Today’s Date:



Charge ticket

Client Name: DOB:

|Problem Focused/Brief MAT Consult Through Full Induction/ 51% in Counseling or Coordinated Care | |

|  |

|  |

|  |5735|

| |013 |

|  |

|  |5731625 |OP Psych Diag Eval MD | | | |

| | | | | | |

|Office/ER/OP Consult |15 |99241 |Problem Focused |Problem Focused |Straightforward |

|Office/ER/OP Consult |30 |99242 |Expanded |Expanded |Straightforward |

|Office/ER/OP Consult |60 |99244 |Comprehensive |Comprehensive |Moderate Complexity |

| | | | | | |

|Office or outpatient visit, new pt. |10 |99201 |Problem Focused |Problem Focused |Straightforward |

|Office or outpatient visit, new pt. |20 |99202 |Expanded |Expanded |Straightforward |

|Office or outpatient visit, new pt. |30 |99203 |Detailed |Detailed |Low Complexity |

|Office or outpatient visit, new pt. |45 |99204 |Comprehensive |Comprehensive |Moderate Complexity |

|Office or outpatient visit, new pt. |60 |99205 |Comprehensive |Comprehensive |High Complexity |

| | | | | | |

|Office or outpatient visit, est. pt. |5 |99211 |Minimal |Minimal |Minimal |

|Office or outpatient visit, est. pt. |10 |99212 |Problem Focused |Problem Focused |Straightforward |

|Office or outpatient visit, est. pt. |15 |99213 |Expanded |Expanded |Low |

|Office or outpatient visit, est. pt. |25 |99214 |Detailed |Detailed |Moderate Complexity |

|Office or outpatient visit, est. pt. |40 |99215 |Comprehensive |Comprehensive |High Complexity |

| | | | | | |

|Chief Complaint (CC) | | | | |

|History of Present Illness (HPI) | | | |

|Review of Systems (ROS) | | | |

|Past, family, and/or social history (PFSH) | | | |

| | | | | | |

|Type of Hx |HPI |ROS |PFSH | | |

|Problem Focused |Brief |N/A |N/A | | |

|Expanded Problem Focused |Brief |Problem Pertinent |N/A | | |

|Detailed |Extended |Extended |Pertinent | | |

|Comprehensive |Extended |Complete |Complete | | |

|HISTORY OF PRESENT ILLNESS (HPI) | | | | | |

|Location | | | | | |

|Quality | | | | | |

|Severity | | | | | |

|Duration | | | | | |

|Timing | | | | | |

|Context | | | | | |

|Modifying factors, and | | | | | |

|Associated signs and symptoms | | | | | |

|PAST, FAMILY AND/OR SOCIAL HISTORY (PFSH) | | | | |

|PFSH consists of 3 areas: | | | | | |

|1. Past history (patient’s past experiences with illnesses, operations, injuries, and treatments | | | | |

|2. Family history (review of medical events in patient’s family, incl. diseases which may be hereditary or place the | | |

|patient at risk); and | | |

|3. Social history (an age appropriate review of past and current activities) | |

| | | | | | |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download