of the Roaring Fork Valley / Attending Provider’s Statement
Basalt Clinic
Glenn Kotz, MD; Bruce Bowen, MD;
Kelly Locke, MD; Karen Locke, MD; Lisa Robbianno, NP
1450 East Valley Road, Ste 101, Basalt, CO 81621
(970) 544-1125 FAX (970) 544-1250 Tax I.D. 84-1375275 / Aspen Clinic
David Borchers, MD, Bennett Gross, MD
225 N. Mill St, #116, Aspen, CO 81611
(970) 544-1292 FAX (970) 544-1310
GUARANTOR: Name, Address, Phone / Visit # / Patient Name / Age / D.O.B. / Provider
Patient # / Name of Insurance / S.S.N. / Co-Pay / Date
OFFICE / NEW FEE / ESTAB. FEE / OTHER CHARGES / CONSULTATION / Complete Physical / NEW FEE / ESTAB.FEE
LEVEL 1
LEVEL 2
LEVEL 3
LEVEL 4
LEVEL 5 / 99201 _____
99202 _____
99203 _____
99204 _____
99205 _____ / 99211 _____
99212 _____
99213 _____
99214 _____
99215 _____ / ER Visit
After Hours
Sunday/Holiday / 99058 _____
99050 _____
99054 _____ / LEVEL I
LEVEL II
LEVEL III
LEVEL IV
LEVEL V / 99241 15 min
99242 30 min
99243 40 min
99244 60 min
99245 80 min / < 1 year
1-4
5-11
12-17
18-39
40-64 yrs
65 + / 99381 ____
99382 ____
99383 ____
99384 ____
99385 ____
99386 ____
99387 ____ / 99391 ____
99392 ____
99393 ____
99394 ____
99395 ____
99396 ____
99397 ____
COUNSELING
LEVEL I
LEVEL II
LEVEL III / 99213 - 15 min
99214 - 25 min
99215 - 40 min
LABORATORY / ICD-9 / PROCEDURES / SUPPLIES
36415 Drawing / Anoscopy 46600 / A4570 Wrist or Thumb Splint
82947 Glucose [ Fast/Non Fast] / Flex Sig w/out Bx 45330 with Bx 45331 / A4460 Ace Bandage
83036 Hgb A1C / PFT 94060 / L4350 Air Brace – Ankle
82043 Microalbumin / VO2 Max 94621 / A4580 Cast Supplies
80048 Basic Panel Chem 7 / Stress Test 93015 / L3650 Clavicle Strap
80053 Chem 13 / EKG/Interpretation 93000 / L4360 Fracture Air Walker
80076 LFT / 82977 GGT / Tympanogram 92567 / 29505 Long Leg Splint
82150 Amylase / Irrigation: Ear / 69210 Eye / 66999 / 29515 Short Leg Splint
80061 Lipids [ Fast/Non Fast] / Foreign Body Removal: Ear/69200 Eye/65205 / 90780 I.V. Setup & Administration
83721 Direct LDL / Foreign Body Skin: Simple/10120 Complicated/10121 / J7120 Ringers Lactate (up to 1,000cc)
82270 Hemoccult / Debridement; skin, partial thickness 11040 / J7030 Normal Saline (up to 1,000cc)
84153 PSA / Burn Care 16020 / 94640 Nebulizer Treatment
86140 C-Reactive Protein / Paring/Cutting Callous/Corn: Single/11055 2-4/11056 / 94665 Nebulizer Follow-Up
82131 Homocysteine / Wart Tx (cryo, acid, etc) <15 = 17110 >=15 = 17111 / A4550 Surgical Tray
83735 Magnesium / Benign/Premalignant Lesion Tx (ie AK) (cryo, etc) / 99070 Peak Flow Meter
84550 Uric Acid / Lesion 1 -- 17000 Lesions 2-14 – 17001 / L3800 Finger Splint
88150 Pap / Trigger Point Injection 20550
88142 Thin Prep / Pap / Nail Removal 11730 / IMMUNIZATION ADMINISTRATION
87800 GC/Chlamy DNA Probe / Aspiration Cyst 10160 / 90471 ______ 90472 x ______
87252-87274 Herpes Culture / Aspiration Joint 20600 / 90702 DT (child)
90718 Td (Adult Tetanus)
90700 DTaP
90720 DTaP and Hib
90669 Prevnar (Conj-Pneumo)
90707 MMR, (live)
90713 Poliomyelitis (inject)
90716 Varicella, (live)
95115 Allergen Injxn: single
95117 Allergen Injxn: >=2 / 90634 Hep A (child)
90632 Hep A (adult)
90744 Hep B (Birth - 11 yo)
90745 Hep B (11-19 yo)
90746 Hep B (>=20 yo)
90659 Influenza
90732 Pneumovax (adult)
90733 Meningococcal
86580 PPD
Other:
86703 HIV / I&D Abscess - Simple/Single/10060
86592 RPR/VDRL / I&D Abscess - Complicated/Many/10061
80074 Hepatitis Panel / Endometrial Biopsy 57500
85025 CBC/Complete / Colposcopy: w/ Bx/57454 w/out Bx/57452
85651 Sed Rate
83540 Iron / 82728 Ferritin / Skin Tag Removal < 15 Lesions 11200
83550 Iron Panel / Skin Lesion Excision:
83520 BNP / Repair: Simple Complex
86038 ANA / 86431 RF / Size: <0.5cm 0.6-1.0cm 1.1-2.0cm / MEDICATION / X-RAY EXAM
84439 T4, Free / 2.1-3.0cm 3.1-4.0cm >4.0cm / 90782 _____
84443 TSH / Site: face, ears, eyelids, nose, lips
84481 Free T3 / scalp, neck, hands, feet, genitalia
81000 Urine Dip / trunk, arm, leg
81001 Urinalysis / *** Hold for Pathology *** / BILLING INFORMATION
87088 Urine Culture / LACERATIONS / BALANCE FORWARD
87880 Rapid Strep Test / Scalp, Neck, Trunk, Arms, Feet / TODAY’S CHARGES
87070 Strep Culture / Simple / Intermediate / ADJUSTMENTS
86308 Mono Spot / 0-2.5 cm / 12001 / 12031
84703 Pregnancy (Serum) / 2.6-7.5 cm / 12002 / 12032 / PAID ON ACCOUNT
VISA M/C CHECK CASH
81025 Pregnancy (Urine) / 7.6-12.5 cm / 12004 / 12034
87045 Stool Culture / 0-2.5 cm / 12041 / TOTAL DUE
87186 Sensitivity / 2.6-7.5 cm / 12042
87210 Wet prep/Fecal WBC’s / 7.8-12.5 cm / 12044
87177 O&P x ______/ Face, Ears, Eyes, Nose, Lips
87328 Giardia-EIA / Simple / Intermediate / PHYSICIAN’S SIGNATURE
87230 C. difficile toxin / 0-2.5 cm / 12011 / 12051 / RETURN VISIT ON:
86677 H. Pylori / 2.6-5.0 cm / 12013 / 12052
85610 PT / INR / 85670 PTT / 5.0-7.5 cm / 12014 / 12053
Infectious & Parasitic Dis
098.0 Gonorrhea, acute
042 HIV
075 Mono/Infectious mononucleosis
487.1 Influenza w/ upper respiratory
795.5 Positive PPD
079.9 Viral Syndrome
Neoplasms
Malignant Neoplasms
174.9 Breast, female, unsp
153.9 Colon, unsp
162.9 Lung, unsp
185 Prostate
173.9 Skin, unsp
Benign Neoplasms
214.9 Lipoma, any site
216.9 Skin, unsp
218.9 Uterus (leiomyoma, unsp.
Endo, Nutr & Meta. Dz
250.91 Diab. mell., I, complicated
250.01 Diab. mell, I, uncomplicated
250.90 Diab.mell, II, complicated
250.00 Diab.mell, II, uncomplicated
790.6 Elevated sugars / Hyperglycemia/Iron
271.3 Glucose intolerance
240.9 Goiter, unspecified
274.9 Gout, unspecified
272.4Hyperlipidimia
272.0 Hypercholesterolemia
242.90 Hyperthyroidism, NOS
276.8 Hypokalemia
244.9 Hypothyroidism, unsp
278.00 Obesity/Overweight; Morbid 278.01
241.0 Thyroid nodule
Blood Diseases
280.9 Anemia, iron deficiency
281.0 Anemia,Pernicious/ B12 Def.
285.9 Anemia, unspecified
683 Lymphadenitis, acute
Mental Disorders
309.9 Adjustment reaction unsp
305.00 Alcohol abuse, unsp
303.90 Alcoholism, unsp
331.0 Alzheimers
307.1 Anorexia nervosa
300.00 Anxiety state, unsp
