Docstoc

CSE Superbill July 2008-Final _2_

Document Sample
CSE Superbill July 2008-Final _2_ Powered By Docstoc
					Cosmetic Surgery Superbill JULY 2008
MTF: Provider's Name and Phone: ICD-9 Code 1: Location: Office/Minor Surgery Room ICD-9 Code 2:

INSTRUCTIONS: (1) Fill in top of form, (2) Circle/Highlight Procedure Description, (3) Check Bilateral column (optional) , and (4) Enter the quantity of each procedure . Patient Name: Visit Date: Anesthesia: / / Monitored Local Block Surgery Date: / / Topical Moderate Sedation General Anesthesia Care None

Operating Room Inpatient Operating Room Outpatient Code Bilateral Quantity 1 1 1 1 1 1 1 1 1

Procedure Description CHEMICAL PEEL

Chemical Peel; facial, epidermal 15788 Chemical Peel; facial, dermal 15789 Chemical Peel; non facial, epidermal 15792 Chemical Peel; non facial, dermal 15793 DERMABRASION Total Face 15780 Segment, facial 15781 Regions, non facial 15782 Dermabrasion; superficial (e.g., tattoo removal) 15783 Abrasion; single lesion (e.g., keratosis, scar) 15786 Abrasion; each addl 4 lesions or less 15787 MICRODERMABRASION Microdermabrasion; total face 17999-Y0001 Microdermabrasion; segment, facial 17999-Y0002 LASER PROCEDURES LASER RESURFACING - ABLATIVE Laser skin resurfacing; total face 17999-Y0003 Laser skin resurfacing; segment, facial 17999-Y0004 LASER RESURFACING - NON-ABLATIVE Laser skin resurfacing; total face 17999-Y0005 Laser skin resurfacing; segment, face 17999-Y0006 Laser skin resurfacing; neck 17999-Y0007 Laser skin resurfacing; chest 17999-Y0008 Laser skin resurfacing; back/shoulders 17999-Y0009 Laser skin resurfacing; arms 17999-Y0010 Laser skin resurfacing; hands 17999-Y0011 Laser skin resurfacing; legs 17999-Y0012 Laser hair removal; lip (perioral) 17999-Y0020 Laser hair removal; lip and chin 17999-Y0021 Laser hair removal; back 17999-Y0022 Laser hair removal; arms 17999-Y0023 Laser hair removal; underarms 17999-Y0024 Laser hair removal; bikini 17999-Y0025 Laser hair removal; legs 17999-Y0026 Laser hair removal; beard 17999-Y0027 Laser hair removal; ears 17999-Y0028 Laser tattoo removal; ≤ 30 sq cm initial session 17999-Y0030 Laser tattoo removal; ≤ 30 sq cm; ea addl session 17999-Y0031 Laser tattoo removal; ≥ 31 sq cm initial session 17999-Y0032 Laser tattoo removal; ≥ 31 sq cm; ea addl session 17999-Y0033 DESTRUCTION-LESION/WART PREMALIGNANT LESIONS Destruction; first premalignant lesion 17000 Destruction; each addl 2 - 14 premalignant lesions 17003 Destruction; 15 or more premalignant lesions 17004 CUTANEOUS VASCULAR PROLIFERATIVE LESIONS < 10 sq cm 17106 10.0 - 50 sq cm 17107 Over 50 sq cm 17108 BENIGN LESIONS Destruction; up to 14 benign lesions 17110 Destruction; 15 or more benign lesions 17111 Chemical Cauterization; granulation tissue 17250 EXCISION, BENIGN LESIONS FACE, MUCOUS MEMBRANES < 0.5 cm excised diameter 11440 0.6 -1.0 cm excised diameter 11441 1.1 - 2.0 cm excised diameter 11442 2.1 - 3.0 cm excised diameter 11443

