Www.colorado.gov



SBHC Encounter Form (rev 07/03/2017)SBHC:SBHC NPI:ON-SITE LAB TESTSDate:INSURANCE IDENTIFICATION?CPTDescriptionName:Company Name:No labs given36415VenipunctureID#:Insurance #:80061Lipid panelDOB: / / ? M ? FProvider Name/NPI:81000Urinaly - dip stickConfidential Visit : ? Y ? NSignature:81001Urinaly,auto.-microOFFICE VISIT81002Urinaly,non-auto-no micro.?ESTAB?NEWConsider use of Modifier 25 (write in +25 after E/M code) if separate services provided at same encounter81003Urinaly, auto.-no micro.99211Minimal evaluation81015Urine - microscopic only9921299201Problem focused81025Urine preg. test-by visual color9921399202Expanded problem focused82270Guiac, occult blood9921499203Detailed82465Cholesterol, total99204Comp, mod complexity 45 min82947Glucose; quantitative; blood9921599205Comp, high complexity82948hCG preg. test (urine) qualitative9935499354Add on code 99215 or 99205 prolong svc pt contact >75 min82962Glucose monitoring deviseTEAM CONFERENCEINDIVIDUAL MEDICAL NUTRITION THERAPY15 MIN EACH84703hCG preg. test (urine) qualitative99366Initial assess/intervention85013Hematocrit99367Pt/family not present 30 min provider97802Initial assess/intervention 85018Hemoglobin99388Pt/family not present 30 min without provider97803Re-assess/intervention86308Mono-spot screenBEHAVIORAL HEALTH86677H. pylori antibody90832Individual psych. 30 minCOMPLEX INTERACTIVE ENCOUNTERS87210Wet mount (e.g., saline) for infect. agents90833Individual psych. 30 min E/M87430Streptococcus, group A culture (NON BILLABLE)90834Individual psych. 45 minReport with interactive code 9078587491Urine CT/GC - amplified probe (NON BILLABLE)90836Individual psych. 45 min E/MReport with interactive code 9078587880Streptococcus, group A (rapid strep test)90837Individual psych. 60 minReport with interactive code 9078592567Tympanometry-impedance testing90838Individual psych. 60 min E/MReport with interactive code 90785PROCEDURES90846Family therapy no pt presentReport with interactive code 90785Consider use of Modifier 59 (write in +59 after procedure code) if procedural services provided at same encounter90847Family therapy pt presentReport with interactive code 9078510060I & D Sample90853Group therapy10120I & D of foreign body, subcutaneous (simple) or complete, for permanent removal90863Psych. Pharmacologic mgmt11730Avulsion of nail plate (simple) H0031Mental health assess. non physician11740Evacuation of subungual hematoma H2001Crisis intervention each 15 min11750Excision of nail and nail matrix, partial or complete for permanent removal 12001Suturing—specify body part Depression Screening11981Implant insertion G8431Adolescent depression screen, positive11985Implant removal G8510Adolescent depression screen, negative11983Implant removal & re-insertion 99420Depression screen, still used by private payers12031Layer closure scalp wounds, axillae, trunk and/or extremities (excl. hands & ft) 2.5 cm Substance Abuse Screening / Assessment Codes16000Initial tx—1st deg burn (loca)< doc % coverage and depth H0049CRAFFT, neg screen without brief intervention - SBIRT 17110Wart removal 99408CRAFFT with brief intervention 15-30 min SBIRT 26641Closed tx of carpometacarpal (thumb) dislocation 99409CRAFFT with brief intervention 30+ min SBIRT 28190Removal of foreign body, foot, subcutaneous Health & Behavioral Assessment / Intervention – Integrated Visit Codes29130Application of finger splint (static) 96150Health & behavior assessment, each 15 min FtF