314.01 ADD w/ hyperactivity
314.00 ADD w/o hyperactivity
296.40 Bipolar Disorder
307.51 Bulimia
311 Depressive disorder, NOS
296.20 Depression, Acute
305.90 Drug abuse, unsp
304.90 Drug dependence, unsp
780.52 Insomia NOS
300.01 Panic disorder
301.9 Personality disorder unsp
290.0 Senile dementia, NOS
302.70 Sexual dysfunction,
780.50 Sleep Disturbance
305.1 Tobacco abuse
Nerve/Sense Disorders
354.0 Carpal tunnel syndrome
432.9 CVA/ Intracranial hemorrhage NOS
345.90 Epilepsy, unsp w/o intractab
784.0 Headache
307.81 Headache, Tension
346.90 Headache, Migraine, w/o intractable
357.9 Neuropathy, unsp
310.2 Postconcussion
333.99 Restless legs
780.39 Seizures, convulsions
333.1 Tremor, essential
Eye Diseases
373.00 Blepharitis, unsp
366.9 Cataract, unsp
373.2Chalazion
372.00 Conjunctivitis, Acute, Bact.
372.14 Conjunctivitis, Allergic
077.99 Conjunctivitis, Viral
918.1 Corneal abrasion
930.9 Eye foreign body, external
365.9 Glaucoma, unsp.
373.11 Hordeolum (stye)
368.10 Visual disturbance, unsp
369.9 Visual loss, unsp.
Ear Diseases
380.4 Cerumen, Impacted
381.81 Eustachian tube dysfunction
389.9 Hearing loss, unsp
380.10 Otitis externa, unsp
382.00 Otitis media, acute
381.10 Otitis media, chronic
386.2 Vertigo, central
386.10 Vertigo, peripheral
Circulatory System
413.9Angina pectoris, stable
424.1Aortic Valve disorder
427.9Arrythmia
414.00 ASHD
427.31 Atrial Fibrillation
414.9 CAD / Ischemic heart disease
426.9 Conduction disorder unsp
428.0CHF
453.9 DVT/Deep Venous Thrombosis
796.2 Elevated BP w/o hypertension
401.1 Hypertension, benign
401.0 Hypertension, malignant
424.0 Mitral Valve / MVP
412 Myocardial infarction, old
458.0 Orthostatic hypotension
427.0 Paroxysmal supraventricular
420.91 Pericarditis, acute
443.9 Peripheral vascular disease
427.60 Premature beats unsp
427.69 PVC/Premature Ventricular Contract.
415.19 Pulmonary embolism
427.81 Sick Sinus Syndrome
451.9 Thrombophlebitis unsp
435.9 TIA/Transient ischemic attack, unsp
454.9 Varicose veins w/o ulcer/inflam
459.81 Venous insufficienciency
427.1 V-tach/Ventricular tachycardia
Respiratory System
493.90 Asthma, unsp.
466.11 Bronchiolitis, acute, due to rsv
466.0 Bronchitis, acute
491.9 Bronchitis, chronic
496 COPD
464.4 Croup
492.8Emphysema
799.0 Hypoxia
464.0 Laryngitis, acute
462 Pharyngitis, acute
472.1 Pharyngitis, chronic
519.1 R.A.D
486 Pneumonia, unsp
477.9 Rhinitis, allergic
472.0 Rhinitis, chronic
461.9 Sinusitis, acute
473.9Sinusitis, chronic
034.0 Strep throat
463 Tonsillitis, acute
465.9URI, acute
Digestive System
571.9 Chronic liver disorder
571.5 Cirrhosis, NOS
562.10 Diverticulosis colon
536.8 Dyspepsia
530.10 Esophagitis, unsp
