CHAPTER 8 – PRACTICAL APPLICATION – FULL – CASE 1 TO CASE 10
CASE 1
Provider: Michael Johnson, MD NPI: 9876543210
Group: Internal Medicine Specialists NPI: 8888888888 EIN: 242424523
Address: 5678 Blue Street, Here, UT 84848-1234
Patient Information:
Name: John Jones
Address: 1212 My Street
City: Mytown
State: UT
Zip: 44444-1234
Telephone: 801-121-2121
Gender: Male
Status: Married
Date of Birth: 04/01/1963
Employer: John’s Towing Work Related: No
Auto Accident: No Other Accident: No Date of Accident: None
Referring Physician: None
Address: Telephone: NPI #:
Insurance Information:
Primary Insurance: Medical Insurance Group
Address: PO Box 11111 City: Atlanta State: GA Zip: 13451-1234
Policy #: 9999977777
Group #: 80923
Name of Insured: Self
DOS: 8/17/20XX
Procedures: 99202, 72070
,Diagnosis: S23.3XXA
to answer questions 1 and 2.
QUESTION# 1
After review of the information provided, are there any errors on the claim
form? If so, which elements are incorrect?
1.Date of birth
2.Date of service
3.Primary insurance policy number
4.Primary insurance group number
5.Secondary insurance policy number
6.Secondary insurance group number
7.Place of service
8.Diagnosis Code
9.Provider signature
10.Work related
CORRECT ANSWER: I, VIII, AND X
Rationale: The date of birth is not in the correct format and the
birth year is incorrect. The date of birth is shown as Item 3 on the
claim form. Enter the patient’s 8-digit birth date (MM|DD|CCYY). The
diagnosis code is a truncated (incomplete) code. Look in the ICD-10-
CM code book for S23.3; a 7th character is required. Two
placeholder Xs are placed in the 5th and 6th positions to keep the
7th character in the 7th position. Box 10 indicates this is
employment related but the demographic information indicates it is
not work related.
QUESTION# 2
What should be done to correct the claim?
, 1.Correct the formatting of Item 3 on the claim.
2.Add the patient’s secondary insurance information on the claim.
3.Enter the ordering provider’s name and NPI.
4.Review the ICD-10-CM codebook and the medical record to determine the
correct diagnosis code.
5.Correct Item 10 to No for Employment.
CORRECT ANSWER: I,IV, AND V
Rationale: Item 3 needs to be formatted to include a zero before the
month and the day so the format of the date of birth is correct and
change the year to 1973 instead of 1963. Because the ICD-10-CM
code is truncated, the biller will need to view the code book to
determine how many characters are needed and medical records is
to complete applying those characters. Item 10 should be marked as
No for Employment related.
CASE 2
Patient Information:
Name: Tonya Stevens
Address: 1515 Donawho Ave., Smith, FL 555551234
Telephone: 954-111-3333
Gender: Female
Status: Single
Date of Birth: 09/10/1962
Employer: County Schools
Work Related: No
Auto Accident: No
Other Accident: No
Date of Accident: None
Referring Physician:
CASE 1
Provider: Michael Johnson, MD NPI: 9876543210
Group: Internal Medicine Specialists NPI: 8888888888 EIN: 242424523
Address: 5678 Blue Street, Here, UT 84848-1234
Patient Information:
Name: John Jones
Address: 1212 My Street
City: Mytown
State: UT
Zip: 44444-1234
Telephone: 801-121-2121
Gender: Male
Status: Married
Date of Birth: 04/01/1963
Employer: John’s Towing Work Related: No
Auto Accident: No Other Accident: No Date of Accident: None
Referring Physician: None
Address: Telephone: NPI #:
Insurance Information:
Primary Insurance: Medical Insurance Group
Address: PO Box 11111 City: Atlanta State: GA Zip: 13451-1234
Policy #: 9999977777
Group #: 80923
Name of Insured: Self
DOS: 8/17/20XX
Procedures: 99202, 72070
,Diagnosis: S23.3XXA
to answer questions 1 and 2.
QUESTION# 1
After review of the information provided, are there any errors on the claim
form? If so, which elements are incorrect?
1.Date of birth
2.Date of service
3.Primary insurance policy number
4.Primary insurance group number
5.Secondary insurance policy number
6.Secondary insurance group number
7.Place of service
8.Diagnosis Code
9.Provider signature
10.Work related
CORRECT ANSWER: I, VIII, AND X
Rationale: The date of birth is not in the correct format and the
birth year is incorrect. The date of birth is shown as Item 3 on the
claim form. Enter the patient’s 8-digit birth date (MM|DD|CCYY). The
diagnosis code is a truncated (incomplete) code. Look in the ICD-10-
CM code book for S23.3; a 7th character is required. Two
placeholder Xs are placed in the 5th and 6th positions to keep the
7th character in the 7th position. Box 10 indicates this is
employment related but the demographic information indicates it is
not work related.
QUESTION# 2
What should be done to correct the claim?
, 1.Correct the formatting of Item 3 on the claim.
2.Add the patient’s secondary insurance information on the claim.
3.Enter the ordering provider’s name and NPI.
4.Review the ICD-10-CM codebook and the medical record to determine the
correct diagnosis code.
5.Correct Item 10 to No for Employment.
CORRECT ANSWER: I,IV, AND V
Rationale: Item 3 needs to be formatted to include a zero before the
month and the day so the format of the date of birth is correct and
change the year to 1973 instead of 1963. Because the ICD-10-CM
code is truncated, the biller will need to view the code book to
determine how many characters are needed and medical records is
to complete applying those characters. Item 10 should be marked as
No for Employment related.
CASE 2
Patient Information:
Name: Tonya Stevens
Address: 1515 Donawho Ave., Smith, FL 555551234
Telephone: 954-111-3333
Gender: Female
Status: Single
Date of Birth: 09/10/1962
Employer: County Schools
Work Related: No
Auto Accident: No
Other Accident: No
Date of Accident: None
Referring Physician:
