Coding pathway: Pertussis see also Whooping cough Tabular List description: Whooping cough, unspecified organism

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1 Healthcare Document Specialist Lesson 24 Practice Exercise Coding pathway: Poisoning, food Tabular List description: Food poisoning, unspecified Coding pathway: Tuberculosis, pulmonary, infiltrative Fifth-digit subclassification: 4= tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture Tabular List description: Tuberculosis of lung, infiltrative, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture Coding pathway: Fever, rabbit Alternative pathway: Rabbit fever Tabular List description: Unspecified tularemia Coding pathway: Pertussis see also Whooping cough Tabular List description: Whooping cough, unspecified organism Coding pathway: Septicemia, Bacteroides Tabular List description: Septicemia due to anaerobes Note: use additional code for SIRS but SIRS or sepsis not noted so no additional code needed Coding pathway: AIDS 042 Tabular List description: 042 Human immunodeficiency virus [HIV] disease Coding pathway: Pneumonia, Pneumocystis (carinii) Tabular List description: Pneumocystosis AK-6

2 Course Three Answer Key 7. Coding pathway: Septicemia, gram-negative Coding pathway: SIRS (systemic inflammatory response syndrome) due to, infectious process MED LINK HMO HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 1. MEDICARE MEDICAID TRICARE CHAMPUS CHAMPVA GROUP HEALTH PLAN FECA BLK LUNG PO BOX 560 YOURTOWN, CO OTHER 1a. INSURED S I.D. NUMBER (For Program in Item 1) (Medicare #) (Medicaid#) (Sponsor s SSN) (Member ID #) X (SSN or ID) (SSN) (ID) PATIENT S NAME (Last Name, First Name, Middle Initial) 3. PATIENT S BIRTH DATE SEX 4. INSURED S NAME (Last Name, First Name, Middle Initial) BLOOMQUIST REBECCA M F X BLOOMQUIST DICK 5. PATIENT S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED S ADDRESS (No., Street) 409 YORKSHIRE Self Spouse Child x Other SAME CITY STATE 8. PATIENT STATUS CITY STATE YOURTOWN CO Single x Married Other ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code) Full-Time Part-Time (970) Employed Student x Student 9. OTHER INSURED S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT S CONDITION RELATED TO: 11. INSURED S POLICY GROUP OR FECA NUMBER NONE WBHMO a. OTHER INSURED S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED S DATE OF BIRTH SEX b. OTHER INSURED S DATE OF BIRTH SEX YES X NO M X F b. AUTO ACCIDENT? Place (State) b. EMPLOYER S NAME OR SCHOOL NAME M F YES X NO WILTON BOOKSTORE c. EMPLOYER S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME YES X NO MED LINK HMO d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENT S OR AUTHORIZED PERSON S SIGNATURE. I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. YES X NO If yes, return to and complete item 9 a-d. 13. INSURED S OR AUTHORIZED PERSON S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below. SIGNED SIGNATURE ON FILE DATE XX SIGNED SIGNATURE ON FILE 14. DATE OF CURRENT 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION ILLNESS (First symptom) OR GIVE FIRST DATE INJURY (Accident) OR XX PREGNANCY (LMP) FROM TO 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES 17a. 17b. FROM TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES YES X NO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3, or 4 to Item 24E by Line.) 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO PRIOR AUTHORIZATION NUMBER 24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J. From To PLACE OF (Explain Unusual Circumstances) DIAGNOSIS DAYS OR EPSDT ID. RENDERING SERVICE EMG CPT/HCPCS MODIFIER POINTER $ CHARGES UNITS FAMILY QUAL. PROVIDER ID. # XX XX FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE X X YES NO $ $ 0 00 $ SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # (970) JAMES HAHNS MD JAMES HAHNS MD 800 MEDICAL COURT 800 MEDICAL COURT YOURTOWN CO YOURTOWN CO SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof. SIGNED DATE a b. a b. AK-7

3 Healthcare Document Specialist Practice Exercise Coding pathway: Encephalitis, viral Tabular List description: Unspecified non-arthropod-borne viral diseases of central nervous system Coding pathway: Varioloid Tabular List description: Modified smallpox Coding pathway: Measles, with, otitis media Tabular List description: Postmeasles otitis media Coding pathway: Measles, German Tabular List description: Rubella without mention of complication Coding pathway: Fever, West, Nile Tabular List description: West Nile fever, unspecified Coding pathway: Rabies 071 Tabular List description: 071 Rabies Coding pathway: Disease, hand, foot and mouth Tabular List description: Hand, foot and mouth disease Coding pathway: Disease, Lyme Alternative pathway: Lyme disease Tabular List description: Lyme disease Coding pathway: Disease, fifth Tabular List description: Erythema infectiosum [fifth disease] AK-8

