Reimbursement Methodologies – Wk6 Assignment

SimClaimTM Case Studies: Set One

Case Study 1-4 Katlyn Tiger

ARNOLD YOUNG MD 21 PROVIDER STREET INJURY NY 12347

101 2027754

EIN: 111234632

PATIENT INFORMATION: Name: TIGER, KATLYN Address: 2 JUNGLE ROAD City: NOWHERE State: NY Zip/4: 12346-1234 Telephone: 101 1112222

Gender: M F x Status: Single x Married Other Date of Birth: 01 03 1954 Employer: JOHN LION CPA Student: FT PT School:

Work Related? Y N x Auto Accident? Y N x State: Other Accident: Y N x Date of Accident:

Referring Physician: Address: Telephone: NPI #:

Patient Number: 1-4

NPI: 0123456789

Primary Insurance Name: BLUECROSS BLUESHIELD Address: PO BOX 1121 City: MEDICAL State: PA Zip/4: 12357-1121

Plan ID#: ZJW334444 Group #: W310 Primary Policyholder: TIGER, KATLYN Address: 2 JUNGLE ROAD City: NOWHERE State: NY Zip/4: 12346-1234 Policyholder Date of Birth: 01 03 1954 Pt Relationship to Insured: Self x Spouse Child Other Employer/School Name: JOHN LION CPA. Reimbursement Methodologies – Wk6 Assignment

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. INITIAL OBSERVATION, COMPREHENSIVE

Dates Code Mod Unit Charge

Days/ Units

Code

1. J18.0 BRONCHOPNEUMONIA

Diagnosis Code

5.

Diagnosis

2.

3.

4.

3.

4.

5.

6.

Special Notes: CARE RENDERED AT GOODMEDICINE HOSPITAL, 1 PROVIDER STREET, ANYWHERE, NY 12345, NPI: 1123456789. ADMISSION 2/28/YYYY DISCHARGE 3/1/YYYY

02 28 YYYY

03 01 YYYY

99220

99217

175 00

65 00

1

1

6.

7.

8.