w patient, initial assessment30300Removal of foreign body, intranasal 96151Re-assessment54050Destruction of lesion(s), penis 96152Health & behavior intervention, each 15 min FtF, individual56501Destruction of lesion(s), vulva 96153Group (2 or more patients)58300IUD insertion 96154Family (with the patient present)58301IUD removal 96155Family (without the patient present)69200Removal foreign body from external auditory canal Case Management69210Removal impacted cerumen (one or both ears) T1016Coord. pt care with primary and BH (case management, each 15 min)57220KOH for skin/hair/nails T1017Targeted case management, each 15 min92551Hearing screen T2022Case management, per month94640Nebulizer treatment T2023Targeted Case management, per month94010Spirometry EPSDT WELL CHILD EXAM / PREVENTIVE MEDICINE99173Vision screen ?ESTAB?NEW?PREVENT. MEDICINE COUNSELING9939199381Infant9940115 minLEGEND99392993821 – 4 years9940230 minCDPHE Performance Measures99393993835 – 11 years9940345 minMedical993949938412 – 17 years9940460 minBehavioral Health993959938518 – 39 yearsBoth Medical/Behavioral or eitherSBHC Encounter Form (rev 07/01/2016)SBHC:SBHC NPI:ORAL HEALTH CODESAvailable to qualified medical professionals(These codes also used by dental professionals)Date:INSURANCE IDENTIFICATIOND0145 Oral health evaluation & counseling with pri-mary caregiver (0-2 yrs) Name:Company Name:D0190 Oral health screening (ages 3-20 yrs) D1206 Topical fluoride varnish (ages 0-20 yrs) ID#:Insurance #:CDPHE PERFORMANCE MEASURESDOB: / /? M ? F Provider Name/NPI:Well Child CheckConfidential Visit : ? Y ? NSignature:Z00.121 Routine child health exam with abnormal findings IMMUNIZATIONSZ00.129 Routine child health exam without abnormal findings Immunizations Administration with provider counselingZ00.00 General adult medical exam without abnormal findings 90460 One immunization—Child 0-18 years 90461 Each additional vaccine Z00.01 General adult medical exam with abnormal findings Immunizations Administration without provider counseling99382 Well Child Exam/Preventive Medicine New patient: aged 1-4 years 90471 One immunization by PERC ID SC or IM—adult 90472 Each additional vaccine 99383 Well Child Exam/Preventive Medicine New patient: aged 5-11 years 90473 One immunization by IN or PO route—adult 90474 Each additional vaccine 99384 Well Child Exam/Preventive Medicine New patient: aged 12-17 years 99385 Well Child Exam/Preventive Medicine New patient: aged 18+ years Well Child Exam/Preventive Medicine New patient: aged 18+ years 90620Meningococcal. recombinant prot & outer membrane vesicle vaccine sergrp B, 2 dose IM 90670Pneumococcal Conjugate, 13 valent, IM99392 Well Child Exam/Preventive Medicine Established patient: aged 1-4 years 90621 Meningococcal. lipoprotein recombinant, serogrp B, 3 dose, IM 90732 Pneumococcal poly-valent, SQ or IM 99393 Well Child Exam/Preventive Medicine Established patient: aged 5-11 years 90733 Meningococcal(polysaccharide), SQ 90649 HPV, quadrivalent, 3 dose, IM 99394 Well Child Exam/Preventive Medicine Established patient: aged12-17 years90734Meningococcal conjugate vaccine, serogrps A, C, Y & W-135, quadrivalent, IM90650HPV, bivalent, 3 dose, IM 99395 Well Child Exam/Preventive Medicine Established patient: aged 18+ years90630 Influenza, quadrivalent, split virus, preservative free, intradermal 90651 HPV 9-valent, recombinant, 3 dose, IM (use also for 2-dose schedule) Body Mass Index90657 Influenza, trivalent, (split