ANDY PEEKE, M.D.
1234 SESAME STREET
YOURTOWN, USA 12345
Phone: 646-703-1834 www.PalosVerdesInc.com
PATIENT NAME: ______
DOB: ______SEX: ______DOS: ______
DIAGNOSIS
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5.
OFFICE SERVICES / PREVENTIVE MEDICINE
¨ 99201
¨ 99202
¨ 99203
¨ 99204
¨ 99205 / ¨ 99211 OFFICE VISIT LEVEL 1
¨ 99212 OFFICE VISIT LEVEL 2
¨ 99213 OFFICE VISIT LEVEL 3
¨ 99214 OFFICE VISIT LEVEL 4
¨ 99215 OFFICE VISIT LEVEL 5 / ¨ 99384 -age 12-17
¨ 99385 -age 18-39
¨ 99386 -age 40-64
¨ 99387 -age 65 / ¨ 99394
¨ 99395
¨ 99396
¨ 99397
ADMINISTRATION FEES
/OFFICE CONSULTS
¨ 90471 ADMINISTRATION OF FIRST VACCINES¨ 90472 ADMINISTRATION OF ADDITIONAL VACCINES
¨ G0008 ADMINISTRATION OF FLU VACCINE
¨ G0009 ADMINISTRATION OF PNEUMO VACCINE
¨ 90782 ADMINISTRATION OF IM/SC MEDICATIONS / ¨ 99241 OFFICE CONSULT LEVEL 1 MINOR
¨ 99242 OFFICE CONSULT LEVEL 2 LOW
¨ 99243 OFFICE CONSULT LEVEL 3
¨ 99244 OFFICE CONSULT LEVEL 4
¨ 99245 OFFICE CONSULT LEVEL 5
INJECTIONS / VACCINATIONS
¨ 90703 TETANUS¨ 90658 FLU
¨ 90732 PNEUMOVAX
¨ 86580 PPD
¨ 90707 MMR
¨ 90665 LYME VACCINE / ¨ 90746 HEP B VACCINE
¨ 90636 HEP A/B VACCINE
¨ J0580 LA-BICILLIN 2.4
¨ J3301 KENALOG 40
¨ J3105 BRETHINE INJ
¨ OTHER ______/ ¨ J0170 EPINEPHRINE
¨ J3420 B-12
¨ J1200 BENADRYL 50MG INJ
¨ J1885 TORADOL 60MG INJ
¨ J2930 SOLUMEDROL 125MG INJ
¨ OTHER ______
LABORATORY / PROCEDURES / SUPPLIES / TESTING
¨ 36410 VENIPUNCTURE¨ 93000 EKG
¨ 94664 BRONCHODILATOR
¨ 94060 COMPLETE SPIROMETRY
¨ 94150 PEAK FLOW
¨ 81025 PREGNANCY TEST
¨ 82962 GLUCOSE TEST/FINGER STICK
¨ 99000-99001 HANDLING SPECIMEN / ¨ 83014 H.PYLORI TEST
¨ G0001 MEDICARE VENIPUNCTURE
¨ 94760 PULSE OXYMETRY
¨ 82270 HEMOCCULT
¨ A4460 ELASTIC BANDAGE ACE
¨ 94640 NEBULIZER/MIST THERAPY
¨ 86580 MANTOUX
¨ OTHER ______/ ¨ 81002 URINALYSIS DIPSTICK
¨ 87880 STREP TEST
¨ 85610 PT/INR
¨ 97602 WOUND CARE
¨ STAPLE REMOVAL
¨ EAR IRRIGATION/WAX REMOVAL
¨ URODYNAMICS (6 CODES)
¨ ECHO
Physician’s Signature ______Next Appt. ______