SYHC PACE ENCOUNTER LOG
Select an area to expand the log and complete the encounter
Primary Care
Service Performed
Please Select
Annual face-to-face obesity screening
Annual Wellness visit
CC: Multiple chronic conditions w/o prt
CC: Case Management
CC: Complex w/o prt 1 hour
CC: Complex w/o prt add'l 30min
CC: Family/prt conf with 3+ staff
CC: IDT; w family/prt conf with 3+ staff
CC: IDT; w/o provider w/o family
CC: IDT; with MD w/o family
Cerumen removal (1 or 2 ears)
Couns: Advance directive, end-of-life
Couns: Alcohol misuse and reduction 15m
Couns: Alcohol misuse and reduction, annual 15m"
Couns: Obesity behavior, indiv, 15m
Couns: Smoking cessation; Inter >10m
Couns: Smoking cessation; Inter 3-10m
D: Cervical Screening/Breast Exam
D: EKG complete; interp & report
D: EKG rhythm; interp & report
E&M with Psychotherapy, individual
E&M: Consultation, New/Estab (1, Psych only) 15m
E&M: Consultation, New/Estab (2, Psych only) 30m
E&M: Consultation, New/Estab (3, Psych only) 40m
E&M: Consultation, New/Estab (4, Psych only) 60m
E&M: Consultation, New/Estab (5, Psych only) 80m
E&M: Depression screening annual
E&M: Estab (1) low severity w or w/o MD
E&M: Estab (2) low-mod severity
E&M: Estab (3) mod severity
E&M: Estab (4) mod-high severity
E&M: New (1) low severity
E&M: New (2) low-mod severity
E&M: New (3) mod severity
E&M: New (4) mod-high severity
E&M: New (5) high severity
E&M: Per phone MD (1) 5-10 m
E&M: Per phone MD (2) 11-20 m
E&M: Per phone MD (3) 21-30 m
E&M: Psychiatric diagnostic evaluation
E&M: Psychiatric diagnostic evaluation- medical services
EKG 1-3 leads, no interp & report Spirometry
Establ Patient Preventive Health visit (age >64)
Establ Patient Preventive Health visit (age 40-64)
Home Visit: Estab prt. (1) Minor <15 m
Home Visit: Estab prt. (2) Mod 25m
Home Visit: Estab prt. (3) Mod -Severe 40m
Home Visit: Estab prt. (4) Unstable 60m
Home Visit: New prt. (1) Minor <20 m
Home Visit: New prt. (2) Mod 30 m
Home Visit: New prt. (3) Mod -Severe 45m
Home Visit: New prt. (4) Severe 60m
Home Visit: New prt. (5) New problem 75 m
Hospital discharge day management; >30 min
Hospital discharge day management; 30 min or less
Incision and removal of foreign body, subcutaneous tissues; complex
Initial hospital care, per day, with high severity
Initial hospital care, per day, with low severity
Initial hospital care, per day, with moderate severity
Initial observation care, with high severity
Initial observation care, with low severity
Initial observation care, with moderare severity
Initial Wellness Visit
Injection, thera/prophy/diag
Inpatient/observ care, discharge same date, low severity
Inpatient/observation care, discharge same date, high severity
Inpatient/observation care, discharge same date, moderate severity
New Patient Preventive Health visit (age >64)
New Patient Preventive Health visit (age 40-64)
Observation stay discharge management
P: Aspiration, fine needle w/o image
P: Biopsy, each additional
P: Biopsy, single
P: Closure of split wound
P: Closure of split wound, w packing
P: Foreign body, removal
P: I&D; hematoma/seroma
P: Inject, major joint/bursa
P: Inject, med joint/bursa
P: Inject, small joint/bursa
P: IV start
P: Nail, debride 1-5
P: Nail, debride 6 or more
P: Nail, removal of bed
P: Nail, removal of plate
P: Puncture aspiration; abscess, hematoma, bulla, cyst
P: Repair, med wound 2.5 cm or less
P: Repair, med wound 2.6 7.5 cm
