Chapter 15 Medical Billing and Reimbursement Essentials 325
Procedure 15.3 Complete an Insurance Claim Form
Name _________________________________________________ Date ______________ Score ___________
Task: To accurately complete a CMS-1500 health insurance claim form using NUCC guidelines
Equipment and Supplies:
• Patient’s health record
• Copy of patient’s insurance ID card or cards
• Patient registration/intake form
• Encounter form
• Insurance claims processing guidelines (Table 15.2)
• Blank CMS-1500 health insurance claim form (Work Product 15.1)
Background: Almost all medical billing is done electronically through practice management billing soft-
ware. The paper CMS-1500 health insurance claim form is provided only to help students practice and
develop their medical billing skills.
Directions: Complete each block (as appropriate) of the CMS-1500 (see Table 15.2 for block descriptions).
Scenario: Kyle Reeves had an appointment with Dr. Walden on March 20, 20XX. He came in because he
was experiencing extreme fatigue, fever, sore throat, head and body aches. On examination, Dr. Walden also
discovered swollen lymph nodes in the neck and armpits along with a swollen liver and spleen. She ordered
a CBC, mononucleosis test, and a urinalysis. The mononucleosis test came back positive.
Patient Demographics Clinic and Provider Information
Kyle T. Reeves (patient) Walden-Martin Family Medical Clinic
8448 Washington Ave 1234 Anystreet
Anytown, AL 12345-1234 Anytown, AL 12345
Phone: 123-255-6499 123-123-1234
DOB: 01/01/2004 POS – 11 Office
SSN: 933-35-3754 Established patient of Julie Walden, MD
HIPAA form on file: Yes – March 19, 20XX Federal Tax ID# 651249831
Signature on file: Yes – March 19, 20XX NPI# 1467253823
Insurance Information
Account Number: 16611
Insured: Kim Reeves (mother)
Blue Cross Blue Shield
Policy/ID Number: K20568R
Group Number: 21548R
Diagnosis: ICD-10-CM code
Infectious mononucleosis O75
Service CPT Code Fee
Est. Expanded OV 99213 $43.00
CBC w/auto differential 85025 $35.00
Mononucleosis test 86663 $34.00
U/A, w/micro non-automated 81001 $27.00
Standard: Complete the procedure and all critical steps in _______ minutes with a minimum score of 85%
within two attempts (or as indicated by the instructor).
Copyright © 2023, Elsevier Inc. All Rights Reserved.
Procedure 15.3 Complete an Insurance Claim Form
Name _________________________________________________ Date ______________ Score ___________
Task: To accurately complete a CMS-1500 health insurance claim form using NUCC guidelines
Equipment and Supplies:
• Patient’s health record
• Copy of patient’s insurance ID card or cards
• Patient registration/intake form
• Encounter form
• Insurance claims processing guidelines (Table 15.2)
• Blank CMS-1500 health insurance claim form (Work Product 15.1)
Background: Almost all medical billing is done electronically through practice management billing soft-
ware. The paper CMS-1500 health insurance claim form is provided only to help students practice and
develop their medical billing skills.
Directions: Complete each block (as appropriate) of the CMS-1500 (see Table 15.2 for block descriptions).
Scenario: Kyle Reeves had an appointment with Dr. Walden on March 20, 20XX. He came in because he
was experiencing extreme fatigue, fever, sore throat, head and body aches. On examination, Dr. Walden also
discovered swollen lymph nodes in the neck and armpits along with a swollen liver and spleen. She ordered
a CBC, mononucleosis test, and a urinalysis. The mononucleosis test came back positive.
Patient Demographics Clinic and Provider Information
Kyle T. Reeves (patient) Walden-Martin Family Medical Clinic
8448 Washington Ave 1234 Anystreet
Anytown, AL 12345-1234 Anytown, AL 12345
Phone: 123-255-6499 123-123-1234
DOB: 01/01/2004 POS – 11 Office
SSN: 933-35-3754 Established patient of Julie Walden, MD
HIPAA form on file: Yes – March 19, 20XX Federal Tax ID# 651249831
Signature on file: Yes – March 19, 20XX NPI# 1467253823
Insurance Information
Account Number: 16611
Insured: Kim Reeves (mother)
Blue Cross Blue Shield
Policy/ID Number: K20568R
Group Number: 21548R
Diagnosis: ICD-10-CM code
Infectious mononucleosis O75
Service CPT Code Fee
Est. Expanded OV 99213 $43.00
CBC w/auto differential 85025 $35.00
Mononucleosis test 86663 $34.00
U/A, w/micro non-automated 81001 $27.00
Standard: Complete the procedure and all critical steps in _______ minutes with a minimum score of 85%
within two attempts (or as indicated by the instructor).
Copyright © 2023, Elsevier Inc. All Rights Reserved.
