Mental Health Encounter Form

Fairmont Heights Northwestern Oxon Hill

Wellness Center Wellness Center Wellness Center

1401 Nye Street 7000 Adelphi Rd 6701 Leyte Dr.

Fairmont Hgts, MD 20743 Hyattsville, MD 20782 Oxon Hill, MD 20745

301-925-2870 301-985-1837 301-749-5241

Medical/Dental Encounter Form

Date of Service: ______Name: ______Student ID: ______D.O.B.:______

Provider: ______Health Ins. Plan:______None ___

NP/PA, MD, DDS, Hygienist

Type of Appointment
NR01 Appointment / NR03 Sent by teacher / NR05 DNKA / NR07 Cancel/patient
NR02 Walk in / NR04 Sent by nurse / NR06 Cancel/staff / NR08 Crisis Intervention
NR09 Minor Consent / NR00 Not Registered / NR Teen parent / NES Non English Speaking
CPT Codes – Medical
E/M Visits / New / Established / Preventative Med / New / Established
Problem Focused / 99201 / 99211 / Infant under (1) / 99381 / 99391
Exp. Problem Focused / 99202 / 99212 / Toddler 1-4 year / 99382 / 99392
Detailed / 99203 / 99213 / Child 12-17 year / 99384 / 99394
Comp / 99204 / 99214 / Child 18-39 year / 99385 / 99395
Comp High / 99205 / 99215 / Risk Assessment / 99420
Counseling / 99401-15 min / 99402-30 min
Counseling / 99403-45 min / 99404-60 min
Case Management
Telephone Call – brief / 99371 / Tx Team Conf – 30 min / 99361 / School Personnel
Telephone Call – Intermediate / 99372 / Tx Team Conf – 60 min / 99362 / Parent/Guardian
Telephone Call – Complex / 99373 / Community/PCP/Specialist
CPT Codes – Dental
Diagnostic / Preventative
Periodic Oral Eval / D0120 / Prophylaxis – Adult / D1110 / Prophylaxis – Child / D1120
Limited Periodic Eval (Problem Focused) / D0140 / Topical Appl Fluoride – Adult / D1204 / Topical Appl Fluoride – Child / D1203
Comprehensive Oral Eval / D0150 / Oral Hygiene Instructions / D1320 / Sealant Per Tooth / D1351
Other:
LABS: In house /

LABS : Out-going

HCG, urine (V72.4) / 84703 / CBC/Diff / 85025 / PAP – thin prep / 88142
Hemacue / 85018 / Chlamydia (DNA probe) / 87490 / Throat culture / 87081
KOH / 87220 / GC (DNA probe) / 87490 / Urine C & S / 87086
Wet Mount / 87210 / HCG serum (quant) / 84702 / Urine LCR-GC
Rapid Strep / 86588 / Herpes Culture / 87252 / Urine LCR-CT / 87491
Urine Dip / 81002 / HIV (blood) / 86701 / VDRL/RPR / 86592
Urine Micro / 81000 / HIV (saliva) / S3645 / Other
Other / PAP – slide / 88164 / Other
IMMUNIZATIONS (V06.9) / PROCEDURES / OTHER
Hep B peds/adol dose / 90744 / Audiometry / 92551 / Drug Admin through MDI / J3535
Hep B >19 / 90746 / Ear Irrigation (1 or both) / 69210 / Vaccine Admin (1) / 90471
Influenza / 90658 / EKG / 93010 / PPD (V74.1) / 86580
MMR / 90707 / Evacuation nail hematoma / 11740 / Venipuncture / 36415
IPV / 90713 / I & D, simple / 10060 / Other / comments:
Td / 90718 / Nebulizer Tx / 94640
DTaP / 90700 / Peak Flow / 94060
Varicella / 90716 / Suture Removal / V58.3
Prevnar / Vision Screening / 92499

CONTACTS

Parent/Family / Psychiatrist / Mental Health or D/A Provider / Healthline (PGCo)
School personnel / Primary Care Provider / Family Planning Services / Other

REFERRAL

MD / Psychiatrist / Mental Health or D/A Provider / Nutritionist
School personnel / Family Planning Services / Primary Care Provider / School Nurse
Dentist / Vision
FOLLOW UP APPT
when w/ whom
Diagnosis Codes (ICD-9)

BREAST/CHEST

Breast disorder, unspecified / 611.9 / Gynecomastia / 611.1 / Chest pain, non-cardiac / 786.50
Breast pain/mastodynia / 611.71 / Breast Lump / 611.72

CARIOVASCULAR

/ Elevated BP Reading / 796.2 / Heart Murmur undiagnosed / 785.2

DENTAL

/ Dental Caries / 521.0 / Dental Exam / V72.2
Gingival/periodontal disease, unspec / 523.9 / Tooth pain / 525.9 / Acute Gingivitis / 523.0
DERM
Acne / 706.1 / Scabies / 133.0 / Rash / 782.1
Bite, Insect / 919.4 / Carbuncle/Furuncle / 680.9 / Tinea* / 110._
Cellulitis/abscess, unspec. / 682.9 / Paranychia / 681.9 / Urticaria, unspec / 708.9
Dermatitis, atopic/eczema / 691.8 / Pruritus, NOS / 698.9 / Wart, common, unspec / 078.10
Dermatitis, contact, unspec / 692.9 / Folliculitis / 704.8 / Tinea, versicolor / 111.0

