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|Alpine Medical Group |Attending Provider’s Statement |

| | |

|of the Roaring Fork Valley | |

| |Basalt Clinic |Aspen Clinic |

| |Glenn Kotz, MD; Bruce Bowen, MD; |David Borchers, MD, Bennett Gross, MD |

| |Kelly Locke, MD; Karen Locke, MD; Lisa Robbianno, NP |225 N. Mill St, #116, Aspen, CO 81611 |

| |1450 East Valley Road, Ste 101, Basalt, CO 81621 |(970) 544-1292 FAX (970) 544-1310 |

| |(970) 544-1125 FAX (970) 544-1250 Tax I.D. 84-1375275 | |

|GUARANTOR: Name, Address, Phone |Visit # |Patient Name |Age |D.O.B. |Provider |

| | | | | | |

| |Patient # |Name of Insurance |S.S.N. |Co-Pay |Date |

| | | | | | |

| | | | | | |

|OFFICE |NEW FEE |ESTAB. FEE |OTHER CHARGES |

|36415 Drawing | |Anoscopy 46600 |A4570 Wrist or Thumb Splint |

|82947 Glucose [ Fast/Non Fast] | |Flex Sig w/out Bx 45330 with Bx 45331 |A4460 Ace Bandage |

|83036 Hgb A1C | |PFT 94060 |L4350 Air Brace – Ankle |

|82043 Microalbumin | |VO2 Max 94621 |A4580 Cast Supplies |

|80048 Basic Panel Chem 7 | |Stress Test 93015 |L3650 Clavicle Strap |

|80053 Chem 13 | |EKG/Interpretation 93000 |L4360 Fracture Air Walker |

|80076 LFT |82977 GGT | |Tympanogram 92567 |29505 Long Leg Splint |

|82150 Amylase | |Irrigation: Ear / 69210 Eye / 66999 |29515 Short Leg Splint |

|80061 Lipids [ Fast/Non Fast] | |Foreign Body Removal: Ear/69200 Eye/65205 |90780 I.V. Setup & Administration |

|83721 Direct LDL | |Foreign Body Skin: Simple/10120 Complicated/10121 | J7120 Ringers Lactate (up to 1,000cc) |

|82270 Hemoccult | |Debridement; skin, partial thickness 11040 | J7030 Normal Saline (up to 1,000cc) |

|84153 PSA | |Burn Care 16020 |94640 Nebulizer Treatment |

|86140 C-Reactive Protein | |Paring/Cutting Callous/Corn: Single/11055 2-4/11056 | 94665 Nebulizer Follow-Up |

|82131 Homocysteine | |Wart Tx (cryo, acid, etc) =15 = 17111 |A4550 Surgical Tray |

|83735 Magnesium | |Benign/Premalignant Lesion Tx (ie AK) (cryo, etc) |99070 Peak Flow Meter |

|84550 Uric Acid | | Lesion 1 -- 17000 Lesions 2-14 – 17001|L3800 Finger Splint |

|88150 Pap | |Trigger Point Injection 20550 | |

|88142 Thin Prep / Pap | |Nail Removal 11730 |IMMUNIZATION ADMINISTRATION |

|87800 GC/Chlamy DNA Probe | |Aspiration Cyst 10160 |( 90471 ______ ( 90472 x ___ |

| | | |______ |

|87252-87274 Herpes Culture | |Aspiration Joint 20600 |90702 DT (child) |90634 Hep A (child) |

