I-1
RUC Staff / Time WC Staff / Time in Your PracticeRUC Staff / Time WC Staff / Time in Your PracticeRUC Staff / Time WC Staff / Time in Your PracticeRUC Staff / Time WC Staff / Time in Your PracticeRUC Staff / Time
WC Staff / Time in Your Practice RN/LPN/MTARN/LPN/MTARN/LPN/MTARN/LPN/MTARN/LPN/MTA s made s23444 ---------- ice RN/LPN/MTARN/LPN/MTARN/LPN/MTARN/LPN/MTARN/LPN/MTA 33333 55556 22222 tions613151516 ies22222 35668 5991213 --2658 33333 ---------- RN/LPN/MTARN/LPN/MTARN/LPN/MTARN/LPN/MTARN/LPN/MTA s, family, 56869 fice visit is made 3653636373
9924499245992139921499215
RUC Equipment Used
Do you use this equipment when providing this service to workers' compensation patients? yes or
no RUC Equipment Used
Do you use this equipment when providing this service to
workers' compensation patients? yes or no
Otoscope-opthalmoscope Otoscope-opthalmoscope
Exam table Exam table
RUC Equipment Used
Do you use this equipment when providing this service to workers' compensation patients? yes or
no RUC Equipment Used
Do you use this equipment when providing this service to
workers' compensation patients? yes or no
Otoscope-opthalmoscope Otoscope-opthalmoscope
Exam table Exam table
RUC Equipment Used
Do you use this equipment when providing this service to workers' compensation patients? yes or
no RUC Equipment Used
Do you use this equipment when providing this service to
workers' compensation patients? yes or no
Otoscope-opthalmoscope Otoscope-opthalmoscope
Exam table Exam table
RUC Equipment Used
Do you use this equipment when providing this service to workers' compensation patients? yes or
no RUC Equipment Used
Do you use this equipment when providing this service to
workers' compensation patients? yes or no
Otoscope-opthalmoscope Otoscope-opthalmoscope
Exam table Exam table
The AMA RUC has accepted the following medical equipment for medical services. Please list procedure-specific medical equipment which your practice has purchased/leased and used in providing these services to workers' compensation patients. Include only equipment with a purchase price of $500 or more that is easily attributale to this service (e.g., an EKG machine for EKG codes; an X-ray view box for fracture services; or parallel bars for therapy services).
99203: Office/outpatient visit, new, presenting problems are of moderate severity.
99204: Office/outpatient visit, new, presenting problems are of moderate severity.
If other equipment is used when providing this service to workers' compensation patients then list below:
If other equipment is used when providing this service to workers' compensation patients then list below:
99212: Office/outpatient visit, established, presenting problems are self-limited/minor.
99213: Office/outpatient visit, established, presenting problems of low to moderate severity.
If other equipment is used when providing this service to workers' compensation patients then list below:
If other equipment is used when providing this service to workers' compensation patients then list below:
99214: Office/outpatient visit, established, presenting problems are of moderate to high severity.
99215: Office/outpatient visit, established, presenting problems of moderate to high severity.
If other equipment is used when providing this service to workers'
compensation patients then list below: If other equipment is used when providing this service to workers' compensation patients then list below:
99244: Office consultation, new/established, presenting problems of moderate to high severity.
99245: Office/outpatient visit, established, presenting problems of moderate to high severity.
If other equipment is used when providing this service to workers' compensation patients then list below:
If other equipment is used when providing this service to workers' compensation patients then list below:
1. 1.
2. 2.
3. 3.
RUC Supplies Used Unit
RUC Units Used E/M Visit Package which consists of:
Drape, sheet 1 item 1
Exam table paper 7 feet 1
Pillow case 1 item 1
Gloves, non-sterile 2 pair 1
Otoscope speculum disposable 1 item 1
Patient education booklet 1 item 1
Patient gown, disposable 1 item 1
Swab, alcohol 2 item 1
Thermometer probe cover, disposable 1 item 1
Tongue depressor 1 item 1
How many units of this supply are used when providing this service to workers' compensation patients?
RUC Supplies Used Unit
RUC Units Used E/M Visit Package which consists of:
Drape, sheet 1 item 1
Exam table paper 7 feet 1
Pillow case 1 item 1
Gloves, non-sterile 2 pair 1
Otoscope speculum disposable 1 item 1
Patient education booklet 1 item 1
Patient gown, disposable 1 item 1
Swab, alcohol 2 item 1
Thermometer probe cover, disposable 1 item 1
Tongue depressor 1 item 1
How many units of this supply are used when providing this service to workers' compensation patients?
The AMA RUC has accepted the following medical supply package for E/M services. Use the E/M Visit Package as a base when determining the medical supplies that are used by your practice while providing E/M services to workers' compensation patients. Include medical supplies that you have purchased and used to provide this service.
Include only supplies that are NOT separately reimbursable. If you use supplies that are not in the E/M Visit Package, then please list those supplies below, along with the units used.
99203: Office/outpatient visit, new, presenting problems are of moderate severity.
If this supply is used when providing this service to workers' compensation patients, how many units are used?
If other supplies are used when providing this service to workers' compensation patients then list below:
99204: Office/outpatient visit, new, presenting problems are of moderate to high severity.
If this supply is used when providing this service to workers' compensation patients, how many units are used?
If other supplies are used when providing this service to workers' compensation patients then list below:
RUC Supplies Used Unit
RUC Units Used
E/M Visit Package which consists of:
Drape, sheet 1 item 1
Exam table paper 7 feet 1
Pillow case 1 item 1
Gloves, non-sterile 2 pair 1
Otoscope speculum disposable 1 item 1
Patient education booklet 1 item 1
Patient gown, disposable 1 item 1
Swab, alcohol 2 item 1
Thermometer probe cover, disposable 1 item 1
Tongue depressor 1 item 1
How many units of this supply are used when providing this service to workers' compensation patients?
RUC Supplies Used Unit
RUC Units Used
E/M Visit Package which consists of:
Drape, sheet 1 item 1
Exam table paper 7 feet 1
Pillow case 1 item 1
Gloves, non-sterile 2 pair 1
Otoscope speculum disposable 1 item 1
Patient education booklet 1 item 1
Patient gown, disposable 1 item 1
Swab, alcohol 2 item 1
Thermometer probe cover, disposable 1 item 1
Tongue depressor 1 item 1
How many units of this supply are used when providing this service to workers' compensation patients?
99212: Office/outpatient visit, established, presenting problems are self-limited/minor.
If this supply is used when providing this service to workers' compensation patients, how many units are used?
If other supplies are used when providing this service to workers' compensation patients then list below:
99213: Office/outpatient visit, established, presenting problems of low to moderate severity.
If this supply is used when providing this service to workers' compensation patients, how many units are used?
If other supplies are used when providing this service to workers' compensation patients then list below:
RUC Supplies Used Unit
RUC Units Used
E/M Visit Package which consists of:
Drape, sheet 1 item 1
Exam table paper 7 feet 1
Pillow case 1 item 1
Gloves, non-sterile 2 pair 1
Otoscope speculum disposable 1 item 1
Patient education booklet 1 item 1
Patient gown, disposable 1 item 1
Swab, alcohol 2 item 1
Thermometer probe cover, disposable 1 item 1
Tongue depressor 1 item 1
How many units of this supply are used when providing this service to workers' compensation patients?
RUC Supplies Used Unit
RUC Units Used
E/M Visit Package which consists of:
Drape, sheet 1 item 1
Exam table paper 7 feet 1
Pillow case 1 item 1
Gloves, non-sterile 2 pair 1
Otoscope speculum disposable 1 item 1
Patient education booklet 1 item 1
Patient gown, disposable 1 item 1
Swab, alcohol 2 item 1
Thermometer probe cover, disposable 1 item 1
Tongue depressor 1 item 1
How many units of this supply are used when providing this service to workers' compensation patients?
99213: Office/outpatient visit, established, presenting problems of low to moderate severity.
If this supply is used when providing this service to workers' compensation patients, how many units are used?
If other supplies are used when providing this service to workers' compensation patients then list below:
99214: Office/outpatient visit, established, presenting problems are of moderate to high severity.
If this supply is used when providing this service to workers' compensation patients, how many units are used?
If other supplies are used when providing this service to workers' compensation patients then list below:
1.
RUC Supplies Used Unit
RUC Units Used
E/M Visit Package which consists of:
Drape, sheet 1 item 1
Exam table paper 7 feet 1
Pillow case 1 item 1
Gloves, non-sterile 2 pair 1
Otoscope speculum disposable 1 item 1
Patient education booklet 1 item 1
Patient gown, disposable 1 item 1
Swab, alcohol 2 item 1
Thermometer probe cover, disposable 1 item 1
Tongue depressor 1 item 1
How many units of this supply are used when providing this service to workers' compensation patients?
RUC Supplies Used Unit
RUC Units Used
E/M Visit Package which consists of:
Drape, sheet 1 item 1
Exam table paper 7 feet 1
Pillow case 1 item 1
Gloves, non-sterile 2 pair 1
Otoscope speculum disposable 1 item 1
Patient education booklet 1 item 1
Patient gown, disposable 1 item 1
Swab, alcohol 2 item 1
Thermometer probe cover, disposable 1 item 1
Tongue depressor 1 item 1
How many units of this supply are used when providing this service to workers' compensation patients?
99215: Office/outpatient visit, established, presenting problems are of moderate to high severity.
If this supply is used when providing this service to workers' compensation patients, how many units are used?
If other supplies are used when providing this service to workers' compensation patients then list below:
99244: Office consultation, new/established patient, presenting problem(s) of moderate to high severity.
If this supply is used when providing this service to workers' compensation patients, how many units are used?
If other supplies are used when providing this service to workers' compensation patients then list below:
RUC Supplies Used Unit
RUC Units Used
E/M Visit Package which consists of:
Drape, sheet 1 item 1
Exam table paper 7 feet 1
Pillow case 1 item 1
Gloves, non-sterile 2 pair 1
Otoscope speculum disposable 1 item 1
Patient education booklet 1 item 1
Patient gown, disposable 1 item 1
Swab, alcohol 2 item 1
Thermometer probe cover, disposable 1 item 1
Tongue depressor 1 item 1
How many units of this supply are used when providing this service to workers' compensation patients?
99245: Office consultation, new/established patient, presenting problem(s) of moderate to high severity.
If this supply is used when providing this service to workers' compensation patients, how many units are used?
If other supplies are used when providing this service to workers' compensation patients then list below: