CONSULT SUPERBILL
PATIENT INFORMATION
First Name
*
Last Name
*
Date of Birth
*
Date of Service
*
Hospital
*
---please select---
KBSC
GCMH
Doc West
Riverside
Berger
MT Carmel
Grant
Physician Name
*
---please select---
Dr. Elizabeth Hewitt
Dr. Melissa Foster
Dr. Gina Palazzi
Dr. Macaira Dyment
Dr. Anastasia A. Koss
Dr. Roshni Patel
Initial Hospital Care
---please select---
99221 - Low complex (30 min)
99222 - Detailed mod complex (50 min)
99223 - Comprehensive mod complex (70 min)
Subsequent Encounters
---please select---
99231 - Low complexity - stable & improving (15 min)
99232 - Mod complexity - no response (25 min)
99233 - Hign complexity - unstable (35 min)
DX
Cellulitis
L03.115 (RT)
L03.116 (LT)
Osteo
M86.171 (RT)
M86.172 (LT)
MSSA
B95.61 (RT)
B95.61 (LT)
Pain
M79.671 (RT)
M79.672 (LT)
Other
Face sheet
Yes
No
Current PT
Yes
No
Today's Date:
Submit
Unable to locate the patient in the system. Please enter the exact First Name, Last Name, and Date of Birth as per what is in the system.