| | | |90718 Td (Adult Tetanus) |90632 Hep A (adult) |

| | | |90700 DTaP |90744 Hep B (Birth - 11 yo) |

| | | |90720 DTaP and Hib |90745 Hep B (11-19 yo) |

| | | |90669 Prevnar (Conj-Pneumo) |90746 Hep B (>=20 yo) |

| | | |90707 MMR, (live) |90659 Influenza |

| | | |90713 Poliomyelitis (inject) |90732 Pneumovax (adult) |

| | | |90716 Varicella, (live) |90733 Meningococcal |

| | | |95115 Allergen Injxn: single |86580 PPD |

| | | |95117 Allergen Injxn: >=2 |Other: |

|86703 HIV | |I&D Abscess - Simple/Single/10060 | | |

|86592 RPR/VDRL | |I&D Abscess - Complicated/Many/10061 | | |

|80074 Hepatitis Panel | |Endometrial Biopsy 57500 | | |

|85025 CBC/Complete | |Colposcopy: w/ Bx/57454 w/out Bx/57452 | | |

|85651 Sed Rate | | | | |

|83540 Iron |82728 Ferritin | |Skin Tag Removal < 15 Lesions 11200 | | |

|83550 Iron Panel | |Skin Lesion Excision: | | |

|83520 BNP | | Repair: ( Simple ( Complex | | |

|86038 ANA |86431 RF | | Size: 4.0cm |90782 _____ | |

|84443 TSH | | Site: ( face, ears, eyelids, nose, lips | | |

|84481 Free T3 | | ( scalp, neck, hands, feet, genitalia | | |

|81000 Urine Dip | | ( trunk, arm, leg | | |

|81001 Urinalysis | |*** Hold for Pathology *** |BILLING INFORMATION |

|87088 Urine Culture | |LACERATIONS |BALANCE FORWARD | |

|87880 Rapid Strep Test | |Scalp, Neck, Trunk, Arms, Feet |TODAY’S CHARGES | |

|87070 Strep Culture | | |Simple |Intermediate |ADJUSTMENTS | |

|86308 Mono Spot | |0-2.5 cm |12001 |12031 | | |

|84703 Pregnancy (Serum) | |2.6-7.5 cm |12002 |12032 |PAID ON ACCOUNT | |

| | | | | |( VISA ( M/C ( CHECK ( CASH | |

|81025 Pregnancy (Urine) | |7.6-12.5 cm |12004 |12034 | | |

|87045 Stool Culture | |0-2.5 cm | |12041 |TOTAL DUE | |

|87186 Sensitivity | |2.6-7.5 cm | |12042 | | |

|87210 Wet prep/Fecal WBC’s | |7.8-12.5 cm | |12044 | |

|87177 O&P x _______ | |Face, Ears, Eyes, Nose, Lips | |

|87328 Giardia-EIA | | |Simple |Intermediate |PHYSICIAN’S SIGNATURE |

|87230 C. difficile toxin | |0-2.5 cm |12011 |12051 | |

| | | | | | |

| | | | | |RETURN VISIT ON: |

|86677 H. Pylori | |2.6-5.0 cm |12013 |12052 | |

|85610 PT / INR |85670 PTT | |5.0-7.5 cm |12014 |12053 | |

Infectious & Parasitic Dis

098.0 Gonorrhea, acute

042 HIV

075 Mono/Infectious mononucleosis

487.1 Influenza w/ upper respiratory

795.5 Positive PPD

079.9 Viral Syndrome

Neoplasms

Malignant Neoplasms

174.9 Breast, female, unsp

153.9 Colon, unsp

162.9 Lung, unsp

185 Prostate

173.9 Skin, unsp

Benign Neoplasms

214.9 Lipoma, any site

216.9 Skin, unsp

218.9 Uterus (leiomyoma, unsp.

Endo, Nutr & Meta. Dz

250.91 Diab. mell., I, complicated

250.01 Diab. mell, I, uncomplicated

250.90 Diab.mell, II, complicated

250.00 Diab.mell, II, uncomplicated

790.6 Elevated sugars / Hyperglycemia/Iron

271.3 Glucose intolerance

240.9 Goiter, unspecified

274.9 Gout, unspecified

4. Hyperlipidimia

272.0 Hypercholesterolemia

242.90 Hyperthyroidism, NOS

276.8 Hypokalemia

244.9 Hypothyroidism, unsp

278.00 Obesity/Overweight; Morbid 278.01

241.0 Thyroid nodule

Blood Diseases

280.9 Anemia, iron deficiency

281.0 Anemia,Pernicious/ B12 Def.

285.9 Anemia, unspecified

683 Lymphadenitis, acute

Mental Disorders

309.9 Adjustment reaction unsp

305.00 Alcohol abuse, unsp

303.90 Alcoholism, unsp

331.0 Alzheimers

307.1 Anorexia nervosa

300.00 Anxiety state, unsp

314.01 ADD w/ hyperactivity

314.00 ADD w/o hyperactivity

296.40 Bipolar Disorder

307.51 Bulimia

311 Depressive disorder, NOS

296.20 Depression, Acute

