MEPS-MPC-Institutional

NODE ID:
PROVIDER ID:

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

PROVIDER NAME: ___________________________________
HOST NAME:

___________________________________

HOST ID:

___________________________________

PATIENT NAME:

___________________________________

EVENT TYPE:

___________________________________

EVENT DATE:

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

DIAGNOSES CONTINUATION SHEET
FOR
SEPARATELY BILLING DOCTORS FOR REFERENCE YEAR 2005

B4a. I need the diagnoses for (this visit/these visits). I would
prefer the ICD-9 codes (or the DSM-4 codes), if they
are available.
[IF CODES ARE NOT USED, RECORD
DESCRIPTIONS.]

CODE
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DESCRIPTION
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___________________

|__|__|
OFFICE

B4b. Which of these was the principal diagnosis?

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___________________

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___________________

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___________________

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___________________

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___________________

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___________________

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___________________

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___________________

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___________________

|__| _____________

___________________

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___________________

|__| _____________

___________________

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___________________

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___________________

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___________________

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___________________

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___________________

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___________________

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___________________

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___________________

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IF ONLY ONE DIAGNOSIS, GO TO B5a.
IF MORE THAN ONE DIAGNOSIS:
„ CHECK BOX FOR PRINCIPAL
DIAGNOSIS
„ CIRCLE '-8' IF PRINCIPAL
DIAGNOSIS NOT KNOWN............... -8

M:\7690\7690.19.04\MPC 2005\Forms\SBD\SBD B4a ContSheet.doc - 1/26/2006 - 12:01 PM - SH

USE
ONLY