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
___ ■ _______________________ _______
___ ■ _______________________ _______
_______
_______
_______
_______
_______
_______
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_______
_______
_______
_______
_______
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
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heat-resistant ink. Sizes 7” x 8-1/2", 8-1/2” x
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colors (see right).
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>
$
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)
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Green 354
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