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 |

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| |

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|MD/DO Signature: ___________________________ |

| |

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