Advanced Family - PSOT
Medicos para la Familia
(Rev. 6-5-07)-WMR
OFFICE SURGERY/ENDOSCOPY
|Patient Name: _______________________________ |
|Date: ___________________________________________ |
|DIAGNOSIS FOR SERVICES ON THIS SHEET |
|1. |
|2. |
|Pulse oximetry[mult readings] 94761 $40 |
|IV infusion first hour 70760 $60 |
|IV infusion each additional hour 90761 $30 |
|IV med injection 90774 $30 |
|IV sedation/analgesia-age>5[cannot bill pulse ox] |
|Same MD performing the procedure 99144 $120 |
|2nd MD doing sed/analgesia 99148 $120 |
|IV supplies/fluids _____ |
|Surgical tray A4550 $30 |
|Needles A4215 $10 |
|Other _____ |
|Meperidine each amp J22175 $10 |
|Valium each amp J3360 $10 |
|Fentanyl each amp J3010 $20 |
|Narcan 0.4mg J2310 $20 |
|Ketorolac 30-60MG IM $30-60 |
|Bupivicaine 0.25% 1 amp TBA $30 |
|Bupivicaine 0.75% spinal 1 amp TBA $30 |
|Morphine 5mg/2ml spinal 1 amp TBA $20 |
|Ketamine 50mg/ml CPT TBA $30 |
| |
|Surgical pathology (varies) _____ $200-440 per bottle. |
|Misdirected specimens are charged back to us. |
|Specimen handling 99000 $10 |
|PROCEDURES |
|Colonoscopy 45378 $600 |
|Colonoscopy w/bx ( 45380 $700 |
|Colonoscopy w/polypectomy 45385 $800 |
|Flex Sig 45330 $200 |
|Flex Sig w/bx 45331 $300 |
|Flex Sig w/polypectomy 45335 $400 |
|UGI Endoscopy 43235 $400 |
|UGI w/bx 43239 $500 |
|H. pylori [CLO test in office] 86677 $ 40 |
| |
|Nasopharyngoscopy 92511 $200 |
| See ENT sheet for other code 92375? |
|Repair Inguinal Hernia xxxxx $1000 |
|Vasectomy $400 |
| |
|Medicos para la Familia offers cancer screening and office surgery services|
|to an underserved community whose psychosocial issues prevent access to the|
|many subspecialists in our urban locations. |
| |
|This is a required part of the MEDICOS practice management curriculum |
|Equipment maintenance is the responsibility of the physician. Every |
|procedure requires a preflight check prior to putting the IV into the |
|patient. |
|Cleaning and disinfection skills are required of the physician. Once |
|mastered the physician can supervise staff in this critical part of the |
|procedure. |
|Before the procedure begins, the physician must fill out the preprocedure |
|diagnostic probabilities, and summarize the indications for the case on the|
|endoscopy medical record. |
|An IV sedation/analgesia log including the recovery phase must be |
|completed for each case. |
|Medicare and Medicaid[Tenncare] do not allow billing of supplies associated|
|with endoscopy. A4550 |
|Pulse oximetry 97461 is “bundled” into the endoscopy and IV sedation |
|charges and cannot be billed separately with Medicaid and Medicare |
|endoscopy unless a second physician administers. |
|Recently passed state regulations governing IV sedation/analgesia require |
|an ACLS trained physician on premises during the endoscopy. Make sure that |
|oxygen and Narcan are available before your start every procedure. |
|Others |
| |
| |
| |
| |
|MD/DO Signature: ___________________________ |
| |
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