575.9 Gallbladder disease
535.50 Gastritis, w/o hemorrhage
009.1 Gastroenteritis, infectious
558.9 Gastroenteritis, noninfectious
530.11 GERD
578.9GI Bleeding
007.1 Giardiasis
455.6Hemorrhoids, NOS
070.30 Hepatitis B
070.51 Hepatitis C
Hernia: hiatal/553.3; inguinal/550.90
553.9 Hernias, other, NOS
560.1 Ileus
564.1Irritable bowel syndrome
792.1 Occult Blood in stool
528.9 Oral, soft tissue disease/Mouth Ulcer
529.9 Oral, tongue disease
577.0 Pancreatitis, acute
533.90 Peptic ulcer disease
569.3 Rectal bleeding
524.60 Temporomandibular joint disorder
112.0 Thrush, oral yeast
Genitourinary System
Renal Failure: Acute/584.9 Chronic/585
580.9Glomerulonephritis, acute
592.9 Kidney Stone
791.0 Proteinuria, nonpost ural
590.10 Pyelonephritis, acute
599.0 UTI (NOS)
Male Genital Organ Disease
302.72 Erectal Dysfunction
604.90 Orchitis/epididymitis
600.0 BPH / Prostatic hypertrophy
601.9Prostatitis, acute
456.4 Varicocele
Breast Diseases
611.72 Breast lump / mass
610.1 Fibrocystic disease
611.6 Galactorrhea
Female Genital Organ Diseases
622.1 Cervical dysplasia
622.7 Cervical polyp, NOS
616.0 Cervicitis
625.0 Dyspareunia
617.9Endometriosis, unsp
626.4 Irregular menses
614.9 PID / Pelvic inflammatory disease
625.6Stress incontinence, .female
131.9 Trichomoniasis, unsp
616.10 Vaginitis/vulvitis
112.1 Vaginitis, Yeast
Disorders of Menstruation
626.0 Amenorrhea
626.2Excessive/frequent menstruation
627.2 Hot Flashes
627.9 Menopausal disorder
625.3 Painful menstruation
V07.4 Postmenopausal hormone replace
625.4 Premenstrual tension syndrome
Fertility Problems
628.9 Infertility, female
606.9 Infertility, male
Pregnancy, Childbirth
634.90 Abortion, spontaneous w/o comp
633.9 Ectopic pregnancy,
V22.2 Pregnancy
640.00 Threatened abortion, unsp
Skin, Subcutaneous
706.1 Acne, other
702.0 Actinic keratosis
682.9 Cellulitis/abscess
707.9 Chronic skin ulcer
692.9 Contact dermatitis
691.0 Diaper rash
691.8 Eczema, atopic dermatitis
057.9 Exanthem, Viral, NOS
054.9 Herpes simplex
053.9 Herpes zoster/shingles
684 Impetigo
703.0 Ingrown nail
683 Lymphadenitis, acute
110.1 Onychomycosis/Fungal Nail
709.9 Other skin disease
698.9 Pruritus, NOS
696.1 Psoriasis
782.1 Rash, nonvesicular
695.3 Rosacea
706.2 Sebaceous cyst
690.10 Seborrheic dermatitis.
702.19 Seborrheic keratosis
701.9 Skin Tag
111.0 Tinea versicolor
692.71 Sunburn
078.19 Warts
Musculoskeletal
716.90 Arthritis
723.9 Cervical disorder
722.2 Disc syndrome, no myelopathy
727.43 Ganglion, unsp
717.9Internal derangement, knee
726.32 Lateral Epicondylitis/Tennis Elbow
724.2Low back pain
724.4 Low back pain w/ radiation
728.85 Muscle Spasm
729.1 Myalgia/myositis
721.90 Osteoarthritis/spine
