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TRUEMEDICINE, P.A.

CONFIDENTIAL - PROTECT PATIENT PRIVACY


BILLING QUESTIONS: (817) 490-9841
Patient Name: Today's Follow-up Appt.: TELEPHONE ENCOUNTER
Patient Address: Charges $ _____ Days _____ Wks *Physician Phone Calls
Patient Phone: (-) _____ Mos _____ Yrs. ONLY*
Acct. #: Payments $ *Must be > than 7 days
DOB: Age: (-) [ ] Check # ____________ from last E/M and > than

Date of Service: Appt. Time: Adj. Amt. $ [ ] Visa [ ] MC [ ] Disc. [ ]AMEX 24 hrs from next E/M*
Treating Phys: (=) [ ] Cash [ ] Paid on Acct. Tele. E/M 5-10 min. 99441

Primary Ins. Co.: Balance $ TODAY'S PAYMENT: Tele. E/M 11-20 min. 99442
Secondary Ins. Co.: Ins. Co-pay: Tele. E/M 21-30 min. 99443

$ $_____________.__________ Email/Online E/M 99443

OFFICE VISIT NEW EST. MEDICARE MODIFIERS MEDICARE SCREENING MED/INJ. ANDMINISTRATION
Straightforward 99201 99211 Medicare waiver signed GA Pap Smear Q0091 IM Antib/Thera Inj. 96372

Exp./ Straightforward 99202 99212 PA/NP Incident to MD YR (every 2 yrs) V76.2 IV Injection 90774

Det./Low complexity 99203 99213 CONSULTATIONS Pelvic/Breast Ex. G0101 MEDICATION 1 2 3 4 UNITS
Comp/Mod. complex 99204 99214 Straightforward 99241 (every 2 yrs) V76.2 Benadryl 50mg J1200

Comp./High complex 99205 99215 Exp./ Straightforward 99242 Flu Vacc. V04.81 90658 Bicillin CR 600K J0530

Sep. E/M Svc (link DX) 25 Det./Low complexity 99243 Flu Vacc. Admin V04.81 G0008 Bicillin LA 600 K J0560

E/M Svc. In Post-op Period (link DX) 24 Comp/Mod. complex 99244 Pneumovax V03.82 90732 B12 1000mg J3420

**After hrs not scheduled** 99050 Comp./High complex 99245 Pneum. Vacc. AdminV03.82 G0009 Celestone 3mg J0702

**After hrs scheduled visit** 99051 TWCC FORM COMPLETION IMMUNIZATIONS DepoMedrol 40mg J1030

**Emergency Visit** 99058 Work Status Report 99080-73 Flu V04.81 90658 DepoMedrol 80mg J1040

**Bill with E/M Code** WC Date of Injury: ____/____/_______ Flu Mist V04.81 90660 Imitrex 6mg J3030

PREVENTIVE VISIT NEW EST. MISCELLANEOUS Hep B - V05.3 90746 Lincocin J2010

Age5-11 99383 99393 Forms Comp./Med Rec 99080 Pneumovax V03.82 90732 Kenalog 10mg J3301

Age 12-17 99384 99394 Missed Appt. Charge NOSHOW Td V06.5 90718 Lidocaine #cc_____ J3490

Age 18-39 99385 99395 Sports Physical (cash) 90000S TT V03.7 90703 Nubain 10mg J2300

Age 40-64 99386 99396 Mini Mental Exam 96116 IMMUNIZATION ADMIN Phenergan 50mg J2550

Age 65 + 99387 99397 (Nurse) First Immunization 90471 Rocephin 250 mg J0696

PROLONGED CARE * FACE TO FACE ALLERGY INJECTION *ea addl #_______ 90472 SoluMedrol 125mg J2930

First 30-74 min (bill w/ E/M Code) 99354 Allergy Inj, Single 95115 Intranasal Immun. 90473 Toradol 15 mg J1885

ea addn 30 min # units _______ 99359 Allergy Inj, 2 or More 95117 PULMONARY Other Durg Desc:

SURGICAL/DIAGNOSTIC PROCEDURES Nebulizer Treat. 94640

Anoscopy 46600 Skin Debridement, Partial 99243 Albuterol 1 mg # _____ J7613 Patient supplied own Meds
Arthrocentesis, aspiration, Small 20600 Full thickness 11041 Albut. Conc 1 mg. #____ J7611 LABORATORY - IN OFFICE ONLY
or injection into joint Medium 20605 Skin and Subcutane 11042 Xopenex .5mg #______ J7614 Creatinine 82570

(Bill J-code for Meds) Large 20610 Skin tag removal up to 15 11200 Xop. conc .5mg #______ J7612 Fecal Hemoccult 82270

Catherization - Simple 51701 Surgical/Suture tray A4550 # units 1 2 3 Glucometer 82948

Cerumen removal, one or both ears 69210 Audiometry-sound booth 92552 Nebulizer admin kit A7003 H pylori analysis 83013

Corn/Callus-Paring/Cutting, single 11055 Hearing Screen 92551 MDI/Neb. Education 94664 H pylori collec (drug admin) 83014

Corn/Callus-Paring/Cutting, 2-4 11056 Tympanogram 92567 Peak Flow Meter (26) 94200 Hemoglobin A1C 83036

I&D Abcess, Simple 10060 Vision Screen 99173 Pulse Oximetry 94760 Influenza A & B Test 87804

Inj, Tendon Sheath/Ganglion Cyst 20550 Tonopen 92120 Spirometry (26) 94010 KOH Prep 87220

Inj. Trigger Point, 1-2 Muscle groups 20552 Bioimpendance 93701 Spirom. B/A Dialtors 94060 Lipid Profile 80061

Inj. Trigger Point, > 3 groups 20553 Exercise Stress Test 93015 LABORATORY - IN OFFICE ONLY Microalbumin 82044

PM Lesion Dest/Cyro, 1st lesion 17000 EKG & Interpretation 93000 UA w/o Micro 81002 Monospot 86308

- ea addl lesion up to 14 # ________ 17003 EKG Interp. Only 93010 Urine Pregnancy Test 81025 PT/INR 85610

Benign Lesion Cryotherapy, up to 14 17110 Chest X-Ray, 2 Views 71020 Venipuncture 36415 Strep Screen 87880

- 15 or more 17111 SMOKING CESSATION Wet Prep/Smear 87210 TB (PPD) 86580

Nail Plate removal - List Toe _______ 11730 Counseling 3-10 min 99406 Urinalysis Auto w/o Micro 81003 TB (Tine) 86585

Nail&Matrix Exc. - List Toe ________ 11750 Counseling > 10 min. 99407

Pathology Pending 46 PROVIDER SIGNATURE:____________________________________________


Medicare E-Prescribing Codes Physician Notes
All Prsc Dur Encntr Qual E-Prsc Sys G8443

Some/All Prsc Handwritten/Phoned In G8446

No Prsc No Access Qual E-Prsc Sys G8445


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