Patient Encounter Form
Date
-
Month
-
Day
Year
Date
Patient Information
Name
First Name
Last Name
Patient ID Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security Number
Phone Number
-
Area Code
Phone Number
Date of birth
-
Month
-
Day
Year
Date
Age
Payment Method
Primary ID Number
Primary Group Number
Secondary ID Number
Secondary Group Number
Payment Method
Cash
Credit Card
Visit Information
Rendering Physician
First Name
Last Name
Referring Physician
First Name
Last Name
Reason for Visit
Modifiers
E/M Modifers
Unrelated E/M service during postop.
Significant, separately identifiable E/M
Decision for surgery
Procedure Modifers
Unusual, excessive procedure
Significant, separately identifiable E/M
Bilateral procedure
Decision for surgery
Multiple surgical procedures on the same day
Reduced/incomplete procedure
Postop. management only
Distinct multiple procedures
Category
Office Visit- New Patient
MOD
FEE
Comments
Minimal office visit - 99201
20 minutes - 99202
30 minutes - 99203
45 minutes - 99204
60 minutes - 99205
Other
Office Visit — Established
MOD
FEE
Comments
Minimal office visit - 99211
10 minutes - 99212
15 minutes - 99213
25 minutes - 99214
40 minutes - 99215
Other
General Procedures
MOD
FEE
Comments
Anoscopy - 46600
Audiometry - 92551
Breast aspiration - 19000
Cerumen removal - 69210
Circumcision - 54150
DDST - 96110
Flex sigmoidoscopy - 45330
Flex sig. w/ biopsy - 45331
Foreign body removal—foot - 28190
Other
Wound Care
MOD
FEE
Comments
Debride partial thick burn -11040
Debride full-thickness burn - 11041
Debride wound, not a burn - 11000
Unna boot application - 29580
Unna boot removal - 29700
Supplies
MOD
FEE
Comments
Ace bandage, 2” -A6448
Ace bandage, 3"-4” -A6449
Ace bandage, 6” - A6450
Coban wrap - A6454
Foley catheter - A4338
Kerlix roll -A6220
Oxygen mask/cannula - A4620
Breast aspiration - 19000
Sleeve, elbow - E0191
Sling - A4565
Splint, ready-made - A4570
Splint, wrist - S8451
Sterile packing - A6407
Surgical tray - A4550
OB Care
MOD
FEE
Comments
Routine OB care - 59400
OB call - 59422
Antepartum 4–6 visits - 59425
Antepartum 7 or more visits 59426
Other
Vitals
B/P
Pulse
Temprature
Height
Weight
Other Visit Information
Lab work to order
Referral to:
Provider Signature
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Month
-
Day
Year
Date
Fees
Total Amount $
Total Charged $
Copay received $
Other Payment $
Remaining balance $
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