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					           Lawndale Christian Health Center                                                                          Lawndale Christian Health Center
           OB/Gyn Billing Sheet                                                                                      OB/Gyn Billing Sheet

Patient Name                                               Date of Birth                                  Patient Name                                               Date of Birth

Chart # (if known)                                         Date of Service                                Chart # (if known)                                         Date of Service
Location             m   Mt. Sinai              m   Other_____________                                    Location             m   Mt. Sinai              m   Other_____________
Provider             m   Gardner                m   Kwak               m     Tuynman                      Provider             m   Gardner                m   Kwak               m     Tuynman

Procedure Codes                                                                                           Procedure Codes
   m    Cervical conization,                                  m    TL at time of C/S (58611)                 m    Cervical conization,                                  m    TL at time of C/S (58611)
        cold knife cone (57520)                               m    TL, laparoscopic (58670)                       cold knife cone (57520)                               m    TL, laparoscopic (58670)
   m    Cervical conization, leep (57522)                     m    TL, laparoscopic, occlusion (58671)       m    Cervical conization, leep (57522)                     m    TL, laparoscopic, occlusion (58671)
   m    Colporrhaphy (57200)                                  m    Tx of incomplete abortion,                m    Colporrhaphy (57200)                                  m    Tx of incomplete abortion,
   m    Colporrhaphy, anterior repair (57240)                      any trimester (59812)                     m    Colporrhaphy, anterior repair (57240)                      any trimester (59812)
   m    Colporrhaphy, AP repair (57260)                       m    Tx of missed abortion,                    m    Colporrhaphy, AP repair (57260)                       m    Tx of missed abortion,
   m    Colporrhaphy, enterocele repair (57268)                    first trimester (59820)                   m    Colporrhaphy, enterocele repair (57268)                    first trimester (59820)
   m    Colporrhaphy, posterior repair (57250)                m    Vulvar bx (56605)                         m    Colporrhaphy, posterior repair (57250)                m    Vulvar bx (56605)
   m    Colposcopy (57452)                                    m    Other_____________                        m    Colposcopy (57452)                                    m    Other_____________
   m    Cystectomy (58925)                                                                                   m    Cystectomy (58925)
   m    Cystectomy, ovarian (58925)                        Diagnosis Codes                                   m    Cystectomy, ovarian (58925)                        Diagnosis Codes
   m    D & C, non-obstetrical (58120)                        m    Cervical dysplasia (622.1)                m    D & C, non-obstetrical (58120)                        m    Cervical dysplasia (622.1)
   m    Delivery, C-Sec w/ ppc (59515)                        m    Ectopic pregnancy (633)                   m    Delivery, C-Sec w/ ppc (59515)                        m    Ectopic pregnancy (633)
   m    Delivery, NSVD w/ ppc (59410)                         m    Endometriosis (617)                       m    Delivery, NSVD w/ ppc (59410)                         m    Endometriosis (617)
   m    Delivery, VBAC w/ ppc (59614)                         m    Genital prolapse (618)                    m    Delivery, VBAC w/ ppc (59614)                         m    Genital prolapse (618)
   m    EUA (57410)                                           m    Infertility (628)                         m    EUA (57410)                                           m    Infertility (628)
   m    Hymenectomy (56700)                                   m    Inflamm Dx of ovary, fallopian tube,      m    Hymenectomy (56700)                                   m    Inflamm Dx of ovary, fallopian tube,
   m    Hysterectomy, supracervical (58180)                        pelvic cellular tissues (614)             m    Hysterectomy, supracervical (58180)                        pelvic cellular tissues (614)
   m    Hysterectomy, total abdominal (58150)                 m    Missed AB (632)                           m    Hysterectomy, total abdominal (58150)                 m    Missed AB (632)
   m    Hysterectomy, vaginal (58260)                         m    Multiparity (V61.5)                       m    Hysterectomy, vaginal (58260)                         m    Multiparity (V61.5)
   m    Hysterectomy, vaginal, remove tube(s)                 m    Ovarian cyst, unspecified (620.2)         m    Hysterectomy, vaginal, remove tube(s)                 m    Ovarian cyst, unspecified (620.2)
        and/or ovary(s) (58260)                               m    Postmenopausal bleeding (627.1)                and/or ovary(s) (58260)                               m    Postmenopausal bleeding (627.1)
   m    Hysterectomy, vaginal,                                m    Spontaneous AB (634)                      m    Hysterectomy, vaginal,                                m    Spontaneous AB (634)
        repair of enterocele (58260)                          m    Sterilization (V25.2)                          repair of enterocele (58260)                          m    Sterilization (V25.2)
   m    Hysteroscopy, diagnostic (58555)                      m    Stress incontinence, female (625.6)       m    Hysteroscopy, diagnostic (58555)                      m    Stress incontinence, female (625.6)
   m    Hysteroscopy, surgical (58558)                        m    Uterine bleeding, abnormal (626)          m    Hysteroscopy, surgical (58558)                        m    Uterine bleeding, abnormal (626)
   m    I/D Bartholins (56420)                                m    Uterus disorder, unspecified (621.9)      m    I/D Bartholins (56420)                                m    Uterus disorder, unspecified (621.9)
   m    Laparoscopy, adnexal                                  m    Vaginitis (616)                           m    Laparoscopy, adnexal                                  m    Vaginitis (616)
        structures removal (58661)                                                                                structures removal (58661)
   m    Laparoscopy, surgical (dx or LOA) (58660)             m    Normal delivery (650)                     m    Laparoscopy, surgical (dx or LOA) (58660)             m    Normal delivery (650)
   m    Myomectomy (58140)                                    m    C-Sec (669.70)                            m    Myomectomy (58140)                                    m    C-Sec (669.70)
   m    Oophorectomy (58940)                                  m    Breech (652.20)                           m    Oophorectomy (58940)                                  m    Breech (652.20)
   m    PPTL (58605)                                          m    Twin (651.00)                             m    PPTL (58605)                                          m    Twin (651.00)
   m    Salpingectomy (58700)                                 m    Vacuum (669.50)                           m    Salpingectomy (58700)                                 m    Vacuum (669.50)
   m    Salpingostomy (58770)                                 m    Forceps (669.50)                          m    Salpingostomy (58770)                                 m    Forceps (669.50)
   m    Salpingostomy, laparoscopic (58673)                                                                  m    Salpingostomy, laparoscopic (58673)
      Lawndale Christian Health Center
      Delivery Card

