Applying Your Knowledge Note: Refer to Chapter 7 to research place of service and claim filing indicator codes. L0 10.4] Case 10.1 Physician Information: Name: Selena R. Rodez, MD NPI: 8901234567 Medicaid PIN: HC29004 Patient Information Form: Name: Grace B. Chin (New Patient) Age: 47 Sex:Female Birth Date: November 7, 1963 Social Security Number: 056-99-0034 Medicaid Eligibility: June 1-30, 2010 (Note: Copayment of $10 per office visit required.) Medicaid Number: 056990034 Insurance Carrier: None Patient's Encounter Form: Date: 6-20-2016 T-98 BP 135/80 CC: Patient has a cut in the left eye, cause unknown. No visual problems. Reports some pain. Dr: Ocular laceration without prolapse or loss of intraocular tissue, left eye. Rx: Ophthalmic solution, 2 drops to left eye X 10 days. Patient's Emcounter Form Date: June 16, 2016 CC: Patient stated that on Wednesday June 16, 2016 a container of butter crme frosting fell from the shelf as entered the pantry and hit her right shoulder. D Right shoulder dislocation List of Fees for the Service: Charges: Office visit, Level II $85 Shoulder X Ray 1 View $68 Supply the following data elements: Billing Provider Billing Provider's Primary Identifier Pationt Relationship WC Claim Number WC Plan WC Group Number Claim Information Accident Cause (check One) Auto Accident Employment Related_Other Accident Date of Accident Another Responsible Party Service Line Information: Date of Service Procedure Code(s). Diagnosis Code(s) Total Charges