Comprehensive Health Insurance

Billing Coding And Reimbursement 2nd

Edition Vines Solutions Manual
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 Z03_VINE7282_01_IRM_APP3.QXD 8/22/12 10:24 PM Page 285
Comprehensive Health Insurance Billing Coding And Reimbursement 2nd Edition Vines Solutions Manual

APPENDIX C:
ANSWERS TO APPENDIX C CASE STUDIES

© 2013 Pearson Education, Inc. Appendix C: Answers to Appendix C Case Studies 285

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Z03_VINE7282_01_IRM_APP3.QXD 8/22/12 10:24 PM Page 286

CASE C-1
1 2 3a PAT 4 TYPE
TOWNSHIP MEMORIAL HOSPITAL C1 CNTL # 56139844 OF BILL
b MED
700 SHADY ST REC # 659431896 111
6 STATEMENT COVERS PERIOD 7
TOWNSHIP NY 12345 5 FED. TAX. NO.
FROM THROUGH

5555550700 750750750 0728XX 0801XX

8 PATIENT NAME a 9 PATIENT ADDRESS a 63 PARK AVE
b WILLIS NESTOR b CAPITAL CITY c NY d 12345 e
ADMISSION CONDITION CODES 29 ACDT 30
10 BIRTHDATE 11 SEX 16 DHR 17 STAT STATE
12 DATE 13 HR 14 TYPE 15 SRC 18 19 20 21 22 23 24 25 26 27 28
092952 F 0728XX 01 1 1 15 01
31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37
CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH
a

b
38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES
WILLIS NESTOR CODE AMOUNT CODE AMOUNT CODE AMOUNT

63 PARK AVE a 80 4
b
CAPITAL CITY NY 12345
c

42 REV.CD. 43 DESCRIPTION 44 HCPCS/RATE/HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED 49
CHARGES
1 120 ROOM BOARD SEMI 450.00 4 1800 00 0 00 1
2 260 IV THERAPY 4 1000 00 0 00 2
3 300 LAB 1 235 00 0 00 3
4 320 RADIOLOGY 1 250 00 0 00 4
5 900 RESPIRATORY SERVICES 4 400 00 0 00 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 001 PAGE 1 OF 1 CREATION DATE 0801XX TOTALS 3685 00 0 00 23
52 REL. 53 ASG.
50 PAYER NAME 51 HEALTH PLAN ID INFO BEN. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI 3434343434
A MEDICAID Y Y 00 00 57 A
B OTHER B
C PRV. ID C
58 INSURED’S NAME 59 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

A WILLIS NESTOR 18 322654921345 A

B B
C C
63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

A 32191321 A
B B
C C
66
DX 486 4928 30511 F G H 68

9
69 ADMIT
DX 786.59 70 PATIENT
REASON DX a b c 71 PPS
CODE
72
ECI a b c 73

74 PRINCIPAL PROCEDURE a OTHER PROCEDURE b OTHER PROCEDURE 75

CODE DATE CODE DATE CODE DATE 76 ATTENDING NPI 1234567890 QUAL

87.44 0728XX LAST WELLS MD FIRST PHIL

c OTHER PROCEDURE d OTHER PROCEDURE e OTHER PROCEDURE
CODE DATE CODE DATE CODE DATE 77 OPERATING NPI QUAL

LAST FIRST

80 REMARKS 81CC
a 78 OTHER NPI QUAL

b LAST FIRST

c 79 OTHER NPI QUAL

d LAST FIRST

286 Appendix C: Answers to Appendix C Case Studies © 2013 Pearson Education, Inc.
Z03_VINE7282_01_IRM_APP3.QXD 8/22/12 10:24 PM Page 287

CASE C-2
1 2 3a PAT 4 TYPE
CAPITAL CITY GENERAL HOSPITAL C2 CNTL # 6132198 OF BILL
b MED
1000 CHERRY ST REC # ML18913 111
6 STATEMENT COVERS PERIOD 7
CAPITAL CITY NY 12345 5 FED. TAX. NO.
FROM THROUGH

5555551000 757575757 1010XX 1013XX

8 PATIENT NAME a 9 PATIENT ADDRESS a 2001 MEADOW RD
b LYLES MELVIN b CAPITAL CITY c NY d 12345 e
ADMISSION CONDITION CODES 29 ACDT 30
10 BIRTHDATE 11 SEX 16 DHR 17 STAT STATE
12 DATE 13 HR 14 TYPE 15 SRC 18 19 20 21 22 23 24 25 26 27 28
051472 M 1010XX 20 1 1 07 01
31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37
CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH
a

b
38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES
LYLES MELVIN CODE AMOUNT CODE AMOUNT CODE AMOUNT

2001 MEADOW RD a 80 3
b
CAPITAL CITY NY 12345
c

42 REV.CD. 43 DESCRIPTION 44 HCPCS/RATE/HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED 49
CHARGES
1 120 ROOM BOARD SEMI 400.00 3 1200 00 0 00 1
2 250 PHARMACY 8 375 00 0 00 2
3 260 IV THERAPY 2 850 00 0 00 3
4 300 LAB 5 450 00 0 00 4
5 320 RADIOLOGY 1 900 00 0 00 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 001 PAGE 1 OF 1 CREATION DATE 1013XX TOTALS 3775 00 0 00 23
52 REL. 53 ASG.
50 PAYER NAME 51 HEALTH PLAN ID INFO BEN. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI 1212121212
A BLUE CROSS BLUE SHIELD 87590 Y Y 00 00 57 A
B OTHER B
C PRV. ID C
58 INSURED’S NAME 59 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

A LYLES SHELBY 01 YYJ561319821 025648 A

B B
C C
63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

A 846465315 GREEN LANDSCAPING CO A

B B
C C
66
DX 25042 58381 27800 V653 V8532 F G H 68

9
69 ADMIT
DX 25002 70 PATIENT
REASON DX a b c 71 PPS
CODE
72
ECI a b c 73

74 PRINCIPAL PROCEDURE a OTHER PROCEDURE b OTHER PROCEDURE 75

CODE DATE CODE DATE CODE DATE 76 ATTENDING 9876543210
NPI QUAL

8848 1011XX 8866 1010XX LAST ALRIGHT MD FIRST ELBY

c OTHER PROCEDURE d OTHER PROCEDURE e OTHER PROCEDURE
CODE DATE CODE DATE CODE DATE 77 OPERATING NPI QUAL

LAST FIRST

80 REMARKS 81CC
a 78 OTHER NPI QUAL

b LAST FIRST

c 79 OTHER NPI QUAL

d LAST FIRST

© 2013 Pearson Education, Inc. Appendix C: Answers to Appendix C Case Studies 287
Z03_VINE7282_01_IRM_APP3.QXD 8/22/12 10:24 PM Page 288

CASE C-3
1 2 3a PAT 4 TYPE
CAPITAL CITY GENERAL HOSPITAL C3 CNTL # 646413 OF BILL
b MED
1000 CHERRY ST REC # 84616489 111
6 STATEMENT COVERS PERIOD 7
CAPITAL CITY NY 12345 5 FED. TAX. NO.
FROM THROUGH

5555551000 757575757 0607XX 0610XX

8 PATIENT NAME a 9 PATIENT ADDRESS a 3009 RIVER RD
b MENDEZ EMILIO b CAPITAL CITY c NY d 12345 e
ADMISSION CONDITION CODES 29 ACDT 30
10 BIRTHDATE 11 SEX 16 DHR 17 STAT STATE
12 DATE 13 HR 14 TYPE 15 SRC 18 19 20 21 22 23 24 25 26 27 28
093084 M 0607XX 17 1 7 11 01
31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37
CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH
a A2 050371
b
38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES
MENDEZ EMILIO CODE AMOUNT CODE AMOUNT CODE AMOUNT

