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e0205503AS02C-44

Medical Coding and Billing SpecialistPack 2

No part of this document may be reproduced or transmitted in any form or by any means, electronic or mechanical, for any purpose, without the express written permission of U.S. Career Institute.

Copyright © 2014, Weston Distance Learning, Inc. All Rights Reserved. e0205503AS02C-44

FOR MORE INFORMATION CONTACT:

U.S. Career InstituteFort Collins, CO 80525

www.uscareerinstitute.edu

Student Assignment Pack 2

Instructions for Quizzes1. Be sure you’ve mastered the Lessons and Practice Exercises that this Quiz covers.2. Mark your answers on the Quiz, and make sure to check your answers by reviewing the Lessons.3. When you’re finished, decide how you will submit your answers and then follow the correct

instructions below. You may only submit your answers for a Quiz once. Important: When submitting your Quiz, be sure to include your name, address, student ID number and course code. Incomplete information may result in your Quiz not being processed.

Scanner Quiz InstructionsFor a Quiz that contains only multiple-choice questions, please select the method of submission:

● Online: Submit your answers online and receive your grade immediately by submitting them to the student site, www.uscareerinstitute.edu.

● Phone: Call the Quiz Line at 1-877-599-5857 and give your answers over the phone to receive your grade immediately.

● Mail: Scanner Answer Sheets and envelopes are included with each Assignment Pack. Transfer your Quiz answers to the Scanner Answer Sheet, using only blue or black ink. Mail your Scanner Answer Sheet using the enclosed envelope.

Instructor-Graded Quiz InstructionsFor the quickest response to instructor-graded Quizzes, simply e-mail your completed Quiz as an attachment to your instructor at [email protected]. In most cases, you will receive the graded Quiz back via e-mail within three business days.

To ensure your instructor can grade your Quiz electronically, please create documents using one of the following preferred software programs: Microsoft® Word, Microsoft® Works or WordPerfect®. Make sure to include your name, student ID, course code and Quiz number in the subject line of your e-mail. Include your address in the e-mail. Finally, please note that these instructions only apply to handwritten Quizzes. Thank you and good luck!

For a Quiz that contains Instructor-graded questions, please select the method of submission:

● Online: Submit your answers online for an instructor to review and grade by submitting them to the student site, www.uscareerinstitute.edu.

● Mail or Fax: Answer Sheets and envelopes are included with each Assignment Pack. Transfer your Quiz answers to the Answer Sheet, using only blue or black ink. Mail your Cover Sheet and Answer Sheet using the enclosed envelope, or fax the forms to 1-877-599-5863.

After you have submitted your Quiz answers, you may begin the next lesson. You do not need to wait for your Quiz results to move on to the next lesson!

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Medical Coding and Billing Specialist

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Quiz 11: Determining PaymentThis is a Scanner Quiz that should be submitted according to the instructions at the beginning of this pack.

Determine if each statement is true or false. Each item is worth 5 points.

1. Offices cannot have more than one fee schedule for each procedure.a. Trueb. False

2. Fee-for-service refers to the amount that most physicians in the community normally charge.a. Trueb. False

3. Medicare used the UCR method for payment in the 1970s.a. Trueb. False

4. The nationally uniform relative value is based on physician work, practice expense and malpractice expense.a. Trueb. False

5. The physician work component includes the physicians’ time and mental effort.a. Trueb. False

6. Global payment method is a one lump-sum payment.a. Trueb. False

7. DRGs are based on diagnosis and procedure codes alone.a. Trueb. False

8. Each DRG contains a range of costs and lengths of stay.a. Trueb. False

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9. DRGs are classified into major diagnostic categories.a. Trueb. False

10. The APC classification system was designed to specify the amount and type of resources used for each outpatient visit.a. Trueb. False

Select the best answer from the choices provided. Each item is worth 5 points.

11. The _____ is an adjustment for location of the practice.a. practice expenseb. conversion factorc. relative value unitd. geographic practice cost index

12. Which is not a true statement regarding capitation?a. The level of services is not reflected in the overall physician payment.b. It’s a set dollar amount determined by the patients enrolled in the program.c. The physician is paid by the number of times the patient is seen in the year.d. The dollar amount is determined by the per member per month calculations.

13. Utilization review is a process intended to ensure that the care a patient receives _____. a. is medically necessaryb. is delivered in the most appropriate locationc. follows generally accepted medical standardsd. all of the above

14. Which statement is true of DRGs?a. DRGs cover provider’s fees.b. They reimburse for provider fees.c. DRGs reimburse for facility use and resources. d. They specify the amount and type of resources used for each outpatient visit.

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15. _____ require patients to have additional time in the hospital.a. APCsb. DRGsc. Outliersd. Provider fees

16. Which is a false statement of a DRG monitor?a. It helps to simplify budget and cost planning.b. It helps the facility receive maximum payment. c. The DRG monitor reviews current fee schedules to ensure fee accuracy.d. The DRG ensures providers receive maximum payments for their services.

17. APCs cover _____.a. home visitsb. ED physiciansc. nursing homesd. emergency department

18. The payments are calculated by multiplying the APC’s relative weight by _____.a. practice expenseb. a conversion factorc. geographic practice cost indexd. the physician’s work component

19. The APCs are classified by ____ procedures while DRGs use ICD-10-PCS.a. CPTb. surgicalc. medicald. emerging technology

20. _____ is/are assigned per clinic visit.a. Multiple DRGsb. Multiple APCsc. Only one APCd. Only one DRG

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Quiz 12: Introduction to AnatomyThis is a Scanner Quiz that should be submitted according to the instructions at the beginning of this pack.


1. The study of how the body is put together and how it works in health and disease is called _____.a. anatomyb. human biologyc. gross anatomyd. macroscopic anatomy

2. The science of the structure of the body is called _____.a. anatomyb. morphologyc. human biologyd. cell physiology

3. There is/are _____ kind(s) of anatomy.a. oneb. twoc. manyd. three

4. Anatomy that includes parts of the body too small to be seen by the naked eye is called _____ anatomy.a. gross b. physicalc. microscopicd. macroscopic

5. The study of how the body works is _____.a. anatomyb. physiologyc. pathologyd. morphology

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6. The names of body parts, the location of body parts and the relationship of two or more body parts all are included in _____ anatomy.a. gross b. physicalc. microscopicd. morphology

7. Microscopic physiology is usually called _____.a. human biologyb. cell physiologyc. pathophysiologyd. macroscopic anatomy

8. The study of human biology when anatomy and/or physiology is abnormal is called _____.a. anatomyb. physiologyc. pathologyd. morphology

