Get Answer: Please Billing Document Question Guide
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Original Question
Please use the billing document below to fill out and make corrections to clerical errors on the CMS-1500 form. Note: Although all medical codes are correct on the billing document, they are not sequenced. Please identify the first-listed diagnosis, sequence the secondary codes, and enter the top 3 on the CMS 1500 form, as this is the maximum number of codes that can be listed on the form. The medical chart linked below will help you code the record properly for sequencing: Outpatient Office Visit Patient Case Number: OPOV01-Hemsworth, Myra Patient Name: Myra Hemsworth DOB: 02-12-68 Sex: F Date of Service: 07-15-XX Physician: Charles Beacon, MD Chief Complaint: Follow-up, Dry eye syndrome OU. Long term Plaquenil Therapy HPI: Dry Eyes OU. Mrs. Hemsworth has been improving since the last visit 3 months ago. She is currently being treated by her rheumatologist Dr. Macon for Sjogren’s and scleroderma. Medical History: Sjogren’s, hypercholesterolemia, scleroderma Medications: Lovastatin, Tramadol, Plaquenil, Nifedipine, Prednisone prn Allergies: Sulfa, Compazine, Ativan, Toradol, plastic tape ROS: Ocular-see HPI Dilation OD: 20/40 OS: 20/25 Extended HPI: OU does seem better but dryness is worse towards the end of the day. External Right Eye Left Eye Pupils Round. Brisk. No RAPD Round. Brisk. No RAPD Motility Full. Orthotropic Full. Orthotropic CVF Full Full Adnexa Normal Ocular Adnexa Normal Ocular Adnexa Anterior Right Eye Left Eye L/C/S Lids Normal, Conjuctiva and sclera without injection Lids Normal, Conjuctiva and sclera without injection Cornea SPK. Clear Stroma. Clear endothelium SPK. Clear Stroma. Clear endothelium Anterior Chamber Normal Depth. Quiet Normal Depth. Quiet Iris Within normal limits Within normal limits Lens Clear Clear Impression/Plan: 1. Dry Eye Syndrome OU. Will treat with Restasis-Lotemax. Recommended artificial tears to use as directed. Samples of tear supplements provided. Begin tears bid. Advised to increase Omega 3 fatty acids in diet or take supplements. 2-4 grams a day. 2. Long term/current use of Plaquenil therapy. Cleared to continue Plaquenil. Advised regular use of Amsler grid. 3. Sjogren’s-samples of tear supplements provided 4. Hypercholesterolemia 5. Scleroderma Follow-up in one month E78.00, M35.01, H04.123, and M34.9.
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