1 1

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

1 1

1 1

Code Description Bilateral Quantity EXCISION, BENIGN LESIONS (con't) FACE, MUCOUS MEMBRANES (con't) 3.1 - 4.0 cm excised diameter 11444 Over 4.0 cm excised diameter 11446 SCALP, NECK, HANDS, FEET, GENITALIA < 0.5 cm excised diameter 11420 0.6 - 1.0 cm excised diameter 11421 1.1 - 2.0 cm excised diameter 11422 2.1 - 3.0 cm excised diameter 11423 3.1 - 4.0 cm excised diameter 11424 Over 4.0 cm excised diameter 11426 TRUNK, ARMS, LEGS < 0.5 cm excised diameter 11400 0.6 -1.0 cm excised diameter 11401 1.1 - 2.0 cm excised diameter 11402 2.1 - 3.0 cm excised diameter 11403 3.1 - 4.0 cm excised diameter 11404 Over 4.0 cm excised diameter 11406 REPAIR, REVISION, SCAR FACE 1.1. - 2.5 cm 13131 2.6 - 7.5 cm 13132 Each additional 5 cm or less 13133 SCALP 1.1. - 2.5 cm 13120 2.6 - 7.5 cm 13121 Each additional 5 cm or less 13122 EAR, NOSE, LIP 1.0 cm or less 13150 1.1 - 2.5 cm 13151 2.6 - 7.5 cm 13152 Each additional 5 cm or less 13153 TRUNK 1.1 - 2.5 cm 13100 2.6 - 7.5 cm 13101 Each additional 5 cm or less 13102 INJECTIONS SUBCUTANEOUS INJECTION OF FILLING MATERIAL (Indicate filling material, quantity, and price below) 1 cc or less 11950 1.1 - 5.0 cc 11951 5.1 - 10.0 cc 11952 More than 10.0 cc 11954 Filling Materials Unit Price Quantity Radience/Radiesse J3490-01 Restylane J3490-02 Zyderm J3490-03 Zyplast J3490-04 Other: _________________________ J3490 MICROLIPOINJECTION/FAT TRANSFER Microlipoinjection/fat transf; per sess 17999-Y4999 1 Fat transfer; lips 17999-Y5000 1 Fat transfer; melolabial folds 17999-Y5001 1 Fat transfer; marionette lines 17999-Y5002 1 Fat transfer; forehead 17999-Y5003 1 Fat transfer; glabella 17999-Y5004 1 Fat transfer; tear troughs 17999-Y5005 1 Fat transfer; crows feet 17999-Y5006 1 INTRALESIONAL INJECTION w/o MEDICAL INDICATION Intralesional Injection, 7 or fewer 11900 1 Intralesional Injection, 8 or more 11901 1

Patient:_________________________ Code Description REPAIR, REVISION AND/OR RECONSTRUCTION BLEPHAROPLASTY, BLEPHAROPTOSIS, CANTHOPLASTY Blepharoplasty; lower eyelid 15820 Blepharoplasty; lower w/extensive herniated fat pad 15821 Blepharoplasty; upper eyelid 15822 Blepharoplasty; upper w/excessive skin 15823 Blepharoptosis; internal approach 67903 Blepharoptosis; external approach 67904 Canthoplasty 67950 RHYTIDECTOMY Brow Lift 15824 Neck w/P-Flap tightening 15825 Glabellar Frown Lines 15826 Cheek, Chin, & Neck 15828 SMAS 15829 NOSE-RHINOPLASTY Rhinoplasty; primary (lateral & alar or elevation of tip) 30400 Rhinoplasty; primary, complete 30410 Rhinoplasty; secondary minor revision 30430 Rhinoplasty; secondary intermediate revision 30435 Rhinoplasty; secondary major revision 30450 OTHER FACIAL Otoplasty; ear reconstruction 69300 Genioplasty; augmentation 21120 Genioplasty; reduction 21121 Genioplasty; mandibular body 21125 Genioplasty; augmentation w/ bone graft 21127 Reconst, Midface, LeFort I 21141 Reconst mandib rami, horiz, vert w/o bone graft 21193 Reconst mandib rami/body, horiz, vert w/bone graft 21194 Osteoplasty; reconst lower jaw w/o fixation 21195 Osteoplasty; reconst lower jaw w/fixation 21196 Osteotomy; mandible, segmental 21198 Osteotomy; maxilla, segmental 21206 Osteoplasty; facial bones, augmentation 21208 Osteoplasty; facial bones, reduction 21209 Bone Graft; nasal, maxillary or malar 21210 Malar, augmentation 21270 Lateral Canthopexy 21282 NECK - CERVICOPLASTY Cervicoplasty 15819 BREAST- REDUCTION, AUGMENTATION, REMOVAL IMPLANT Nipple reduction 19350-R Nipple enlargement 19350-E Mastopexy (Breast Lift) 19316 Mammoplasty; reduction 19318 Mammoplasty; augmentation w/o implant 19324 Mammoplasty; augmentation w/ implant 19325 Removal of intact mammary implant 19328 Removal of implant material 19330 Immediate insertion of implant 19340 Mastectomy - Gynecomastia 19300 Pectoral Augmentation; male chest 21899