ENDO

/ Diabetes (insulin dependent) / 250.01

EYE

Conjunctivitis, acute, unspec / 372.00 / Vision Problem / V41.0 / Stye / 313.11
ENT/RESP
Allergic Rhinitis, unspec / 477.9 / Epistaxis / 784.7 / Pharyngitis/Sore throat acute / 462
Asthma/RAD, acute*, unspec / 493.91 / Hyperventilation, hysterical / 300.11 / Pneumonia / 486
Cough / 786.2 / Impacted Cerumen / 380.4 / Sinusitis, acute, unspec / 461.9
Otitis, serous / 381.1 / Otitis externa, infectious,unspec / 380.10 / Thrush / 112.0
URI, acute / 465.9 / Otitis media, acute w/o rupture / 382.00
FAMILY PLANNING / PREGNANY
Family Planning Advice / V25.09 / Pregnancy / V22.2 / Suspected Pregnancy / V72.4
Contraceptive surv. / V25.40 / Pregnancy, unspec, high risk / V23.9 / Threatened Abortion* / 640.0
GI
Abdominal Pain / 789.00 / Diarrhea / 787.91 / Heart Burn / 787.1
Constipation / 564.0 / Gastroenteritis / 009.0 / Nausea & vomiting / 787.01
GU (NON-STI)
Dysuria / 788.1 / Hernia, inguinal / 550.90 / Urinary frequency / 788.41
Hematuria / 599.7 / Hydrocele / 603.9 / UTI, site not specified / 599.0
GYN (NON-STI)
Bacterial Vaginosis/Vulvavaginitis, NOS / 616.10 / Gyn Exam, routine + PAP / V72.3 / PAP smear, nonspecific, abn / 795.0
Candida vulvovaginitis / 112.1 / Irregular menses / 626.4 / Pelvic pain / 625.9
Delayed Menses / 626.8 / Menstruation, excessive or frequent / 626.2 / Polycystic ovary syndrome / 256.4
Dysfunctional uterine bleeding, NOS / 626.8 / Amenorhea / 626.0 / Vulvar lesion / 616.50
Dysmenorrhea / 625.3 / Cervical atypia or dysplasia / 622.1
HEME
Anemia not due to blood loss, unspec / 285.9 / Iron deficiency anemia, unspec / 280.9 / Sickle Cell anemia, unspec* / 282.60
INFECTIONS
Herpes stomatitis / 054.2 / Influenza / 487.1 / Viral Infection, unspec / 079.99
INJURY
Wound/Cut* / 879._ / Muscle Sprain / 848._ / Contusion* / 924._
MUSCULOSKELETAL
Backache, unspec / 724.5 / Joint pain / 719.40 / Pain in limb / 729.5
Scoliosis, idiopathic / 737.30 / Osgood-Schlatter / 732.4
NEURO
Syncope / 780.2 / Dizziness/vertigo / 780.4 / Headache / 784.0
NUTRITION
Dietary Counseling / V65.3 / Inappropriate diet and eating habits / V69.1 / Weight Loss, abnormal / 783.2
Obesity / 278.0
PSYCHOSOCIAL/SUBSTANCE ABUSE
Abuse/Assault* / 995.-- / Cannabis Abuse / 305.20 / Mental Disorder NOS / 300.9
Academic Problem / V62.3 / Depression NOS / 311 / Parent/Child Relational Prob / V61.20
Alcohol Abuse / 305.00 / Eating Disorder NOS / 307.50 / Relational Problem NOS / V62.81
Bereavement / V62.82 / Homelessness/lack of housing / V60.0 / Substance abuse/use couns. / V65.42
Anxiety NOS / 300.00
SIGNS/SYMPTOMS
Allergic Reaction, NOS / 995.3 / Fever / 780.6 / Malaise & fatigue & gen weak / 780.7
Lymphadenopathy / 785.0 / Sleep Disturbance / 780.5
STI
Cervicitis / 616.0 / Gonorrhea / 098.0 / STI Testing / V74.5
Chlamydia, NOS / 079.98 / HIV Counseling / V65.44 / STI Contact/Exposure / V01.6
Genital Herpes, unspec / 054.10 / Pediculus pubis/crabs / 132.2 / Trichomonal vulvovaginitis / 131.01
Genital Warts, NOS / 078.19 / STI Counseling / V65.45 / Urethritis, nongonococcal, unspec / 099.40
ADDITIONAL V CODES / Feared Complaint (no dx) / V65.5
Follow up exam, unspecified / V67.9 / Health Advice, NOS (counseling) / V65.40 / Unspecified Comb Vaccine / V06.9
GAPS Screening / V82.9 / Health exam of school child/pre-employ / V70.5 / Sports/Camp Physical / V70.3
Cleared / Not Cleared
Other

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