Allscripts Procedure Code Master File

Allscripts Procedure Code Master File
Complete this request form when a new procedure code must be added to the system. All information is required unless otherwise noted and must be complete for this request to be honored. This form can also be used to request a change to an existing record by noting the information that is to be revised.
Procedure Code:
Description:
Modifier(s)
ie: 26, 50, SA, AQ
Rate
Procedure Code:
Description:
Modifier(s)
ie: 26, 50, SA, AQ
Rate
Procedure Code:
Description:
Modifier(s)
ie: 26, 50, SA, AQ
Rate
Procedure Code:
Description:
Modifier(s)
ie: 26, 50, SA, AQ
Rate
Procedure Code:
Description:
Modifier(s)
ie: 26, 50, SA, AQ
Rate
Procedure Code:
Description:
Modifier(s)
ie: 26, 50, SA, AQ
Rate
Procedure Code:
Description:
Modifier(s)
ie: 26, 50, SA, AQ
Rate
Procedure Code:
Description:
Modifier(s)
ie: 26, 50, SA, AQ
Rate
If request is more than 10 please upload here:

Upload a File

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Procedure Code Note Optional :
Is this note an Insurance Carrier requirement?:
Is this a New Code:
Fee Change Only:
Need RVU Loaded?
RVU Value:
Effective Date:

MonthDayYear
Termination Date:

MonthDayYear
Group Code(s)
Facility Code(s)
Effective Date of Rate:
TOS Code:
Global Aftercare Days:
Insurance Carriers to add to:
HPSA AQ Modifier eligible:
AQ Modifier Facility Codes:
Special Instructions:
Procedure Additional Information – used in charge entry – please check response
Stop Date of Service:
Stop at Units:
Units Default:
enter the standard number of units charged for the procedure
Multiply Units:
Stop at Amount:
Last Visit Date Update:
Submitted By:

First NameLast Name
Date Submitted

MonthDayYear
Phone Number

Area CodePhone Number
Fax

Area CodePhone Number
E-mail
Internal Use
Status:
Status Details:
Vision Request Completed By:

First NameLast Name
Date:

MonthDayYear
Enterprise Request Completed By:

First NameLast Name
Date:

MonthDayYear
Completed Upload

Upload a File

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Patricia Cochran Notified if applicable for update in EPIC?(pcochran@stfranciscare.org)
Should be Empty:

Allscripts Procedure Code Master File

Procedure Additional Information – used in charge entry – please check response