Module 05 Assignment - Billing and Medical Necessity Worksheet
Part 1: Outpatient Patient Encounter
Instructions: Use the Outpatient Patient Encounter Information in the table below to answer the questions
located beneath it.
Outpatient Patient Encounter Information
Provider and Insurance Information Patient Information
Treating Provider: Name: Bethany L. Branch
Donald L. Givings, M.D. Address: 401 Parkway Court
Givings & Associates City: Anywhere
11350 Medical Drive State: US
Anywhere, US 12345 Zip Code: 54955
(101) 111-5555 Telephone: (101) 333-4445
EIN: 11-1234562 Gender: Female
NPI: 1234567890 Date of Birth: 10-04-1947
Occupation: Retired
Referring Provider: Marital Status: Widower
James P Jones, MD Employer: Retired
NPI: 3215647889 Insurance: Medicare
Account Number: E3456987 Payer ID: 235578
Provider Accepts Assignment Insurance ID: 145-87-8859A
Group Number: 04559
Benefit Consent: Other Insurance: None
Assignment of Benefits and Release of Information Relationship to Insured: Self
Consent: On file and complete Condition Related to:
Employment – No
Auto Accident—No
Other Accident—No
Visit Information-Initial Encounter Visit Information-Subsequent Encounter
Date of Service: Today’s Date Date of Service: Two days since initial visit (2 days
Place of Service: Provider Office subsequent to “Today’s date used for Initial Encounter)
CC (Chief Complaint by patient): Swollen neck glands, CC (Chief Complaint by patient): Continued throat pain,
fever, and headache with general malaise. fever, and swelling of tonsils
Onset 2 days ago DX (diagnosis): Peritonsillar abscess ICD-10-CM J36
DX (diagnosis) Peritonsillar cellulitis, ICD-10 CM J36 Hypertrophied tonsils ICD-10 CM J35.3
RX: Rest, fluids, Tylenol for headache prn. Recheck in 3 RX: Throat Culture & Sensitivity
days if no improvement Ampicillin 500 mg IM. Return in 2 days.
Established Patient-Office Visit: 99212 Established Patient-Office Visit: 99213
Charges: $35 Charges: $40.50
Outpatient Patient Encounter Questions:
1. There are 3 types of information required for beginning the billing process (as explained in the
Inpatient and Outpatient Billing Lesson Content). Give the patient data or information that
fulfills these three components. Patient Information, Provider information, visit information
Part 1: Outpatient Patient Encounter
Instructions: Use the Outpatient Patient Encounter Information in the table below to answer the questions
located beneath it.
Outpatient Patient Encounter Information
Provider and Insurance Information Patient Information
Treating Provider: Name: Bethany L. Branch
Donald L. Givings, M.D. Address: 401 Parkway Court
Givings & Associates City: Anywhere
11350 Medical Drive State: US
Anywhere, US 12345 Zip Code: 54955
(101) 111-5555 Telephone: (101) 333-4445
EIN: 11-1234562 Gender: Female
NPI: 1234567890 Date of Birth: 10-04-1947
Occupation: Retired
Referring Provider: Marital Status: Widower
James P Jones, MD Employer: Retired
NPI: 3215647889 Insurance: Medicare
Account Number: E3456987 Payer ID: 235578
Provider Accepts Assignment Insurance ID: 145-87-8859A
Group Number: 04559
Benefit Consent: Other Insurance: None
Assignment of Benefits and Release of Information Relationship to Insured: Self
Consent: On file and complete Condition Related to:
Employment – No
Auto Accident—No
Other Accident—No
Visit Information-Initial Encounter Visit Information-Subsequent Encounter
Date of Service: Today’s Date Date of Service: Two days since initial visit (2 days
Place of Service: Provider Office subsequent to “Today’s date used for Initial Encounter)
CC (Chief Complaint by patient): Swollen neck glands, CC (Chief Complaint by patient): Continued throat pain,
fever, and headache with general malaise. fever, and swelling of tonsils
Onset 2 days ago DX (diagnosis): Peritonsillar abscess ICD-10-CM J36
DX (diagnosis) Peritonsillar cellulitis, ICD-10 CM J36 Hypertrophied tonsils ICD-10 CM J35.3
RX: Rest, fluids, Tylenol for headache prn. Recheck in 3 RX: Throat Culture & Sensitivity
days if no improvement Ampicillin 500 mg IM. Return in 2 days.
Established Patient-Office Visit: 99212 Established Patient-Office Visit: 99213
Charges: $35 Charges: $40.50
Outpatient Patient Encounter Questions:
1. There are 3 types of information required for beginning the billing process (as explained in the
Inpatient and Outpatient Billing Lesson Content). Give the patient data or information that
fulfills these three components. Patient Information, Provider information, visit information