9. A person _____ have abnormal physiology and normal anatomy.a. can b. cannot

10. Abnormal physiology is sometimes called _____.a. human biologyb. cell physiologyc. pathophysiologyd. macroscopic anatomy

11. The _____ branch of a nerve carries a message to the brain from a muscle.a. afferentb. efferentc. superiord. transverse

12. A(n) _____ artery carries blood away from the heart.a. afferentb. efferentc. superiord. transverse

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13. A sagittal plane made slightly to one side or the other of the midline is called a(n) _____ plane.a. unevenb. superiorc. transversed. parasagittal

14. The heart, blood vessels and lymph vessels are part of the _____ system.a. endocrineb. respiratoryc. cardiovasculard. musculoskeletal

15. If a doctor describes the size, shape, color, contour and texture of a body part, he is talking about _____.a. anatomyb. physiologyc. pathologyd. morphology

16. In the anatomic position, the chin is anterior and _____ to the heel.a. deepb. inferiorc. superiord. transverse

17. The antonym of superficial is _____.a. deepb. inferiorc. superiord. transverse

18. A(n) _____ plane divides the body into superior and inferior sections.a. deepb. inferiorc. superiord. transverse

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19. The opposite of ventral is _____.a. deepb. dorsalc. afferentd. efferent

20. In the anatomic position, the palms of the hands are facing _____.a. forwardb. backward

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Quiz 13: Anatomy: Landmarks and Divisions This is a Scanner Quiz that should be submitted according to the instructions at the beginning of this pack.

Select the best answer from the choices provided. Remember, you may use your flashcards to answer these items. Each item is worth 5 points.

1. _____ anatomy refers to the study of body parts and systems that can be seen without the aid of a microscope.a. Grossb. Cellularc. Epitheliald. Microscopic

2. The study of the surface of the body is often called _____ anatomy.a. supineb. surfacec. subdurald. superficial

3. When the body is _____, it is lying flat on its back.a. proneb. supinec. transversed. superficial

4. When the body is lying _____, it is face down.a. proneb. supinec. transversed. subdural

5. When doctors examine the abdomen, they mentally divide the abdomen into _____ areas or regions.a. twob. sixc. nined. three

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6. A simpler method of division is the quadrant method. Each quadrant is _____ of the abdominal region.a. one-halfb. one-fifthc. one-tenthd. one-fourth

7. Body cavities have two functions: _____ the organs and keeping the organs in a fairly constant location.a. movingb. nourishingc. developingd. protecting

8. The two principal body cavities are the _____ body cavity and the ventral body cavity.a. dorsalb. centralc. nervousd. cranial

9. Body membranes come from two basic tissue groups: _____ tissue and connective tissue.a. serousb. epithelialc. endocrined. exoskeletal

10. Epithelial membranes include _____ membrane, mucous membrane and serous membrane.a. cranialb. cutaneousc. connectived. keratinized layer

11. The mucous membranes often secrete _____, which prevents body cavities from drying out.a. melatoninb. lymphc. mucusd. serosa

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12. Muscle tissue _____.a. can extend and contractb. connects other types of tissuesc. covers every surface of the bodyd. makes up the spinal cord and peripheral nerves

13. The brain and spinal cord are protected by _____.a. mucusb. meningesc. thoracic fluidd. the mediastinum

14. The largest serous membrane of the body is called the _____, and it protects the abdominopelvic cavity.a. craniumb. thoracicalc. peritoneumd. synovial membrane

15. An organ outside of the abdominal cavity is known as a _____ organ.a. meninxb. systemicc. dysfunctionald. retroperitoneal

16. The _____ line(s) the joints of the shoulders, knees and toes.a. spinal meningesb. parietal peritoneumc. synovial membranesd. cutaneous membranes

17. _____ tissue covers every surface of the body.a. Brainb. Musclec. Epitheliald. Connective

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18. _____ tissue connects other types of tissues.a. Brainb. Musclec. Epitheliald. Connective

19. _____ is/are the smallest unit in the body.a. A cellb. Tissuec. A systemd. Membranes

20. You encounter the phrase, “RLQ pain—onset and history not typical for appendicitis.” You know that the acronym RLQ stands for _____.a. right or left quadrantb. right lower quadrantc. really lasting quinined. region of lower quadrant

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Quiz 14: Cell and Tissue Anatomy and PathologyThis is a Scanner Quiz that should be submitted according to the instructions at the beginning of this pack.

Select the best answer from the choices provided. Remember, you may use your flashcards to answer these items. Each item is worth 5 points.

1. _____ are the building blocks of the body.a. Cellsb. Organsc. Tissuesd. Organ systems

2. The _____ is made up of proteins, lipids and carbohydrates that provide energy to the cell.a. DNAb. nucleusc. cytoplasmd. cell membrane

3. _____ contains other cellular structures called organelles.a. RNAb. Cytoplasmc. The cell membraned. The Golgi apparatus

4. Lysosomes are membrane-bound bodies, or sacs of _____, in the digestive part of the cell.a. waterb. proteinc. enzymesd. carbohydrates

5. The _____ is an organelle that packages proteins and other products of a cell for delivery to the rest of the body.a. vacuoleb. centriolec. ribosomed. Golgi apparatus

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6. _____ is a term used for any diseases or conditions where the etiology is unknown.a. Iatrogenicb. Idiopathicc. Inflammationd. Immunologic

7. Intracellular accumulation is a type of _____.a. tissue deathb. inflammationc. cell adaptationd. allergic reaction

8. Inflammation has _____ symptoms or signs.a. fourb. threec. manyd. no visible

9. _____ is caused when swelling of the tissues pinches nerve cells.a. Painb. Agingc. Deathd. Redness

10. Pseudomembranous inflammation is a form of _____ inflammation combined with fibrinopurulent drainage.a. chronicb. subacutec. ulceratived. granulomatous

Select the correct term(s) to match the definition. Each item is worth 5 points.

11. The decreased availability of oxygen to the cells _____ a. Virusesb. Hypoxiac. Atrophyd. Chronic Inflammation

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12. Type of microbial pathogens that invade cells and destroy them _____a. Virusesb. Hypoxiac. Aging of the celld. Irreversible injury

13. The natural process that causes illness and eventual death due to cells being unable to regenerate _____a. Virusesb. Hypoxiac. Aging of the celld. Irreversible injury

14. Injury caused by the inappropriate application of force or toxic agents _____a. Traumab. Hypoxiac. Aging of the celld. Irreversible injury

15. Diabetes mellitus and Tay-Sachs disease are examples of this type of cell injury _____a. Atrophyb. Metaplasiac. Metabolic/geneticd. Allergic/immune reactions

16. The term used to describe decreases in size of a cell, tissue, organ, or body _____a. Atrophyb. Metaplasiac. Metabolic/geneticd. Allergic/immune reactions

17. Disorders in which the body’s defense mechanisms try to destroy their own cells _____a. Atrophyb. Metaplasiac. Metabolic/geneticd. Allergic/immune reactions

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18. Occurs when cells change from one type to another _____a. Atrophyb. Metaplasiac. Metabolic/geneticd. Allergic/immune reactions

19. Injury to the cell that cannot be stopped _____a. Traumab. Hypoxiac. Aging of the celld. Irreversible injury

20. Infections that don’t completely heal, slow injury, and slow allergic irritation _____a. Virusesb. Hypoxiac. Atrophyd. Chronic Inflammation

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Quiz 15: Introducing the CMS-1500 Claim FormThis is an Instructor-graded Quiz that should be submitted according to the instructions at the beginning of this pack.

Determine the correct term(s) to complete each sentence. Each item is worth 1 point.

1. 484 and 01/19/XX in field 14 means the patient’s _____ was on 01/19/XX.

2. Complete field 22 with the original _____ to show proof of timely filing on Medicaid claims that are resubmitted.

3. Complete _____ only when the number is different from the data provided in field 33a.

4. _____ use punctuation in the patient’s street address.

5. Enter the _____ name in field 4 for workers’ compensation claims.

6. Even though the field is labeled MM DD YY, you will enter a _____-digit year for all birth dates.

7. If there is not an insurance primary to Medicare, enter the word _____ into field 11.

8. For field 1a, you will use the _____ for TRICARE claims.

9. For field 6, a _____ as defined by the insurance plan is a child.

10. If field 11d is marked yes, you will complete fields _____.

11. If Martin Davis, MD is the ordering provider and James Scott, MD is the referring provider, you will enter _____ in field 17.

12. If both EIN and SSN are provided, use the _____.

13. In field 21, the _____ identifies the ICD code set being used on the claim.

14. Only one diagnosis pointer is allowed per procedure for _____ claims.

15. The _____ helps determine which health plan is the primary policy.

16. The _____ is entered in the white space on the top right side of the claim form.

17. The _____ is issued by the Internal Revenue Service (IRS) and is used for 1099 taxable income reporting purposes.

18. The _____ provider is the person or company who provides the actual care.

19. Leave field 24H blank for Medicare and _____ claims.

20. Mark _____ in field 1 for a workers’ compensation claim.

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For items 21 and 22, complete the CMS-1500 form. Each claim form is worth 40 points.

For the Quiz, you will be graded on your ability to complete the claim forms correctly by hand, which requires your instructor to see the forms. If you plan to mail or fax in the Quiz, you can use the Quiz Cover Sheet and claims included. However, we encourage you to send this Quiz by e-mail. Simply contact your instructor by phone or e-mail, and request a PDF claim form. A blank PDF claim form will be e-mailed to you with instructions on how to complete the claim forms for this Quiz.

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21. Complete the entire CMS-1500 version 02/12 claim form for Brandon Niles, using the encounter form below.

Austin Fredrick, MD 11 Physician Office 24 Mockingbird Lane 12 Private Residence Yampa, CO 80004-4719 22 Outpatient Hospital (970) 555 -2024 23 Hospital Emergency Room

Physician signature: Austin Fredrick, MD Participating Provider Y N

EIN: 80-1001509 NPI: 01-55011830

Patient Information Name Brandon C. Niles Date of Birth 04-15-2010 Address 2777 Lincoln Ave Sex Male City Yampa State CO ZIP 80004 Home Phone 970-555-9111

Insurance Information Primary Insurance Secondary Insurance Name Net Life Name Blue Cross of CO ID# 38-40848 ID# 768311900 Group# 629 Group# 318 Address PO Box 32 Address PO Box 99 City Yampa City Yampa State CO ZIP 80004-0629 State CO ZIP 80004-2299 Primary Insured Name Gary Travis Niles Secondary Insured Name Theresa K. Niles Relation to Patient father Relation to Patient mother DOB/Sex 1-29-1977 Male DOB/Sex 11-16-1977 Female Address 2777 Lincoln Ave Address 2777 Lincoln Ave City Yampa State CO City Yampa State CO ZIP 80004 ZIP 80004 Phone 970-555-9111 Phone 970-555-9111 I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Gary Niles Signature of patient (or parent of minor child)

I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Theresa K. Niles Signature of patient (or parent of minor child)

Date of Service 11-18-XX Injury Date 11-18-XX Diagnosis Procedure ChargeS53.401A Elbow sprain 99212 Office visit, Est. Patient $50.00 W14.XXXA Y92.830 Y99.0 Today’s Charge $50.00 Cash/Check $0.00 Balance $50.00

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22. Complete the entire CMS-1500 version 02/12 claim form for Bonnie Schmidt, using the encounter form below.

Luke R. Johnson, MD Laura K. Knott, MD Charles Peterson, MD NPI: 0657490049 NPI: 0405891109 NPI: 0275695402

Medical Care Center 100 South Main

Brown, CO 80001-9898 (970) 555-1111

Physician signature: Laura K. Knott, MD 11 Physician Office Group NPI: 06-65544004 12 Private Residence EIN: 99-7653456 22 Outpatient Hospital CLIA#: CM8402 23 Hospital Emergency Room Participating Provider Y N

Patient Information Name Bonnie K. Schmidt Date of Birth June 25, 1962 Address 1810 Bluegrass Drive Sex F City Springtown State CO ZIP 80002 Home Phone 970-555-9041

Insurance Information Primary Insurance Secondary Insurance Name Health Services Inc. Name CHAMPVA ID# 560-1113 ID# 635-00-7213 Group# 208 Group# Address PO Box 324 Address 4500 Cherry Creek Drive City Springtown City Denver State CO ZIP 80002-0324 State CO ZIP 80222-0009 Primary Insured Name Bonnie Secondary Insured Name Richard J. Schmidt Relation to Patient self Relation to Patient spouse DOB/Sex Sept 15, 1962 Male Address 1810 Bluegrass Drive City Springtown State CO ZIP 80002 Phone 970-555-9041 I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

BBonnie K. Schmidt Signature of patient (or parent of minor child)


Richard J. Schmidt Signature of patient (or parent of minor child)

Date of Service 5-6-XX Diagnosis Procedure ChargeM20.11 Bunion 99211 Office visit, Est. Patient $45.00 Today’s Charge $45.00 Cash/Check $5.00 Balance $40.00

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Fold on dotted line

This Space for Instructor Use

1. Fill in your student ID and your course code below.

STUDENT ID NUMBER COURSE CODE

2. Be sure your name and address are fi lled in below.3. Transfer your answers to this cover sheet.

NAME

ADDRESS

CITY STATE ZIP

U.S. Career Institute2001 Lowe StreetFort Collins, CO 80525

Medical Coding and Billing SpecialistQuiz 15

1. _____________________________________________

2. _____________________________________________

3. _____________________________________________

4. _____________________________________________

5. _____________________________________________

55-CL

Grade: ___________

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6. _____________________________________________

7. _____________________________________________

8. _____________________________________________

9. _____________________________________________

10. _____________________________________________

11. _____________________________________________

12. _____________________________________________

13. _____________________________________________

14. _____________________________________________

15. _____________________________________________

16. _____________________________________________

17. _____________________________________________

18. _____________________________________________

19. _____________________________________________

20. _____________________________________________

Include your completed CMS-1500 claims forms with this Cover Sheet.

