TeleMed Progress Note
Name
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Facility of Service
*
St. Rose de Lima
Siena Hospital
St. Martin
Telehealth Consultations
*
Emergency Department
Inpatient
Service Type
*
G0425 - Telehealth consultation, emergency department or initial inpatient, typically 30 minutes communicating with the patient via telehealth
99231 - Subsequent hospital care, per day, for the evaluation and management of a patient, 15 minutes
G0426 - Telehealth consultation, emergency department or initial inpatient, typically 50 minutes communicating with the patient via telehealth
99232 - Subsequent hospital care, per day, for the evaluation and management of a patient, 25 minutes
G0427 - Telehealth consultation, emergency department or initial inpatient, typically 70 minutes or more communicating with the patient via telehealth
99233 - Subsequent hospital care, per day, for the evaluation and management of a patient, 35 minutes
Diagnosis
*
F43.23 - Adjustment disorder with mixed anxiety and depressed mood
F43.20 - Adjustment disorder, unspecified
F43.22 - Adjustment disorder with anxiety
F43.21 - Adjustment disorder with depressed mood
F43.25 - Adjustment disorder w mixed disturb of emotions and conduct
F41.9 - Anxiety disorder, unspecified
F41.1 - Anxiety disorder, Generalized
F90.0 - Attention-deficit hyperactivity disorder, predominantly inattentive type
F90.2 - Attention-deficit hyperactivity disorder, combined type
F06.1 - Catatonic disorder due to known physiological condition
F84.0 - Childhood autism
F34.1 - Dysthymic disorder
F32.0 - Major depressive disorder, single episode, mild
F32.1 - Major depressive disorder, single episode, moderate
F32.9 - Major depressive disorder, single episode, unspecified
F33.0 - Major depressive disorder, recurrent, mild
F33.1 - Major depressive disorder, recurrent, moderate
F33.2 - Major depressive disorder, recurrent severe without psychotic features
F42.2 - Mixed obsessional thoughts and acts
F40.228 - Other natural environment type phobia
F41.0 - Panic disorder without agoraphobia
F60.9 - Personality disorder, unspecified
F43.10 - Post-traumatic stress disorder, unspecified
F43.12 - Post-traumatic stress disorder, chronic
Z63.0 - Problems in relationship with spouse or partner
Other
Signature
*
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