virus), .25mL, IM 90700 DTaP < 7yrs Z68.51 BMI less than 5th percentile for age 90658 Influenza, trivalent, (split virus), .5 mL, IM90702 Diptheria and Tetanus (DT) < 7yrs Z68.52 BMI 5th percentile to less than 85th percentile for age 90660 Influenza, trivalent, live, intranasal90707 Measles, Mumps, Rubella Z68.53 BMI 85th percentile to less than 95th percentile for age 90672Influenza, quadrivalent, live, intranasal90713 IPV (polio) Z68.54 BMI greater than or equal to 95th percentile for age 90686Influenza, quadrivalent, (split virus), .5 mL, IM, preservative free90714 Tetanus and Diphtheria (Td) ≥ 7 yrs E66.01 Morbid obesity due to excess calories 90688Influenza, quadrivalent, (split virus), .5 mL, IMWith perservative90715 Tdap ≥ 7yrs E66.09 Other obesity due to excess calories 90633 Hep A 90716 Varicella SQ E66.3 Overweight 90647 HIB(PRP-OMP) [PedvaxHIB] 90744 Hep B 3 dose IM E66.8 Other obesity 90648 HIB(PRP-T) [ActHIB or OmniHIB] 90748 Hep B/Hib Combination IM E66.9 Obesity, unspecified R63.6UnderweightMEDICATIONS, SUPPLIES & DURABLE MEDICAL EQUIPMENTNutrition CounselingJ0696Injection, Ceftriaxone 250mg IM per vial A4261 Cervical cap for contraceptive use Z71.3 Dietary counseling and surveillance J0171Adrenaline, epinephrine up to 1ml A4266 Diaphragm for contraceptive 97802 Individual medical nutrition therapy: initial assessment/intervention J1050Injection, medroxyprogesterone acetate, 1 mg A4267 Condom, Male 97803 Individual medical nutrition therapy: re-assess/intervention J2250Promethazine HCI, injection up to 50 mg A4268 Condom, Female Physical Activity CounselingJ7298Levonorgesterel-releasing intrauterine (Mirena) A4269 Spermicidal agent Z71.89 Other specified counselingJ7300Intrauterine copper contraceptive (Paragard) A4614 Peak flow meter, hand held Chlamydia ScreeningJ7303Hormone Containing Vaginal Ring (Nuvaring) J7307Etenogestrel contraceptive implant system (i.e. Nexplanon) Z11.8 Encounter for screening for Chlamydia J7304Hormone Containing Patch (Ortho Evra) S4989 IUD other than above (Progestacert) Z11.3 Screening for infections with predominately sexual mode of transmission J7611Albuterol, concentrated form, 1 mg Q9984Levonorgestrel-releasing IUD (Kyleena) 86631Chlamydia antibodyJ7613Albuterol, unit dose form, 1 mg S4993 Contraceptive pills for birth control 86632Chlamydia, IgMJ7297Liletta Q0144 Azithromycin oral powder 1 gm. Mang.Care only 87110Culture, Chlamydia, any sourceJ7301Skyla 87270Chlamydia trachomatisFOLLOW UP87320Chlamydia trachomatisReturn to School-Based Health Center (follow-up date):To Provider:87490Chlamydia trachomatis, direct probe technique87491Chlamydia trachomatis, amp probe technique87942Chlamydia trachomatis, quantification87801Infectious agent detection by nucleic acid, multiple organisms, amp probe techniqueREFERRAL87810Chlamydia trachomatisDIAGNOSIS (ICD-10) (Code # and Name):Depression ScreeningG8431 Adolescent depression screen, positive G8510 Adolescent depression screen, negative 99420 Depression screen, still used by private payers DIAGNOSIS (ICD-10) (Code # and Name):96160Adm of patient-focused health risk assessment instrument w/ scoring & documentation96127Brief emotional/behavioral assessment w/ scoring &documentationG0444Annual depression screen, 15 minOral HealthD0190 Oral health screening: aged 3-20 years K02.xxDental caries ................
................

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

Google Online Preview   Download