P: Repair, med wound head/gen 2.5 cm or less
P: Repair, med wound head/gen 2.6-7.5 cm
P: Repair, superficial wound 2.5 cm or less
P: Repair, superficial wound 2.6-7.5 cm
P: Skin lesion, trim (1)
P: Skin lesion, trim (2-4)
P: Skin lesion; shave single; scalp, neck, hands, feet, gen; 0.5 cm or less
P: Skin lesion; shave single; scalp, neck, hands, feet, gen; 0.6-1.0 cm
P: Skin lesion; shave single; trunk, arms, or legs; 0.5 cm or less
P: Skin lesion; shave single; trunk, arms, or legs; 0.6-1.0 cm
P: Suture removal, not by MD who placed
P: Trigger point injection, single/multiple, 1 0or 2 muscle
Pap smear, obtain,prepare, send
Power mobility device documentation by MD
RCFE Visit: Estab prt. (1) Minor <15 m
RCFE Visit: Estab prt. (2) Mod 25m
RCFE Visit: Estab prt. (3) Mod -Severe 40m
RCFE Visit: Estab prt. (4) Unstable 60m
RCFE Visit: New prt. (1) Minor <20 m
RCFE Visit: New prt. (2) Mod 30 m
RCFE Visit: New prt. (3) Mod -Severe 45m
RCFE Visit: New prt. (4) Mod -Severe 45m
RCFE Visit: New prt. (5) New problem 75 m
Screen sexuallytransmitted dis, incl tests for chlamydia, syphilis, hep B
SNF: Annual assessment 30 m
SNF: Discharge mgmt. 30m
"SNF: Discharge mgmt. add’l 30 m"
SNF: Initial 25 m
SNF: Initial 35 m
SNF: Initial 45 m
SNF: Subseq visit (1), stable 10 m
SNF: Subseq visit (2), minor comp 15 m
SNF: Subseq visit (3), new prob 25 m
SNF: Subseq visit (4), unstable/new prob 35 m
Special reports or forms E&M: Estab (5) high severity
Spirometry pre/post bronchodilator
Subseq hospital care, per day, not improving or complication
Subseq hospital care, per day, stable or improving
Subseq hospital care, per day, unstable or signif complication
Subseq observ care, per day, not improving or complication
Subseq observ care, per day, stable or improving
Subseq observ care, per day, unstable or significant complication
Tobacco counseling >10 min
Tobacco counseling 3-10 min
Travel Time
Trimming of nondystrophic nails
Welcome to Medicare Visit
Wound debridment 20 sq cm or less
Wound debridment, each add'l 20 sq cm or less
Place of Service
Please Select
01 Pharmacy
02 Unassigned
03 School
04 Homeless Shelter
05 Indian Health Service, Free-standing Facility
06 Indian Health Service, Provider-based Facility
07 Tribal 638, Free-standing Facility
08 Tribal 638, Provider-based Facility
09 Prison/Correctional Facility
10 Unassigned
11 Office
12 Home
13 Assisted Living Facility
14 Group Home
15 Mobile Unit
16 Temporary Lodging
17 Walk-in Retail Health Clinic
18 Place of employment-Worksite
19 Off Campus-Outpatient Hospital
20 Urgent Care Facility
21 Inpatient Hospital
22 On Campus-Outpatient Hospital
23 Emergency Room-Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
27 Unassigned
28 Unassigned
29 Unassigned
30 Unassigned
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
35 Unassigned
36 Unassigned
37 Unassigned
38 Unassigned
39 Unassigned
40 Unassigned
41 Ambulance-Land
42 Ambulance-Air or Water
43 Unassigned
44 Unassigned
45 Unassigned
46 Unassigned
47 Unassigned
48 Unassigned
49 Independent Clinic
50 Federally Qualified Health Center
51 Inpatient Psychiatric Facility
52 Psychiatric Facility- Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/ Individuals with Intellectual Disabilities
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Facility
57 Non-residential Substance Abuse Treatment Facility
58 Unassigned
59 Unassigned
60 Mass Immunication Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