3009 RIVER RD a 80 3
b
CAPITAL CITY NY 12345
c

42 REV.CD. 43 DESCRIPTION 44 HCPCS/RATE/HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED 49
CHARGES
1 120 ROOM BOARD SEMI 400.00 3 1200 00 0 00 1
2 250 PHARMACY 7 400 00 0 00 2
3 260 IV THERAPY 3 900 00 0 00 3
4 300 LAB 6 700 00 0 00 4
5 0 00 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 001 PAGE 1 OF 1 CREATION DATE 0610XX TOTALS 3200 00 0 00 23
52 REL. 53 ASG.
50 PAYER NAME 51 HEALTH PLAN ID INFO BEN. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI 1212121212
A BLUE CROSS BLUE SHIELD 87590 Y Y 00 00 57 A
B OTHER B
C PRV. ID C
58 INSURED’S NAME 59 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

A MENDEZ EMILIO 18 YY2156349873 252354 A

B B
C C
63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

A 5168431313 TOUGH GUYS GYM A

B B
C C
66
DX 03810 5265 F G H 68

9
69 ADMIT
DX 5265 70 PATIENT
REASON DX a b c 71 PPS
CODE
72
ECI a b c 73

74 PRINCIPAL PROCEDURE a OTHER PROCEDURE b OTHER PROCEDURE 75

CODE DATE CODE DATE CODE DATE 76 ATTENDING 9876543210
NPI QUAL

9052 0607XX LAST ALRIGHT MD FIRST ELBY

c OTHER PROCEDURE d OTHER PROCEDURE e OTHER PROCEDURE
CODE DATE CODE DATE CODE DATE 77 OPERATING NPI QUAL

LAST FIRST

80 REMARKS 81CC
a 78 OTHER NPI QUAL

b LAST FIRST

c 79 OTHER NPI QUAL

d LAST FIRST

288 Appendix C: Answers to Appendix C Case Studies © 2013 Pearson Education, Inc.
Z03_VINE7282_01_IRM_APP3.QXD 8/22/12 10:24 PM Page 289

CASE C-4
1 2 3a PAT 4 TYPE
COUNTY COMMUNITY HOSPITAL C4 CNTL # 564321 OF BILL

1600 CLOVER ST
b MED
REC # 005332496 111
6 STATEMENT COVERS PERIOD 7
CAPITAL CITY NY 12345 5 FED. TAX. NO.
FROM THROUGH
5555551600 70707070 1122XX 1124XX
8 PATIENT NAME a 9 PATIENT ADDRESS a 532 CREEK ST
b JANOVICH HAROLD b TOWNSHIP c NY d 12345 e
ADMISSION CONDITION CODES 29 ACDT 30
10 BIRTHDATE 11 SEX 16 DHR 17 STAT STATE
12 DATE 13 HR 14 TYPE 15 SRC 18 19 20 21 22 23 24 25 26 27 28
121271 M 1122XX 18 1 7 17 01
31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37
CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH
a

b
38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES
JANOVICH HAROLD CODE AMOUNT CODE AMOUNT CODE AMOUNT
532 CREEK ST a 80 2
TOWNSHIP NY 12345 b

42 REV.CD. 43 DESCRIPTION 44 HCPCS/RATE/HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED 49
CHARGES
1
120 ROOM BOARD SEMI 400.00 2 800 00 0 00 1
2 250 PHARMACY 5 400 00 0 00 2
3 260 IV THERAPY 2 950 00 0 00 3
4 270 MED SURG SUPPLIES 1 500 00 0 00 4
5 300 LAB 2 300 00 0 00 5
6 320 RADIOLOGY 1 650 00 0 00 6
7 360 OR SERVICES 1 1200 00 0 00 7
8 370 ANESTHESIA 1 600 00 0 00 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 001 PAGE 1 OF 1 CREATION DATE 1124XX TOTALS 5400 00 0 00 23
52 REL. 53 ASG.
50 PAYER NAME 51 HEALTH PLAN ID INFO BEN. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI 6767676767
A AETNA 06599 Y Y 00 00 57 A
B OTHER B
C PRV. ID C
58 INSURED’S NAME 59 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

A JANOVICH HAROLD 18 65321313 97390 A

B B
C C
63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

A 10564598 BUY N SAVE GROCERS LTD A

B B
C C
66
DX 5409 F G H 68

9
69 ADMIT
DX 78903 70 PATIENT
REASON DX a b c 71 PPS
CODE
72
ECI a b c 73

74 PRINCIPAL PROCEDURE
CODE DATE
a OTHER PROCEDURE
CODE DATE
b OTHER PROCEDURE
CODE DATE
75 76 ATTENDING 0123456789
NPI QUAL

4709 1122XX 8876 1122XX LAST MENDS MD FIRST MANNIE

c OTHER PROCEDURE d OTHER PROCEDURE e OTHER PROCEDURE
CODE DATE CODE DATE CODE DATE 77 OPERATING NPI QUAL

LAST FIRST

80 REMARKS 81CC
a 78 OTHER NPI QUAL

b LAST FIRST

c 79 OTHER NPI QUAL

d LAST FIRST

© 2013 Pearson Education, Inc. Appendix C: Answers to Appendix C Case Studies 289
Z03_VINE7282_01_IRM_APP3.QXD 8/22/12 10:24 PM Page 290

CASE C-5
1 2 3a PAT 4 TYPE
TOWNSHIP MEMORIAL HOSPITAL C5 CNTL # 594313 OF BILL
700 SHADY ST b MED
REC # RK654142 111
6 STATEMENT COVERS PERIOD 7
TOWNSHIP NY 12345 5 FED. TAX. NO.
FROM THROUGH
5555550700 750750750 1212XX 1214XX
8 PATIENT NAME a 9 PATIENT ADDRESS a 14 BERRY LN
b KEDAR RAMESH b TOWNSHIP c NY d 12345 e
ADMISSION CONDITION CODES 29 ACDT 30
10 BIRTHDATE 11 SEX 16 DHR 17 STAT STATE
12 DATE 13 HR 14 TYPE 15 SRC 18 19 20 21 22 23 24 25 26 27 28
030767 M 1212XX 00 1 1 10 01
31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37
CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH
a

b
38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES
KEDAR RAMESH CODE AMOUNT CODE AMOUNT CODE AMOUNT
14 BERRY LN a 80 2
TOWNSHIP NY 12345 b

42 REV.CD. 43 DESCRIPTION 44 HCPCS/RATE/HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED 49
CHARGES
1
120 ROOM BOARD SEMI 400.00 2 800 00 0 00 1
2 250 PHARMACY 3 375 00 0 00 2
3 260 IV THERAPY 3 1200 00 0 00 3
4 300 LAB 6 450 00 0 00 4
5 320 RADIOLOGY 1 1000 00 0 00 5
6 730 EKG 1 150 00 0 00 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 001 PAGE 1 OF 1 CREATION DATE 1212XX TOTALS 3975 00 0 00 23
52 REL. 53 ASG.
50 PAYER NAME 51 HEALTH PLAN ID INFO BEN. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI 6767676767
A HEALTH AMERICA 87431 Y Y 00 00 57 A
B OTHER B
C PRV. ID C
58 INSURED’S NAME 59 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

A KEDAR RAMESH 18 65432678 6649 A

B B
C C
63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

A 545777888 WHOLESALE ELECTRONICS INC A

B B
C C
66
DX 41519 30000 4019 F G H 68

9
69 ADMIT
DX 786.05 70 PATIENT
REASON DX a b c 71 PPS
CODE
72
ECI a b c 73

74 PRINCIPAL PROCEDURE
CODE DATE
a OTHER PROCEDURE
CODE DATE
b OTHER PROCEDURE
CODE DATE
75 76 ATTENDING NPI 0246802468 QUAL

9215 1212XX 8872 1212XX 8952 1212XX LAST HART MD FIRST IVA
c OTHER PROCEDURE d OTHER PROCEDURE e OTHER PROCEDURE
CODE DATE CODE DATE CODE DATE 77 OPERATING NPI QUAL

LAST FIRST

80 REMARKS 81CC
a 78 OTHER NPI QUAL

b LAST FIRST

c 79 OTHER NPI QUAL

d LAST FIRST

290 Appendix C: Answers to Appendix C Case Studies © 2013 Pearson Education, Inc.
Z03_VINE7282_01_IRM_APP3.QXD 8/22/12 10:24 PM Page 291

CASE C-6
1 2 3a PAT 4 TYPE
CAPITAL CITY GENERAL HOSPITAL C6 CNTL # 4616549 OF BILL
1000 CHERRY ST b MED
REC # ZA16836401 0111
6 STATEMENT COVERS PERIOD 7
CAPITAL CITY NY 123452222 5 FED. TAX. NO.
FROM THROUGH
5555551000 757575757 0901XX 0905XX
8 PATIENT NAME a 9 PATIENT ADDRESS a 9832 GRASS RD
b ZBEGAN ARTHUR b CAPITAL CITY c NY d 12345 e
ADMISSION CONDITION CODES 29 ACDT 30
10 BIRTHDATE 11 SEX 16 DHR 17 STAT STATE
12 DATE 13 HR 14 TYPE 15 SRC 18 19 20 21 22 23 24 25 26 27 28
041139 M 0901XX 02 1 7 11 01
31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37
CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH
a

b
38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES
ZBEGAN ARTHUR CODE AMOUNT CODE AMOUNT CODE AMOUNT
9832 GRASS RD a 80 4
CAPITAL CITY NY 12345 b

42 REV.CD. 43 DESCRIPTION 44 HCPCS/RATE/HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED 49
CHARGES
1
0210 CORONARY CARE 650.00 4 2600 00 0 00 1
2 0250 PHARMACY 5 425 00 0 00 2
3 0260 IV THERAPY 4 1200 00 0 00 3
4 0270 MED SURG SUPPLIES 1 800 00 0 00 4
5 0300 LAB 5 450 00 0 00 5
6 0360 OR SERVICES 1 2300 00 0 00 6
7 0370 ANESTHESIA 1 675 00 0 00 7
8 0730 EKG 1 175 00 0 00 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 0001 PAGE 1 OF 1 CREATION DATE 0905XX TOTALS 8625 00 0 00 23
52 REL. 53 ASG.
50 PAYER NAME 51 HEALTH PLAN ID INFO BEN. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI 1212121212
A MEDICARE 62541 Y Y 00 00 57 A
B OTHER B
C PRV. ID C
58 INSURED’S NAME 59 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

A ZBEGAN ARTHUR 18 629417113A A

B B
C C
63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

A 5463664535 A
B B
C C
66
DX 41181 41400 40200 V4581 F G H 68

9
69 ADMIT
DX 4139 70 PATIENT
REASON DX a b c 71 PPS
CODE
72
ECI a b c 73

74 PRINCIPAL PROCEDURE
CODE DATE
a OTHER PROCEDURE
CODE DATE
b OTHER PROCEDURE
CODE DATE
75 76 ATTENDING NPI 0246802468 QUAL

3612 0902XX 8944 0901XX 88.72 0901XX LAST HART MD FIRST IVA
c OTHER PROCEDURE d OTHER PROCEDURE e OTHER PROCEDURE
CODE DATE CODE DATE CODE DATE 77 OPERATING NPI QUAL

8952 0901XX LAST FIRST

80 REMARKS 81CC
a 78 OTHER NPI QUAL

b LAST FIRST

c 79 OTHER NPI QUAL

d LAST FIRST

© 2013 Pearson Education, Inc. Appendix C: Answers to Appendix C Case Studies 291
Z03_VINE7282_01_IRM_APP3.QXD 8/22/12 10:24 PM Page 292

CASE C-7
1 2 3a PAT 4 TYPE
CAPITAL CITY GENERAL HOSPITAL CNTL # 0063259 OF BILL
1000 CHERRY STREET b MED
REC # 000233168 0111
6 STATEMENT COVERS PERIOD 7
CAPITAL CITY NY 12345 5 FED. TAX. NO.
FROM THROUGH
5555551000 757575757 0114XX 0116XX
8 PATIENT NAME a 9 PATIENT ADDRESS a 4 S. ORANGE WAY
b MANGINO RITA b TOWNSHIP c NY d 12345 e
ADMISSION CONDITION CODES 29 ACDT 30
10 BIRTHDATE 11 SEX 16 DHR 17 STAT STATE
12 DATE 13 HR 14 TYPE 15 SRC 18 19 20 21 22 23 24 25 26 27 28
02081957 F 0114XX 06 1 1 13 01
31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37
CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH
a A2 110657
b
38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES
MANGINO, RITA CODE AMOUNT CODE AMOUNT CODE AMOUNT
4 S. ORANGE WAY, a 80 2
CAPITAL CITY NY 12345 b

42 REV.CD. 43 DESCRIPTION 44 HCPCS/RATE/HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED 49
CHARGES
1
120 ROOM/BOARD/SEMI 450.00 0114XX 2 900 00 0 00 1
2 320 RADIOLOGY 0114XX 2 500 00 0 00 2
3 300 LAB 0114XX 1 105 00 0 00 3
4 260 IV THERAPY 0114XX 2 820 00 0 00 4
5 270 MED/SURG SUPPLIES 0114XX 5 400 00 0 00 5
6 250 PHARMACY 0114XX 1 375 00 0 00 6
7 900 RESPIRATORY SERVICES 0114XX 3 600 00 0 00 7
8 0114XX 3 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 0001 PAGE 1 OF 1 CREATION DATE 0116XX TOTALS 3700 00 0 00 23
52 REL. 53 ASG.
50 PAYER NAME 51 HEALTH PLAN ID INFO BEN. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI 1212121212
A AETNA 21084 Y Y 00 00 57 A
B OTHER B
C PRV. ID C
58 INSURED’S NAME 59 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

A MANGINO, BRUCE 01 4783900 493 A

B B
C C
63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

A 5331648 CRITTER’S CAMPUS A

B B
C C
66
DX 5180 493.92 F G H 68

9
69 ADMIT
DX 493.92 70 PATIENT
REASON DX a b c 71 PPS
CODE
72
ECI a b c 73

74 PRINCIPAL PROCEDURE a OTHER PROCEDURE b OTHER PROCEDURE 75

CODE DATE CODE DATE CODE DATE 76 ATTENDING NPI 1234567890 QUAL

34.91 0114XX 87.44 0114XX LAST WELLS MD FIRST PHIL

c OTHER PROCEDURE d OTHER PROCEDURE e OTHER PROCEDURE
CODE DATE CODE DATE CODE DATE 77 OPERATING NPI QUAL

LAST FIRST

80 REMARKS 81CC
a 78 OTHER NPI QUAL

b LAST FIRST

c 79 OTHER NPI QUAL

d LAST FIRST

292 Appendix C: Answers to Appendix C Case Studies © 2013 Pearson Education, Inc.
Z03_VINE7282_01_IRM_APP3.QXD 8/22/12 10:24 PM Page 293

CASE C-8
1 2 3a PAT 4 TYPE
CAPITAL CITY GENERAL HOSPITAL C8 CNTL # 198761 OF BILL
1000 CHERRY ST b MED
REC # 00025643189 0111
6 STATEMENT COVERS PERIOD 7
CAPITAL CITY NY 123452222 5 FED. TAX. NO.
FROM THROUGH
5555551000 757575757 0814XX 0818XX
8 PATIENT NAME a 9 PATIENT ADDRESS a 777 SYCAMORE CIR
b GREER DOROTHY b CAPITAL CITY c NY d 12345 e
ADMISSION CONDITION CODES 29 ACDT 30
10 BIRTHDATE 11 SEX 16 DHR 17 STAT STATE
12 DATE 13 HR 14 TYPE 15 SRC 18 19 20 21 22 23 24 25 26 27 28
100249 M 0814XX 09 1 7 14 01
31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37
CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH
a

b
38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES
GREER DOROTHY CODE AMOUNT CODE AMOUNT CODE AMOUNT
777 SYCAMORE CIR a 80 4
CAPITAL CITY NY 12345 b

42 REV.CD. 43 DESCRIPTION 44 HCPCS/RATE/HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED 49
CHARGES
1
0210 CORONARY CARE 600.00 4 2400 00 0 00 1
2 0250 PHARMACY 5 350 00 0 00 2
3 0260 IV THERAPY 4 1000 00 0 00 3
4 0270 MED SURG SUPPLIES 1 900 00 0 00 4
5 0300 LAB 5 600 00 0 00 5
6 0360 OR SERVICES 1 1950 00 0 00 6
7 0370 ANESTHESIA 1 700 00 0 00 7
8 0730 EKG 1 150 00 0 00 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 0001 PAGE 1 OF 1 CREATION DATE 0818XX TOTALS 8050 00 0 00 23
52 REL. 53 ASG.
50 PAYER NAME 51 HEALTH PLAN ID INFO BEN. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI 1212121212
A MEDICARE 62541 Y Y 00 00 57 A
B OTHER B
C PRV. ID C
58 INSURED’S NAME 59 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

A GREER DOROTHY 18 629417113A A

B B
C C
63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

A 198131332 A
B B
C C
66
DX 99601 7802 F G H 68

9
69 ADMIT
DX 7802 70 PATIENT
REASON DX a b c 71 PPS
CODE
72
ECI a b c 73

74 PRINCIPAL PROCEDURE
CODE DATE
a OTHER PROCEDURE
CODE DATE
b OTHER PROCEDURE
CODE DATE
75 76 ATTENDING NPI 0246802468 QUAL

0050 0814XX 8944 0814XX 8872 0814XX LAST HART MD FIRST IVA
c OTHER PROCEDURE d OTHER PROCEDURE e OTHER PROCEDURE
CODE DATE CODE DATE CODE DATE 77 OPERATING NPI QUAL

8952 0814XX LAST FIRST

80 REMARKS 81CC
a 78 OTHER NPI QUAL

b LAST FIRST

c 79 OTHER NPI QUAL

d LAST FIRST

© 2013 Pearson Education, Inc. Appendix C: Answers to Appendix C Case Studies 293
Z03_VINE7282_01_IRM_APP3.QXD 8/22/12 10:24 PM Page 294

CASE C-9
1 2 3a PAT 4 TYPE
CAPITAL CITY GENERAL HOSPITAL C9 CNTL # 578877 OF BILL
1000 CHERRY ST b MED
REC # 654943233 111
6 STATEMENT COVERS PERIOD 7
CAPITAL CITY NY 123452222 5 FED. TAX. NO.
FROM THROUGH
5555551000 757575757 0311XX 0315XX
8 PATIENT NAME a 9 PATIENT ADDRESS a 934 SMITHFIELD ST
b MOORE VIRGINIA b CAPITAL CITY c NY d 12345 e
ADMISSION CONDITION CODES 29 ACDT 30
10 BIRTHDATE 11 SEX 16 DHR 17 STAT STATE
12 DATE 13 HR 14 TYPE 15 SRC 18 19 20 21 22 23 24 25 26 27 28
012744 F 0311XX 17 2 1 14 62
31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37
CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH
a

b
38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES
MOORE VIRGINIA CODE AMOUNT CODE AMOUNT CODE AMOUNT
934 SMITHFIELD ST a 80 4
CAPITAL CITY NY 12345 b

42 REV.CD. 43 DESCRIPTION 44 HCPCS/RATE/HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED 49
CHARGES
1 650.00 4 1
120 ROOM BOARD SEMI 2600 00 0 00
2 250 PHARMACY 5 400 00 0 00 2
3 260 IV THERAPY 4 1200 00 0 00 3
4 270 MED SURG SUPPLIES 1 1200 00 0 00 4
5 300 LAB 2 400 00 0 00 5
6 320 RADIOLOGY 1 250 00 0 00 6
7 360 OR SERVICES 1 2600 00 0 00 7
8 370 ANESTHESIA 1 800 00 0 00 8
9 730 EKG 1 175 00 0 00 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 001 PAGE 1 OF 1 CREATION DATE 0315XX TOTALS 9625 00 0 00 23
52 REL. 53 ASG.
50 PAYER NAME 51 HEALTH PLAN ID INFO BEN. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI 1212121212
A MEDICAID 92101 Y Y 00 00 57 A
B OTHER B
C PRV. ID C
58 INSURED’S NAME 59 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

A MOORE VIRGINIA 18 629417113972 A

B B
C C
63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

A 519843131 A
B B
C C
66
DX 82020 73310 71509 4019 F G H 68

9
69 ADMIT
DX 82020 70 PATIENT
REASON DX a b c 71 PPS
CODE
72
ECI a b c 73

74 PRINCIPAL PROCEDURE a OTHER PROCEDURE b OTHER PROCEDURE 75

CODE DATE CODE DATE CODE DATE 76 ATTENDING NPI 1357613579 QUAL

8151 0312XX 8826 0311XX 8952 0312XX LAST TISS MD FIRST ARTHUR
c OTHER PROCEDURE d OTHER PROCEDURE e OTHER PROCEDURE
CODE DATE CODE DATE CODE DATE 77 OPERATING NPI QUAL

LAST FIRST

80 REMARKS 81CC
a 78 OTHER NPI QUAL

b LAST FIRST

c 79 OTHER NPI QUAL

d LAST FIRST

294 Appendix C: Answers to Appendix C Case Studies © 2013 Pearson Education, Inc.
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CASE C-10
1 2 3a PAT 4 TYPE
CAPITAL CITY GENERAL HOSPITAL C10 CNTL # 015356 OF BILL
1000 CHERRY ST b MED
REC # AK45329 0111
6 STATEMENT COVERS PERIOD 7
CAPITAL CITY NY 123452222 5 FED. TAX. NO.
FROM THROUGH
5555551000 757575757 0403XX 0407XX
8 PATIENT NAME a 9 PATIENT ADDRESS a 601 SUNFLOWER DR
b KIM ALBERT b CAPITAL CITY c NY d 12345 e
ADMISSION CONDITION CODES 29 ACDT 30
10 BIRTHDATE 11 SEX 16 DHR 17 STAT STATE
12 DATE 13 HR 14 TYPE 15 SRC 18 19 20 21 22 23 24 25 26 27 28
060230 M 0403XX 16 1 7 12 03
31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37
CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH
a

b
38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES
KIM ALBERT CODE AMOUNT CODE AMOUNT CODE AMOUNT
601 SUNFLOWER DR a 80 4
CAPITAL CITY NY 12345 b

42 REV.CD. 43 DESCRIPTION 44 HCPCS/RATE/HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED 49
CHARGES
1
0210 CORONARY CARE 650.00 4 2600 00 0 00 1
2 0250 PHARMACY 5 375 00 0 00 2
3 0260 IV THERAPY 4 1000 00 0 00 3
4 0270 MED SURG SUPPLIES 1 400 00 0 00 4
5 0300 LAB 2 220 00 0 00 5
6 0320 RADIOLOGY 2 550 00 0 00 6
7 0730 EKG 1 150 00 0 00 7
8 0900 RESPIRATORY SERVICES 1 400 00 0 00 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 0001 PAGE 1 OF 1 CREATION DATE 0407XX TOTALS 5695 00 0 00 23
52 REL. 53 ASG.
50 PAYER NAME 51 HEALTH PLAN ID INFO BEN. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI 1212121212
A MEDICARE 62541 Y Y 00 00 57 A
B OTHER B
C PRV. ID C
58 INSURED’S NAME 59 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

A KIM ALBERT 18 629417113A A

B B
C C
63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

A 646819900 A
B B
C C
66
DX 42001 4280 F G H 68

9
69 ADMIT
DX 7865 70 PATIENT
REASON DX a b c 71 PPS
CODE
72
ECI a b c 73

74 PRINCIPAL PROCEDURE a OTHER PROCEDURE b OTHER PROCEDURE 75

CODE DATE CODE DATE CODE DATE 76 ATTENDING NPI 0246802468 QUAL

3491 0405XX 8744 0403XX LAST HART MD FIRST IVA

c OTHER PROCEDURE d OTHER PROCEDURE e OTHER PROCEDURE
CODE DATE CODE DATE CODE DATE 77 OPERATING NPI QUAL

LAST FIRST

80 REMARKS 81CC
a 78 OTHER NPI QUAL

b LAST FIRST

c 79 OTHER NPI QUAL

d LAST FIRST

© 2013 Pearson Education, Inc. Appendix C: Answers to Appendix C Case Studies 295
Z03_VINE7282_01_IRM_APP3.QXD 8/22/12 10:24 PM Page 296

CASE C-11
1 2 3a PAT 4 TYPE
CAPITAL CITY GENERAL HOSPITAL C11 CNTL # 213652 OF BILL
1000 CHERRY ST b MED
REC # OM24965 131
6 STATEMENT COVERS PERIOD 7
CAPITAL CITY NY 12345 5 FED. TAX. NO.
FROM THROUGH
5555551000 757575757 0823XX 0823XX
8 PATIENT NAME a 9 PATIENT ADDRESS a 4142 VALLEY RD
b MARSELLE OLIVIA b CAPITAL CITY c NY d 12345 e
ADMISSION CONDITION CODES 29 ACDT 30
10 BIRTHDATE 11 SEX 16 DHR 17 STAT STATE
12 DATE 13 HR 14 TYPE 15 SRC 18 19 20 21 22 23 24 25 26 27 28
102975 F 0823XX 7 01
31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37
CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH
a

b
38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES
MARSELLE OLIVIA CODE AMOUNT CODE AMOUNT CODE AMOUNT
4142 VALLEY RD a

CAPITAL CITY NY 12345 b

42 REV.CD. 43 DESCRIPTION 44 HCPCS/RATE/HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED 49
CHARGES
1 36415 0823XX 1 1
300 LAB 20 00 0 00
2 301 LAB 80053 0823XX 2 230 00 0 00 2
3 305 LAB 85025 0823XX 1 25 00 0 00 3
4 450 ER 0823XX 1 350 00 0 00 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 001 PAGE 1 OF 1 CREATION DATE 0823XX TOTALS 625 00 0 00 23
52 REL. 53 ASG.
50 PAYER NAME 51 HEALTH PLAN ID INFO BEN. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI 1212121212
A MEDICAID 92101 Y Y 00 00 57 A
B OTHER B
C PRV. ID C
58 INSURED’S NAME 59 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

A MARSELLE OLIVIA 18 0564616665659 A

B B
C C
63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

A A
B B
C C
66
DX 9604 49322 F G H 68

9
69 ADMIT
DX
70 PATIENT
REASON DX 78701a b c 71 PPS
CODE
72
ECI E9304 a b c 73

74 PRINCIPAL PROCEDURE a OTHER PROCEDURE b OTHER PROCEDURE 75

CODE DATE CODE DATE CODE DATE 76 ATTENDING NPI 1471471471 QUAL

LAST LOTTS MD FIRST KAREN

c OTHER PROCEDURE d OTHER PROCEDURE e OTHER PROCEDURE
CODE DATE CODE DATE CODE DATE 77 OPERATING NPI QUAL

LAST FIRST

80 REMARKS 81CC
a 78 OTHER NPI QUAL

b LAST FIRST

c 79 OTHER NPI QUAL

d LAST FIRST

296 Appendix C: Answers to Appendix C Case Studies © 2013 Pearson Education, Inc.
Z03_VINE7282_01_IRM_APP3.QXD 8/22/12 10:24 PM Page 297

CASE C-12
1 2 3a PAT 4 TYPE
CAPITAL CITY GENERAL HOSPITAL C12 CNTL # 869244 OF BILL
1000 CHERRY ST b MED
REC # AR3461 131
6 STATEMENT COVERS PERIOD 7
CAPITAL CITY NY 12345 5 FED. TAX. NO.
FROM THROUGH
5555551000 757575757 0518XX 0518XX
8 PATIENT NAME a 9 PATIENT ADDRESS a 32 PLANK CIR
b RODRIGUEZ ANTONIO b CAPITAL CITY c NY d 12345 e
ADMISSION CONDITION CODES 29 ACDT 30
10 BIRTHDATE 11 SEX 16 DHR 17 STAT STATE
12 DATE 13 HR 14 TYPE 15 SRC 18 19 20 21 22 23 24 25 26 27 28
042854 M 0518XX 1 01
31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37
CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH
a A2 073059
b
38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES
RODRIGUEZ ANTONIO CODE AMOUNT CODE AMOUNT CODE AMOUNT
32 PLANK CIR a

CAPITAL CITY NY 12345 b

42 REV.CD. 43 DESCRIPTION 44 HCPCS/RATE/HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED 49
CHARGES
1 400 00 0 00 1
260 IV THERAPY 0518XX 1
2 270 MED SURG SUPPLIES 500 00 0 00 2
0518XX 1
3 500 AMBUL SURG 45384 0518XX 1 2200 00 0 00 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 001 PAGE 1 OF 1 CREATION DATE 0518XX TOTALS 3100 00 0 00 23
52 REL. 53 ASG.
50 PAYER NAME 51 HEALTH PLAN ID INFO BEN. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI 1212121212
A BLUE CROSS BLUE SHIELD 87590 Y Y 00 00 57 A
B OTHER B
C PRV. ID C
58 INSURED’S NAME 59 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

A RODRIGUEZ CASSANDRA 01 YY294004954 727524 A

B B
C C
63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

A RICHIE RICH BANK OF USA A

B B
C C
66
DX 2303 F G H 68

9
69 ADMIT
DX
70 PATIENT
REASON DX a b c 71 PPS
CODE
72
ECI E9304a b c 73

74 PRINCIPAL PROCEDURE a OTHER PROCEDURE b OTHER PROCEDURE 75

CODE DATE CODE DATE CODE DATE 76 ATTENDING 0123456789
NPI QUAL

LAST MENDS MD FIRST MANNIE

c OTHER PROCEDURE d OTHER PROCEDURE e OTHER PROCEDURE
CODE DATE CODE DATE CODE DATE 77 OPERATING NPI QUAL

LAST FIRST

80 REMARKS 81CC
a 78 OTHER NPI QUAL

b LAST FIRST

c 79 OTHER NPI QUAL

d LAST FIRST

© 2013 Pearson Education, Inc. Appendix C: Answers to Appendix C Case Studies 297
Z03_VINE7282_01_IRM_APP3.QXD 8/22/12 10:24 PM Page 298

CASE C-13
1 2 3a PAT 4 TYPE
COUNTY COMMUNITY HOSPITAL CNTL # 04698 OF BILL
1600 CLOVER ST b MED
REC # RP1297 131
6 STATEMENT COVERS PERIOD 7
CAPITAL CITY NY 12345 5 FED. TAX. NO.
FROM THROUGH
707070707 1125XX 1125XX
8 PATIENT NAME a 9 PATIENT ADDRESS a 231 BOSTON AVE APT 5
b PAUL RANDALL b CAPITAL CITY c NY d 12345 e
ADMISSION CONDITION CODES 29 ACDT 30
10 BIRTHDATE 11 SEX 16 DHR 17 STAT STATE
12 DATE 13 HR 14 TYPE 15 SRC 18 19 20 21 22 23 24 25 26 27 28
120959 M 1125XX 1 01
31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37
CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH
a

b
38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES
PAUL RANDALL CODE AMOUNT CODE AMOUNT CODE AMOUNT
231 BOSTON AVE APT 5 a

CAPITAL CITY NY 12345 b

42 REV.CD. 43 DESCRIPTION 44 HCPCS/RATE/HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED 49
CHARGES
1 90 00 0 00 1
250 PHARMACY 1125XX 1
2 260 IV THERAPY 575 00 0 00 2
1125XX 1
3 320 RADIOLOGY 74170 1125XX 1 850 00 0 00 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 001 PAGE 1 OF 1 CREATION DATE 1125XX TOTALS 1515 00 0 00 23
52 REL. 53 ASG.
50 PAYER NAME 51 HEALTH PLAN ID INFO BEN. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI 676767676
A AETNA 06599 Y Y 00 00 57 A
B OTHER B
C PRV. ID C
58 INSURED’S NAME 59 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

A PAUL RANDALL 18 YY204753589 A

B B
C C
63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

A RANDYS GAMING STOP A

B B
C C
66
DX 78930 F G H 68

9
69 ADMIT
DX
70 PATIENT
REASON DX a b c 71 PPS
CODE
72
ECI a b c 73

74 PRINCIPAL PROCEDURE a OTHER PROCEDURE b OTHER PROCEDURE 75

CODE DATE CODE DATE CODE DATE 76 ATTENDING 987654321
NPI QUAL

LAST ALRIGHT MD FIRST ELBY

c OTHER PROCEDURE d OTHER PROCEDURE e OTHER PROCEDURE
CODE DATE CODE DATE CODE DATE 77 OPERATING NPI QUAL

LAST FIRST

80 REMARKS 81CC
a 78 OTHER NPI QUAL

b LAST FIRST

c 79 OTHER NPI QUAL

d LAST FIRST

298 Appendix C: Answers to Appendix C Case Studies © 2013 Pearson Education, Inc.
Z03_VINE7282_01_IRM_APP3.QXD 8/22/12 10:24 PM Page 299

CASE C-14
1 2 3a PAT 4 TYPE
CAPITAL CITY GENERAL HOSPITAL C14 CNTL # 462013 OF BILL
1000 CHERRY ST b MED
REC # MB8020 131
6 STATEMENT COVERS PERIOD 7
CAPITAL CITY NY 12345 5 FED. TAX. NO.
FROM THROUGH
5555551000 757575757 0916XX 0916XX
8 PATIENT NAME a 9 PATIENT ADDRESS a 5834 CLIFF ST
b BISHOP MEGAN b CAPITAL CITY c NY d 12345 e
ADMISSION CONDITION CODES 29 ACDT 30
10 BIRTHDATE 11 SEX 16 DHR 17 STAT STATE
12 DATE 13 HR 14 TYPE 15 SRC 18 19 20 21 22 23 24 25 26 27 28
103162 F 0916XX 1 01
31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37
CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH
a

b
38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES
BISHOP MEGAN CODE AMOUNT CODE AMOUNT CODE AMOUNT
5834 CLIFF ST a

CAPITAL CITY NY 12345 b

42 REV.CD. 43 DESCRIPTION 44 HCPCS/RATE/HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED 49
CHARGES
1 775 00 0 00 1
320 RADIOLOGY 77057 0916XX 1
2 972 RADIOLOGIST 100 00 0 00 2
0916XX 1
3 3
1
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 001 PAGE 1 OF 1 CREATION DATE 0916XX TOTALS 875 00 0 00 23
52 REL. 53 ASG.
50 PAYER NAME 51 HEALTH PLAN ID INFO BEN. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI 1212121212
A BLUE CROSS BLUE SHIELD 87590 Y Y 00 00 57 A
B OTHER B
C PRV. ID C
58 INSURED’S NAME 59 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

A BISHOP MEGAN 18 YYJ846168930 688112 A

B B
C C
63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

A VIDEOS PLUS A
B B
C C
66
DX V7612 F G H 68

9
69 ADMIT
DX
70 PATIENT
REASON DX a b c 71 PPS
CODE
72
ECI a b c 73

74 PRINCIPAL PROCEDURE a OTHER PROCEDURE b OTHER PROCEDURE 75

CODE DATE CODE DATE CODE DATE 76 ATTENDING 0987654321
NPI QUAL

LAST SOONE MD FIRST BETTE

c OTHER PROCEDURE d OTHER PROCEDURE e OTHER PROCEDURE
CODE DATE CODE DATE CODE DATE 77 OPERATING NPI QUAL

LAST FIRST

80 REMARKS 81CC
a 78 OTHER NPI QUAL

b LAST FIRST

c 79 OTHER NPI QUAL

d LAST FIRST

© 2013 Pearson Education, Inc. Appendix C: Answers to Appendix C Case Studies 299
Z03_VINE7282_01_IRM_APP3.QXD 8/22/12 10:24 PM Page 300

CASE C-15
1 2 3a PAT 4 TYPE
COUNTY COMMUNITY HOSPITAL C15 CNTL # 665090 OF BILL
1600 CLOVER ST b MED
REC # PV7539 131
6 STATEMENT COVERS PERIOD 7
CAPITAL CITY NY 12345 5 FED. TAX. NO.
FROM THROUGH
5555551600 707070707 0619XX 0619XX
8 PATIENT NAME a 9 PATIENT ADDRESS a 988 MILL RUN RD
b VLAH PATRICIA b TOWNSHIP c NY d 12345 e
ADMISSION CONDITION CODES 29 ACDT 30
10 BIRTHDATE 11 SEX 16 DHR 17 STAT STATE
12 DATE 13 HR 14 TYPE 15 SRC 18 19 20 21 22 23 24 25 26 27 28
021100 F 0619XX 1 01
31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37
CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH
a

b
38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES
VLAH SUZANNE CODE AMOUNT CODE AMOUNT CODE AMOUNT
988 MILL RUN RD a

TOWNSHIP NY 12345 b

42 REV.CD. 43 DESCRIPTION 44 HCPCS/RATE/HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED 49
CHARGES
1 150 00 0 00 1
250 PHARMACY 0619XX 1
2 260 IV THERAPY 750 00 0 00 2
0619XX 1
3 270 MED SURG SUPPLIES 0619XX 1 400 00 0 00 3
4 370 ANESTHESIA 0619XX 1 700 00 0 00 4
5 500 AMBUL SURG 42820 0619XX 1 1500 00 0 00 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 001 PAGE 1 OF 1 CREATION DATE 0619XX TOTALS 3500 00 0 00 23
52 REL. 53 ASG.
50 PAYER NAME 51 HEALTH PLAN ID INFO BEN. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI 676767676
A AETNA 06599 Y Y 00 00 57 A
B OTHER B
C PRV. ID C
58 INSURED’S NAME 59 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