305.90 Drug abuse, unsp

304.90 Drug dependence, unsp

780.52 Insomia NOS

300.01 Panic disorder

301.9 Personality disorder unsp

290.0 Senile dementia, NOS

302.70 Sexual dysfunction,

780.50 Sleep Disturbance

305.1 Tobacco abuse

Nerve/Sense Disorders

354.0 Carpal tunnel syndrome

432.9 CVA/ Intracranial hemorrhage NOS

345.90 Epilepsy, unsp w/o intractab

784.0 Headache

307.81 Headache, Tension

346.90 Headache, Migraine, w/o intractable

357.9 Neuropathy, unsp

310.2 Postconcussion

333.99 Restless legs

780.39 Seizures, convulsions

333.1 Tremor, essential

Eye Diseases

373.00 Blepharitis, unsp

366.9 Cataract, unsp

2. Chalazion

372.00 Conjunctivitis, Acute, Bact.

372.14 Conjunctivitis, Allergic

077.99 Conjunctivitis, Viral

918.1 Corneal abrasion

930.9 Eye foreign body, external

365.9 Glaucoma, unsp.

373.11 Hordeolum (stye)

368.10 Visual disturbance, unsp

369.9 Visual loss, unsp.

Ear Diseases

380.4 Cerumen, Impacted

381.81 Eustachian tube dysfunction

389.9 Hearing loss, unsp

380.10 Otitis externa, unsp

382.00 Otitis media, acute

381.10 Otitis media, chronic

386.2 Vertigo, central

386.10 Vertigo, peripheral

Circulatory System

9. Angina pectoris, stable

1. Aortic Valve disorder

9. Arrythmia

414.00 ASHD

427.31 Atrial Fibrillation

414.9 CAD / Ischemic heart disease

426.9 Conduction disorder unsp

428. CHF

453.9 DVT/Deep Venous Thrombosis

796.2 Elevated BP w/o hypertension

401.1 Hypertension, benign

401.0 Hypertension, malignant

424.0 Mitral Valve / MVP

412 Myocardial infarction, old

458.0 Orthostatic hypotension

427.0 Paroxysmal supraventricular

420.91 Pericarditis, acute

443.9 Peripheral vascular disease

427.60 Premature beats unsp

427.69 PVC/Premature Ventricular Contract.

415.19 Pulmonary embolism

427.81 Sick Sinus Syndrome

451.9 Thrombophlebitis unsp

435.9 TIA/Transient ischemic attack, unsp

454.9 Varicose veins w/o ulcer/inflam

459.81 Venous insufficienciency

427.1 V-tach/Ventricular tachycardia

Respiratory System

493.90 Asthma, unsp.

466.11 Bronchiolitis, acute, due to rsv

466.0 Bronchitis, acute

491.9 Bronchitis, chronic

496 COPD

464.4 Croup

8. Emphysema

799.0 Hypoxia

464.0 Laryngitis, acute

462 Pharyngitis, acute

472.1 Pharyngitis, chronic

519.1 R.A.D

486 Pneumonia, unsp

477.9 Rhinitis, allergic

472.0 Rhinitis, chronic

461.9 Sinusitis, acute

9. Sinusitis, chronic

034.0 Strep throat

463 Tonsillitis, acute

9. URI, acute

Digestive System

571.9 Chronic liver disorder

571.5 Cirrhosis, NOS

562.10 Diverticulosis colon

536.8 Dyspepsia

530.10 Esophagitis, unsp

575.9 Gallbladder disease

535.50 Gastritis, w/o hemorrhage

009.1 Gastroenteritis, infectious

558.9 Gastroenteritis, noninfectious

530.11 GERD

9. GI Bleeding

007.1 Giardiasis

6. Hemorrhoids, NOS

070.30 Hepatitis B

070.51 Hepatitis C

Hernia: hiatal/553.3; inguinal/550.90

553.9 Hernias, other, NOS

560.1 Ileus

1. Irritable bowel syndrome

792.1 Occult Blood in stool

528.9 Oral, soft tissue disease/Mouth Ulcer

529.9 Oral, tongue disease

577.0 Pancreatitis, acute

533.90 Peptic ulcer disease

569.3 Rectal bleeding

524.60 Temporomandibular joint disorder

112.0 Thrush, oral yeast

Genitourinary System

Renal Failure: Acute/584.9 Chronic/585

9. Glomerulonephritis, acute

592.9 Kidney Stone

791.0 Proteinuria, nonpost ural

590.10 Pyelonephritis, acute

599.0 UTI (NOS)

Male Genital Organ Disease

302.72 Erectal Dysfunction

604.90 Orchitis/epididymitis

600.0 BPH / Prostatic hypertrophy