4 Course Three Answer Key Practice Exercise Coding pathway: Syphilis, cardiovascular (early) Tabular List description: Cardiovascular syphilis, unspecified Coding pathway: Cystitis, gonococcal (acute) Tabular List description: Gonococcal cystitis (acute) upper Coding pathway: Infection, fungus, foot Tabular List description: Dermatophytosis, Of foot Coding pathway: Fever, desert Tabular List description: Primary coccidioidomycosis (pulmonary) Coding pathway: Disease, hookworm Tabular List description: Ancylostomiasis and necatoriasis, unspecified Coding pathway: Scabies (any site) Tabular List description: Scabies AK-9

5 Healthcare Document Specialist 7. Coding pathway: Human immunodeficiency virus, infection V08 Coding pathway: Hepatitis, viral, type C, chronic MOUNTAIN STATES HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 1. MEDICARE MEDICAID TRICARE CHAMPUS CHAMPVA GROUP HEALTH PLAN FECA BLK LUNG 1801 SW VINE ST DENVER, CO OTHER 1a. INSURED S I.D. NUMBER (For Program in Item 1) (Medicare #) (Medicaid#) (Sponsor s SSN) (Member ID #) X (SSN or ID) (SSN) (ID) PATIENT S NAME (Last Name, First Name, Middle Initial) 3. PATIENT S BIRTH DATE SEX 4. INSURED S NAME (Last Name, First Name, Middle Initial) FOX BENJAMIN M X F SAME 5. PATIENT S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED S ADDRESS (No., Street) 1227 COMET DRIVE APT 6B Self X Spouse Child Other CITY STATE 8.PATIENT STATUS CITY STATE SPRINGTOWN CO Single X Married Other ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code) Part-Time Student (970) Employed X Full-Time Student 9. OTHER INSURED S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT S CONDITION RELATED TO: 11. INSURED S POLICY GROUP OR FECA NUMBER NONE 120 a. OTHER INSURED S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED S DATE OF BIRTH SEX b. OTHER INSURED S DATE OF BIRTH SEX YES X NO M F b. AUTO ACCIDENT? Place (State) b. EMPLOYER S NAME OR SCHOOL NAME M F YES X NO PHILCO GAS c. EMPLOYER S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME YES X NO MOUNTAIN STATES d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENT S OR AUTHORIZED PERSON S SIGNATURE. I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. YES X NO If yes, return to and complete item 9 a-d. 13. INSURED S OR AUTHORIZED PERSON S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below. SIGNED SIGNATURE ON FILE DATE XX SIGNED SIGNATURE ON FILE 14. DATE OF CURRENT 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION ILLNESS (First symptom) OR GIVE FIRST DATE INJURY (Accident) OR XX PREGNANCY (LMP) FROM TO 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES 17a. 17b. FROM TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES YES X NO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3, or 4 to Item 24E by Line.) 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 1. V PRIOR AUTHORIZATION NUMBER 24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J. From To PLACE OF (Explain Unusual Circumstances) DIAGNOSIS DAYS OR EPSDT ID. RENDERING SERVICE EMG CPT/HCPCS MODIFIER POINTER $ CHARGES UNITS FAMILY QUAL. PROVIDER ID. # XX XX FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE X X YES NO $ $ 0 00 $ SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # (970) JAMES HAHNS MD JAMES HAHNS MD 800 MEDICAL COURT 800 MEDICAL COURT YOURTOWN CO YOURTOWN CO SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof. SIGNED DATE a b. a b. AK-10

6 Course Three Answer Key Practice Exercise Coding pathway: Glioma, specified site NEC see Neoplasm, by site, malignant New pathway: Neoplasm, cerebrum, Malignant, Primary Tabular List description: Malignant neoplasm of brain, Cerebrum, except lobes and ventricles Coding pathway: Carcinoma see also Neoplasm, by site, malignant New pathway: Neoplasm, brain NEC, Malignant, Secondary Tabular List description: Secondary malignant neoplasm, Brain and spinal cord Coding pathway: Neoplasm, lung, Malignant, Primary Tabular List description: Malignant neoplasm of trachea, bronchus and lung, Bronchus and lung, unspecified Coding pathway: Hodgkin s, sarcoma Alternative pathway: Sarcoma, Hodgkin s Fifth-digit subclassification: 0 = unspecified site, extranodal and solid organ sites Tabular List description: Hodgkin s sarcoma, unspecified site, extranodal and solid organ sites Coding pathway: Neoplasm, scalp, Benign Tabular List description: Benign neoplasm of skin, Scalp and skin of neck Coding pathway: Fibromyoma, uterus Tabular List description: Leiomyoma of uterus, unspecified Coding pathway: Adenocarcinoma see also Neoplasm, by site, malignant New pathway: Neoplasm, gastric see Neoplasm, stomach New pathway: Neoplasm, stomach, lesser curvature, Malignant, Primary Tabular List description: Malignant neoplasm of stomach, Lesser curvature, unspecified Note: the type of biopsy helps determine the site of the neoplasm. AK-11

