Teen Clinic

<table>
<colgroup>
<col style="width: 2%" />
<col style="width: 6%" />
<col style="width: 13%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 10%" />
<col style="width: 2%" />
<col style="width: 7%" />
<col style="width: 40%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="11">Provider</td>
<td colspan="3">Date</td>
</tr>
<tr class="even">
<td colspan="11">New Established</td>
<td colspan="3">Education</td>
</tr>
<tr class="odd">
<td></td>
<td>99201</td>
<td colspan="2">Brief</td>
<td colspan="2"></td>
<td colspan="5">99211 – nurse</td>
<td></td>
<td>99078</td>
<td>Teaching, group</td>
</tr>
<tr class="even">
<td></td>
<td>99202</td>
<td colspan="2">Limited</td>
<td colspan="2"></td>
<td colspan="5">99212</td>
<td></td>
<td>99401</td>
<td>Preventive medicine counseling 15 min</td>
</tr>
<tr class="odd">
<td></td>
<td>99203</td>
<td colspan="2">Intermediate</td>
<td colspan="2"></td>
<td colspan="5">99213</td>
<td></td>
<td>99402</td>
<td>Preventive medicine counseling 30 min</td>
</tr>
<tr class="even">
<td></td>
<td>99204</td>
<td colspan="2">Extended</td>
<td colspan="2"></td>
<td colspan="5">99214</td>
<td></td>
<td>99403</td>
<td>Preventive medicine counseling 45 min</td>
</tr>
<tr class="odd">
<td></td>
<td>99205</td>
<td colspan="2">Comprehensive</td>
<td colspan="2"></td>
<td colspan="5">99215</td>
<td></td>
<td>99404</td>
<td>Preventive medicine counseling 60 min</td>
</tr>
<tr class="even">
<td colspan="11">Health Supervision</td>
<td></td>
<td>99411</td>
<td>Preventive, group 30 min</td>
</tr>
<tr class="odd">
<td colspan="11">New Established</td>
<td></td>
<td>99412</td>
<td>Preventive, group 60 min</td>
</tr>
<tr class="even">
<td></td>
<td>99384</td>
<td colspan="2">12 – 17 years</td>
<td colspan="2"></td>
<td colspan="3">99394</td>
<td colspan="2">12 – 17 years</td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11">Procedures</td>
<td colspan="3">Diagnosis</td>
</tr>
<tr class="even">
<td></td>
<td>94640</td>
<td>Nebulizer TX</td>
<td colspan="2"></td>
<td colspan="3">94760</td>
<td colspan="3">Oximetry</td>
<td></td>
<td>250.00</td>
<td>DM unspecified, not stated as uncontrolled</td>
</tr>
<tr class="odd">
<td></td>
<td>94150</td>
<td>Peak Flow</td>
<td colspan="2"></td>
<td colspan="3">94761</td>
<td colspan="3">Multiple O2 sat</td>
<td></td>
<td>250.01</td>
<td>DM uncomplicated/T-1/IDDM, NS UN</td>
</tr>
<tr class="even">
<td colspan="11">Removal Foreign Body</td>
<td></td>
<td>250.02</td>
<td>Type II NIDDM, unspecified, uncontrolled</td>
</tr>
<tr class="odd">
<td></td>
<td>11730</td>
<td colspan="4">Toenail</td>
<td></td>
<td colspan="3">65205</td>
<td>Eye</td>
<td></td>
<td>648.8</td>
<td>Gestational, specify type ___________________</td>
</tr>
<tr class="even">
<td></td>
<td>10060</td>
<td colspan="4">I&amp;D abscess</td>
<td></td>
<td colspan="3">30300</td>
<td>Nose</td>
<td></td>
<td>579.8</td>
<td>Intolerance of Carbohydrate NEC</td>
</tr>
<tr class="odd">
<td></td>
<td>17110</td>
<td colspan="4">Common wart</td>
<td></td>
<td colspan="3">69200</td>
<td>Ear</td>
<td></td>
<td>300.00</td>
<td>Anxiety state, NOS</td>
</tr>
<tr class="even">
<td></td>
<td>69210</td>
<td colspan="4">Cerumen, impacted</td>
<td></td>
<td colspan="3"></td>
<td></td>
<td></td>
<td>311</td>
<td>Depressive disorder NEC</td>
</tr>
<tr class="odd">
<td colspan="11">Immunization Administration</td>
<td></td>
<td>648.73</td>
<td>Bone disorder – antepartum</td>
</tr>
<tr class="even">
<td></td>
<td>90471</td>
<td colspan="9">One vaccine (single or combination vaccine/toxoid)</td>
<td></td>
<td>648.93</td>
<td>Other current condition – antepartum</td>
</tr>
<tr class="odd">
<td></td>
<td>90472</td>
<td colspan="9">Each additional vaccine X ___________</td>
<td></td>
<td>790.6</td>
<td>ABN blood chemistry</td>
</tr>
<tr class="even">
<td colspan="11">Injections/Medications</td>
<td></td>
<td>706.1</td>
<td>Acne NEC</td>
</tr>
<tr class="odd">
<td></td>
<td rowspan="2">90782</td>
<td colspan="9" rowspan="2"><p>Therapeutic injection – subcutaneous or
intramuscular</p>
<p>Specify material injected _______________________</p></td>
<td></td>
<td>465.9</td>
<td>Acute URI NOS</td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td>780.39</td>
<td>Other convulsions</td>
</tr>
<tr class="odd">
<td></td>
<td>90784</td>
<td colspan="9">Intravenous injection</td>
<td></td>
<td>V25.0</td>
<td>General counseling/advice contraceptive</td>
</tr>
<tr class="even">
<td></td>
<td rowspan="2">90788</td>
<td colspan="9" rowspan="2"><p>Intramuscular injection of antibiotic</p>
<p>Specify material injected_______________________</p></td>
<td></td>
<td>V25.01</td>
<td>Prescription of oral contraceptive</td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td>V25.09</td>
<td>Contraceptive management NEC</td>
</tr>
<tr class="even">
<td></td>
<td>J1055</td>
<td colspan="9">Depo-Provera</td>
<td></td>
<td>V25.40</td>
<td>Contraceptive surveillance, unspecified</td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td colspan="9"></td>
<td></td>
<td>V25.9</td>
<td>Unspecified contraceptive management</td>
</tr>
<tr class="even">
<td colspan="11">Laboratory (done in clinic)</td>
<td></td>
<td>V65.49</td>
<td>Counseling NEC</td>
</tr>
<tr class="odd">
<td></td>
<td>82962</td>
<td colspan="9">Accucheck</td>
<td></td>
<td>V64.41</td>
<td>Counseling, exercise</td>
</tr>
<tr class="even">
<td></td>
<td>88164</td>
<td colspan="9">Pap Smear</td>
<td></td>
<td>V65.42</td>
<td>Counseling on substance used and abuse</td>
</tr>
<tr class="odd">
<td></td>
<td>87880</td>
<td colspan="9">Rapid strep screen</td>
<td></td>
<td>V65.43</td>
<td>Counseling on injury prevention</td>
</tr>
<tr class="even">
<td></td>
<td>81002</td>
<td colspan="9">Urinalysis, dip stick</td>
<td></td>
<td>V65.44</td>
<td>HIV counseling</td>
</tr>
<tr class="odd">
<td></td>
<td>84703</td>
<td colspan="9">HCG, qualitative</td>
<td></td>
<td>V65.45</td>
<td>Counseling on sexually transmitted diseases</td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td colspan="9"></td>
<td></td>
<td>V65.3</td>
<td>Dietary surveillance and counseling</td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td colspan="9"></td>
<td></td>
<td>V01.89</td>
<td>Exposure communicable disease, other</td>
</tr>
<tr class="even">
<td colspan="11">Patient Information</td>
<td></td>
<td>V72.3</td>
<td>Gynecologic examination</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="10" rowspan="10"></td>
<td></td>
<td>V76.2</td>
<td>PAP smear w/o general examination</td>
</tr>
<tr class="even">
<td rowspan="2"></td>
<td></td>
<td>V72.4</td>
<td>Pregnancy examination/test, pregnancy unconfirm</td>
</tr>
<tr class="odd">
<td></td>
<td>V22.0</td>
<td>Supervision of normal first pregnancy</td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td>V22.0</td>
<td>Supervision of other normal pregnancy</td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td>V72.6</td>
<td>Laboratory examination</td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td>V73.88</td>
<td>Screening for chlamydia</td>
</tr>
<tr class="odd">
<td rowspan="3"></td>
<td></td>
<td>V73.89</td>
<td>Screening for other viral diseases</td>
</tr>
<tr class="even">
<td></td>
<td>V74.5</td>
<td>Screening for venereal disease</td>
</tr>
<tr class="odd">
<td></td>
<td>V74.8</td>
<td>Screening for whooping cough</td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td>V70.3</td>
<td>Medical examination NEC – Sports PE</td>
</tr>
</tbody>
</table>

Revised 11/12/03