Laser Charge Tickets 25 (left) Improve communication and reduce coding
page 25 ENCOUNTER FORMS/CHARGE TICKETS FREE CODING CHECK - At your request, your Control-o-fax representative will review your current charge ticket to make sure all procedure and diagnosis codes are current and correct. Standard Ink Colors Black PATIENT INFORMATION ACCOUNT # DOB S DOC. INS DATE OF SERVICE Laser Charge Tickets (left) INSURED TELEPHONE RESPONSIBLE PARTY REF. PHYSICIAN C. PAY DATE CURRENT 30-59 60-89 PREV. BAL 90-119 120 + DIAGNOSIS (ICD-9-CM) ___285.9 ___280.9 ___281.0 ___413.9 ___411.1 ___300.00 ___440.9 ___440.20 ___780.7 ___719.49 ___493.90 ___493.91 ___691.8 ___427.31 ___296.7 ___466.0 ___727.3 ___425.4 ___354.0 ___682.9 ___434.9 ___847.0 ___786.50 ___575.0 ___574.2 ___571.2 ___428.0 other: _____________________________________________________________________________________________________________________________________________ ___372.80 Conjunctivitis ___455. Hemorrhoids I-07E-3 ___590.10 Pyelonephritis Anemia ___692.9 Contact Dermatitis ___550.90 Hernia, Inguinal ___530.1 Reflux Esophagitis Anemia, Iron Def. ___924.9 Contusion ___722.2 Herniated Interv. Disc. ___593.9 Renal Insufficiency Anemia, Pernicious ___496 COPD ___272.2 Hyperlipidemia ___584.9 Renal Failure Angina Pectoris ___414.0 Coronary Artery Disease ___401.9 Hypertension ___518.81 Respiratory Failure Angina, Unstable ___733.99 Costochondritis ___402.90 Hypertensive Heart Disease ___714.0 Rheumatoid Arthritis Anxiety ___555.9 Crohn's Disease ___244.9 Hypothyroidism ___477.0 Rhinitis, Allergic Arterioscl. Heart ___595.0 Cystitis, Acute ___564.1 Irritable Bowel ___724.3 Sciatica Arteriosclerotic Peripheral Vas. Dis. ___453.8 Deep Venous Thrombosis ___386.30 Labyrinthitis ___702.1 Seborrheic Keratosis ___311. Depression ___722.10 Lumbar Disc Syn. Asthenia ___053.9 Shingles Arthralgia ___250.01 Diabetes Type I ___847.2 Lumbar Strain ___V05.9 Shot Only, No Disease Asthma w/o Stat. Asth. ___250.00 Diabetes Type II ___627.9 Menopause ___461.9 Sinusitis, Acute Asthma w/o Stat. Asth. ___562.10 Diverticulosis, Colon ___424.0 Mitral Valve Prolapse ___780.2 Syncope Atopic Dermatitis ___562.11 Diverticulitis, Colon ___729.2 Neuralgia ___435.9 TIA Atrial Fib. ___995.2 Drug Reaction ___355.9 Neuropathy ___726.90 Tendinitis ___784.5 Dysphagia ___715.90 Osteoarthritis Bipolar (Manic Depression) ___245.9 Thyroiditis Bronchitis, Acute ___692.9 Eczema ___733.00 Osteoporosis ___465.9 URI Bursitis ___492.8 Emphysema ___380.1 Otitis Externa ___599.0 UTI Cardiomyopathy ___V70.3 Exam. General ___382.9 Otitis Media ___556 Ulcerative Colitis Carpal Tunnel Syn. ___610.2 Fibrocystic Dis. ___427.1 PAT ___708.9 Urticaria ___729.0 Fibrositis ___332.0 Parkinson's Disease Cellulitis ___V04.8 Vaccination, Influenza Cerebrovascular infarction ___535.00 Gastritis, Acute ___533.90 Peptic Ulcer Disease ___616.10 Vaginitis Cervical Strain ___558.9 Gastroenteritis/Colitis ___462 Pharyngitis ___627.3 Vaginitis, Atrophic Chest Pain ___274.0 Gout ___482.9 Pneumonia, Bacterial ___780.4 Vertigo Cholecystitis ___242.01 Grave's Thyroditis ___211.3 Polyps/Benign, Colon Cholelithiasis ___346.9 Headache, Migraine ___600 Prostatic Hypertrophy ___ ______ _____________________________ Cirrhosis ___784.0 Headache, NOS ___601.9 Prostatitis ___ ______ _____________________________ Congest. Heart Failure ___569.3 Hematochezia ___427.60 PVC’s ___ ______ _____________________________ ___ ______ OFFICE SERVICE NEW ESTAB DX _____________________________ ___ ______ FEE Focused ■ 99201 ■ 99211 _______ _______ Expanded ■ 99202 ■ 99212 _______ _______ Detailed ■ 99203 ■ 99213 _______ _______ PROCEDURES CODE ■ I & D Abscess * 2-10060 ■ Sigmoidoscopy, flex 2-45330 ■ Sigmoidoscopy w/Biop. 2-45331 ■ Rhythm Strip 5-93041WP ■ Holter Monitor > 12 5-93235WP ■ Cryosurgery 2-17340 ■ Cerumen Removal 2-69210 ■ Aerosol Bronchodilation 1-94664 ■ EKG w/interp. 