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OM Billing Worksheet
OM Billing Worksheet
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Patient Name
*
First
Last
Patient DOB
*
MM slash DD slash YYYY
Patient Sex (M/F)
*
Male
Female
Date of Service
*
MM slash DD slash YYYY
Market
*
Arizona
California
Nevada
Utah
Texas
Florida
ICD-10 Diagnosis Codes:
At least 4, starting with the wound codes and most appropriate diagnoses:
1
*
5
2
*
6
3
*
7
4
*
8
CPT Codes:
*
(Check as many as apply)
99345 – Initial home/AL visit high complexity
99345 – Initial home/AL visit high complexity – Modifier-25
99344 – Initial home/AL visit moderate complexity
99344 – Initial home/AL visit moderate complexity – Modifier-25
99350 – Follow up home/AL visit high complexity
99350 – Follow up home/AL visit high complexity – Modifier-25
99349 – Follow up home/AL visit moderate complexity
99349 – Follow up home/AL visit moderate complexity – Modifier-25
11043 – Debridement muscle/fascia (up to 20 cm squared)
11046 – Debridement muscle/fascia each additional unit of up to 20 cm squared
11042 – Debridement subcutaneous tissue only (up to 20 cm squared)
11045 – Debridement subcutaneous tissues, each additional unit of up to 20 cm squared
17250 – Chemical Cauterization of hypergranulation tissue
17250 – Chemical Cauterization of hypergranulation tissue – Modifier-59
29580 – Application of UNNA boot
29580 – Application of UNNA boot – Modifier-59
29580 – Application of UNNA boot – Bileteral application (-50)
97606 – Application of wound vac
97610 – Low frequency non-contact non-thermal ultrasound therapy
97610 – Low frequency non-contact non-thermal ultrasound therapy – Modifier-59
15271 – Skin Substitute – Trunk, arms, legs (≤25 cm²)
15271 – Skin Substitute – Trunk, arms, legs (≤25 cm²) – Modifier-59
15272 – Skin Substitute – Trunk arms, legs (each additional 25 cm²)
15272 – Skin Substitute – Trunk arms, legs (each additional 25 cm²) – Modifier-59
15273 – Skin Substitute – Face, scalp, hands, feet, genitalia (≤25 cm²)
15273 – Skin Substitute – Face, scalp, hands, feet, genitalia (≤25 cm²) – Modifier-59
15274 – Skin Substitute – Face, scalp, hands, feet, genitalia (each additional 25 cm²)
15274 – Skin Substitute – Face, scalp, hands, feet, genitalia (each additional 25 cm²) – Modifier-59
11046 – Debridement muscle/fascia each additional unit of up to 20 cm squared
Number of each additional of up to 20 cm squared
11045 – Debridement subcutaneous tissue, each additional unit of up to 20 cm squared
Number of each additional of up to 20 cm squared
Provider Name:
*
Provider NPI:
*
Provider Signature:
*
Date
*
MM slash DD slash YYYY
Time
*
Hours
:
Minutes
AM
PM
AM/PM
Δ
