ࡱ>  =bjbj mjj9l$JJJPbJ4J.M.M.M.M.M N N N$y J, N N N N N,5^.M.MA5^5^5^ N>.M.M5^ N5^5^eR(Z.M"M p!PFJGV@zpZ W0p\Z5^Alpine Medical Group of the Roaring Fork Valley Attending Providers StatementBasalt Clinic Glenn Kotz, MD; Bruce Bowen, MD; Kelly Locke, MD; Karen Locke, MD; Lisa Robbianno, NP 1450 East Valley Road, Ste 101, Basalt, CO 81621 (970) 544-1125 FAX (970) 544-1250 Tax I.D. 84-1375275Aspen Clinic David Borchers, MD, Bennett Gross, MD 225 N. Mill St, #116, Aspen, CO 81611 (970) 544-1292 FAX (970) 544-1310GUARANTOR: Name, Address, PhoneVisit #Patient NameAgeD.O.B.Provider Patient #Name of InsuranceS.S.N.Co-PayDate OFFICENEW FEEESTAB. FEEOTHER CHARGESCONSULTATIONComplete PhysicalNEW FEEESTAB.FEELEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 599201 _____ 99202 _____ 99203 _____ 99204 _____ 99205 _____99211 _____ 99212 _____ 99213 _____ 99214 _____ 99215 _____ER Visit After Hours Sunday/Holiday99058 _____ 99050 _____ 99054 _____LEVEL I LEVEL II LEVEL III LEVEL IV LEVEL V99241 15 min 99242 30 min 99243 40 min 99244 60 min 99245 80 min< 1 year 1-4 5-11 12-17 18-39 40-64 yrs 65 +99381 ____ 99382 ____ 99383 ____ 99384 ____ 99385 ____ 99386 ____ 99387 ____99391 ____ 99392 ____ 99393 ____ 99394 ____ 99395 ____ 99396 ____ 99397 ____COUNSELINGLEVEL I LEVEL II LEVEL III99213 - 15 min 99214 - 25 min 99215 - 40 minLABORATORYICD-9PROCEDURESSUPPLIES36415 DrawingAnoscopy 46600A4570 Wrist or Thumb Splint82947 Glucose [ Fast/Non Fast]Flex Sig w/out Bx 45330 with Bx 45331A4460 Ace Bandage83036 Hgb A1CPFT 94060L4350 Air Brace Ankle82043 MicroalbuminVO2 Max 94621A4580 Cast Supplies80048 Basic Panel Chem 7Stress Test 93015L3650 Clavicle Strap80053 Chem 13EKG/Interpretation 93000L4360 Fracture Air Walker80076 LFT82977 GGTTympanogram 9256729505 Long Leg Splint82150 AmylaseIrrigation: Ear / 69210 Eye / 6699929515 Short Leg Splint80061 Lipids [ Fast/Non Fast]Foreign Body Removal: Ear/69200 Eye/6520590780 I.V. Setup & Administration83721 Direct LDLForeign Body Skin: Simple/10120 Complicated/10121 J7120 Ringers Lactate (up to 1,000cc)82270 HemoccultDebridement; skin, partial thickness 11040 J7030 Normal Saline (up to 1,000cc)84153 PSABurn Care 1602094640 Nebulizer Treatment86140 C-Reactive ProteinParing/Cutting Callous/Corn: Single/11055 2-4/11056 94665 Nebulizer Follow-Up82131 HomocysteineWart Tx (cryo, acid, etc) <15 = 17110 >=15 = 17111A4550 Surgical Tray83735 MagnesiumBenign/Premalignant Lesion Tx (ie AK) (cryo, etc)99070 Peak Flow Meter84550 Uric Acid Lesion 1 -- 17000 Lesions 2-14 17001L3800 Finger Splint88150 PapTrigger Point Injection 2055088142 Thin Prep / PapNail Removal 11730IMMUNIZATION ADMINISTRATION87800 GC/Chlamy DNA ProbeAspiration Cyst 10160( 90471 ______ ( 90472 x ___ ______87252-87274 Herpes CultureAspiration Joint 2060090702 DT (child) 90718 Td (Adult Tetanus) 90700 DTaP 90720 DTaP and Hib 90669 Prevnar (Conj-Pneumo) 90707 MMR, (live) 90713 Poliomyelitis (inject) 90716 Varicella, (live) 95115 Allergen Injxn: single 95117 Allergen Injxn: >=290634 Hep A (child) 90632 Hep A (adult) 90744 Hep B (Birth - 11 yo) 90745 Hep B (11-19 yo) 90746 Hep B (>=20 yo) 90659 Influenza 90732 Pneumovax (adult) 90733 Meningococcal 86580 PPD Other:86703 HIVI&D Abscess - Simple/Single/1006086592 RPR/VDRLI&D Abscess - Complicated/Many/1006180074 Hepatitis PanelEndometrial Biopsy 5750085025 CBC/CompleteColposcopy: w/ Bx/57454 w/out Bx/57452 85651 Sed Rate83540 Iron82728 FerritinSkin Tag Removal < 15 Lesions 1120083550 Iron PanelSkin Lesion Excision:83520 BNP Repair: ( Simple ( Complex86038 ANA86431 RF Size: <0.5cm 0.6-1.0cm 1.1-2.0cmMEDICATIONX-RAY EXAM84439 T4, Free 2.1-3.0cm 3.1-4.0cm >4.0cm90782 _____84443 TSH Site: ( face, ears, eyelids, nose, lips84481 Free T3 ( scalp, neck, hands, feet, genitalia81000 Urine Dip ( trunk, arm, leg81001 Urinalysis*** Hold for Pathology ***BILLING INFORMATION87088 Urine CultureLACERATIONSBALANCE FORWARD87880 Rapid Strep TestScalp, Neck, Trunk, Arms, FeetTODAYS CHARGES87070 Strep CultureSimpleIntermediateADJUSTMENTS86308 Mono Spot0-2.5 cm120011203184703 Pregnancy (Serum)2.6-7.5 cm1200212032PAID ON ACCOUNT ( VISA ( M/C ( CHECK ( CASH81025 Pregnancy (Urine)7.6-12.5 cm120041203487045 Stool Culture0-2.5 cm12041TOTAL DUE87186 Sensitivity2.6-7.5 cm1204287210 Wet prep/Fecal WBCs7.8-12.5 cm1204487177 O&P x _______Face, Ears, Eyes, Nose, Lips87328 Giardia-EIASimpleIntermediatePHYSICIANS SIGNATURE87230 C. difficile toxin0-2.5 cm1201112051 RETURN VISIT ON: 86677 H. Pylori2.6-5.0 cm120131205285610 PT / INR 85670 PTT5.0-7.5 cm1201412053 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 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 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 Angina pectoris, stable Aortic Valve disorder Arrythmia 414.00 ASHD 427.31 Atrial Fibrillation 414.9 CAD / Ischemic heart disease 426.9 Conduction disorder unsp 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 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 Sinusitis, chronic 034.0 Strep throat 463 Tonsillitis, acute 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 GI Bleeding 007.1 Giardiasis 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 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 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 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 Endometriosis, unsp 626.4 Irregular menses 614.9 PID / Pelvic inflammatory disease Stress incontinence, .female 131.9 Trichomoniasis, unsp 616.10 Vaginitis/vulvitis 112.1 Vaginitis, Yeast Disorders of Menstruation 626.0 Amenorrhea 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 Internal derangement, knee 726.32 Lateral Epicondylitis/Tennis Elbow 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 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 Sprain/strain: wrist 842.10 Sprain/strain: hand Signs and Symptoms 789.00 Abdominal pain Abnormal glucose tolerance test 793.8 Abnormal Mammogram 790.93 Abnormal ( PSA 790.4 Abnormal transaminase / LDH Abnormal PAP 793.1 Abnormal Chest Xray lung 783.0 Anorexia 719.40 Arthralgia, unsp 786.50 Chest pain, unsp. 564.0 Constipation 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 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 <60min 850.1 Concussion w/ LOC <60min Foreign body: ear/931 nose/932 skin/919.6 Insect bite 870-897 Laceration: ___________________ 995.2 Medication reaction, adverse Supplemental V65.40 Advice/health instruction V01.9 Contact/exposure, infec. Dis V25.01 Contraception, oral V25.02 Contraception, oth V25.40 Contraception, surveillance V61.10 Couns for marital & partner V61.20 Counseling for parent/child V70.3 DOT, I.N.S. PE, Sports PE V72.81 EKG / Pre-Op Cardiovasc Exam V72.84 Pre-Op Physical Exam V61.0 Family disruption V25.09 Family planning V67.4 Followup exam V72.3 Gynecological exam V70.0 Health checkup V58.61 High Risk Med: Coumadin V58.69 High Risk Med: Other V69.2 High Risk Sexual Behavior V01.9 STD Contact/ Exposure V06.9 Immunization V03.2 Immunization: PPD V03.5 Immunization: Td V06.8 Immunization: DTaP V06.4 Immunization: MMR V05.3 Immunization: Hep B V05.8 Immunization: Hib V76.9 Screening, cancer V58.3 Suture Removal/ Dressing Change V20.2 Well child check V65.5 Worried Well Family History V16.0 Colon CA V16.1 Lung CA V16.3 Breast CA V16.42 Prostate CA V17.1 Stroke/CVA V17.4 ASHD/Atherosclerotic Heart Disease V18.0 Diabetes 2PSa!. 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