5-93000WP Comp./Mod. ■ 99204 ■ 99214 _______ _______ Comp./High ■ 99205 ■ 99215 _______ _______ CODE 5-82948 5-84443 5-85025 5-80019 5-88151 5-82270 5-81000 5-85650 5-80070 5-85610 5-84153 5-87210 5-36415 ___ ■ _______________________ _______ ___ ■ _______________________ _______ _______ ___ ■ _______________________ _______ _______ INJECTIONS _______ ■ Influenza Virus Vacc _______ ■ Decadron 1cc x_______ _______ ■ Diphtheria and Tetanus _______ ■ Rocephin 250 x_______ _______ ■ Estradiol 5mg _______ ■ Vitamin B12 1000 mcg _______ ■ Stadol ■ 2mg ■ 4mg _______ ■ Zinacef 750mg _______ ■ Allergy x_______ ■ Imitrex _______ _______ ■ Claforan 1gm _______ _______ ■ Toradol x_______ ■ IM - Inj. _______ _______ ___ ■ _______________________ _______ _______ _______ ___ ■ _______________________ _______ ___ ■ _______________________ _______ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ LABORATORY Glucose, Finger Stick TSH Complete Blood Count SMA 24 Pap Smear Hemocult Urinalysis Sed. Rate Thyroid Panel Prothrombin Time PSA Wet Prep Venipuncture ___ ■ _______________________ _______ ___ ■ _______________________ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ Return:______ Days ______ Weeks ______ Months _____________________________ ___ ______ DX _______ _______ _______ _______ _______ _______ _______ _______ _______ FEE _______ _______ _______ _______ _______ _______ _______ _______ _______ Process Blue Brown 476 Navy 540 _____________________________ Green 357 MISCELLANEOUS ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ _______ _______ TODAY'S CHARGES _______ _______ _______ _______ _______ _______ CODE 1-90724 1-J1100 1-90702 1-J0696 1-J1000 1-J3420 1-J3490 1-J0697 1-95115 1-90799 1-J0698 1-J1885 1-90782 Improve communication and reduce coding errors with our top-of-the-line laser charge tickets formatted to work with your software and printed on premium laser stock with heat-resistant ink. Sizes 7” x 8-1/2", 8-1/2” x 8-1/2" and 11” x 8-1/2". Choose from 17 ink colors (see right). _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ > $ PAYMENT RECEIVED > $ ADJUSTMENTS > $ CURRENT BALANCE > $ I.D.# 00-0000000 Green 347 PROV.# 000000 THOMAS W. SMITH, M.D. Internal Medicine Eggplant 526 123 MAIN ST. ANYTOWN, USA 00000 (555) 234-4651 _______ _______ Next Appt. ______ Day ______ Month ______ Date ______ Time ■ AM ■ PM Bordeaux 221 Continuous Charge Tickets (right) • Available in one, two, three or four parts • Three sizes: 9-1/2” x 7", 9-1/2” x 8-1/2", or 9-1/2“ x 11" • Choice of 17 ink colors (see right) Red 185 Reflex Blue Royal Blue 300 Green 354 Encounter Forms/Snapsets (left) • Printed to your specifications • One, two or three parts • Any size up to 8-1/2” x 11-3/4" Forest Green 335 Teal 320 Burgundy 207 WE OFFER COMPATIBLE FORMS to work with many health care software packages, including Calyx®, Easy Dental®, MED-1®, Medical Manager®, Medisoft®, Perfect Care®, SpectraMED®, Total Recall® and more. Ask your representative. Cool Gray 2 clinical records and forms Brown 168
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