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Urget Care Superbill

Urget Care Superbill

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Published by Mayer Rosenberg

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Published by: Mayer Rosenberg on Sep 13, 2009
Copyright:Attribution Non-commercial

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05/17/2012

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URGENT CARE
Provider 
1315
CPTDESCRIPTIONFEECPTDESCRIPTIONFEENEW PATIENTSX-RAY; (cont'd)
99201LEVEL 1, BRIEF; 10 min73060HUMERUS; 2+ VIEWS99202LEVEL 2, LIMITED: 20 min73560KNEE; AP & LAT99203LEVEL 3, EXPANDED; 30 min72110
LS SPINE; COMPLETE W/OBLIQUES
99204LEVEL 4, COMPREHENSIVE; 45 min70110MANDIBLE; COMPLETE99205LEVEL 5, COMPREHENSIVE; 60 min70160NASAL BONES; COMPLETE99025NEW PT. INITIAL VISIT W/*PROC.72190PELVIS; 3+VIEWS
ESTABLISHED PATIENTS
04209POST REDUCTION90025OFFICE VISIT, NO CHARGEN/C71100RIB, UNILATERAL, 2 VIEWS99211LEVEL 1, BRIEF: 72220
SACRUM & COCCYX; 2+ VIEWS
99212LEVEL 2, LIMITED: 73050
SHOULDER AC JTS; BILATERAL
99213LEVEL 3, EXPANDED: 73030SHOULDER; COMPLETE99214LEVEL 4, COMPREHENSIVE: 70360SOFT TISSUE99215LEVEL 5, COMPREHENSIVE: 72070THORACIC SPINE; AP&LAT99354PROLONGED SERVICE 1st HOUR73590TIB-FIB; AP&LAT99355PROLONGED SERV. EA ADD'L 30min73110WRIST; COMPLETE
PROCEDURES
LAB (POST CHARGES FROM LAB TICKET ONLY)
46600ANOSCOPY36415VENIPUNCTURE11730*AVULSION NAIL, SIMPLE86308
MONO SCREEN (HETEROPHILE)
16030*BURN CARE; LG, NO ANEST81025PREGNANCY TEST - URINE16025*BURN CARE, MED, NO ANEST87880RAPID STREP ANTIGEN16020*BURN CARE, SMALL, NO ANEST81001UA COMPLETE53670CATHETERIZATION (ADD TRAY)80100Urine Drug Screen30903EPISTAXIS CONTROL; COMPLEX30901EPISTAXIS CONTROL, SIMPLE
SUPPLIES (SENT HOME WITH PATIENT)
10060*I&D ABSCESS; SIMPLE02074ACE WRAP 4"10140*I&D HEMATOMA/SEROMA/FLUID02075ACE WRAP 6"10120*REM. FB SUB Q; SIMPLE02786ADAPTIC DRESSING65222*REM. FB CORNEA W/SLIT LAMP02019ANKLE BRACE07008REMOVE CONSTRICTING RING02620ANKLE BRACE: AIR CAST
LACERATION REPAIRS
02604ANKLE, E-Z WRAP; RIGID12001*REP LAC 2.5cm OR LESS02686BURN DRESSING, LARGE12002*REP LAC 2.6 - 7.5cm02685BURN DRESSING, SMALL12004*REP LAC 7.6 - 12.5cm02066CERVICAL COLLA12011*FACIAL LAC 2.5cm OR LESS02007CLAVICLE STRAP12013*FACIAL LAC 2.6 - 5.0 cm02077DRESSINGS; LARGE12031*
LAYER CLOS. SCALP/AXILLA/TRUNK ; <2.5CM
03201DRESSINGS; MEDIUM12032*
LAYER CLOS.SCALP/AXILLA/TRUNK 2.6-7.5CM
02076DRESSINGS; SMALL12041*
LAYER CLOSURE; NECK/HANDS/FEET <2.5CM
02011ELBOW SUPPORT12042*
LAYER CLOSURE;NECK/HANDS/ FEET 2.6-7.5CM
02082FINGER SPLINT
SPLINTS / SUPPLIES
02013KNEE IMMOBILIZER 29505APPLY LONG LEG SPLINT02087KNEE SLEEVE29515APPLY SHORT LEG SPLINT02387KWIK COLD
LOCATION
(CIRCLE ONE)
 
29125APPLY SHORT ARM SPLINT02200MALLET FINGER SPLINT29105APPLY LONG ARM SPLINT02127ORTHO SHOE02222ORTHOGLASS; ARM02129RIB BELT02223ORTHOGLASS; LEG
X-RAY
74000ABDOMEN (1 VIEW)74022ABDOMINAL SERIES73610ANKLE; COMPLETE72052CERVICAL SPINE; COMPLETE71020CHEST PA & LAT73000CLAVICLE; COMPLELTE73080ELBOW; COMPLETE70150FACIAL BONES; COMPLETE73630FOOT; COMPLETE73090FOREARM; AP&LAT73130HAND; 3+ VIEWS73510HIP; COMPLETE, UNILATERAL
 
Federal ID #
INJURY DATE:
CPTDESCRIPTIONFEESUPPLIES (SENT HOME WITH PATIENT)
02110SLING, ARM02084UNIVERSAL THUMB SPLINT02150WRIST BRACE, LIBERTY02010WRIST SPLINT
TRAYS AND OTHER SUPPLIES
02534EYE TRAY02111SIMPLE TRAY02097SMALL SUTURE TRAY W/ANES02033SUTURE REMOVAL KIT02094
TRAY, PELVIC / SMALL W/ANESTHESIA
02795
TRAY, SMALL W/O ANESTHESIA
02101
INSERTION TRAY W/FOLEY W/O BAG
02389STRAIGHT TIP CATHETER 02027IV SUPPLIES02795I&D TRAYJ7030
INFUSION NORMAL SALINE: 1000 cc
J7040
INFUSION N/S, STERILE; 500ml = 1 UNIT
J7120LACTATED RINGERS; 1000cc
MISCELLANEOUS
93000EKG; COMPLETE99291CRITICAL CARE; 1ST HOUR 99292
CRITICAL CARE; EA ADD'L 30 MIN
TOTAL TIME:________ to __________ 
02474DISPOSABLE CAUTERY UNIT69210EAR IRRIGATION94640NEBULIZER TREATMENT02026OXYGEN SUPPLIES94760OXIMETRY
INJECTIONS AND ADMINISTRATIONS90780IV INFUSION; UP TO 1 HOU90781
IV INFUSION; EA ADD'L HR TO 8 HRS
90782
THERAP/ DIAG INJECTION; SUB Q/ IM
90784THERAP/ DIAG INJECTION; IV90788
IM INJECTION OF ANTIBIOTIC
J0150J1200BENADRYL; 50mg03524J0702J2175J1030J1160DIGOXIN UP TO 0.5mgADENOSINE; 6mg
X _____ 
CARDIAZEM PER 25MG
X ______ 
CELESTONE; 3mg/ml
X ______ 
DEMEROL; PER 100mg
X _____ 
DEPOMEDROL 40mg
X ______ 

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