms99080 Nail removal, partial11730 Hep B-Hib 90748 Disability/Workers comp99455 Nail removal, w/matrix11750 Hib, 4 dose 90645 Radiology Skin tag, 1-1511200 HPV 90649 Wart, flat, 1-1417110 IPV 90713 Wart, plantar, single17000 MMR 90707Diagnoses Wart, plantar, each add’l17003 Pneumonia, >2 y 907321 Medications Units Pneumonia conjugate, <5 y906692 Ampicillin, up to 500mgJ0290 Td, >7 y 907183 B-12, up to 1,000 mcgJ3420 Varicella 907164 Epinephrine, up to 1mlJ0170 Immunizations & InjectionsUnitsNext office visit Kenalog, 10mgJ3301 Allergen, one95115 Recheck • Prev • PRN_____ D W M Y Lidocaine, 10mgJ2001 Allergen, multiple95117 Instructions: Normal saline, 1000ccJ7030 Imm admin, one90471 Phenergan, up to 50mgJ2550 Imm admin, each add’l90472 Progesterone, 150mgJ1055 Imm admin, intranasal, one90473 Referral Rocephin, 250mgJ0696 Imm admin, intranasal, add’l90474 To: Testosterone, 200mgJ1080 Injection, joint, small20600 Tigan, up to 200 mgJ3250 Injection, joint, intermediate20605 Instructions: Toradol, 15mgJ1885 Injection, joint, major20610 Miscellaneous services Injection, ther/proph/diag90772 Injection, tendon sheath20552 Physician signature Supplies X__________________________________