63 Unassigned
64 Unassigned
65 End-stage Renal Disease Treatment Facility
66 Unassigned
67 Unassigned
68 Unassigned
69 Unassigned
70 Unassigned
71 Public Health Clinic
72 Rural Health Clinic
73 Unassigned
74 Unassigned
75 Unassigned
76 Unassigned
77 Unassigned
78 Unassigned
79 Unassigned
80 Unassigned
81 Independent Laboratory
82 Unassigned
83 Unassigned
84 Unassigned
85 Unassigned
86 Unassigned
87 Unassigned
88 Unassigned
89 Unassigned
90 Unassigned
91 Unassigned
92 Unassigned
93 Unassigned
94 Unassigned
95 Unassigned
96 Unassigned
97 Unassigned
98 Unassigned
99 Other Place of Service
Total Units
Encounter Completed by
First Name
Last Name
Date
-
Month
-
Day
Year
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Nursing
Service Performed
Please Select
Cather Change (Cystostomy)
CC: Multiple chronic conditions w/o prt
CC: Case Management
CC: Complex w/o prt 1 hour
CC: Complex w/o prt add'l 30min
CC: Family/prt conf with 3+ staff
CC: IDT; w family/prt conf with 3+ staff
CC: IDT; w/o MD w/o family
CC: IDT; with MD w/o family
Change gastrostomy tube
Clinical visit/encounter, all- inclusive
Collection of blood specimen from a infusaport or portacath
D: Blood Collection from central venous line
D: EKG complete; interp & report
D: Fecal Occult Blood - FIT
D: Fecal Occult Blood - Hemoccult
D: Glucose fingerstick
D: Influenza swab
D: Oximetry - multiple
D: Oximetry - single
D: PT/INR (Point of Care)
D: Specimen handling
D: Sputum specimen collection
D: Strep A swab
D: TB Skin Test
D: Urine - Timed volume collection
D: Urine Dipstick
D: Venipuncture
Drug through metered dose inhaler
E&M: Estab (1) low severity w or w/o MD
E&M: Home assessment
E&M: Nursing RN
E&M: Per phone non-MD (1) 5-10 min
E&M: Per phone non-MD (2) 11-20 min
E&M: Per phone non-MD (2) 11-20 min
E&M: Per phone non-MD (3) 21-30 min
Edu: Diabetes self-mgmt. group 30m
Edu: Diabetes self-mgmt. indiv 30m
Edu: Insulin pump initial
Edu: Materials
Edu: Self mgmt. for Asthma
Edu: Self mgmt. non MD Smoking cessation
Edu: Self mgmt. non-MD 1 prt
Edu: Self mgmt. non-MD 1 prt
Edu: Self mgmt. non-MD 2- 4 prt
Edu: Self mgmt. non-MD 5- 8 prt
Edu: Self mgmt. non-MD group
Edu: Self mgmt. on-line
Edu: Self mgmt. Respiratory treatment/inhaler
EKG 1-3 leads, no interp & report
Enteral Tube feeding (gravity)
Hemoglobin (in clinic)
Home: ADL assist/personal care
Home: Catheter care
Home: IM injection
Home: Respiratory treatment
Home: Skilled service RN mgmt. Plan of Care
Home: Skilled service RN/LVN
Home: Skilled service RN/LVN assessment
Home: Skilled service RN/LVN education
Home: Stoma care
Home: Visit unspecified
Home: Wound Care
Mechanical Vent care
Med: Injection IM/SC Non- vaccine
Med: Injection IM/SC vaccine
Med: Injection IM/SC vaccine, each add'l
Med: Injection IV (single drug)
Med: Metered dose inhaler
Med: Nebulizer treatment
Med: Oral, or topical
Med: Topical vaginal
Negative Pressure wound therapy, < 50 sq cm surface area
Negative Pressure wound therapy, < 50 sq cm surface area
Nursing care in home by LPN, per diem
Nursing care in home by RN, per diem
P: Ear irrigation/Cerumen removal
P: IV Hydration, 31 min to 1 hr
P: IV Hydration, each add'l hr
P: IV medication, each add'l hr
P: IV Medication, up to 1 hr
P: IV start
P: LVN services up to 15 min
P: Nails, trim any number
P: RN services up to 15 min
P: SC Hydration, each add'l hr
P: SC Hydration, up to 1 hr
P: Unna boot application
