Confidential Screening/Billing Report (PM 160) Claim Form ...

Other Tests OTHER TESTS—PLEASE REFER TO THE CHDP LIST OF TEST CODES. Screening procedure codes 13 through 24 are not pre-printed and must be entered on the form. When one of these tests is performed, enter either a check mark (() in outcome column A or an appropriate numeric follow-up code in outcome column C and/or D. ................
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