MTF:____________________________________ Bilateral Quantity Description EXCISION, EXCESSIVE SKIN Submental fat pad 1 Brachioplasty (Arm Lift) 1 Abdominoplasty 1 Panniculectomy 1 Panniculectomy w/Abdominoplasty 1 Hip Lift 1 Thigh Lift 1 Buttock Lift 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Code

Page 2 Bilateral Quantity 1 1 1 1 1 1 1 1 1 1

CHEMODENERVATION (Procedure performed by resident? Yes 64612 Chemodenervation; facial 64613 Chemodenervation; neck 64614 Chemodenervation; extremity OTHER REVISIONS Lip Augmentation; pair 40799 Lip Augmentation; upper or lower; unpaired 17999-Y5834 Buttock Augmentation w/implant 17999-Y5835 Buttock Augmentation w/o implant 17999-Y5836 Calf Augmentation 17999-Y5837 Umbilicoplasty 17999-Y5838
CSE Superbill July 2008-Final (2)

■

No

■)

1 1 1 1 1 1 1 1 1

15838 15836 17999-Y5831 15830 15847 15834 15832 15835 15832 Partial Lower Body Lift (Thigh Lift + Buttock Lift) 15835 17999-Y5831 Total Lower Body Lift 15832 (Abdominoplasty + Thigh Lift + Buttock Lift) 15835 LIPO-SUCTION ASSISTED LIPECTOMY (ANY USE OF LIPO-EQUIPMENT) Head & Neck 15876 Trunk 15877 Upper Extremity 15878 Lower Extremity 15879 15877 15878 Total body; excluding head & neck 15879 LIPO-ULTRASOUND ASSISTED (ANY USE OF EQUIPMENT) Head & Neck 17999-Y5876 Trunk 17999-Y5877 Upper Extremity 17999-Y5878 Lower Extremity 17999-Y5879 Total body; excluding head & neck 17999-Y5875 SCLEROTHERAPY Sclerosing; face 36469 Sclerosing; limb, trunk 36468 Sclerosing single vein 36470 Sclerosing multi veins, same leg 36471 VEIN STRIPPING Short saph veins 37718 Long saph veins, knee/ below 37722 37735 Long or short saph veins w/ radical excision ulcered skin 37765 Stab Phleb veins - one extremity 10-20 stab incisions 37766 Stab Phleb veins - one extremity 20+ incisions Ligation of long saph vein @ saphenofemoral junct. 37700 LASER Laser Treatment of Leg Veins 17999-Y0050 HAIR REMOVAL/TRANSPLANT Electrolysis Epilation; 30 minute session 17380 1-15 Hair grafts 15775 More than 15 Hair grafts 15776 Micro/mini grafts 1-500 hairs 17999-Y5775 PIERCING Ear Piercing 69090 Piercing, Other Body Parts 17999-Y6001 DENTAL Porcelain Veneers, per tooth D2962 External Bleaching, per arch D9972 External Bleaching, per tooth D9973 Internal Bleaching, per tooth D9974 Laser Teeth Whitening, per treatment D9999 OTHER SUPPLIES Unit Price A9270 A9270 A9270 A9270
7/7/2008 9:58 AM

1 1 1 1 1

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

1 1

Quantity


				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:86
posted:11/5/2009
language:English
pages:2