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200 Chapter 13 Instructions clical scanning guidelines to complete a CMS-1500 for case studies 13-A and 13-8. Obtain a blank claim by making a copy of the CMS-1500 claim in Appendix I of the textbook Refer to the CMS-1500 claims completion instructions (primary) in the textbook Case Study 13-A Donald L. Givings, M.D. 11350 Medical Drive Anywhere NY 12345 (101)111-5555 EN: 15-1234562 NP1234567800 PATIENT INFORMATION: INSURANCE INFORMATION: Nama Patent Number Monty L. Bocker Address: Place of Service 47 Snowflake Road City: Anywhere Prinary Insurance Plan Primary Insurance Plan 10 Group NY 12345 Zip Code: Telephone: Gender (101) 333-5555 Male Primary Policyholder Policyholder Date of Birth Date of Birth 12-25-1006 Occupation Relationship to Patient Secondary Insurance Plan Bahor Employer: Atlanta Publisher Secondary Insurance Plan ID: Spouse's Employer: Secondary Policyholder: Patient Status Married Divorced Single DIAGNOSIS INFORMATION Diagnosis Code 1. Abnormal loss of weight 5 2. Polydipsia 6. 3. Polyphaga 7. PROCEDURE INFORMATION Description of Procedure or Service Date 1. New patient 0V level II Charge $100.00 $10.00 01-19-YYYY 01-10 YYYY 2. Urinalysis, with microscopy 3 5. SPECIAL NOTES: Return visit: 3 weeks Ⓒ2021-Cengage Learning inc. May not be scanned copied or duplicated, or posted to a publicly accessible in whole or in part Diagnosis Code ISA Offe BLUBCROSS BLUESHIELD XXY878223434 Monty L. Booker 12-45-1966 Student □oher Code
Donald L. Givings, M.D. 350 Medical Drive Anywhere NY 12345 (101) 111-5555 EN 11-1234562 NP1234567890 PATIENT INFORMATION: Anita B. Strong Name 124 Prosper Way Address Anywhere NY 12345 (101) 333-6655 Female 04-25-1959 Author Anywhere Weekly News Married City: State: Zip Code Telephone: Gender: Date of Birth: Occupation: Employer: Spouse's Employer: Patient Status 201 BlueCross BlueShield Case Study 13-B INSURANCE INFORMATION: Patient Number: Place of Service: Primary Insurance Plan Primary Insurance Plan ID#: Group #: Primary Policyholder: Policyholder Date of Birth: Relationship to Patient: Secondary Insurance Planc Secondary Insurance Plan ID#: Secondary Policyholder: Divorced Single DIAGNOSIS INFORMATION Diagnosis Code 1. Migraine, classical 2 7. PROCEDURE INFORMATION Code Description of Procedure or Service 1. Est. patient OV level I Date 11-07-YYYY Charge $55.00 2 SPECIAL NOTES: Return visit: PRN Patient paid $20.00 toward today's bill. Ⓒ2021 Cengage Leaming, Inc. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part Diagnosis 13-8 Office BLUECROSS BLUESHIELD XW0214566666 Anita B. Strong 04-25-1960 Self Student Code other