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21.

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22.

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Quiz 16: The UB-04 Claim FormThis is a Scanner Quiz that should be submitted according to the instructions at the beginning of this pack.

Determine if each statement is true or false. Each item is worth 2.86 points.

1. In FL 15, you’ll enter a two-digit code indicating the source of referral for this admission. a. Trueb. False

2. If the payment is to be sent to a different address than the one in field locator 1, you will complete FL 2. a. Trueb. False

3. The responsible party is usually the primary insured. a. Trueb. False

4. The federal tax number is completed without using a hyphen. a. Trueb. False

5. The condition codes identify events relating to the bill that may affect processing. a. Trueb. False

6. You will use a two-digit year for the beginning and ending service dates. a. Trueb. False

7. A two-digit year is required for the patient’s birth date. a. Trueb. False

8. The accommodation rate for the room and board is entered in FL 44. a. Trueb. False

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9. To record the admission hour of 2 p.m., you will record 02. a. Trueb. False

10. You will refer to the UB-04 manual for specific patient discharge status code requirements. a. Trueb. False

11. The health plan ID is the same as the insured’s ID. a. Trueb. False

12. You will complete field 29 with the state abbreviation indicating where the accident occurred on all Medicare claims. a. Trueb. False

13. Enter the NPI for the billing provider in FL 56. a. Trueb. False

14. You will record decimals when recording the dollar amount associated with the service. a. Trueb. False

15. If assigned, you should complete the health plan ID for each payer listed. a. Trueb. False

16. If the treatment was preauthorized, you’ll indicate that in FL 63. a. Trueb. False

17. The two-digit code 18 indicates the patient is also the insured. a. Trueb. False

18. The principal diagnosis is always the same as the admitting diagnosis. a. Trueb. False

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19. You may list up to five additional procedure codes in fields 74A-E. a. Trueb. False

20. You should enter the estimated amount due in FL 47. a. Trueb. False

Quiz continues

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Use the following UB-04 to answer as directed. Each item is worth 2.86 points.

21. What code is entered for the type of bill?a. XXXXb. 0111

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22. Marco P. Sanchez was discharged to his home. The discharge status is found in FL _____.a. 15b. 16c. 17d. 18

23. The source of the referral for this admission is indicated in FL _____.a. 15b. 16c. 17d. 18

24. SC5526CA is the _____ number.a. policyb. tax IDc. medical record

25. Code 01 in FL 39 indicates the room Marco stayed in was _____.a. privateb. semi-private

26. Marco’s patient control number is located in FL _____.a. 3ab. 3b

27. The revenue code that indicates total charges is _____.a. 0001b. XXXX

28. Who is the primary insurance carrier? a. Marco Sanchezb. Medicarec. Charles Peterson

29. Who is the primary insured? a. Marco Sanchezb. Medicarec. Charles Peterson

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30. The NPI number for the billing provider is _____.a. CS2473Ab. SC5526CAc. 0275695402d. 6565886565

31. The NPI number assigned to the attending physician is _____.a. CS2473Ab. SC5526CAc. 0275695402d. 6565886565

32. The principal procedure code is _____.a. FM3321b. I301c. R079d. B246ZZZ

33. The principal diagnosis code is _____.a. FM3321b. I301c. R079d. B246ZZZ

34. Treatment authorization code _____ indicates that preauthorization was obtained for these services.a. FM3321b. I301c. R079d. B246ZZZ

35. According to FL (number) __________, Marco has given permission to release his medical information in order to process this claim.a. 52b. 53c. 63d. 67

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Important Notice about MedLook QuizzesDear Student:

We have an important update about your quizzes that instruct you to use MedLook, the billing software that is used in your course. Because it has come to our attention some students were experiencing technical difficulties in printing or saving and submitting claim forms from MedLook, you may now submit all claim form quizzes (except the final practicum) using the PDF claim form download available on your student site.

It is important that you complete the practice exercises and assignments in all lessons. The final assignment in your course includes claim forms that will require you to use MedLook to submit your quiz answers. You will be glad you took the time to gain a good understanding of the software in the practice exercises to complete the final lesson.

This change is a result of our valued student input and we do not want your studies to slow down due to technical difficulties. If you are having difficulties using MedLook, please contact the instruction department at your convenience to troubleshoot MedLook before you reach the final quiz.

Thank you and good luck with your studies.

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Quiz 17: Medical Billing TechnologyThis is an Instructor-graded Quiz that should be submitted according to the instructions at the beginning of this pack.


1. A clearinghouse is a(n) _____.a. insurance companyb. discount retail storec. provider’s computer systemd. business that formats, edits and transmits claims

2. Insurance companies are known as _____.a. payersb. modemsc. providersd. clearinghouses

3. A clearinghouse is a company that processes claims information into standardized formats and then _____.a. fills out CMS-1500 formsb. sends the claims to patientsc. stores the claims in a warehoused. submits the claims to insurance companies

4. Electronic billing provides electronic acknowledgement that a transaction was received, proving _____.a. timely filingb. monetary savingsc. eligibility benefitsd. peace of mind

5. When data is entered in a computer record, it becomes _____.a. digitizedb. downloadedc. transmittedd. an electronic transaction

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6. Which of the following is NOT a reason that using a computer to file claims is beneficial? a. It saves paper.b. It saves time.c. It saves money.d. It is more expensive.