7 Healthcare Document Specialist Practice Exercise Coding pathway: Hypothyroidism, postsurgical Tabular List description: Acquired hypothyroidism, Postsurgical hypothyroidism Coding pathway: Diabetic, coma, hypoglycemia Alternative pathway: Hypoglycemia, coma, diabetic Fifth-digit subclassification 3 = type 1, uncontrolled Tabular List description: Diabetes with other coma, type 1, uncontrolled Coding pathway: Hyperparathyriodism, primary Tabular List description: Primary hyperparathyroidism Coding pathway: Polycystic, ovary, ovaries Tabular List description: Polycystic ovaries Coding pathway: Gouty, arthropathy Alternative pathway: Arthropathy, gouty Tabular List description: Gouty arthropathy Coding pathway: Disease, sickle cell, with, crisis Tabular List description: Sickle-cell disease, Hb-SS disease with crisis Coding pathway: Syndrome, big spleen Alternative pathway: Big spleen syndrome Tabular List description: Hypersplenism AK-12

8 Course Three Answer Key 8. Coding pathway: Hypercalcemia Coding pathway: Cancer see also Neoplasm, by site, malignant New pathway: Neoplasm, thyroid, Malignant, Primary Country Group HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 1. MEDICARE MEDICAID TRICARE CHAMPUS CHAMPVA GROUP HEALTH PLAN FECA BLK LUNG PO BOX 324 SPRINGTOWN, CO OTHER 1a. INSURED S I.D. NUMBER (For Program in Item 1) (Medicare #) (Medicaid#) (Sponsor s SSN) (Member ID #) X (SSN or ID) (SSN) (ID) PATIENT S NAME (Last Name, First Name, Middle Initial) 3. PATIENT S BIRTH DATE SEX 4. INSURED S NAME (Last Name, First Name, Middle Initial) SCHMIDT BONNIE M F X SAME 5. PATIENT S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 1810 BLUEGRASS DRIVE Self X Spouse Child Other CITY STATE 8. PATIENT STATUS SPRINGTOWN CO Single Married X Other ZIP CODE TELEPHONE (Include Area Code) (970) Employed X Full-Time Part-Time Student Student 9. OTHER INSURED S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT S CONDITION RELATED TO: 11. INSURED S POLICY GROUP OR FECA NUMBER SCHMIDT RICHARD 208 a. OTHER INSURED S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED S DATE OF BIRTH SEX YES X NO M F b. OTHER INSURED S DATE OF BIRTH SEX b. AUTO ACCIDENT? Place (State) b. EMPLOYER S NAME OR SCHOOL NAME M X F YES X NO KAIN GRAPHICS c. EMPLOYER S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME USAF YES X NO COUNTRY GROUP d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? CHAMPVA X READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENT S OR AUTHORIZED PERSON S SIGNATURE. I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. YES NO If yes, return to and complete item 9 a-d. 13. INSURED S OR AUTHORIZED PERSON S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below. SIGNED SIGNATURE ON FILE DATE XX SIGNED SIGNATURE ON FILE 14. DATE OF CURRENT 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION ILLNESS (First symptom) OR GIVE FIRST DATE INJURY (Accident) OR XX PREGNANCY (LMP) FROM TO 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES 17a. 17b. FROM TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES YES X NO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3, or 4 to Item 24E by Line.) 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO PRIOR AUTHORIZATION NUMBER 24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J. From To PLACE OF (Explain Unusual Circumstances) DIAGNOSIS DAYS OR EPSDT ID. RENDERING SERVICE EMG CPT/HCPCS MODIFIER POINTER $ CHARGES UNITS FAMILY QUAL. PROVIDER ID. # XX XX FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE X X YES NO $ $ 0 00 $ SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # (970) FRONT RANGE FAMILY CARE FRONT RANGE FAMILY CARE 1800 CIRCLE COURT 1800 CIRCLE COURT YOURTOWN CO YOURTOWN CO SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof. SIGNED DATE a b. a b. AK-13