Read it carefully!! Case 3 Maria Torres has come to the office today complaining of chest pain. After seeing the provider, you need to complete the superbill for Maria. Using the blank superbill provided for BWW Medical Associates and Using the Superbill as Bill/Receipt, complete the superbill using the following information. DOB: 6/4/xx Group: 56123 Patient: Maria Torres MRN: 001-564-879 Insurance: Aetn Subscriber: Patient Procedures: 99213- $82.00, 93000 - $45.00, 36415 - $15.00 Diagnoses: Chest wall pain, Anxiety syndrome Payment Made: $25.00 copayment Physician: Elizabeth Williams, MD Return Appt: PRN

Read it carefully!! Answer and fill the information only what provide Case 3 Maria Torres has come to the office today complaining of chest pain. After seeing the provider, you need to complete the superbill for Maria. Using the blank superbill provided for BWW Medical Associates and Using the Superbill as Bill/Receipt, complete the superbill using the following information. DOB: 6/4/xx Group: 56123 Patient: Maria Torres MRN: 001-564-879 Insurance: Aetn Subscriber: Patient Procedures: 99213- $82.00, 93000 - $45.00, 36415 - $15.00 Diagnoses: Chest wall pain, Anxiety syndrome Payment Made: $25.00 copayment Physician: Elizabeth Williams, MD Return Appt: PRN

BWW Medical Associates, PC 305 Main Street, Port Snead YZ 12345-9876, Tel: 555-654-3210, Fax: 555-987-6543 O PRIVATE D BLUECROSS IND. MEDICARE MEDI-CAL O HMO PATIENT'S LAST NAME FIRST ACCOUNT # TODAY'S DATE BIRTHDATE 1 PLAN # / SEX O MALE O FEMALE SUB. # / / INSURANCE COMPANY SUBSCRIBER GROUP ASSIGNMENT: I hereby assign my insurance benefits to be paid directly to the undersigned physician. I am financially responsible for non-covered services. SIGNED: (Patient, or Parent, If Minor) DATE: 1 RELEASE: I hereby authorize the physician to release to my insurance carriers any information required to process this claim. SIGNED: (Patient, or Parent, If Minor) DATE: FEE FEE FEE DESCRIPTION M/Care CPT/Mod DxRo OFFICE CARE NEW PATIENT Brief 99201 Limited 99202 Intermediate 99203 Extended 99204 Comprehensive 99205 DESCRIPTION M/Care CPT/Mod DxRe PROCEDURES Tread Mill Office) 93015 24 Hour Holter (complete) 93224 Holter (setup only) 93225 Physician Interpret 93227 EKG w/Interpretation 93000 EKG (tracing only) 93005 Sigmoidoscopy 45300 Sigmoidoscopy, Flexible 45330 Sigmoidos, Flex. w/Bx. 45331 Spirometry, FEV/FVC 94010 Spirometry, Post-Dilator 94060 ESTABLISHED PATIENT Minimal 99211 Brief 99212 Limited 99213 Intermediate 99214 Extended 99215 Comprehensive 99215 DESCRIPTION M/Care CPT/Mod DxRo INJECTIONS/IMMUNIZATIONS Tetanus/Diphtheria 90718 MMR 90707 Pneumococcal 90732 Influenza 90656 TB Skin Test (PPD) 86580 Antigen Injection-Single 95115 Multiple 95117 B12 Injection J3420 90782 Injection, IM 90782 Compazine J0780 90782 Demerol J2175 90782 Vistaril J3410 90782 Susphrine JO170 90782 Decadron J0890 90782 Estradiol J1000 90782 Testosterone J1080 90782 Lidocaine J2000 90782 Solumedrol J2920 90782 Solucortet J1720 90782 Hydeltra J1690 90782 CONSULTATION-OFFICE Focused 99241 Expanded 99242 Detailed 99243 Comprehensive 1 99244 Comprehensive 2 99245 MCR Pts - use E/M codes Case Management 98900 LABORATORY Blood Draw Fee Urinalysis, Chemical Throat Culture Occult Blood Pap Handling Charge Pap Life Guard Gram Stain Hanging Drop Urine Drug Screen 36415 81000 87081 82270 99000 88150-90 87205 87210 80100 Post-op Exam 99024 INJECTIONS - JOINT/BURSA Small Joints 20600 Intermediate 20605 Large Joints 20610 Trigger Point 20552 MISCELLANEOUS SUPPLIES 276.9 780.7 610.1 829.0 Cirrhosis DIAGNOSIS: ICD-9 Gout 274.0 Abdominal Pain 789.0 Asthma 493.90 Abscess (Site) 682.9 Asthmatic Bronchitis 493.90 Adverse Drug Rx 995.2 Atrial Fib. 427.31 Alcohol Detox 291.8 Atrial Tachi. 427.0 Alcoholism 303.90 Bowel Obstruct. 560.9 Allergic Rhinitis 477 Breast Mass 611.72 Allergy 995.3 Bronchitis 490 Alzheimer's Dis 290.1 Bursitis 727.3 Anemia 285.9 Cancer, Breast (Site) 174.9 Anemia - Pernicious 281.0 Metastatic (Site) 199.1 Angina 413.9 Colon 153.9 Anxiety Synd. 300.00 Cancer, Rectal 154.1 Appendicitis 541 Lung (Site) 162.9 Arterioscl. H.D. 414.0 Skin (Site) 173.9 Arthritis, Osteo. 715.90 Card. Arrhythmia (Type) 427.9 Rheumatoid 714.0 Cardiomyopathy 425.4 Lupus 710.0 Cellulitis (Site) 682.9 DIAGNOSIS: (IF NOT CHECKED ABOVE) C.V.A. - Acute 436 Cere. Vas. Accid. (Old) 438 Cerumen 380.4 Chestwall Pain 786.59 Cholecystitis 575.0 Cholelithiasis 574.00 COPD 492.8 571.5 Cong. Heart Fail. 428.9 Conjunctivitis 372.30 Contusion (Sito) 924.9 Costochondritis 733.99 Depression 311. Dermatitis 692.9 Diabetes Mellitus 250.00 Diabetic Ketosis 250.1 Diverticulitis 562.11 Diverticulosis 562.10 Electrolyte Dis. Fatigue Fibrocys. Br. Dis Fracture (Site) Open/Close Fungal Infect. (Site) Gastric Ulcer Gastritis Gastroenteritis G.I. Bleeding Glomerulonephritis Headache Headache, Tension Migraine (Type) Hemorrhoids Hernia, Hiatal Inguinal Hepatitis 110.8 531.90 535.0 558.9 578.9 583.9 784.0 307.81 346.9 455.6 553.3 550.9 573.3 Herpes Simplex 054.9 Herpes Zoster Hydrocelo 603.9 Hyperlipidemia 272.4 Hypertension 401.9 Hyperthyroidism 242.9 Hypothyroidism 244.9 Labyrinthitis 386,30 Lipoma (Site) 214.9 Lymphoma 202.8 Mit. Valve Prolapse 424,0 Myocard. Infarction (Area) 410.9 M.I., Old 412 Myositis 729.1 Nausea/Vomiting 787.0 Neuralgia 729.2 Nevus (Site) 216.9 Obesity 278.0 SERVICES PERFORMED AT: Office OE.R. REFERRING PHYSICIAN & ID. NUMBER CLAIM CONTAINS NO ORDERED REFERRING SERVICE RETURN APPOINTMENT INFORMATION: 5. 