"P: Urinary catheter insertion- indwelling"
"P: Urinary catheter insertion- straight"
P: Wound care
Spirometry
Spirometry pre/post bronchodilator
Travel Time
Place of Service
Please Select
01 Pharmacy
02 Unassigned
03 School
04 Homeless Shelter
05 Indian Health Service, Free-standing Facility
06 Indian Health Service, Provider-based Facility
07 Tribal 638, Free-standing Facility
08 Tribal 638, Provider-based Facility
09 Prison/Correctional Facility
10 Unassigned
11 Office
12 Home
13 Assisted Living Facility
14 Group Home
15 Mobile Unit
16 Temporary Lodging
17 Walk-in Retail Health Clinic
18 Place of employment-Worksite
19 Off Campus-Outpatient Hospital
20 Urgent Care Facility
21 Inpatient Hospital
22 On Campus-Outpatient Hospital
23 Emergency Room-Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
27 Unassigned
28 Unassigned
29 Unassigned
30 Unassigned
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
35 Unassigned
36 Unassigned
37 Unassigned
38 Unassigned
39 Unassigned
40 Unassigned
41 Ambulance-Land
42 Ambulance-Air or Water
43 Unassigned
44 Unassigned
45 Unassigned
46 Unassigned
47 Unassigned
48 Unassigned
49 Independent Clinic
50 Federally Qualified Health Center
51 Inpatient Psychiatric Facility
52 Psychiatric Facility- Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/ Individuals with Intellectual Disabilities
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Facility
57 Non-residential Substance Abuse Treatment Facility
58 Unassigned
59 Unassigned
60 Mass Immunication Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
63 Unassigned
64 Unassigned
65 End-stage Renal Disease Treatment Facility
66 Unassigned
67 Unassigned
68 Unassigned
69 Unassigned
70 Unassigned
71 Public Health Clinic
72 Rural Health Clinic
73 Unassigned
74 Unassigned
75 Unassigned
76 Unassigned
77 Unassigned
78 Unassigned
79 Unassigned
80 Unassigned
81 Independent Laboratory
82 Unassigned
83 Unassigned
84 Unassigned
85 Unassigned
86 Unassigned
87 Unassigned
88 Unassigned
89 Unassigned
90 Unassigned
91 Unassigned
92 Unassigned
93 Unassigned
94 Unassigned
95 Unassigned
96 Unassigned
97 Unassigned
98 Unassigned
99 Other Place of Service
Total Units
Encounter Completed by
First Name
Last Name
Date
-
Month
-
Day
Year
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Rehabilitation
Service Performed
Please Select
Airway Clearance
Behavioral and qualitative analysis of voice and resonance
Biofeedback
CC: Case Management
CC: Complex w/o prt 1 hour
CC: Family/prt conf with 3+ staff
Contrast Baths
Device, handling, & ordering for items require fitting,
DME repair (not oxygen)
Dysphagia Intervention
E&M: Home assessment
E&M: Per phone non-MD
E&M: Swallowing function
Edu: Exercise class, non MD per session
Edu: materials
Edu: Self mgmt. non-MD 1 prt per session
Edu: Self mgmt. on-line
Evaluation of speech fluency
Evaluation of speech sound production
Evaluation of speech sound production with evaluation of language comprehension and expression
Home modifications; per service
Light agent - Infared
Light agent - Ultraviolet
Modalities
Modality: by therapist
Modality: Electric stim - no therapist contact
Modality: Electric stim - therapist
Modality: Hot/Cold - no therapist contact
Modality: Paraffin - no therapist contact
Modality: Ultrasound - therapist
OT Evaluation
OT Re-evaluation
OT: in home
PT Evaluation
PT Re-evaluation
PT: in home
Sensorimotor Training
Therapy
Therapy: Cognitive skill dev.
