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WHAT GOES ON BOX 21 OF THE CMS 1500 BASED ON THIS INFORMATION 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. View less AI answer & explanation To correctly fill out the CMS-1500 form for Myra Hemsworth’s office visit, we must first identify and sequence the diagnosis codes properly based on the medical chart provided. The diagnosis codes listed in the document are: E78.00: Pure hypercholesterolemia M35.01: Sicca syndrome with keratoconjunctivitis (Sjogren’s syndrome) H04.123: Dry eye syndrome (lacrimal gland dysfunction) in both eyes (OU) M34.9: Systemic sclerosis, unspecified (scleroderma) Based on the Chief Complaint and the Impression/Plan given, we should prioritize the codes as follows for the CMS-1500 form: H04.123: Dry eye syndrome, since this is the primary reason for the visit as indicated by the Chief Complaint and Impression/Plan. M35.01: Sjogren’s syndrome, which is related to the patient’s symptoms and treatment plan for dry eyes. M34.9: Scleroderma, which is another part of the patient’s ongoing health issues influencing the treatment. Now that we have the sequenced codes, let’s use these in the CMS-1500 form. Since only three diagnosis codes can be entered, we’ll leave out the hypercholesterolemia code (E78.00). Filling Out the CMS-1500 Form Below, find a simplified guide for entering the information on the form. Please note that the CMS-1500 form is standardized with specific field numbers and areas to fill out. Patient Name: Myra Hemsworth Date of Birth: 02-12-1968 Sex: F Date of Service: 07-15-20XX Physician Information: Charles Beacon, MD Relevant sections for diagnosis codes: Box 21 (Diagnosis or Nature of Illness or Injury): 21A: H04.123 21B: M35.01 21C: M34.9 For additional fields: Box 24F: Enter the charges for provided services. Box 24E: Indicate the letter (A, B, C) that corresponds to the diagnosis codes relevant to each service. Other fields will require standard patient and insurance information, which is not provided here. Please ensure the rest of the CMS-1500 form is filled with appropriate demographic, insurance, and service details. It’s advisable to consult the CMS guidelines and examples if you’re unfamiliar with this form.
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