Outpatient Encounter Form

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[Company Name]
Outpatient Encounter Form
Patient Information
Payment Method
Visit Information
Patient ID number
Primary
Visit date
Patient name
Primary ID number
Visit number
Address
Primary group number
Rendering physician
City/State
Secondary
Referring physician
Social Security number
Secondary ID number
Reason for visit
Phone number
Secondary group no.
Date of birth
Cash/credit card
Age
Other billing
E/M Modifiers
Procedure Modifiers
Other Modifiers
24 — Unrelated E/M service during postop.
22 — Unusual, excessive procedure
25 — Significant, separately identifiable E/M
50 — Bilateral procedure
57 — Decision for surgery
51 — Multiple surgical procedures in same day
52 — Reduced/incomplete procedure
55 — Postop. management only
59 — Distinct multiple procedures
CATEGORY
CODE
MOD
FEE
CATEGORY
CODE
MOD
FEE
Office Visit — New Patient
Wound Care
Minimal office visit
99201
Debride partial thick burn
11040
20 minutes
99202
Debride full thickness burn
11041
30 minutes
99203
Debride wound, not a burn
11000
45 minutes
99204
Unna boot application
29580
60 minutes
99205
Unna boot removal
29700
Other
Other
Office Visit — Established
Supplies
Ace bandage, 2”
Minimal office visit
99211
A6448
10 minutes
99212
Ace bandage, 3"-4”
A6449
Ace bandage, 6”
15 minutes
99213
A6450
25 minutes
99214
Cast, fiberglass
A4590
40 minutes
99215
Coban wrap
A6454
Other
Foley catheter
A4338
Immobilizer
L3670
General Procedures
Anascopy
46600
Kerlix roll
A6220
Audiometry
92551
Oxygen mask/cannula
A4620
Breast aspiration
19000
Sleeve, elbow
E0191
Cerumen removal
69210
Sling
A4565
Circumcision
54150
Splint, ready-made
A4570
DDST
96110
Splint, wrist
S8451
Flex sigmoidoscopy
45330
Sterile packing
A6407
Flex sig. w/ biopsy
45331
Surgical tray
A4550
Foreign body removal—foot
28190
Other
Nail removal
11730
OB Care
Nail removal/phenol
11750
Routine OB care
59400
Trigger point injection
20552
OB call
59422
Tympanometry
92567
Ante partum 4–6 visits
59425
Visual acuity
99173
Ante partum 7 or more visits
59426
Other
Other
Vitals:
Other Visit Information:
Fees:
B/P
Lab Work to Order:
Total Charges:
$
Pulse
Referral to:
Copay Received: $
Temp.
Provider Signature:
Other Payment:
$
Height
Next Appointment:
Total Due:
$
Weight
Company Name, Street Address, City, State ZIP Code, phone number

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