Claim Form for a Workman’s Comp Patient

Case Study 1-18Use the registration form to complete a CMS-1500 Claim Form for a Workman’s Comp Patient. Open the patient registration information.

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 1. Z47.2 RETAINED HARDWARE Diagnosis Code 5. Diagnosis 2. 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 20680 650 00 1 6. 7.