715.90 Osteoarthrosis, unsp
733.90 Osteopenia
733.00 Osteoporosis
729.5 Pain in limb
714.0 Rheumatoid arthritis
726.10 Shoulder syndrome
726.2Shoulder Impingment Syndrome
Dislocations & Strains
836.2 Knee meniscus injury
845.00 Sprain/strain: ankle
845.10 Sprain/strain: foot
844.9 Sprain/strain: knee/leg
846.9 Sprain/strain: low back
847.0 Sprain/strain: neck
842.0Sprain/strain: wrist
842.10 Sprain/strain: hand
Signs and Symptoms
789.00 Abdominal pain
790.2Abnormal glucose tolerance test
793.8 Abnormal Mammogram
790.93 Abnormal PSA
790.4 Abnormal transaminase / LDH
795.0Abnormal PAP
793.1 Abnormal Chest Xray lung
783.0 Anorexia
719.40 Arthralgia, unsp
786.50 Chest pain, unsp.
564.0 Constipation
786.2Cough
276.5 Dehydration
787.91 Diarrhea, NOS
780.4 Dizziness/vertigo
787.2 Dysphagia
788.1 Dysuria
782.3 Edema localized
719.00 Effusion/swelling of joint
784.7 Epistaxis
783.41 Failure to thrive
780.79 Fatigue/Malaise
780.6 Fever, nonperinatal
787.3 Gas/bloating
787.1 Heartburn
599.7 Hematuria
789.1 Hepatomegaly
784.49 Hoarseness
788.30 Incontinence/enuresis
785.6 Lymph nodes, enlarged
785.2 Murmur of heart, undiagnosed
787.02Nausea, alone
782.0 Numbness
785.1 Palpitations
786.05 Shortness of breath
780.2 Syncope
788.41 Urinary frequency
787.03 Vomiting, alone
783.1 Weight gain
783.21 Weight loss
786.07 Wheezing
Other Trauma, Adverse Effects
919.0 Abrasion, unsp
995.3 Allergic Reaction
924.9 Bruise contusion
949.0 Burn, degree:______
991.9 Cold injury
850.0 Concussion w/out LOC; LOC <60min 850.1 Concussion w/ LOC <60min
Foreign body: ear/931 nose/932 skin/919.6
919.4Insect bite
870-897 Laceration: ______
995.2 Medication reaction, adverse
Supplemental
V65.40 Advice/health instruction
V01.9 Contact/exposure, infec. Dis
V25.01 Contraception, oral
V25.02 Contraception, oth
V25.40 Contraception, surveillance
V61.10 Couns for marital & partner
V61.20 Counseling for parent/child
V70.3 DOT, I.N.S. PE, Sports PE
V72.81 EKG / Pre-Op Cardiovasc Exam
V72.84 Pre-Op Physical Exam
V61.0 Family disruption
V25.09 Family planning
V67.4 Followup exam
V72.3 Gynecological exam
V70.0 Health checkup
V58.61 High Risk Med: Coumadin
V58.69 High Risk Med: Other
V69.2 High Risk Sexual Behavior
V01.9 STD Contact/ Exposure
V06.9 Immunization
V03.2 Immunization: PPD
V03.5 Immunization: Td
V06.8 Immunization: DTaP
V06.4 Immunization: MMR
V05.3 Immunization: Hep B
V05.8 Immunization: Hib
V76.9 Screening, cancer
V58.3 Suture Removal/ Dressing Change
V20.2 Well child check
V65.5 Worried Well
Family History
V16.0 Colon CA
V16.1 Lung CA
V16.3 Breast CA
V16.42 Prostate CA
V17.1 Stroke/CVA
V17.4 ASHD/Atherosclerotic Heart Disease
V18.0 Diabetes