Therapy: Exercises - therapist
Therapy: Gait training
Therapy: Improve function
Therapy: Manual Therapy
Therapy: Massage
Therapy: Procedure, non specified
Therapy: Procedures, 2+ prts
Therapy: Reeducation neuromuscular
Traction devices
Training: IADL training
Training: ADL training, self- mgmt.
Training: Orthotic mgmt.
Training: Orthotic/Prosthetic re eval
Training: Prosthetic
Training: Wheelchair mgmt.
Travel Time
Unlisted modality
Wound care
Wound care
Wound care
Place of Service
Please Select
01 Pharmacy
02 Unassigned
03 School
04 Homeless Shelter
05 Indian Health Service, Free-standing Facility
06 Indian Health Service, Provider-based Facility
07 Tribal 638, Free-standing Facility
08 Tribal 638, Provider-based Facility
09 Prison/Correctional Facility
10 Unassigned
11 Office
12 Home
13 Assisted Living Facility
14 Group Home
15 Mobile Unit
16 Temporary Lodging
17 Walk-in Retail Health Clinic
18 Place of employment-Worksite
19 Off Campus-Outpatient Hospital
20 Urgent Care Facility
21 Inpatient Hospital
22 On Campus-Outpatient Hospital
23 Emergency Room-Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
27 Unassigned
28 Unassigned
29 Unassigned
30 Unassigned
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
35 Unassigned
36 Unassigned
37 Unassigned
38 Unassigned
39 Unassigned
40 Unassigned
41 Ambulance-Land
42 Ambulance-Air or Water
43 Unassigned
44 Unassigned
45 Unassigned
46 Unassigned
47 Unassigned
48 Unassigned
49 Independent Clinic
50 Federally Qualified Health Center
51 Inpatient Psychiatric Facility
52 Psychiatric Facility- Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/ Individuals with Intellectual Disabilities
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Facility
57 Non-residential Substance Abuse Treatment Facility
58 Unassigned
59 Unassigned
60 Mass Immunication Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
63 Unassigned
64 Unassigned
65 End-stage Renal Disease Treatment Facility
66 Unassigned
67 Unassigned
68 Unassigned
69 Unassigned
70 Unassigned
71 Public Health Clinic
72 Rural Health Clinic
73 Unassigned
74 Unassigned
75 Unassigned
76 Unassigned
77 Unassigned
78 Unassigned
79 Unassigned
80 Unassigned
81 Independent Laboratory
82 Unassigned
83 Unassigned
84 Unassigned
85 Unassigned
86 Unassigned
87 Unassigned
88 Unassigned
89 Unassigned
90 Unassigned
91 Unassigned
92 Unassigned
93 Unassigned
94 Unassigned
95 Unassigned
96 Unassigned
97 Unassigned
98 Unassigned
99 Other Place of Service
Total Units
Encounter Completed by
First Name
Last Name
Date
-
Month
-
Day
Year
Date Picker Icon
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Social Work
Service Performed
Please Select
Assess Causes of Problematic Behavior
Assess Cognitive Functioning
Assess Depressive Symptoms
Assess for Anxiety/Depression
Assess/Eval: Health & behavior, initial
Assess/Eval: Health & behavior, reassessment
Caregiver Support and Education
CC: Multiple chronic conditions w/o prt
CC: Case Management
CC: Complex w/o prt 1 hour
CC: Complex w/o prt add'l 30min
CC: Family/prt conf with 3+ staff
CC: IDT; w family/prt conf with 3+ staff
CC: IDT; w/o provider w/o family
CC: IDT; with MD w/o family
Couns: Advance directive, end-of-life
E&M with Psychotherapy, individual
E&M: Psychiatric diagnostic evaluation
Health & Behavior Intervention: 2+ prts
Health & Behavior Intervention: family w/o prt
Health & Behavior Intervention: individual
Health & Behavior Intervention: prt and family
Hypnotherapy
Pay 1:1 Home Visit
Provide 1:1 Counseling to Decrease Problematic Behavior
