Case Study 1-18

Use the registration form to complete a CMS-1500 Claim Form for a Workman’s Comp Patient.

Open the patient registration information.

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Open a blank fillable CMS-1500 form.

When doing this assignment, remember to:

·         Use the NUCC Instructions to complete your CMS-1500

·         Review your completed form for errors

Case Study 1-18
Iona J. Million
ANGELA DILALIO MD
99 PROVIDER DRIVE
INJURY NY 12347
101 2014321
EIN: 111982342
PATIENT INFORMATION:
Name: MILLION, IONA, J
Address: 100A PASTURES COURT
City: ANYWHERE
State: NY
Zip/4: 12345-1234
Telephone: 101 7590839
Gender: M F x
Status: Single Married Other
Date of Birth: 01 01 1970
Employer: ANYWHERE GOLF COURSE
Student: FT PT School:
Work Related? Y x N
Auto Accident? Y N x State:
Other Accident: Y N x
Date of Accident: 09 08 YYYY
Referring Physician:
Address:
Telephone:
NPI #:
Patient Number: 1-18
NPI: 4567890123
Primary Insurance Name: DFEC
Address: 21 WASHINGTON AVE
City: FEDERAL
State: MD
Zip/4: 10001
Plan ID#: 235568956
Group #: 10173
Primary Policyholder: ANYWHERE GOLF COURSE
Address: ROUTE 20
City: GOLF
State: NY
Zip/4: 12348-1234
Policyholder Date of Birth:
Pt Relationship to Insured: Self Spouse Child Other x
Employer/School Name: ANYWHERE GOLF COURSE
INSURANCE INFORMATION:
Primary Insurance
Secondary Insurance
Secondary Insurance Name:
Address:
City:
State:
Zip/4:
Plan ID#:
Group #:
Primary Policyholder:
Address:
City:
State:
Zip/4:
Policyholder Date of Birth:
Pt Relationship to Insured: Self Spouse Child Other
Employer/School Name:
ENCOUNTER INFORMATION:
Place of Service: 22
DIAGNOSIS INFORMATION
PROCEDURE INFORMATION
Description of Procedure/Service

  1. REMOVAL, INTERNAL FIXATION DEVICE, LT ANKLE, DEEP
    Dates Code Mod
    Unit
    Charge
    Days/
    Units
    Code
  2. Z47.2 RETAINED HARDWARE
    Diagnosis Code
    5.
    Diagnosis
  3. Z98.890 STATUS POST FRACTURE SURGERY
    3.M25.572 PAIN, HEALED FRACTURE SITE, LEFT ANKLE
    4.M84.472S DUE TO PREVIOUS PATH FRACTURE, LEFT ANKLE
    3.
    4.
    5.
    6.
    Special Notes: HOSPITAL INFO: GOODMEDICINE HOSPITAL, 1 PROVIDER ST, ANYWHERE, NY 12345, NPI: 1123456789. CLAIM# 10173
    DOI: 09/08/YYYY. PT MAY RETURN TO WORK 04/01/YYYY. ADMISSION/DISCHARGE DATE: 03/10/YYYY.
    PATIENT’S SSN IS 235-56-8956. DIVISION OF FEDERAL EMPLOYEE’S COMPENSATION (DFEC)
    03 10YYYY 2

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