9. Prostatitis, acute

456.4 Varicocele

Breast Diseases

611.72 Breast lump / mass

610.1 Fibrocystic disease

611.6 Galactorrhea

Female Genital Organ Diseases

622.1 Cervical dysplasia

622.7 Cervical polyp, NOS

616.0 Cervicitis

625.0 Dyspareunia

9. Endometriosis, unsp

626.4 Irregular menses

614.9 PID / Pelvic inflammatory disease

6. Stress incontinence, .female

131.9 Trichomoniasis, unsp

616.10 Vaginitis/vulvitis

112.1 Vaginitis, Yeast

Disorders of Menstruation

626.0 Amenorrhea

2. Excessive/frequent menstruation

627.2 Hot Flashes

627.9 Menopausal disorder

625.3 Painful menstruation

V07.4 Postmenopausal hormone replace

625.4 Premenstrual tension syndrome

Fertility Problems

628.9 Infertility, female

606.9 Infertility, male

Pregnancy, Childbirth

634.90 Abortion, spontaneous w/o comp

633.9 Ectopic pregnancy,

V22.2 Pregnancy

640.00 Threatened abortion, unsp

Skin, Subcutaneous

706.1 Acne, other

702.0 Actinic keratosis

682.9 Cellulitis/abscess

707.9 Chronic skin ulcer

692.9 Contact dermatitis

691.0 Diaper rash

691.8 Eczema, atopic dermatitis

057.9 Exanthem, Viral, NOS

054.9 Herpes simplex

053.9 Herpes zoster/shingles

684 Impetigo

703.0 Ingrown nail

683 Lymphadenitis, acute

110.1 Onychomycosis/Fungal Nail

709.9 Other skin disease

698.9 Pruritus, NOS

696.1 Psoriasis

782.1 Rash, nonvesicular

695.3 Rosacea

706.2 Sebaceous cyst

690.10 Seborrheic dermatitis.

702.19 Seborrheic keratosis

701.9 Skin Tag

111.0 Tinea versicolor

692.71 Sunburn

078.19 Warts

Musculoskeletal

716.90 Arthritis

723.9 Cervical disorder

722.2 Disc syndrome, no myelopathy

727.43 Ganglion, unsp

9. Internal derangement, knee

726.32 Lateral Epicondylitis/Tennis Elbow

2. Low back pain

724.4 Low back pain w/ radiation

728.85 Muscle Spasm

729.1 Myalgia/myositis

721.90 Osteoarthritis/spine

715.90 Osteoarthrosis, unsp

733.90 Osteopenia

733.00 Osteoporosis

729.5 Pain in limb

714.0 Rheumatoid arthritis

726.10 Shoulder syndrome

2. Shoulder Impingment Syndrome

Dislocations & Strains

836.2 Knee meniscus injury

845.00 Sprain/strain: ankle

845.10 Sprain/strain: foot

844.9 Sprain/strain: knee/leg

846.9 Sprain/strain: low back

847.0 Sprain/strain: neck

842. Sprain/strain: wrist

842.10 Sprain/strain: hand

Signs and Symptoms

789.00 Abdominal pain

2. Abnormal glucose tolerance test

793.8 Abnormal Mammogram

790.93 Abnormal ( PSA

790.4 Abnormal transaminase / LDH

795. Abnormal PAP

793.1 Abnormal Chest X-ray lung

783.0 Anorexia

719.40 Arthralgia, unsp

786.50 Chest pain, unsp.

564.0 Constipation

2. Cough

276.5 Dehydration

787.91 Diarrhea, NOS

780.4 Dizziness/vertigo

787.2 Dysphagia

788.1 Dysuria

782.3 Edema localized

719.00 Effusion/swelling of joint

784.7 Epistaxis

783.41 Failure to thrive

780.79 Fatigue/Malaise

780.6 Fever, nonperinatal

787.3 Gas/bloating

787.1 Heartburn

599.7 Hematuria

789.1 Hepatomegaly

784.49 Hoarseness

788.30 Incontinence/enuresis

785.6 Lymph nodes, enlarged

785.2 Murmur of heart, undiagnosed

02. Nausea, alone

782.0 Numbness

785.1 Palpitations

786.05 Shortness of breath

780.2 Syncope

788.41 Urinary frequency

787.03 Vomiting, alone

783.1 Weight gain

783.21 Weight loss

786.07 Wheezing

Other Trauma, Adverse Effects

919.0 Abrasion, unsp

995.3 Allergic Reaction

924.9 Bruise contusion

949.0 Burn, degree:________________

991.9 Cold injury

850.0 Concussion w/out LOC; LOC ................
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