MEPS-MPC-Office Based

NODE ID:
PROVIDER ID:

___________________________________
|___|___|___|___|___|___|

PROVIDER NAME: ___________________________________
HOST NAME:

___________________________________

HOST ID:

___________________________________

PATIENT NAME:

___________________________________

EVENT TYPE:

___________________________________

EVENT DATE:

_____/_____/_____ (to _____/_____/_____)

SERVICES AND CHARGES CONTINUATION SHEET
FOR
SEPARATELY BILLING DOCTORS FOR REFERENCE YEAR 2005

B5a. I need to know what services were provided during
(this visit/these visits). I would prefer the CPT-4
codes, if they are available.
[IF CPT-4 CODES ARE NOT USED, RECORD
DESCRIPTIONS OF SERVICES AND
PROCEDURES PROVIDED.]
B5b. ASK FOR EACH CPT-4 CODE OR DESCRIPTION:
What was the full established charge for this
service, before any adjustments or discounts?
[EXPLAIN IF NECESSARY: The full established
charge is the charge maintained in the physician’s
billing system for billing insurance carriers and
Medicare or Medicaid. It is the “list price” for the
service, before consideration of any discounts or
adjustments resulting from contractual arrangements
or agreements with insurance plans.]
[IF NO CHARGE: Some practices that don't charge
for each individual service do associate dollar
amounts with services for purposes of budgeting or
cost analysis. This is sometimes called a "charge
equivalent." Could you give me the charge
equivalents for these procedures? ]

C2. [IF NOT VOLUNTEERED, ASK:] And what was the
total? [IF NOT AVAILABLE, COMPUTE.]

CPT-4 (including
modifier)

Full established charge
at time of visit or
charge equivalent

l. ___________________

$___________.__

m. ___________________

$___________.__

n. ___________________

$___________.__

o. ___________________

$___________.__

|__|__|
OFFICE
USE
ONLY

p. ___________________

$___________.__

q. ___________________

$___________.__

r. ___________________

$___________.__

s. ___________________

$___________.__

t. ___________________

$___________.__

u. ___________________

$___________.__

v. ___________________

$___________.__

w. ___________________

$___________.__

x. ___________________

$___________.__

y. ___________________

$___________.__

z. ___________________

$___________.__

aa. ___________________

$___________.__

bb. ___________________

$___________.__

cc. ___________________

$___________.__

dd. ___________________

$___________.__

ee. ___________________

$___________.__

ff. ___________________

$___________.__

TOTAL CHARGES

$___________._
_

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