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Original Question

In this activity, you will determine how to complete many of the blocks of the Physician or Supplier Information Section of a CMS-1500 form. Review the scenario and the Physician or Supplier Information Section of the form, pictured below, as you answer the following questions. Scenario: Alice Jones had an EKG (93000) done during her office visit (place of service 11) on 07/01/YY because she was complaining of chest pain that she started experiencing the day before. The provider diagnosis for this claim is chest pain. The provider spent 15-20 minutes in the office face-to-face with the patient (99213). The charge for the office visit is $75.00 and the charge for the EKG is $45.00. A sample insurance claim form, Blocks 14 through 33. 14. DATE OF CURRENT ILLNESS INJURY Or PREGNANCY (LMP) 15. Other Date 16. Dates Patient Unable To Work In Current Occupation 17. Name Of Referring Provider Or Other Source 18. Hospitalization Dates Related To Current Services 19. Additional Claim Information (Designated by NUCC) 20. Outside Lab? Dollar Charges 21. Diagnosis Or Nature Of Illness Or Injury Relate A-L To Service Line Below (24e) 22. Resubmission: Code Original Ref. No. 23. Prior Authorization Number 24. A. Date(S) Of Service B. Place Of Service C. EMG D. Procedures Services Or Supplies (Explain Unusual Circumstances) E. Diagnosis Pointer F. $ Charges G. Days Or Units H. EPSDT Family Plan I. ID. Qual. J. Rendering Provider Id. # 25. Federal Tax I.D. Number 26. Patient’s Acco

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