7. Direct deposit allows an insurance company to _____.a. keep better accounting recordsb. send a check to a physicianc. send cash to the medical billing specialistd. electronically transfer funds to a physician’s account

8. Carrier-direct claim submission means that, when you work as a medical billing specialist, you need to _____.a. submit paper claims onlyb. transmit claims directly to the clearinghousec. transmit claims directly to the insurance companyd. file two copies of each claim, one with a clearinghouse and one with

the insurance company

9. To enter a new patient in the MedLook program, you will select Patients and New Patient from _____ on the main menu bar.a. Fileb. Reportsc. Foldersd. Activities

10. Entering information into the patient database _____.a. is not an option in MedLookb. is a step that the provider must completec. allows you to enter a charge for the patientd. can be initiated from Tools in the main menu bar

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For this portion of the Quiz, you will submit the claims you complete using the MedLook billing software. Complete a claim for Andrew Lee-Carter, Kristen Arnold and Rebecca Bloom as directed.

To submit a claim to your instructor by mail or fax, please print your claim as follows:

● From Billing, select the date of the charge. Click View/eClaims, and then click Print, select your printer and click Print again. A dialog box will ask Print Current Page (Yes) or All Pages (No)? You will select No so the entire claim prints on one page.

To submit a claim to your instructor by e-mail, please do the following:First, install Microsoft XPS Document Writer:Please note, some computers already have this pre-installed. To determine if you have it, click the windows icon and go to your Control Panel. Under Hardware and Sound you should fi nd Devices and Printers. Click that to view the printers associated with your computer. If you see Microsoft XPS Document Writer, skip this step. If you don’t have it, 1. Go to http://msdn.microsoft.com/en-us/library/windows/desktop/dd145058%28v=vs.85%29.aspx2. Under “Installation,” select “Microsoft Download Center”3. In the search box on the top right corner in the Download Center, type “XPS document writer”4. Click “Application” to go to download page5. Download

Then, in MedLook: Step 1: In MedLook, go to the Billing tab.Step 2: Verify the Billing Type is set to Insurance.Step 3: Click View/eClaims to display the CMS-1500 form.Step 4: Click Print at the top left.Step 5: Choose Microsoft XPS Document Writer as your selected printer, and click Print.Step 6: Print Current Page (yes) or All Pages (No)? Select No.Step 7: Enter File name based upon the Quiz number and patient name.Step 8: Click the Save button.Step 9: Attach your Quiz to your e-mail for grading.

For items 11, 12 and 13, create a CMS-1500 version 02/12 form using MedLook as directed. Each claim form is worth 20 points.

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11. Use the following encounter form for Andrew Lee-Carter to create a claim using MedLook.

FAMILY CARE Kenneth Miles, MD NPI: 02-67679942 11 Physician Office1800 Circle Court David Mills, MD NPI: 08-10998051 12 Private ResidenceBrown, CO 80001-9898 X Roger Small, MD NPI: 01-44878804 22 Outpatient Hospital(970) 555-3344 Group NPI: 08-81099885 23 Hospital Emergency Room

Participating Provider Y NPhysician signature: Roger Small, MD EIN 66-6870600

Patient InformationName Andrew Paul Lee-Carter Date of Birth January 15, 2007 Address 883 Center Circle Sex male City Avon State CO ZIP 80000Home Phone 970-555-8812

Insurance InformationPrimary Insurance Secondary InsuranceName Blue Cross of Wyoming Name CIGNA ID# 630A ID# 1191031 Group# BM Group# 488C Address PO Box 456 Address 1212 Drake City Casper City Cleveland State WY ZIP 82002-0456 State OH ZIP 44102-1912 Primary Insured Name Mark K. Carter Secondary Insured Name Cecelia Lee Relation to Patient father Relation to Patient mother DOB/Sex July 6, 1978 male DOB/Sex Oct 9, 1980 female Address/Phone Same as patient Address/Phone Same as patient I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Mark K. Carter Signature of patient (or parent of minor child)


Cecelia Lee Signature of patient (or parent of minor child)

Date of Service 3-25-20XX Date of Injury 3-19-20XX Diagnosis Procedure Charge S93.421A Ankle sprain 99242 Office Consult $140.00 W01.0XXA Tripped over dog

Today’s Charge $140.00 Notes: Referring Physician Christine Jones, MD Cash/Check $ 0.00 Balance $140.00

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12. Use the following encounter form for Kristen Arnold to create a claim using MedLook.

FAMILY CARE X Kenneth Miles, MD NPI: 02-67679942 11 Physician Office1800 Circle Court David Mills, MD NPI: 08-10998051 12 Private ResidenceBrown, CO 80001-9898 Roger Small, MD NPI: 01-44878804 22 Outpatient Hospital(970) 555-3344 Group NPI: 08-81099885 23 Hospital Emergency Room

Participating Provider Y NPhysician signature: Kenneth Miles, MD EIN 66-6870600

Patient InformationName Kristen Ann Arnold Date of Birth April 7, 2011 Address 3519 Habit Road Sex F City Yampa State CO ZIP 80004Home Phone 970-555-8838

Insurance InformationPrimary Insurance Secondary InsuranceName Blue Cross of OH Name Country Group Life ID# 811924 ID# 73055 Group# J620 Group# 210B Address 3737 Sylvania Avenue Address PO Box 37 City Toledo City Toledo State OH ZIP 43623-4422 State OH ZIP 43623-0037 Primary Insured Name Barbara Jane Arnold Secondary Insured Name Peter James Arnold Relation to Patient Mother Relation to Patient Father DOB/Sex 01-10-1989 female DOB/Sex 12-23-1990 male Address/Phone Same as patient Address/Phone Same as patient I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Barbara J. Arnold Signature of patient (or parent of minor child)


Peter J. Arnold Signature of patient (or parent of minor child)

Date of Service 10/15/20XX Date of Injury 10/11/20XX Diagnosis Procedure Charge J06.9 Upper Respiratory Infection 99213 Est Patient Office Visit $69.00 H65.21 Chronic Serous Otitis Media

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13. Use the following encounter form for Rebecca Bloom to create a claim using MedLook.

Greg North, MD 11 Physician Office800 Medical Court 12 Private ResidenceBrown, CO 80001-9898 22 Outpatient Hospital(970) 555-2222 23 Hospital Emergency Room

Physician signature: Greg North, MD Participating Provider Y N

EIN: 47-9823559 NPI: 04-05674390 Patient seen at Weston Hospital

Patient InformationName Rebecca Kay Bloom Date of Birth June 25, 2007 Address 409 Yorkshire Court Sex F City Brown State CO ZIP 80001Home Phone 970-555-5875

Insurance InformationPrimary Insurance Secondary Insurance noneName MedLink Name ID# 52960 ID# Group# WB02 Group# Address PO Box 560 Address City Brown City State CO ZIP 80001-0560 State ZIP Primary Insured Name Richard Michael Bloom Secondary Insured Name Relation to Patient Father Relation to Patient DOB/Sex March 10, 1977 male DOB Address/Phone Same as patient Address I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Richard M. Bloom Signature of patient (or parent of minor child)


Signature of patient (or parent of minor child)

Date of Service 12/01/XX Date of Illness 11/27/20XX Diagnosis Procedure Charge J42 Chronic Bronchitis 99283 Emergency Department $125.00

Today’s Charge $125.00 Cash/Check $ 0.00 Balance $125.00

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NAME

ADDRESS

CITY STATE ZIP



1. _____

2. _____

3. _____

4. _____

5. _____

6. _____

7. _____

8. _____

9. _____

10. _____

11, 12 and 13

For this portion of the Quiz, include the claims you complete using the MedLook billing software, and submit as directed.

55-ML

Grade: ___________

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Quiz 18: Preparing the CMS-1500 Claim FormThis is an Instructor-graded Quiz that should be submitted according to the instructions at the beginning of this pack.

For this Quiz, submit the claims you complete using the MedLook billing software. Each claim is worth 25 points.

To submit a claim to your instructor by mail or fax, please print your claim as follows:

● From Billing, select the date of the charge. Click View/eClaims, and then click Print. Select your printer and click Print again. A dialog box will ask Print Current Page (Yes) or All Pages (No)? You will select No so the entire claim will print on one page.

To submit a claim to your instructor by e-mail, please do the following:First, install Microsoft XPS Document Writer:Please note, some computers already have this pre-installed. To determine if you have it, click the windows icon and go to your Control Panel. Under Hardware and Sound you should fi nd Devices and Printers. Click that to view the printers associated with your computer. If you see Microsoft XPS Document Writer, skip this step. If you don’t have it, 1. Go to http://msdn.microsoft.com/en-us/library/windows/desktop/dd145058%28v=vs.85%29.aspx2. Under “Installation,” select “Microsoft Download Center”3. In the search box on the top right corner in the Download Center, type “XPS document writer”4. Click “Application” to go to download page5. Download

Then, in MedLook: Step 1: In MedLook, go to the Billing tab.Step 2: Verify the Billing Type is set to Insurance.Step 3: Click View/eClaims to display the CMS-1500 form.Step 4: Click Print at the top left.Step 5: Choose Microsoft XPS Document Writer as your selected printer, and click Print.Step 6: Print Current Page (yes) or All Pages (No)? Select No.Step 7: Enter File name based upon the Quiz number and patient name.Step 8: Click the Save button.Step 9: Attach your Quiz to your e-mail for grading.

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1. Use the following encounter form for Bonnie Schmidt to create a claim using MedLook.

FAMILY CARE Kenneth Miles, MD NPI: 0267679942 11 Physician Office1800 Circle Court X David Mills, MD NPI: 0810998051 12 Private ResidenceBrown, CO 80001-9898 Roger Small, MD NPI: 0144878804 22 Outpatient Hospital(970) 555-3344 Group NPI: 0881099885 23 Hospital Emergency Room

Participating Provider Y NPhysician signature: David Mills, MD EIN: 66-6870600

Patient InformationName Bonnie K. Schmidt Date of Birth June 25, 1962 Address 1810 Bluegrass Drive Sex F City Springtown State CO ZIP 80002Home Phone 970-555-9041

Insurance InformationPrimary Insurance Secondary InsuranceName Country Group Life Name CHAMPVA ID# 560001113 ID# 635 00 7213 Group# 208 Group# Address PO Box 37 Address 4500 Cherry Creek Drive City Toledo City Denver State OH ZIP 43623-0037 State CO ZIP 80222-0009 Primary Insured Name Bonnie Secondary Insured Name Richard J. Schmidt Relation to Patient self Relation to Patient spouse DOB/Sex same as above female DOB/Sex Sept 15, 1962 male Address/Phone same as above Address/Phone same as patient I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Bonnie K. Schmidt Signature of patient (or parent of minor child)


Richard J. Schmidt Signature of patient (or parent of minor child)

Date of Service 5/10/XX Diagnosis Procedure Charge M20.11 Hallux valgus, right Consultation 99242 $140.00

Today’s Charge $140.00 Note: Consult for Eric Sulliman, MD Payment Cash $ 20.00 Balance $120.00

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2. Use the following encounter form for Catherine Harrison to create a claim using MedLook.

Roger Floyd, MD NPI: 0102033210

Joyce Hart, MD NPI: 0188123456

Scott Olson, MD NPI: 0199654321

The Womens Clinic 1200 Carol Lane

Brown, CO 80001-4790 (970) 555-1010 EIN: 99-9889009 NPI: 0220332233

11 Physician Office 12 Private Residence

22 Outpatient Hospital 23 Hospital Emergency Room

Participating Provider Y N

Physician signature: Joyce Hart, MD

Patient Information Name Catherine R. Harrison Date of Birth August 9, 1977 Address 2419 Zendt Drive Sex Female City Avon State CO ZIP 80000 Home Phone (970) 555-2112

Insurance Information Primary Insurance Secondary Insurance Name Blue Cross of Wyoming Name ID# 6410 ID# Group# GE54002 Group# Address PO Box 456 Address City Casper City State WY ZIP 82002-0456 State ZIP Primary Insured Name Thomas E. Harrison Secondary Insured Name Relation to Patient spouse Relation to Patient DOB/Sex 08-02-69 male DOB Address/Phone same as patient Address I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Catherine R. Harrison Signature of patient (or parent of minor child)



Date of Service 02/16/XX Diagnosis Procedure ChargeM75.51 L. shoulder bursitis 99212 Office visit, est. patient $42.00

Today’s Charge $42.00 Cash/Check $10.00 Balance $32.00

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3. Use the following encounter form for Andrew Lee-Carter to create a claim using MedLook.

Donald Allen, MD NPI: 0304851124

Michael Shell, MD NPI: 0189218600

Springtown Clinic 1824 Park Avenue

Springtown, CO 80002-1824 970 555-1834

EIN: 86-8990600 NPI: 0304455166

11 Physician Office 12 Private Residence

22 Outpatient Hospital 23 Hospital Emergency Room


Physician signature: Donald Allen, MD

Patient Information Name Andrew P. Lee-Carter Date of Birth 1/15/2007 Address 883 Center Circle Sex M City Avon State CO ZIP 80000 Home Phone (970) 555-8812

Insurance Information Primary Insurance Secondary Insurance Name Blue Cross of Wyoming Name CIGNA ID# 630A ID# 1191031 Group# BM Group# 488C Address PO Box 456 Address 1212 Drake City Casper City Cleveland State WY ZIP 82002-0456 State OH ZIP 44102-1912 Primary Insured Name Mark K. Carter Secondary Insured Name Cecelia Lee DOB/Sex 7/6/78 male DOB/Sex 10/9/80 female Relation to Patient father Relation to Patient mother Address/Phone same as patient Address/Phone same as patient I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Mark K. Carter Signature of patient (or parent of minor child)


Cecelia Lee Signature of patient (or parent of minor child)

Date of Service 7/19/XX Diagnosis Procedure ChargeT18.2XXA Swallowed foreign body 99202 New Patient, Office $71.00 Referring Provider: Christine Jones MD

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4. Use the following encounter form for Emma Davis to create a claim using MedLook.

Medical Care Center Luke R. Johnson, MD NPI: 06-57490049 11 Physician Office100 South Main X Laura K. Knott, MD NPI: 04-05891109 12 Private ResidenceBrown, CO 80001-9898 Charles Peterson, MD NPI: 02-75695402 22 Outpatient Hospital(970) 555-1111 Group NPI: 0665544004 23 Hospital Emergency Room

Participating Provider Y N Physician signature: Laura K. Knott, M.D. EIN: 99-7653456 CLIA #: CM8402

Patient InformationName Emma Sue Davis Date of Birth 1-30-40 Address 1410 Iris Drive Sex F City Maya State CO ZIP 80005Home Phone 970-555-5843

Insurance InformationPrimary Insurance Secondary InsuranceName Medicare Name none ID# 501 00 7319A ID# Group# Group# Address 600 Grant Street Address City Denver City State CO ZIP 80203-4791 State ZIP

DOB DOB Relation to Patient self Relation to Patient I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Emma S. Davis Signature of patient (or parent of minor child)



Date of Service 5/20/XX Diagnosis Procedure Charge R42 dizziness 99203 office visit $103.00

Today’s Charge $103.00 Cash/Check $ 10.00 Balance $ 93.00

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NAME

ADDRESS

CITY STATE ZIP



55-ML

Grade: ___________

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Important Notice about MedLook QuizzesDear Student:

We have an important update about your quizzes that instruct you to use MedLook, the billing software that is used in your course. Because it has come to our attention some students were experiencing technical difficulties in printing or saving and submitting claim forms from MedLook, you may now submit all claim form quizzes (except the final practicum) using the PDF claim form download available on your student site.

It is important that you complete the practice exercises and assignments in all lessons. The final assignment in your course includes claim forms that will require you to use MedLook to submit your quiz answers. You will be glad you took the time to gain a good understanding of the software in the practice exercises to complete the final lesson.

This change is a result of our valued student input and we do not want your studies to slow down due to technical difficulties. If you are having difficulties using MedLook, please contact the instruction department at your convenience to troubleshoot MedLook before you reach the final quiz.

Thank you and good luck with your studies.

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Quiz 19: Explanation of BenefitsThis is an Instructor-graded Quiz that should be submitted according to the instructions at the beginning of this pack.

Determine the correct term(s) for each sentence. Each item is worth 4 points.

1. Corrections reflecting changes on a previously submitted claim are known as _____.

2. Before an insurance plan will begin to cover healthcare costs, the insured must pay any _____ required.

3. Richard visits Dr. Jones for a suspected sinus infection. On his way out, Richard pays $20 for this visit for his portion of the cost of the service. Richard pays this _____ each time he visits Dr. Jones’ office.

4. Suzy queries Mountain States Insurance regarding Daniel Sizemore’s unpaid claim. The representative for Mountain States Insurance tells her that Mr. Sizemore’s claim is in _____, or in review.

5. Dr. Kuzzin is a participating provider in the Blue Cross Blue Shield program in his state. His billing specialist submitted a claim for $46 for a child who received a chickenpox vaccine. The corresponding EOB showed that Blue Cross Blue Shield will only reimburse Dr. Kuzzin $37, or Blue Cross Blue Shield’s _____, for this vaccine.

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Refer to the following EOB for Stacey Jones to answer as directed. Each item is worth 4 points.

6. Who is the member or subscriber of this insurance policy?

7. What company is the subscriber’s employer?

8. Who received the $47.52 from the insurance company?

9. What was the total amount the insurance company did not cover (disallowed)?

10. If the patient has not already paid the copayment, how much does she owe on this claim?

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Refer to the following EOB for Joann Smith to answer as directed. Each item is worth 4 points.

11. What is the provider’s NPI?

12. For how much of this claim is the patient responsible?

13. How much did Healthy Choice Insurance reimburse Maria Barns, MD?

14. What amount did the insurance company allow for procedure 99214?

15. What is the numerical code that explains that the patient is not responsible for noncovered charges?

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Refer to the following EOB for Daniel Jones to answer as directed. Each item is worth 4 points.

16. What is the amount applied to the patient’s deductible?

17. What is the patient’s annual deductible?

18. What is the member/policy number listed on the EOB?

19. What was the amount another insurance company paid?

20. How much will Healthy Choice Insurance send to Maria Barns, MD for this claim?

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Use the following EOB to answer as directed. Each item is worth 2 points.

EXPLANATION OF BENEFITS 10/28/XX

BENEFICIARY NAME PERFORMING SUPPLIER SERVICE PLACE - TYPE

PROCEDURE AMOUNT BILLED

AMOUNT APPROVED

SEE NOTE

DEDUCTIBLE COINSURANCE PAYMENT

M.I.C. NO. CONTROL NUMBER FROM MO-DAY

TO DAY-YR

CODE -MODIFIERS

R. STONE 850 10-10 10-XX 1 99204 80.00 68.20 56 13.64 54.56379 82948 10-10 10-XX 1 99070 45.00 12.50 56 2.50 10.00

NOTE----------------------------------------- EXPLANATION ---------------------------------------------56 THIS IS THE CHARGE ALLOWED BASED UPON THE PREVAILING OR USUAL AND CUSTOMARY RATE.

