Niatx Buprenorphine Implementation Toolkit Sample Form: Charge Ticket
NIATx Buprenorphine Implementation Toolkit
Sample Form: Charge Ticket
02/2017
Charge ticket
Client Name: DOB:
Problem Focused/Brief MAT Consult Through Full Induction/ 51% in Counseling or Coordinated Care5731601 / OV New Patient 10 min / 5731603 / OV New Patient 10 min
5731605 / OV New Patient 20 min / 5731607 / OV New Patient 20 min
5731609 / OV New Patient 30 min / 5731610 / OV New Patient 30 min
5735004 / OV New Patient 45 min / 5735006 / OV New Patient 45 min
5735000 / OV New Patient 60 min / 5735002 / OV New Patient 60 min
Brief Management Appointments or Motivational in Nature/51% in Counseling or Coordinated Care
5731612 / OV Est. Patient 5 min / 5731614 / OV Est. Patient 5 min
5731616 / OV Est. Patient 10 min / 5735618 / OV Est. Patient 10 min
5735008 / OV Est. Patient 15 min / 5735011 / OV Est. Patient 15 min
MAT/Day 2 Induction/Alcohol or 51% in Counseling or Coordinated Care
5735013 / OV Est. Patient 25 min / 5735015 / OV Est. Patient 25 min
5731621 / OV Est. Patient 40 min / 5731623 / OV Est. Patient 40 min
Med. Management Group
5731616 / OV Est. Patient 10 min / 5735618 / OV Est. Patient 10 min
Psych Evaluations
5731625 / OP Psych Diag Eval MD / 5731669 / OP Psych Diag. Eval. MD
5731694 / OP Psych Diag Eval with Medical / 5731696 / OP Psych Diag. Eval. with Medical
Time (Min) / CPT Code / History / Exam / Decision Making
Office/ER/OP Consult / 15 / 99241 / Problem Focused / Problem Focused / Straightforward
Office/ER/OP Consult / 30 / 99242 / Expanded / Expanded / Straightforward
Office/ER/OP Consult / 60 / 99244 / Comprehensive / Comprehensive / Moderate Complexity
Office or outpatient visit, new pt. / 10 / 99201 / Problem Focused / Problem Focused / Straightforward
Office or outpatient visit, new pt. / 20 / 99202 / Expanded / Expanded / Straightforward
Office or outpatient visit, new pt. / 30 / 99203 / Detailed / Detailed / Low Complexity
Office or outpatient visit, new pt. / 45 / 99204 / Comprehensive / Comprehensive / Moderate Complexity
Office or outpatient visit, new pt. / 60 / 99205 / Comprehensive / Comprehensive / High Complexity
Office or outpatient visit, est. pt. / 5 / 99211 / Minimal / Minimal / Minimal
Office or outpatient visit, est. pt. / 10 / 99212 / Problem Focused / Problem Focused / Straightforward
Office or outpatient visit, est. pt. / 15 / 99213 / Expanded / Expanded / Low
Office or outpatient visit, est. pt. / 25 / 99214 / Detailed / Detailed / Moderate Complexity
Office or outpatient visit, est. pt. / 40 / 99215 / Comprehensive / Comprehensive / High Complexity
Chief Complaint (CC)
History of Present Illness (HPI)
Review of Systems (ROS)
Past, family, and/or social history (PFSH)
Type of Hx / HPI / ROS / PFSH
Problem Focused / Brief / N/A / N/A
Expanded Problem Focused / Brief / Problem Pertinent / N/A
Detailed / Extended / Extended / Pertinent
Comprehensive / Extended / Complete / Complete
HISTORY OF PRESENT ILLNESS (HPI)
Location
Quality
Severity
Duration
Timing
Context
Modifying factors, and
Associated signs and symptoms
PAST, FAMILY AND/OR SOCIAL HISTORY (PFSH)
PFSH consists of 3 areas:
1. Past history (patient’s past experiences with illnesses, operations, injuries, and treatments
2. Family history (review of medical events in patient’s family, incl. diseases which may be hereditary or place the patient at risk); and
3. Social history (an age appropriate review of past and current activities)