Coder: Physician Case #

Patient Demographic Information

MRN

Last Name: GOLDBERG

First Name: Stephen

Date of Birth: 11-24-1950

Age: 71

Gender (check one) M F

ICD Diagnosis Codes
DX1	DX2	DX3	DX4
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• Each CPT/HCPCS code should be entered in a separate row
• Enter up to 2 PHYSICIAN modifiers and sequence the modifier that affects reimbursement first
• Enter Physician ID or last name if given
• Link the diagnosis to the appropriate procedure or service; the same dx may be linked to more than one CPT/HCPCS code.

CPT/HCPCS Procedure Codes and OP Reimbursement Information
Date of Service	CPT Code	Units	Modifier 1	Modifier 2	Place of service	Dx link
: 08-11-2021		1.0			11