Question: ASSIGNMENT 14.12 COMPLETE A CLAIM FORM FOR A WORKERS COMPENSATION CASE Performance Objective Complete A CMS-1500 Claim Form For A Workers’ Compensation Case. Task: Conditions: Use Carlos A. Giovanni’s Patient Record, A CMS-1500 Claim Form, A Pen Or Pencil. Standards: Claim Productivity Measurement Time: Minutes Accuracy: (Note: The Time Element And …

ASSIGNMENT 14.12 COMPLETE A CLAIM FORM FOR A WORKERS COMPENSATION CASE Performance Objective Complete a CMS-1500 claim form for a workers’ compensation case. Task: Conditions: Use Carlos A. Giovanni’s patient record, a CMS-1500 claim form, a pen or pencil. Standards: Claim Productivity Measurement Time: minutes Accuracy: (Note: The time element and accuracy criteria may be given by your instructor.) Directions: 1. Using NUCC guidelines, complete a CMS-1500 claim form for November dates of service and direct it to the correct workers’ compensation carrier for this workers’ compensation claim. Refer to Mr. Carlos A. Giovanni’s patient record for information to record on the claim. Date the claim November 30 of the current year. Note: A progress report is being submitted with this claim; complete a separate CMS-1500 for services for December. 2. Refer to Chapter 14 (Fig. 14.10) of the textbook for instructions on how to complete this claim form and to view a workers’ compensation template. 3. A Performance Evaluation Checklist may be reproduced from the “Instruction Guide to the Workbook” that appears in a section before Chapter 1 if your instructor wishes you to submit it to assist with scoring and comments. After the instructor has returned your work to you, either make the necessary corrections and place your work in a three- ring notebook for future reference or, if you received a high score, place it in your portfolio for reference when applying for a job. Name: 600 S. Lafayette Park Place COLLEGE CLINIC 4567 Broad Avenue, Woodland Hills. XY 12345-0001 (555)-486-9002 Fax: (555) 487-8976 NPI: 3664021CC PATIENT INFORMATION: INSURANCE INFORMATION: State Compensation Ins Carlos A. Giovanni Primary: Address: Fund 89 Beaumont Court Woodland Hills, XY 12345 Telephone: (555) 677-3485 Ehrlich, XY 12350 Date of Birth: 10/24/1955 Policy Number: 57780 556-XX-9699 Date of Injury: 11/11/20XX TV REPAIRMAN Subscriber: Giant Television Company Secondary: none 8764 Ocean Avenue Policy Number: Woodland Hills, XY 12345 Group Number: Married Subscriber: Maria Giovanni Social Security: Occupation: Employer Fracture of skull and facial bones, initial encounter for closed fracture Code Charge 152.98 99223-57 2. WC Report 99080 50.00 61314 2548.09 Status: Spouse: DIAGNOSIS INFORMATION 1. S02.91xA 2. S06.0x1 Concussion with loss of consciousness of 30 minutes or less 3. W13.xxxA Fall from, out of or through building or structure PROCEDURE INFORMATION Description Date 1. Hospital admit 11/11/20XX 11/11/20XX 3. Craniotomy 11/12/20XX 4. Hospital visits 11/13-29/20XX 5. Discharge 11/30/20XX 6. Office visit 12/07/20XX 7. Office visit 12/21/20XX 8. Office visit 12/29/20XX 12/29/20XX NOTES: Referred by: Giant Television Company Treating MD: Astro Parkinson, MD NPI: 46789377XX Place of service: College Clinic for 12/7-12/29 College Hospital for 11/11-11/30 4500 Broad Avenue, Woodland Hills, XY 12345 NPI: X950731067 Patient unable to work from 11/12/20xx-01/14/20xx 99024 N/C 99024 99024 N/C N/C N/C 99024 9. Medical report 99024 N/C 99080 50.00 4 The Paper Claim: CMS-1500