Based on this scenario, complete blocks 21 and 24 of CMS 1500

5/1/10 New F pt comes in complaining of lt great toe pain. Incised, drained, and cleaned area around nail on lt great toe. Dx. Onychia and paronychia. Started on antibiotic and adv to retn in 2 days for permanent excision of nail plate (EPF HX/PX SF/MDM).
5/3/10 Pt returns for nail excision; injected procaine in lt great toe; removed entire toenail. Drs applied. PTR in 5 days for PO check
5/7/10 PO check. Dressing changed, nail bed healing well. Pt to continue on AB until gone. Retn PRN (PF HX/PX SF/MDM).

21. DIAGNOSIS

24 A.DATES OF SERVICE B. PLACE OF SERVICE C. EMG D. PROCEDURES, SERVICES OR SUPPLIES E. DIAGNOSIS POINTER G. DAYS OF UNIT

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I am unsure what code is needed on the CMS-1500 form on section 21-24 can you help?
What does the PF HX PX means. I' looking in the Evaluation and Management/Consultations section, can't locate the answer. Please help.
PF=Problem Focused, HX PX=History and Physical Examination.
diagnose is 681.11 E/M 99202, I&D great toe 10060 modifier TA, Excision great toe 11750 modifier TA, and 99024 PO check..
po check
CMS 1500 FORM
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