Psychotherapy, indivi or with family 45 min
Psychotherapy, indivi or with family 60 min
Psychotherapy, family w/o prt
Psychotherapy, family with prt
Psychotherapy, for crisis add’l 30 minutes
Psychotherapy, for crisis first 60 minutes
Psychotherapy, group
Psychotherapy, indivi or with family 30 min
Psychotherapy, multiple family group
Stress Management
SW Services: in home 15m
Travel Time
Place of Service
Please Select
01 Pharmacy
02 Unassigned
03 School
04 Homeless Shelter
05 Indian Health Service, Free-standing Facility
06 Indian Health Service, Provider-based Facility
07 Tribal 638, Free-standing Facility
08 Tribal 638, Provider-based Facility
09 Prison/Correctional Facility
10 Unassigned
11 Office
12 Home
13 Assisted Living Facility
14 Group Home
15 Mobile Unit
16 Temporary Lodging
17 Walk-in Retail Health Clinic
18 Place of employment-Worksite
19 Off Campus-Outpatient Hospital
20 Urgent Care Facility
21 Inpatient Hospital
22 On Campus-Outpatient Hospital
23 Emergency Room-Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
27 Unassigned
28 Unassigned
29 Unassigned
30 Unassigned
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
35 Unassigned
36 Unassigned
37 Unassigned
38 Unassigned
39 Unassigned
40 Unassigned
41 Ambulance-Land
42 Ambulance-Air or Water
43 Unassigned
44 Unassigned
45 Unassigned
46 Unassigned
47 Unassigned
48 Unassigned
49 Independent Clinic
50 Federally Qualified Health Center
51 Inpatient Psychiatric Facility
52 Psychiatric Facility- Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/ Individuals with Intellectual Disabilities
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Facility
57 Non-residential Substance Abuse Treatment Facility
58 Unassigned
59 Unassigned
60 Mass Immunication Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
63 Unassigned
64 Unassigned
65 End-stage Renal Disease Treatment Facility
66 Unassigned
67 Unassigned
68 Unassigned
69 Unassigned
70 Unassigned
71 Public Health Clinic
72 Rural Health Clinic
73 Unassigned
74 Unassigned
75 Unassigned
76 Unassigned
77 Unassigned
78 Unassigned
79 Unassigned
80 Unassigned
81 Independent Laboratory
82 Unassigned
83 Unassigned
84 Unassigned
85 Unassigned
86 Unassigned
87 Unassigned
88 Unassigned
89 Unassigned
90 Unassigned
91 Unassigned
92 Unassigned
93 Unassigned
94 Unassigned
95 Unassigned
96 Unassigned
97 Unassigned
98 Unassigned
99 Other Place of Service
Total Units
Encounter Completed by
First Name
Last Name
Submit
Care Coordination
Service Performed
Please Select
CC: Family/prt conf with 3+ staff
Edu: materials
Edu: Nutrition class, non MD per session
Edu: Self mgmt. non-MD 1 prt per session
Edu: Self mgmt. on-line
Education
IDT & Individual Disciplines
IDT & Individual Disciplines, not physician
IDT & Individual in-person meeting with participants and/or caregivers
IDT & Individual in-person meeting with participants and/or caregivers
IDT & Individual in-person meeting with participants and/or caregivers
IDT & Individual in-person meeting with participants and/or caregivers
IDT & Individual in-person meeting with participants and/or caregivers
IDT & Nursing
IDT & Physician
Other
Other
Stress Management Strategies
Place of Service
Please Select
01 Pharmacy
02 Unassigned
03 School
04 Homeless Shelter
05 Indian Health Service, Free-standing Facility
06 Indian Health Service, Provider-based Facility
07 Tribal 638, Free-standing Facility
08 Tribal 638, Provider-based Facility
09 Prison/Correctional Facility
10 Unassigned
11 Office
12 Home
