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Section Seven: Appendixes
CASE 1: HOSPITAL OUTPATIENT LABORATORY

Summary Patient Name: Myra Singerson Date: 03/19/200_
Established patient, 39 years of age, presents today for a follow-up visit. She indicates she is feeling extremely tired and run down. History and exam performed. I ordered a CBC and hepatic function tests to assess the patients viral hepatitis B and progressive anemia. Patient to return in 5 days to discuss the results. Case 1: Hospital Outpatient Laboratory Directions: The patient face sheet/charge detail, laboratory requisition, and laboratory report are included in this case. Complete this case and prepare a CMS-1450 (UB-92) as follows: Step 1: Assign revenue codes (see Appendix B) to each category of services listed on the patient face sheet/charge detail. Submit your patient face sheet/charge detail to your instructor for review. Step 2: The Coding Worksheet included in this case must be completed before data can be entered on the computer. Complete the Case 1 Coding Worksheet as follows: a. Record the code(s) describing the admitting, principal and other diagnoses. b. Record HCPCS code(s) describing the laboratory procedures. c. Record the code(s) for the items listed below the charge detail. All other charges listed on the patient face sheet have been coded and posted by other departments. d. Assign UB data codes (see Appendix B) to other information, as required, on the Coding Worksheet. Submit your Coding Worksheet to your instructor for review. Step 3: Complete a CMS-1450 (UB-92) claim form for this case. Claim forms can be completed manually or utilizing the software. Your instructor will advise if a manual claim is required. Otherwise begin completing the Student Software Case. Student Software Case 1 Directions: After installing the CD-ROM bound into the back of this textbook, use your completed Coding Worksheet and the software program to produce a completed CMS-1450 (UB-92). Follow these instructions to complete Student Software Case 1. Step 1: The Coding Worksheet should be completed before entering data into the software. Use your completed Coding Worksheet and the patient face sheet/charge detail (after they are reviewed by your instructor) to enter information into the proper elds on the software. Follow the software screen by screen. Step 2: Once you have completed each screen, preview your completed CMS-1450 (UB-92). Make required corrections before printing. Step 3: Save your completed CMS-1450 (UB-92) to your computer or disk in PDF format. Print your completed claim form and submit to your instructor for review.
Actual hospital cases offer students an opportunity to apply the concepts used throughout the chapters to real-life scenarios.
Appendix A: Cases
571
Community General Hospital

Federal Tax ID#62-1026428
Case 1: Hospital Outpatient LaboratoryMyra Singerson
PATIENT FACE SHEET AND CHARGE DETAIL Admit/Discharge Date Admit: 03/19/200_ Disch: 03/19/200_ Patient Name Myra Singerson Patient Address 157 Main St. Admit/Discharge Hour Admit: 09:45 AM Disch: 10:45 AM DOB 02/26/1967 Admission Source Physician Referral Release Info Y City, ST Zip Mars, Florida 37373 INSURANCE INFORMATION Primary Carrier Blue Cross/Blue Shield Secondary Carrier Insureds Name Myra Singerson Insureds Name Identication# 00005148263 Group Name and # Identication # Group Name and # Pt Relationship Self Pt Relationship Employer Name Target Employer Name Employer Location 1716 Santana Street, Mars, Florida 37373 Employer Location PHYSICIANS/CLINICAL INFORMATION Attending/Referring/Ordering Physician/ID# Johnathan Jamar MD #ME53461 Other Physician/ID # Johanna Sangchung MD #ME52743 CHARGE DETAIL Revenue Code Service Description LAB/CHEMISTRY LAB/HEMATOLOGY HCPCS/Rates Service Units 1 1 Total Charges 114.00 48.00 Occurrence Date Admission Type Elective
8192 South Street Mars, Florida 37373 (747)722-1800
Med Record / Soc Sec # MR S654379821
Patient Control # 15364572 Sex F Phone 747 549-3176 Marital Status M
Assignment Ben Y
Discharge Status Discharge to Home
Provider # 00356572 Provider #
Treatment Authorization #
Treatment Authorization #
Condition/Value Info
Non -Covered Charges
TOTAL CHARGE
162.00
OTHER CHARGES TO BE (CODED, POSTED AND ADDED TO CHARGE DETAIL ABOVE) NONE

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Section Seven: Appendixes

CASE 1: HOSPITAL OUTPATIENT LABORATORY

Community General Hospital

8192 South Street Mars, Florida 37373 (747)722-1800

Med Record / Soc Sec # MR S654379821

Patient Control # 15364572 Sex F Phone 747 549-3176 Marital Status M

Discharge Status Discharge to Home

Provider # 00356572 Provider #

Non -Covered Charges

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