A VLAH SUZANNE 19 6561946 649104 A

B B
C C
63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

A CUTS N CURLS SALON A

B B
C C
66
DX 47402 F G H 68

9
69 ADMIT
DX
70 PATIENT
REASON DX a b c 71 PPS
CODE
72
ECI a b c 73

74 PRINCIPAL PROCEDURE a OTHER PROCEDURE b OTHER PROCEDURE 75

CODE DATE CODE DATE CODE DATE 76 ATTENDING 0123456789
NPI QUAL

LAST MENDS MD FIRST MANNIE

c OTHER PROCEDURE d OTHER PROCEDURE e OTHER PROCEDURE
CODE DATE CODE DATE CODE DATE 77 OPERATING NPI QUAL

LAST FIRST

80 REMARKS 81CC
a 78 OTHER NPI QUAL

b LAST FIRST

c 79 OTHER NPI QUAL

d LAST FIRST

300 Appendix C: Answers to Appendix C Case Studies © 2013 Pearson Education, Inc.
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CASE C-16
1 2 3a PAT 4 TYPE
CAPITAL CITY GENERAL HOSPITAL C16 CNTL # 925259 OF BILL
1000 CHERRY ST b MED
REC # BC69281 131
6 STATEMENT COVERS PERIOD 7
CAPITAL CITY NY 12345 5 FED. TAX. NO.
FROM THROUGH
5555551000 757575757 1101XX 1101XX
8 PATIENT NAME a 9 PATIENT ADDRESS a 205 GLASS RD
b CHUNG BRYSON b CAPITAL CITY c NY d 12345 e
ADMISSION CONDITION CODES 29 ACDT 30
10 BIRTHDATE 11 SEX 16 DHR 17 STAT STATE
12 DATE 13 HR 14 TYPE 15 SRC 18 19 20 21 22 23 24 25 26 27 28
012197 M 1101XX 7 01
31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37
CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH
a A2 042878
b
38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES
CHUNG MELISSA CODE AMOUNT CODE AMOUNT CODE AMOUNT
205 GLASS RD a

CAPITAL CITY NY 12345 b

42 REV.CD. 43 DESCRIPTION 44 HCPCS/RATE/HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED 49
CHARGES
1 75 00 0 00 1
250 PHARMACY 1101XX 1
2 300 LAB 1 20 00 0 00 2
36415 1101XX
3 301 LAB 80053 1101XX 1 250 00 0 00 3
4 305 LAB 85025 1101XX 1 30 00 0 00 4
5 450 ER 1101XX 1 350 00 0 00 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 001 PAGE 1 OF 1 CREATION DATE 0619XX TOTALS 725 00 0 00 23
52 REL. 53 ASG.
50 PAYER NAME 51 HEALTH PLAN ID INFO BEN. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI 1212121212
A HEALTH AMERICA 62400 Y Y 00 00 57 A
B OTHER B
C PRV. ID C
58 INSURED’S NAME 59 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

A CHUNG MICHAEL 43 4684646 5215 A

B B
C C
63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

A CUTS N CURLS SALON A

B B
C C
66
DX 4878 F G H 68

9
69 ADMIT
DX
70 PATIENT
REASON DX a b c 71 PPS
CODE
72
ECI a b c 73

74 PRINCIPAL PROCEDURE a OTHER PROCEDURE b OTHER PROCEDURE 75

CODE DATE CODE DATE CODE DATE 76 ATTENDING NPI 1471471471 QUAL

LAST LOTTS MD FIRST KAREN

c OTHER PROCEDURE d OTHER PROCEDURE e OTHER PROCEDURE
CODE DATE CODE DATE CODE DATE 77 OPERATING NPI QUAL

LAST FIRST

80 REMARKS 81CC
a 78 OTHER NPI QUAL

b LAST FIRST

c 79 OTHER NPI QUAL

d LAST FIRST

© 2013 Pearson Education, Inc. Appendix C: Answers to Appendix C Case Studies 301
Z03_VINE7282_01_IRM_APP3.QXD 8/22/12 10:24 PM Page 302

CASE C-17
1 2 3a PAT 4 TYPE
TOWNSHIP MEMORIAL HOSPITAL C17 CNTL # 728438 OF BILL
700 SHADY ST b MED
REC # KL693321 0131
6 STATEMENT COVERS PERIOD 7
CAPITAL CITY NY 12345 5 FED. TAX. NO.
FROM THROUGH
5555550700 750750750 0106XX 0106XX
8 PATIENT NAME a 9 PATIENT ADDRESS a 174 JEFFERSON ST
b LOMBARDO KEITH b TOWNSHIP c NY d 12345 e
ADMISSION CONDITION CODES 29 ACDT 30
10 BIRTHDATE 11 SEX 16 DHR 17 STAT STATE
12 DATE 13 HR 14 TYPE 15 SRC 18 19 20 21 22 23 24 25 26 27 28
051333 M 0106XX 1 01
31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37
CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH
a A2 042878
b
38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES
LOMBARDO KEITH CODE AMOUNT CODE AMOUNT CODE AMOUNT
174 JEFFERSON ST a

TOWNSHIP NY 12345 b

42 REV.CD. 43 DESCRIPTION 44 HCPCS/RATE/HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED 49
CHARGES
1 300 00 0 00 1
0320 RADIOLOGY 76770 0106XX 1
2 0972 RADIOILOGIST 125 00 0 00 2
0106XX 1
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 0001 PAGE 1 OF 1 CREATION DATE 0106XX TOTALS 425 00 0 00 23
52 REL. 53 ASG.
50 PAYER NAME 51 HEALTH PLAN ID INFO BEN. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI 3434343434
A MEDICARE 15877 Y Y 00 00 57 A
B OTHER B
C PRV. ID C
58 INSURED’S NAME 59 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

A LOMBARDO KEITH 18 649331304A A

B B
C C
63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

A A
B B
C C
66
DX 5920 F G H 68

9
69 ADMIT
DX
70 PATIENT
REASON DX a b c 71 PPS
CODE
72
ECI a b c 73

74 PRINCIPAL PROCEDURE a OTHER PROCEDURE b OTHER PROCEDURE 75

CODE DATE CODE DATE CODE DATE 76 ATTENDING NPI 1234567890 QUAL

LAST WELLS MD FIRST PHIL

c OTHER PROCEDURE d OTHER PROCEDURE e OTHER PROCEDURE
CODE DATE CODE DATE CODE DATE 77 OPERATING NPI QUAL

LAST FIRST

80 REMARKS 81CC
a 78 OTHER NPI QUAL

b LAST FIRST

c 79 OTHER NPI QUAL

d LAST FIRST

302 Appendix C: Answers to Appendix C Case Studies © 2013 Pearson Education, Inc.
Z03_VINE7282_01_IRM_APP3.QXD 8/22/12 10:24 PM Page 303

CASE C-18
1 2 3a PAT 4 TYPE
TOWNSHIP MEMORIAL HOSPITAL C18 CNTL # 210158 OF BILL
700 SHADY ST b MED
REC # TC11720 131
6 STATEMENT COVERS PERIOD 7
TOWNSHIP NY 12345 5 FED. TAX. NO.
FROM THROUGH
5555550700 750750750 0821XX 0821XX
8 PATIENT NAME a 9 PATIENT ADDRESS a 55 LOCKWOOD DR
b CLARK TYRONE b TOWNSHIP c NY d 12345 e
ADMISSION CONDITION CODES 29 ACDT 30
10 BIRTHDATE 11 SEX 16 DHR 17 STAT STATE
12 DATE 13 HR 14 TYPE 15 SRC 18 19 20 21 22 23 24 25 26 27 28
061580 M 0821XX 7 01
31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37
CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH
a A2 042878
b
38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES
CLARK TYRONE CODE AMOUNT CODE AMOUNT CODE AMOUNT
55 LOCKWOOD DR a