13 Assisted Living Facility
14 Group Home
15 Mobile Unit
16 Temporary Lodging
17 Walk-in Retail Health Clinic
18 Place of employment-Worksite
19 Off Campus-Outpatient Hospital
20 Urgent Care Facility
21 Inpatient Hospital
22 On Campus-Outpatient Hospital
23 Emergency Room-Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
27 Unassigned
28 Unassigned
29 Unassigned
30 Unassigned
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
35 Unassigned
36 Unassigned
37 Unassigned
38 Unassigned
39 Unassigned
40 Unassigned
41 Ambulance-Land
42 Ambulance-Air or Water
43 Unassigned
44 Unassigned
45 Unassigned
46 Unassigned
47 Unassigned
48 Unassigned
49 Independent Clinic
50 Federally Qualified Health Center
51 Inpatient Psychiatric Facility
52 Psychiatric Facility- Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/ Individuals with Intellectual Disabilities
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Facility
57 Non-residential Substance Abuse Treatment Facility
58 Unassigned
59 Unassigned
60 Mass Immunication Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
63 Unassigned
64 Unassigned
65 End-stage Renal Disease Treatment Facility
66 Unassigned
67 Unassigned
68 Unassigned
69 Unassigned
70 Unassigned
71 Public Health Clinic
72 Rural Health Clinic
73 Unassigned
74 Unassigned
75 Unassigned
76 Unassigned
77 Unassigned
78 Unassigned
79 Unassigned
80 Unassigned
81 Independent Laboratory
82 Unassigned
83 Unassigned
84 Unassigned
85 Unassigned
86 Unassigned
87 Unassigned
88 Unassigned
89 Unassigned
90 Unassigned
91 Unassigned
92 Unassigned
93 Unassigned
94 Unassigned
95 Unassigned
96 Unassigned
97 Unassigned
98 Unassigned
99 Other Place of Service
Total Units
Encounter Completed by
First Name
Last Name
Date
-
Month
-
Day
Year
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Submit
Nutrition
Service Performed
Please Select
CC: Case Management
CC: Complex w/o prt 1 hour
Cognitive behavioral therapy
"E&M: Per phone non-MD (1) 5-10min"
"E&M: Per phone non-MD (2) 11-20min"
Nutrition therapy, initial assess and intervention (1prt)
Nutrition therapy, re-assess and intervention (1 prt)
Nutrition therapy/reeval indiv 15m
Other
Other
Other
Travel Time
Place of Service
Please Select
01 Pharmacy
02 Unassigned
03 School
04 Homeless Shelter
05 Indian Health Service, Free-standing Facility
06 Indian Health Service, Provider-based Facility
07 Tribal 638, Free-standing Facility
08 Tribal 638, Provider-based Facility
09 Prison/Correctional Facility
10 Unassigned
11 Office
12 Home
13 Assisted Living Facility
14 Group Home
15 Mobile Unit
16 Temporary Lodging
17 Walk-in Retail Health Clinic
18 Place of employment-Worksite
19 Off Campus-Outpatient Hospital
20 Urgent Care Facility
21 Inpatient Hospital
22 On Campus-Outpatient Hospital
23 Emergency Room-Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
27 Unassigned
28 Unassigned
29 Unassigned
30 Unassigned
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
35 Unassigned
36 Unassigned
37 Unassigned
38 Unassigned
39 Unassigned
40 Unassigned
41 Ambulance-Land
42 Ambulance-Air or Water
43 Unassigned
44 Unassigned
45 Unassigned
46 Unassigned
47 Unassigned
48 Unassigned
49 Independent Clinic
50 Federally Qualified Health Center
51 Inpatient Psychiatric Facility
52 Psychiatric Facility- Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/ Individuals with Intellectual Disabilities
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Facility
57 Non-residential Substance Abuse Treatment Facility
58 Unassigned
59 Unassigned
