Case 15.16

Prepare the claim for this case by completing the appropriate fields in the CMS-1500 form provided. Accuracy is important. Please note that tabbing through the form works inconsistently; it is recommended that you click in each field for which you want to enter information. For the purposes of Connect, all dates you should be entered in 8-digit format (XX in MM field; XX in DD field; in YY field) except for Section 24, where the dates should be entered in 6-digit format (XX in MM field; XX in DD field; XX in YY field). NOTES: this medical facility does not use an outside lab; the patient’s chart number should be used for the patient account number; we have tried to include information you might need from earlier Case Studies, but please refer back to Chapter 7 if necessary. Be sure to follow NUCC directions for CMS-1500 claim completion in regards to punctuation in addresses. Related to this, do not include punctuation for Item Number 31. Follow Medicare guidelines and abbreviate street addresses (i. e. ST rather than Street). Per NUCC Guidelines, use SOF in this exercise for Signature on File if appropriate. Functionality TIP: if you can't see the entire form and don't have scroll bar functionality (especially if you click "Check my work"), click anywhere in the form and use the arrow keys on your keyboard to help you navigate. Be sure to use the BILLING PROVIDER’S phone number in Item Number 33.

Billing Provider: Valley Associates PC
NPI: 1476543215

Employer ID Number: 16-1234567
Address: 1400 West Center Street, Toledo, OH 43601-0213 (Please note that there is a different ZIP code listed in the text for Valley Associates PC. For these exercises, use the ZIP code provided here.)
Telephone: 555-967-0303
Rendering Provider: Nancy Ronkowski, MD
Employer ID Number: 06-7890123
NPI: 9475830260
Assignment: Accepts
Signature: On File (1-1-2018)

From the Patient Information Form

Name: Sylvia Evans
Sex: F
Birth Date: 06/10/1935
Marital Status: Married
Address: 13 Ascot Way, Sandusky, OH 44870
Telephone: 555-229-3614
Employer: Retired
Race: White
Ethnicity: Not Hispanic or Latino
Preferred Language: English
Insured: Self
Health Plan: TRICARE
Insurance ID Number: 140396602
Copayment/Deductible Amt.: $10 copay
Assignment of Benefits: Y
Signature on File: 05/30/2018
Condition Unrelated to Employment, Auto Accident, or Other Accident
Physician: Nancy Ronkowski, MD

Account No.: EVANSSY0

Encounter Date: 10/15/2018

Diagnoses
The patient presents with postmenopausal bleeding due to estrogen deficiency.

Procedures
Saw this established patient in the office for a follow-up visit on her postmenopausal bleeding. Performed a problem-focused history and exam with straightforward decision making.