TOWNSHIP NY 12345 b

42 REV.CD. 43 DESCRIPTION 44 HCPCS/RATE/HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED 49
CHARGES
1 50 00 0 00 1
250 PHARMACY 0821XX 1
2 450 ER 275 00 0 00 2
0821XX 1
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 001 PAGE 1 OF 1 CREATION DATE 0821XX TOTALS 325 00 0 00 23
52 REL. 53 ASG.
50 PAYER NAME 51 HEALTH PLAN ID INFO BEN. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI 3434343434
A MEDICAID 43062 Y Y 00 00 57 A
B OTHER B
C PRV. ID C
58 INSURED’S NAME 59 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

A CLARK TYRONE 18 498481614 A

B B
C C
63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

A A
B B
C C
66
DX 6926 F G H 68

9
69 ADMIT
DX
70 PATIENT
REASON DX a b c 71 PPS
CODE
72
ECI a b c 73

74 PRINCIPAL PROCEDURE a OTHER PROCEDURE b OTHER PROCEDURE 75

CODE DATE CODE DATE CODE DATE 76 ATTENDING NPI 1471471471 QUAL

LAST LOTTS MD FIRST KAREN

c OTHER PROCEDURE d OTHER PROCEDURE e OTHER PROCEDURE
CODE DATE CODE DATE CODE DATE 77 OPERATING NPI QUAL

LAST FIRST

80 REMARKS 81CC
a 78 OTHER NPI QUAL

b LAST FIRST

c 79 OTHER NPI QUAL

d LAST FIRST

© 2013 Pearson Education, Inc. Appendix C: Answers to Appendix C Case Studies 303
Z03_VINE7282_01_IRM_APP3.QXD 8/22/12 10:24 PM Page 304

CASE C-19
1 2 3a PAT 4 TYPE
CAPITAL CITY GENERAL HOSPITAL C19 CNTL # 319654 OF BILL
1000 CHERRY ST b MED
REC # DH40195 0131
6 STATEMENT COVERS PERIOD 7
CAPITAL CITY NY 123452222 5 FED. TAX. NO.
FROM THROUGH
5555551000 757575757 1125XX 1125XX
8 PATIENT NAME a 9 PATIENT ADDRESS a 46 HARLEY DR
b HUNT DAWN b CAPITAL CITY c NY d 12345 e
ADMISSION CONDITION CODES 29 ACDT 30
10 BIRTHDATE 11 SEX 16 DHR 17 STAT STATE
12 DATE 13 HR 14 TYPE 15 SRC 18 19 20 21 22 23 24 25 26 27 28
092143 F 1125XX 7 01
31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37
CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH
a

b
38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES
HUNT DAWN CODE AMOUNT CODE AMOUNT CODE AMOUNT
46 HARLEY DR a

CAPITAL CITY NY 12345 b

42 REV.CD. 43 DESCRIPTION 44 HCPCS/RATE/HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED 49
CHARGES
1 200 00 0 00 1
0320 RADIOLOGY 73090 1125XX 1
2 0320 RADIOLOGY 200 00 0 00 2
73100 1125XX 1
3 0450 ER 1125XX 1 300 00 0 00 3
4 0700 CASTING 1125XX 1 95 00 0 00 4
5 29075 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 0001 PAGE 1 OF 1 CREATION DATE 1125XX TOTALS 795 00 0 00 23
52 REL. 53 ASG.
50 PAYER NAME 51 HEALTH PLAN ID INFO BEN. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI 1212121212
A MEDICARE 62541 Y Y 00 00 57 A
B OTHER B
C PRV. ID C
58 INSURED’S NAME 59 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

A HUNT DAWN 18 5328651498A A

B B
C C
63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

A A
B B
C C
66
DX 81344 F G H 68

9
7295 a b c E8809 a b c
69 ADMIT 70 PATIENT 71 PPS 72 73
DX REASON DX CODE ECI
74 PRINCIPAL PROCEDURE a OTHER PROCEDURE b OTHER PROCEDURE 75
CODE DATE CODE DATE CODE DATE 76 ATTENDING NPI 1471471471 QUAL

LAST LOTTS MD FIRST KAREN

c OTHER PROCEDURE d OTHER PROCEDURE e OTHER PROCEDURE
CODE DATE CODE DATE CODE DATE 77 OPERATING NPI QUAL

LAST FIRST

80 REMARKS 81CC
a 78 OTHER NPI QUAL

b LAST FIRST

c 79 OTHER NPI QUAL

d LAST FIRST

304 Appendix C: Answers to Appendix C Case Studies © 2013 Pearson Education, Inc.
Z03_VINE7282_01_IRM_APP3.QXD 8/22/12 10:24 PM Page 305

CASE C-20
1 2 3a PAT 4 TYPE
TOWNSHIP MEMORIAL HOSPITAL C20 CNTL # 751259 OF BILL
700 SHADY ST b MED
REC # JM820135 0131
6 STATEMENT COVERS PERIOD 7
TOWNSHIP NY 123452222 5 FED. TAX. NO.
FROM THROUGH
5555550700 750750750 0720XX 0720XX
8 PATIENT NAME a 9 PATIENT ADDRESS a 388 ATLANTIC AVE
b MASTERS JENNA b TOWNSHIP c NY d 12345 e
ADMISSION CONDITION CODES 29 ACDT 30
10 BIRTHDATE 11 SEX 16 DHR 17 STAT STATE
12 DATE 13 HR 14 TYPE 15 SRC 18 19 20 21 22 23 24 25 26 27 28
031250 F 0720XX 1 01
31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37
CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH
a

b
38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES
MASTERS JENNA CODE AMOUNT CODE AMOUNT CODE AMOUNT
388 ATLANTIC AVE a

TOWNSHIP NY 12345 b

42 REV.CD. 43 DESCRIPTION 44 HCPCS/RATE/HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED 49
CHARGES
1 175 00 0 00 1
0250 PHARMACY 0720XX 1
2 0260 IV THERAPY 1 825 00 0 00 2
0720XX
3 0270 MED SURG SUPPLIES 0720XX 1 450 00 0 00 3
4 0300 LAB 0720XX 1 375 00 0 00 4
5 0310 LAB PATH 0720XX 1 300 00 0 00 5
6 0370 ANESTHESIA 0720XX 1 750 00 0 00 6
7 0500 AMBUL SURG 38510 0720XX 1 1700 00 0 00 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 0001 PAGE 1 OF 1 CREATION DATE 0720XX TOTALS 4575 00 0 00 23
52 REL. 53 ASG.
50 PAYER NAME 51 HEALTH PLAN ID INFO BEN. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI 3434343434
A MEDICARE 15877 Y Y 00 00 57 A
B OTHER B
C PRV. ID C
58 INSURED’S NAME 59 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

A MASTERS JENNA 18 853614253A A

B B
C C
63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

A A
B B
C C
66
DX 7856 F G H 68

9
69 ADMIT
DX
70 PATIENT
REASON DX a b c 71 PPS
CODE
72
ECI a b c 73

74 PRINCIPAL PROCEDURE a OTHER PROCEDURE b OTHER PROCEDURE 75

CODE DATE CODE DATE CODE DATE 76 ATTENDING 0123456789
NPI QUAL

LAST MENDS MD FIRST MANNIE

c OTHER PROCEDURE d OTHER PROCEDURE e OTHER PROCEDURE
CODE DATE CODE DATE CODE DATE 77 OPERATING NPI QUAL

LAST FIRST

80 REMARKS 81CC
a 78 OTHER NPI QUAL

b LAST FIRST

c 79 OTHER NPI QUAL

d LAST FIRST

© 2013 Pearson Education, Inc. Appendix C: Answers to Appendix C Case Studies 305
 Z03_VINE7282_01_IRM_APP3.QXD 8/22/12 10:24 PM Page 306
Comprehensive Health Insurance Billing Coding And Reimbursement 2nd Edition Vines Solutions Manual

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