60 Mass Immunication Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
63 Unassigned
64 Unassigned
65 End-stage Renal Disease Treatment Facility
66 Unassigned
67 Unassigned
68 Unassigned
69 Unassigned
70 Unassigned
71 Public Health Clinic
72 Rural Health Clinic
73 Unassigned
74 Unassigned
75 Unassigned
76 Unassigned
77 Unassigned
78 Unassigned
79 Unassigned
80 Unassigned
81 Independent Laboratory
82 Unassigned
83 Unassigned
84 Unassigned
85 Unassigned
86 Unassigned
87 Unassigned
88 Unassigned
89 Unassigned
90 Unassigned
91 Unassigned
92 Unassigned
93 Unassigned
94 Unassigned
95 Unassigned
96 Unassigned
97 Unassigned
98 Unassigned
99 Other Place of Service
Total Units
Encounter Completed by
First Name
Last Name
Date
-
Month
-
Day
Year
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Home Health Coordination
Service Performed
Please Select
Attendant care
Attendant care
Chore services
Chore services
Companion care (IADL/ADL)
Companion care (IADL/ADL)
Home delivery meals
Homemaker services
Homemaker services
In home technology (tele-monitoring)
Meals per diem NOS
Medication reminder (non face to face)
Non-skilled care (nurse aide)
Personal care (non-inpatient setting)
Personal care (non-inpatient setting)
Respite
Respite
Skilled home health aide
Skilled home health aide
Skilled home health aide (Medicare)
Unskilled respite
Unskilled respite
Place of Service
Please Select
01 Pharmacy
02 Unassigned
03 School
04 Homeless Shelter
05 Indian Health Service, Free-standing Facility
06 Indian Health Service, Provider-based Facility
07 Tribal 638, Free-standing Facility
08 Tribal 638, Provider-based Facility
09 Prison/Correctional Facility
10 Unassigned
11 Office
12 Home
13 Assisted Living Facility
14 Group Home
15 Mobile Unit
16 Temporary Lodging
17 Walk-in Retail Health Clinic
18 Place of employment-Worksite
19 Off Campus-Outpatient Hospital
20 Urgent Care Facility
21 Inpatient Hospital
22 On Campus-Outpatient Hospital
23 Emergency Room-Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
27 Unassigned
28 Unassigned
29 Unassigned
30 Unassigned
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
35 Unassigned
36 Unassigned
37 Unassigned
38 Unassigned
39 Unassigned
40 Unassigned
41 Ambulance-Land
42 Ambulance-Air or Water
43 Unassigned
44 Unassigned
45 Unassigned
46 Unassigned
47 Unassigned
48 Unassigned
49 Independent Clinic
50 Federally Qualified Health Center
51 Inpatient Psychiatric Facility
52 Psychiatric Facility- Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/ Individuals with Intellectual Disabilities
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Facility
57 Non-residential Substance Abuse Treatment Facility
58 Unassigned
59 Unassigned
60 Mass Immunication Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
63 Unassigned
64 Unassigned
65 End-stage Renal Disease Treatment Facility
66 Unassigned
67 Unassigned
68 Unassigned
69 Unassigned
70 Unassigned
71 Public Health Clinic
72 Rural Health Clinic
73 Unassigned
74 Unassigned
75 Unassigned
76 Unassigned
77 Unassigned
78 Unassigned
79 Unassigned
80 Unassigned
81 Independent Laboratory
82 Unassigned
83 Unassigned
84 Unassigned
85 Unassigned
86 Unassigned
87 Unassigned
88 Unassigned
89 Unassigned
90 Unassigned
91 Unassigned
92 Unassigned
93 Unassigned
94 Unassigned
95 Unassigned
96 Unassigned
97 Unassigned
98 Unassigned
99 Other Place of Service
Total Units
Encounter Completed by
First Name
Last Name
Date
-
Month
-
Day
Year
Date Picker Icon
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