                                         Delivery Type
LCHC Provider                            m NSVD w/ ppc (59410)
                                         m C-Sec w/ ppc (59515)
Mom Name                                 m VBAC w/ ppc (59614)
                                         m Other_____________
DOB
                                         Diagnosis(es)
Delivery Date                            m Normal delivery (650)
                                         m Breech (652.20)
Baby Sex        Male / Female            m C-Sec (669.70)
                                         m Twin (651.00)
Weight                    grams          m Vacuum (669.50)
                                         m Forceps (669.50)
Apgars               1          5        m Other_____________

Hospital                            Feeding Plan    Breast / Bottle

Covering OB                         Contraception

Notes
     Lawndale Christian Health Center
     Hospital Services Card
                              Initial Date
                              (mark under applicable complexity)
                                  Low       Mod        High
Provider Name


                              Subsequent Date(s)
Diagnosis                       Low       Mod           High

Service Type
 m Admission
 m Consultation
 m Observation

Other Services
Date           CPT/Service




                              Discharge Date
                                 Low       Mod          High
     Lawndale Christian Health Center
     Hospital Services Key


Initial Date
Admission         99221    99222   99223
Consultation      99251    99253   99255
Observation       99234    99235   99236

Subsequent Date(s)
Admission          99231   99232   99233
Consultation       99261   99262   99263

Discharge Date
Admission         99238    99239   99239
     Lawndale Christian Health Center
     Hospital Services Card
                              Initial Date
                              (mark under applicable complexity)
                                  Low       Mod        High
Provider Name


                              Subsequent Date(s)
Diagnosis                       Low       Mod           High

Service Type
 m Admission
 m Consultation
 m Observation

Other Services
Date           CPT/Service




                              Discharge Date
                                 Low       Mod          High

				
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posted:9/22/2011
language:English
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