Emergency Care And Monitoring Template Page 2
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2Emergency Care and Monitoring – 82 Billable for Exclusive Bedside Monitoring of unstable Pt ONLY:
Please note that fee item 82 is not payable for managing Pt’s family, discussions with other health care professionals, arranging transfers
etc. Payable ONLY for the period of constant bedside monitoring of an unstable Pt.
Doctor Name ______________________________________
Pt Name __________________________________________
(Please attach ER sheet or Pt label)
Date of Service ____________________________________
1st ½ hr ________ to _______
2nd ½ hr ________ to ______
3rd ½ hr ________ to ______
_____ anaphylaxis
_____ anaphylaxis
_____ anaphylaxis
_____ dysrhythmia
_____ dysrhythmia
_____ dysrhythmia
_____ hyper/hypoglycemic
_____ hyper/hypoglycemic
_____ hyper/hypoglycemic
_____ hyper/hypotensive
_____ hyper/hypotensive
_____ hyper/hypotensive
_____ hypoxic
_____ hypoxic
_____ hypoxic
_____ septic
_____ septic
_____ septic
_____ seizures
_____ seizures
_____ seizures
_____ shock
_____ shock
_____ shock
_____ trauma
_____ trauma
_____ trauma
Other ____________________
Other ____________________
Other ____________________
_________________________
_________________________
_________________________
Systems monitored:
Systems monitored:
Systems monitored:
_____ cardiovascular
_____ cardiovascular
_____ cardiovascular
_____ respiratory
_____ respiratory
_____ respiratory
_____ neurological
_____ neurological
_____ neurological
_____ musculoskeletal
_____ musculoskeletal
_____ musculoskeletal
_____ metabolic
_____ metabolic
_____ metabolic
Other ____________________
Other ____________________
Other ____________________
th
4th ½ hr ________ to _______
5th ½ hr ________ to _______
6
½ hr ________ to _______
_____ anaphylaxis
_____ anaphylaxis
_____ anaphylaxis
_____ dysrhythmia
_____ dysrhythmia
_____ dysrhythmia
_____ hyper/hypoglycemic
_____ hyper/hypoglycemic
_____ hyper/hypoglycemic
_____ hyper/hypotensive
_____ hyper/hypotensive
_____ hyper/hypotensive
_____ hypoxic
_____ hypoxic
_____ hypoxic
_____ septic
_____ septic
_____ septic
_____ seizures
_____ seizures
_____ seizures
_____ shock
_____ shock
_____ shock
_____ trauma
_____ trauma
_____ trauma
Other ____________________
Other ____________________
Other ____________________
_________________________
_________________________
_________________________
Systems monitored:
Systems monitored:
Systems monitored:
_____ cardiovascular
_____ cardiovascular
_____ cardiovascular
_____ respiratory
_____ respiratory
_____ respiratory
_____ neurological
_____ neurological
_____ neurological
_____ musculoskeletal
_____ musculoskeletal
_____ musculoskeletal
_____ metabolic
_____ metabolic
_____ metabolic
Other ____________________
Other ____________________
Other ____________________
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