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PT superbill 10-07

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PT superbill 10-07 Powered By Docstoc
					                                                                                                              1st Visit            Intermediate Visit    Discharge Visit
                     Grand Canyon Physical Therapy                                                              Yes                      Yes                   Yes
                     Encounter Form

Patient
Name:
                                                          DOB/ID#:
Date:

Insurance:


EVALUTION                                               THERAPEUTIC PROCEDURES – 15 Minute units                    MODALITIES- CONSTANT ATTENDANCE                     MATERIAL & SUPPLIES
Initial Evaluation                    ____ 97001        Therapeutic Exercises                    ____ 97110         Electrical Stimulation 15 min       ____ 97032      Custom Orthotic                                 L3030
Re-evaluation limited                 ____ 97002        Neuromuscular Re-ed                      ____ 97112         Iontophoresis 15 min                ____ 90733      Wrist Support                                   L3908
                                                        Gait Training                            ____ 97116         Ultrasound 15 min                   ____ 97035      ASO Ankle Brace                                 L1902
                                                        Massage Ice or Therapeutic               ____ 97124         Hydrotherapy 15 min                 ____ 97036      Hot/Cold Pack                                   E0210
                                                        Orthotics Training                       ____ 97504         Phonophoresis specify time          ____ 97039      Thumb Spica                                     L3895
                                                        ADL Training                             ____ 97535                                                             Tennis Elbow Sleeve                             L3999
                                                        Therapeutic Activity                     ____ 97530         MODALITIES SUPERVISED                               Thera Band                                      A9300
                                                        Manuel Therapy Techniques                ____ 97140         Application hot or cold pack        ____ 97010      Straight Cane                                   E0100
                                                                                                                    Mechanical Traction                 ____ 97012      Thera Putty- not covered by ins                 A9300
                                                        WOUND CARE                                                  Electrical Stimulation              ____ 97014      Chopat Knee Str                                 L1825
                                                        Wound Care Debridement                   ____ 97602         Whirlpool                           ____ 97022      Heel Cup                                        L3332



DIAGNOSIS ICD-9 Codes


Head                                                    Elbow and Forearm                                           Trunk                                               Knee
Jaw Pain                                  812.20                                                                    Thoracic spine strain                     847.1
TMJ pain syndrome                         524.60        Radial Collateral Ligament sprain               841.0       Thoracic Pain                             724.1     Knee Lateral Collateral Ligament                 844.0
                                                        Ulnar Collateral Ligament sprain                841.1       Fracture, Rib                             807.0     Knee Medial Collateral Ligament                  844.1
                                                        Radiohumeral (joint) sprain                     841.2       Sternoclavicular                         848.41     Knee Cruciate Ligament                           844.2

Neck                                                    Lateral Epicondylitis                          726.32                                                           Tibiofibular (joint) (ligament)                  844.3
                                                                                                                    Low Back                                            superior
Neck sprain                                    847.0    Unspecified sprain of elbow & forearm           841.9       Lumbar sprain                            847.2      Knee Pain                                       719.46
Neck pain                                     723.10    Radius Fracture                                813.81       Sacrum sprain                            847.3      Meniscus tear Medial                             836.0
DJD cervical spine                             722.4    Humerus Fracture                               812.20       Coccyx sprain                            847.4      Meniscus tear Lateral                            836.1
Arm radiculopathy                              723.4    Complex Regional Pain Syndrome                  729.5       Pelvis                                    848.5     Chondromalacia patella                           717.7
                                                                                                                    Disc herniation w//radiculopathy          722.2
                                                                                                                    Lumbosacral joint sprain                  846.0

Shoulder and Upper Arm                                                                                              DJD L spine                              721.90

Pain Shoulder                                 719.41    Wrist and Hand                                              Sacroiliac ligament                       846.1     Lower Leg/Ankle/Foot
AC joint ligament sprain                       840.0    Wrist Unspecified sprain                       842.00       Lumbar Pain                               724.2     Ankle Unspecified site sprain                   845.00
Infraspinatus muscle/tendon sprain             840.3    Wrist Carpal (joint) sprain                    842.01                                                           Ankle Deltoid                                   845.01
Rotator Cuff sprain/tear                       840.4    Radiocarpal joint ligament sprain              842.02                                                           Ankle Calcaneofibular                           845.02
Subcapularis (muscle) sprain                   840.5    Fracture metacarpal/phlange                    815.00       Hip and Thigh                                       Ankle Tibiofibular;distal                       845.03

Supraspintus muscle/tendon sprain              840.6    Fracture, Radius distal                        813.42       Iliofemoral (ligament)                    843.0     Fracture trimalleolar                           824.60
Superior glenoid labrum lesion                 840.7    Fracture Radius & Humerus, foosh               813.44       Ischiocapsular (ligament)                 843.1     Fracture, fibula                                823.81
Unspecified site shoulder sprain              840.9     Carpal tunnel syndrome                         354.00       Other sites of hip and thigh              843.8     Fracture, tibia                                 823.80
Fracture, clavicle                        810.00        Tenosynovitis hand                             727.05       Unspecified site                          843.9     Fracture, tib/fib                               823.82
Fracture, humerus                         812.20        Dequervains                                    727.04       Sciatic pain                              724.3     Foot pain                                        729.5
Impingement                               726.2         Hand Pain                                       729.5       Trochanteric Bursitis                     726.5     Complex Regional Pain Syndrome                   729.5
                                                                                                                                                                        Plantar Fasciitis                               728.71
                                                                                                                                                                        Tenosynovitis foot                              727.06




 Grand Canyon Physical Therapy Encounter
Provider:
Follow-Up               _______ Days _____ Weeks            _____ Months          Referral to:                                                           Cash                       PATIENT SIGNATURE
                                                                                                                                                         Initial
Phy Exam/ WW                                                                                                                                             Credit Card
Well Child              Time:                                                                                                                            Check #                    X
                                                                                                                                                         ____________
  Date Last Paid                Previous PT            Today’s Charge           Discount Amount               Amount Due              Amount Paid           Balance Due             ASSIGNMENT AND RELEASE:             I hereby
                                  Balance                                                                                                                                           authorize my insurance benefits to be paid
                                                                                                                                                                                    directly to North Country HealthCare. If my
                                                                                                                                                                                    insurance or Medicare decides them to be
                                                                                                                                                                                    non-covered, I agree to be financially
                                                                                                                                                                                    responsible. I authorize North Country to
                                                                                                                                                                                    release any information required to process
                                                                                                                                                                                    this claim.

				
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posted:4/18/2011
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