2. DISCHARGE HOME

1. PICA 1:
2. PICA 2:
3. PICA 3:
4. Medicare: Off
5. Patient’s Name:
6. Medicaid#: Off
7. ID#DoD#: Off
8. Member ID #: Off
9. ID #: Off
10. FECA ID #: Off
11. Other ID #: Off
12. Insured’s ID #:
13. Insured’s Name:
14. Insured’s Address:
15. City:
16. State:
17. Zip Code:
18. Area Code:
19. Phone#:
20. Insured’s Policy Group:
21. Insured’s Sex: Off
22. Insured’s Sex F: Off
23. Insured’s DOB 1:
24. Insured’s DOB 2:
25. Insured’s DOB 3:
26. Patient’s Address:
27. Patient City:
28. Patient State:
29. Patient Zip Code:
30. Patient Area Code:
31. Patient Phone#:
32. Other Insured’s Name:
33. Other Insured’s Policy Group #:
34. Insurance Plan Name:
35. Patient Sex M: Off
36. Patient Sex F: Off
37. Patient’s DOB 1:
38. Patient’s DOB 2:
39. Patient’s DOB 3:
40. Patient Relationship 1: Off
41. Patient Relationship 2: Off
42. Patient Relationship 3: Off
43. Patient Relationship 4: Off
44. Patient Signature:
45. Patient Signature Date:
46. Employment Y: Off
47. Employment N: Off
48. Auto Accident Y: Off
49. Auto Accident n: Off
50. Other Accident Y: Off
51. Other Accident N: Off
52. Accident State:
53. Claim Codes:
54. Claim ID 1:
55. Claim ID 2:
56. Insurance Plan Name 2:
57. HBP Y: Off
58. HBP N: Off
59. Insured’s Signature:
60. Month:
61. Day:
62. Year:
63. Qual1:
64. Qual2:
65. Month1:
66. Day1:
67. Year1:
68. Prefix1:
69. Provider Name:
70. Additional Claim Info:
71. 17a:
72. 17b:
73. Unable to Work 1:
74. Unable to Work 2:
75. Unable to Work 3:
76. Unable to Work 4:
77. Unable to Work 5:
78. Unable to Work 6:
79. PICA 4:
80. PICA 5:
81. PICA 6:
82. ICD Ind:
83. 21e:
84. 21a:
85. 21i:
86. 21b:
87. 21f:
88. 21j:
89. 21c:
90. 21g:
91. 21k:
92. 21d:
93. 21h:
94. 21l:
95. Hospital Date M:
96. Hospital Date D:
97. Hospital Date Y:
98. Hospital Date M1:
99. Hospital Date D1:
100. Hospital Date Y1:
101. Outside Lab Y: Off
102. Outside Lab N: Off
103. 20 1:
104. 20 2:
105. Resubmission Code:
106. Original Ref:
     1. No:
107. Prior Authorization No:
108. Text52:
109. Text53:
110. Text54:
111. Text52 1:
112. Text53 1:
113. Text54 1:
114. Text52 2:
115. Text53 2:
116. Text54 2:
117. Text52 3:
118. Text53 3:
119. Text54 3:
120. Text52 4:
121. Text53 4:
122. Text54 4:
123. Text52 5:
124. Text53 5:
125. Text54 5:
126. MM1:
127. DD1:
128. YY1:
129. MM2:
130. DD2:
131. YY2:
132. MM3:
133. DD3:
134. YY3:
135. MM4:
136. DD4:
137. YY4:
138. MM5:
139. DD5:
140. YY5:
141. MM6:
142. DD6:
143. YY6:
144. B1:
145. B2:
146. B3:
147. B4:
148. B5:
149. B6:
150. EMG1:
151. EMG2:
152. EMG3:
153. EMG4:
154. EMG5:
155. EMG6:
156. CPT/HCPCS 1:
157. CPT/HCPCS 2:
158. CPT/HCPCS 3:
159. CPT/HCPCS 4:
160. CPT/HCPCS 5:
161. CPT/HCPCS 6:
162. Mod 1a:
163. Mod 1b:
164. Mod 1c:
165. Mod 1d:
166. Mod 2a:
167. Mod 2b:
168. Mod 2c:
169. Mod 2d:
170. Mod 3a:
171. Mod 3b:
172. Mod 3c:
173. Mod 3d:
174. Mod 4a:
175. Mod 4b:
176. Mod 4c:
177. Mod 4d:
178. Mod 5a:
179. Mod 5b:
180. Mod 5c:
181. Mod 5d:
182. Mod 6a:
183. Mod 6b:
184. Mod 6c:
185. Mod 6d:
186. E1:
187. E2:
188. E3:
189. E4:
190. E5:
191. E6:
192. F1:
193. F1a:
194. F2:
195. F2a:
196. F3:
197. F3a:
198. F4:
199. F4a:
200. F5:
201. F5a:
202. F6:
203. F6a:
204. G1:
205. G2:
206. G3:
207. G4:
208. G5:
209. G6:
210. H1:
211. H2:
212. H3:
213. H4:
214. H5:
215. H6:
216. Text8:
217. Text9:
218. Text10:
219. Text11:
220. Text12:
221. Text13:
222. I1:
223. I2:
224. I3:
225. I4:
226. I5:
227. I6:
228. J1a:
229. J1b:
230. J2a:
231. J2b:
232. J3a:
233. J3b:
234. J4a:
235. J4b:
236. J5a:
237. J5b:
238. J6a:
239. J6b:
240. Check Box16: Off
241. Check Box17: Off
242. Fed Tax ID #:
243. Patient Account #:
244. Check Box20: Off
245. Check Box21: Off
246. Signature:
247. Date:
248. Text24:
249. Text242:
250. Text241:
251. Total Charge Dollars:
252. Amount Paid Dollars:
253. Text243:
254. Text245:
255. Text244:
256. Text27:
257. Text28:
258. Text29:
259. Text30:
260. Text31:
261. Text32:
262. Total Charge Cents:
263. Amount Paid Cents:
264. 17a2:
265. Mailing Address 4:
266. Mailing Address 3:
267. Mailing Address 2:
268. Mailing Address 1:
269. CenterTopNotes:
270. Cover Field: