Exercise 12.1: Complete the CMS-1500 claim for Figure 12-3, Mary S. Patient (below) ERIN A. HELPER, M.D. 101 Medic Driv

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Exercise 12.1: Complete the CMS-1500 claim for Figure12-3, Mary S. Patient (below)
ERIN A. HELPER, M.D. 101 Medic Drive, Anywhere, NY 12345 (101)111-1234 (Office) (101) 111-9292 (Fax) EIN: NPI: PATIENTINFORMATION: INSURANCE INFORMATION: Name: Patient, Mary S. PatientNumber: 12-2 Address: 91 Home Street Place of Service: HospitalInpatient City: Nowhere Primary Insurance Plan: Conn General State:NY Primary Insurance Plan ID #: 222017681 Zip Code: 12367-1234Primary Policyholder: James W. Patient Telephone: (101) 201-8989Policyholder Date of Birth: 03-01-1948 Gender: Female Employer:Alstom Date of Birth: 10-10-1959 Relationship to Patient: SpouseOccupation: Homemaker Secondary Insurance Plan: Employer: AlstomSecondary Insurance Plan ID #: Secondary Policyholder: PatientStatus X Married Divorced Single Student DIAGNOSIS INFORMATIONDiagnosis Code Diagnosis Code 1. Abnormal ECG R94.30 5. 2.Prinzmetal angina I20.1 6. 3. Familial combined hyperlipidemiaE78.4 7. 4. 8. PROCEDURE INFORMATION Description of Procedure orService Date Code Charge 1. Initial hospital visit, level III01-07-YYYY 99223 150.00 2. Subsequent hospital visit, level I01-08-YYYY 99231 75.00 3. Discharge visit, 30 minutes 01-09-YYYY99238 75.00 4. 5. SPECIAL NOTES: Case Study 11-1234523 1234567890Date symptoms started: 01-07-YYYY Recheck: 01/17/YYYY HospitalInformation: Goodmedicine Hospital, Anywhere Street, Anywhere, NY12345-1234 (NPI: 2345678901) Referred to: Dr. Cardiac for ThalliumStress test on 01-10-YYYY Figure 12-3 Mary S. Patient case stud