21. The amount billed for procedure 99204 was __________.

22. The amount approved for procedure 99204 was __________.

23. The amount billed for procedure 99070 was __________.

24. The amount approved for procedure 99070 was __________.

25. The total amount of the claim is __________.

26. The total amount of benefits the insurance carrier paid for the patient is __________.

27. The patient will be responsible for the coinsurance amount totaling __________.

28. According to the note, $80.70 is the charge allowed based upon the prevailing or __________ rate.

29. Assuming the patient didn’t pay anything at the time of service, the provider will bill the patient __________.

30. Since the provider accepts assignment from the insurance, she will write off __________.

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NAME

ADDRESS

CITY STATE ZIP



1. _______________________________

2. _______________________________

3. _______________________________

4. _______________________________

5. _______________________________

6. _______________________________

7. _______________________________

8. _______________________________

55-G

Grade: ___________

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9. _______________________________

10. _______________________________

11. _______________________________

12. _______________________________

13. _______________________________

14. _______________________________

15. _______________________________

16. _______________________________

17. _______________________________

18. _______________________________

19. _______________________________

20. _______________________________

21. _______________________________

22. _______________________________

23. _______________________________

24. _______________________________

25. _______________________________

26. _______________________________

27. _______________________________

28. _______________________________

29. _______________________________

30. _______________________________

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Quiz 20: Secondary ClaimsThis is an Instructor-graded Quiz that should be submitted according to the instructions at the beginning of this pack.

Complete the CMS-1500 form as directed. This Quiz is worth 100 points.

For the Quiz, you will be graded on your ability to complete the claim forms correctly by hand, which requires your instructor to see the forms. If you plan to mail or fax in the Quiz, you can use the Quiz Cover Sheet and claims included. However, we encourage you to send this Quiz by e-mail. Simply contact your instructor by phone or e-mail, and request a PDF claim form. A blank PDF claim form will be e-mailed to you with instructions on how to complete the claim forms for this Quiz.

1. Use the original encounter information and the explanation of benefits to complete the secondary insurance claim form for Kristen Arnold.

FAMILY CARE Kenneth Miles, MD NPI: 02-67679942 11 Physician Office1800 Circle Court X David Mills, MD NPI: 08-10998051 12 Private Residence Brown, CO 80001-9898 Roger Small, MD NPI: 01-44878804 22 Outpatient Hospital (970) 555-3344 Group NPI: 08-81099885 23 Hospital Emergency Room

Physician signature: David Mills, MDParticipating Provider Y N

EIN: 66-6870600

Patient Information Name Kristen Ann Arnold Date of Birth April 7, 2011 Address 3519 Habit Road Sex F City Yampa State CO ZIP 80004 Home Phone 970-555-8838

Insurance Information Primary Insurance Secondary Insurance Name Blue Cross of Ohio Name Country Group Life ID# 811924 ID# 73055 Group# J620 Group# 210B Address 3737 Sylvania Avenue Address PO Box 37 City Toledo City Toledo State OH ZIP 43623-4422 State OH ZIP 43623-0037 Primary Insured Name Barbara J Arnold Secondary Insured Name Peter J Arnold Relation to Patient mother Relation to Patient father DOB/Sex 01-10-1989 Female DOB/Sex 12-23-1990 Male Address/Phone ame as patie ddress/Phone Same as patient I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Barbara J Arnold Signature of patient (or parent of minor child)


Peter J Arnold Signature of patient (or parent of minor child)

Date of Service 03/13/XX Date of Injury 03/12/XX Diagnosis Procedure ChargeS93.401A Sprain Ankle 99215 Est Patient Office Visit $100.00 73600 Radiology $ 50.00 Today’s Charge $150.00 Cash/Check $0.00 Balance $150.00

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2. Use the original encounter information and the explanation of benefits to complete the secondary insurance claim form for Amanda Tree.

FAMILY CARE X Kenneth Miles, MD NPI: 02-67679942 11 Physician Office1800 Circle Court David Mills, MD NPI: 08-10998051 12 Private Residence Brown, CO 80001-9898 Roger Small, MD NPI: 01-44878804 22 Outpatient Hospital (970) 555-3344 Group NPI: 08-81099885 23 Hospital Emergency Room Physician signature: Kenneth Miles, MD EIN: 66-6870600


Patient Information Name Amanda Diane Tree Date of Birth 7/10/2011 Address 35 Elm Street Sex F City Maya State CO ZIP 80005 Home Phone 970-555-3234

Insurance Information Primary Insurance Secondary Insurance Name Mutual Life Name Health Services Inc. ID# 542-32-5310 ID# 3519 Group# L558 Group# 683 Address PO Box 911 Address PO Box 324 City Denver City Springtown State CO ZIP 80111-0911 State CO ZIP 80002-0324 Primary Insured Name Sandra Violet Tree Secondary Insured Name Cole R Tree Relation to Patient mother Relation to Patient father DOB/Sex 02-13-1989 Female DOB/Sex 10-10-1987 Male Address Same as patient Address 475 Oak Street, Maya, CO 80005 Phone Same as patient Phone 970-555-1912 I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Sandra Violet Tree Signature of patient (or parent of minor child)


Cole R Tree Signature of patient (or parent of minor child)

Date of Service 9/14/XX Date of Illness 9/10/XX Diagnosis Procedure ChargeJ03.80 Tonsillitis 99212 Est. Patient, office visit $50.00 B95.0 due to strep 86403 Rapid Strep $15.00 Today’s Charge $65.00 Cash/Check $0.00 Balance $65.00

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3. Use the following encounter form for Sally Tucker to create a claim using MedLook. Then post a payment of $40.00 from a check payment from Blue Cross of Iowa. Finally, create a secondary claim to submit for grading.

Roger Floyd, MDNPI: 0102033210

Joyce Hart, MDNPI: 0188123456

Scott Olson, MDNPI: 0199654321

The Womens Clinic1200 Carol Lane

Brown, CO 80001-4790(970) 555-1010EIN: 99-9889009NPI: 0220332233

11 Physician Office12 Private Residence22 Outpatient Hospital23 Hospital Emergency Room


Physician signature: Scott Olson, MD

Patient InformationName Sally R. Tucker Date of Birth 11-26-70 Address 1801 Peterson Court Sex female City Springtown State CO ZIP 80002Home Phone 970-555-3255

Insurance InformationPrimary Insurance Secondary InsuranceName Blue Cross of Iowa Name Mutual Life ID# 321-1010 ID# 402-4679 Group# BA1503 Group# LA4832 Address PO Box 1677 Address PO Box 911 City Sioux City City Denver State IA ZIP 51102-1677 State CO ZIP 80111-0911 Primary Insured Name Sally Secondary Insured Name Gregory S. Tucker DOB DOB/Sex 9-2-71 male Relation to Patient self Relation to Patient spouse

Address/Phone same as patient I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Sally R. Tucker Signature of patient (or parent of minor child)


Gregory S. Tucker Signature of patient (or parent of minor child)

Date of Service 4/1/XX Diagnosis Procedure Charge Z01.419 GYN exam 99202 Office visit $71.00 81000 urinalysis $10.00

Today’s Charge $81.00 Copayment $ 0.00 Balance $81.00

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NAME

ADDRESS

CITY STATE ZIP


Grade: ___________

55-ML



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