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					                                                         DOCTOR FEEL-BETTER, MD
NAME:                                                                 DATE:                                                             PAID: $
 99201    Office - New Patient     20526    Injection, Carpal Tunnel       76005       Fluoroscopy                       98925        OMT 1 – 2 Regions
 99202    Office - New Patient     27096    Sacroiliac Joint Injection     J7320       Synvisc                           98926        OMT 3 – 4 Regions
 99203    Office - New Patient     20610    Injection, Joint Large         J0585       Botox injection                   95860        EMG One Extremity
 99204    Office - New Patient     20605    Injection, Joint Medium        J1040       Depo-Medrol 80 mg                 95861        EMG Two Extremities
 99241    Office - Consultation    20600    Injection, Joint Small         J2000       Lidocaine                         95863        EMG Three Extremities
 99242    Office - Consultation    20550    Tendon/Ligament Injection      90780       IV Infusion Therapy               95864        EMG Four Extremities
 99243    Office - Consultation    20552    Trigger Point Injec12Muscle    J0760       Colchicine                        95903        NCV Motor Nerve & F-Wave
 99244    Office - Consultation    20553    Trigger Point Injec3-Muscle    90782       IM Injection/Therapeutic          95904        NCV Sensory Each Nerve
 99211    Office - Follow-up       64405    Greater Occipital Nerve Block  J3420       B12 injection                     95934        H Reflex Gastroc/Soleus
 99212    Office - Follow-up       64400    Trigeminal Nerve Block         J2175       Demerol injection                 L3999        Wrist Splint
 99213    Office - Follow-up       64450    Peripheral Nerve Block Misc    J3410       Vistaril injection                L0120        Cervical Collar, Foam,
 99214    Office - Follow-up       64505    Sphenopalatine Block           76075       DEXA                              E0100        Cane

 DISC-HNP Cervical – 722.0        Thoracic – 722.11              Lumbar – 722.10               Radiculopathy Cervical–353.2               Lumbar – 353.4
 Cervical                         Neck Pain – 723.1              Neuralgia – 729.2             Facet Syndrome – 724.8                     RSD – UL-337.21
 Thoracic Radiculopathy 353.3     Mid Back Pain – 724.1          Neuralgia – 724.4             Fracture Thoracic – 805.2                  RSD – LL – 337.22
 Lumbar                           LBP – 724.2                    Neuralgia – 724.4             Fracture Lumbar – 805.4                    Coccydynia – 724.79
 Neuralgia                        HandShoulderElbow-354.9        Hip – 355.8                   Postherpes Neuralgia 053.19                TrigeminalNeuralgia350.1
 Headache Cluster - 346.2         Headache – 784.0               Migraine w/o aura – 346.10    Intractable – 346.11                       Post-spinal Headache349.0
 Osteoarthritis Knee – 715.96     Wrist & finger – 716.94        Ankle & Foot –716.97          Hip - 716.95                               Polyarthritis – 719.49
 Enthesopathy Wrist – 726.4       Elbow - 726.32                 Shoulder - 726.90             Hip – 726.5                                Ankle – 726.70
 Mononeuritis Median - 354.1      Brachial Neuritis – 723.4      Ulnar – 354.2                 Radial – 723.4                             MP-355.1 Other LL355.7
 Peripheral Neuropathy 357.7      Multiplexa – 354.5             Trigeminalneuropathy350.8     AIDP – 357.0                               Diabetic poly – 357.2
 Seizure - CPSz – 345.40          Gen Sz – 345.10                Narcolepsy – 347              Syncope – 780.2                            Tinnitus – 388.30
 Extrapyramidal – 333.90          Torticollis - .83              Ptosis – 374.30               BET – 333.1                                PD – 332.0, 332.1(Sec)
 Vestbular neuronitis–386.12      Dizziness – 780.4              Optic neuritis – 377.30       Diplopia – 368.2                           MS – 340
 Amnesia – 294.0                  Dysphagia – 787.2              Bell’s Palsy – 351.0          Lyme – 088.8                               Amaurosis fugax – 362.34
 Hemiplegia – 342.9               Monoplegia UL – 344.4          LL – 344.3                    Paraplegia – 344.1                         Aphasia – 784.3
 Senile-postmenopause-733.01      Drug- Osteoporosis733.09       EKG - Preop. – V72.81         Hypertension – 401.1                       Palpitation 785.1
Diagnosis Code(s): ________ Same as previous visit

                                                         DOCTOR FEEL-BETTER, MD
NAME:                                                                 DATE:                                                             PAID: $
 99201    Office - New Patient     20526    Injection, Carpal Tunnel       76005       Fluoroscopy                       98925        OMT 1 – 2 Regions
 99202    Office - New Patient     27096    Sacroiliac Joint Injection     J7320       Synvisc                           98926        OMT 3 – 4 Regions
 99203    Office - New Patient     20610    Injection, Joint Large         J0585       Botox injection                   95860        EMG One Extremity
 99204    Office - New Patient     20605    Injection, Joint Medium        J1040       Depo-Medrol 80 mg                 95861        EMG Two Extremities
 99241    Office - Consultation    20600    Injection, Joint Small         J2000       Lidocaine                         95863        EMG Three Extremities
 99242    Office - Consultation    20550    Tendon/Ligament Injection      90780       IV Infusion Therapy               95864        EMG Four Extremities
 99243    Office - Consultation    20552    Trigger Point Injec12Muscle    J0760       Colchicine                        95903        NCV Motor Nerve & F-Wave
 99244    Office - Consultation    20553    Trigger Point Injec3-Muscle    90782       IM Injection/Therapeutic          95904        NCV Sensory Each Nerve
 99211    Office - Follow-up       64405    Greater Occipital Nerve Block  J3420       B12 injection                     95934        H Reflex Gastroc/Soleus
 99212    Office - Follow-up       64400    Trigeminal Nerve Block         J2175       Demerol injection                 L3999        Wrist Splint
 99213    Office - Follow-up       64450    Peripheral Nerve Block Misc    J3410       Vistaril injection                L0120        Cervical Collar, Foam,
 99214    Office - Follow-up       64505    Sphenopalatine Block           76075       DEXA                              E0100        Cane

 DISC-HNP Cervical – 722.0        Thoracic – 722.11              Lumbar – 722.10               Radiculopathy Cervical–353.2               Lumbar – 353.4
 Cervical                         Neck Pain–723.1                Neuralgia – 729.2             Facet Syndrome – 724.8                     RSD – UL-337.21
 Thoracic Radiculopathy 353.3     Mid Back Pain – 724.1          Neuralgia – 724.4             Fracture Thoracic – 805.2                  RSD – LL – 337.22
 Lumbar                           LBP – 724.2                    Neuralgia – 724.4             Fracture Lumbar – 805.4                    Coccydynia – 724.79
 Neuralgia                        HandShoulderElbow-354.9        Hip – 355.8                   Postherpes Neuralgia 053.19                TrigeminalNeuralgia350.1
 Headache Cluster - 346.2         Headache – 784.0               Migraine w/o aura – 346.10    Intractable – 346.11                       Post-spinal Headache349.0
 Osteoarthritis Knee – 715.96     Wrist & finger – 716.94        Ankle & Foot –716.97          Hip - 716.95                               Polyarthritis – 719.49
 Enthesopathy Wrist – 726.4       Elbow - 726.32                 Shoulder - 726.90             Hip – 726.5                                Ankle – 726.70
 Mononeuritis Median - 354.1      Brachial Neuritis – 723.4      Ulnar – 354.2                 Radial – 723.4                             MP-355.1 Other LL355.7
 Peripheral Neuropathy 357.7      Multiplexa – 354.5             Trigeminalneuropathy350.8     AIDP – 357.0                               Diabetic poly – 357.2
 Seizure - CPSz – 345.40          Gen Sz – 345.10                Narcolepsy – 347              Syncope – 780.2                            Tinnitus – 388.30
 Extrapyramidal – 333.90          Torticollis - .83              Ptosis – 374.30               BET – 333.1                                PD – 332.0, 332.1(Sec)
 Vestbular neuronitis–386.12      Dizziness – 780.4              Optic neuritis – 377.30       Diplopia – 368.2                           MS – 340
 Amnesia – 294.0                  Dysphagia – 787.2              Bell’s Palsy – 351.0          Lyme – 088.8                               Amaurosis fugax – 362.34
 Hemiplegia – 342.9               Monoplegia UL – 344.4          LL – 344.3                    Paraplegia – 344.1                         Aphasia – 784.3
 Senile-postmenopause-733.01      Drug- Osteoporosis733.09       EKG - Preop. – V72.81         Hypertension – 401.1                       Palpitation 785.1
Diagnosis Code(s): ________ Same as previous visit
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