10 - 15 - 20 - 30 - 40 - 60 NEXT APPOINTMENT M. T. W. TH.F.S DAYS) WKS.JI MOS.] PRN) DATE / TIME: INSTRUCTIONS TO PATIENT FOR FILING INSURANCE CLAIMS: 1. Complete upper portion of this form, sign, and date. 2. Attach this form to your own insurance company's form for direct reimbursement. MEDICARE PATIENTS - DO NOT SEND THIS TO MEDICARE. WE WILL SUBMIT THE CLAIM FOR YOU. ACCEPT DOCTOR'S SIGNATURE ASSIGNMENT? AM O YES PM O NO O CASH TOTAL TODAY'S FEE HECK # OLD BALANCE O VISA TOTAL DUE O MC COPAY AMOUNT REC'D. TODAY BWW Medical Associates, PC 305 Main Street, Port Snead YZ 12345-9876, Tel: 555-654-3210, Fax: 555-987-6543 O PRIVATE D BLUECROSS IND. MEDICARE MEDI-CAL O HMO PATIENT'S LAST NAME FIRST ACCOUNT # TODAY'S DATE BIRTHDATE 1 PLAN # / SEX O MALE O FEMALE SUB. # / / INSURANCE COMPANY SUBSCRIBER GROUP ASSIGNMENT: I hereby assign my insurance benefits to be paid directly to the undersigned physician. I am financially responsible for non-covered services. SIGNED: (Patient, or Parent, If Minor) DATE: 1 RELEASE: I hereby authorize the physician to release to my insurance carriers any information required to process this claim. SIGNED: (Patient, or Parent, If Minor) DATE: FEE FEE FEE DESCRIPTION M/Care CPT/Mod DxRo OFFICE CARE NEW PATIENT Brief 99201 Limited 99202 Intermediate 99203 Extended 99204 Comprehensive 99205 DESCRIPTION M/Care CPT/Mod DxRe PROCEDURES Tread Mill Office) 93015 24 Hour Holter (complete) 93224 Holter (setup only) 93225 Physician Interpret 93227 EKG w/Interpretation 93000 EKG (tracing only) 93005 Sigmoidoscopy 45300 Sigmoidoscopy, Flexible 45330 Sigmoidos, Flex. w/Bx. 45331 Spirometry, FEV/FVC 94010 Spirometry, Post-Dilator 94060 ESTABLISHED PATIENT Minimal 99211 Brief 99212 Limited 99213 Intermediate 99214 Extended 99215 Comprehensive 99215 DESCRIPTION M/Care CPT/Mod DxRo INJECTIONS/IMMUNIZATIONS Tetanus/Diphtheria 90718 MMR 90707 Pneumococcal 90732 Influenza 90656 TB Skin Test (PPD) 86580 Antigen Injection-Single 95115 Multiple 95117 B12 Injection J3420 90782 Injection, IM 90782 Compazine J0780 90782 Demerol J2175 90782 Vistaril J3410 90782 Susphrine JO170 90782 Decadron J0890 90782 Estradiol J1000 90782 Testosterone J1080 90782 Lidocaine J2000 90782 Solumedrol J2920 90782 Solucortet J1720 90782 Hydeltra J1690 90782 CONSULTATION-OFFICE Focused 99241 Expanded 99242 Detailed 99243 Comprehensive 1 99244 Comprehensive 2 99245 MCR Pts - use E/M codes Case Management 98900 LABORATORY Blood Draw Fee Urinalysis, Chemical Throat Culture Occult Blood Pap Handling Charge Pap Life Guard Gram Stain Hanging Drop Urine Drug Screen 36415 81000 87081 82270 99000 88150-90 87205 87210 80100 Post-op Exam 99024 INJECTIONS - JOINT/BURSA Small Joints 20600 Intermediate 20605 Large Joints 20610 Trigger Point 20552 MISCELLANEOUS SUPPLIES 276.9 780.7 610.1 829.0 Cirrhosis DIAGNOSIS: ICD-9 Gout 274.0 Abdominal Pain 789.0 Asthma 493.90 Abscess (Site) 682.9 Asthmatic Bronchitis 493.90 Adverse Drug Rx 995.2 Atrial Fib. 427.31 Alcohol Detox 291.8 Atrial Tachi. 427.0 Alcoholism 303.90 Bowel Obstruct. 560.9 Allergic Rhinitis 477 Breast Mass 611.72 Allergy 995.3 Bronchitis 490 Alzheimer's Dis 290.1 Bursitis 727.3 Anemia 285.9 Cancer, Breast (Site) 174.9 Anemia - Pernicious 281.0 Metastatic (Site) 199.1 Angina 413.9 Colon 153.9 Anxiety Synd. 300.00 Cancer, Rectal 154.1 Appendicitis 541 Lung (Site) 162.9 Arterioscl. H.D. 414.0 Skin (Site) 173.9 Arthritis, Osteo. 715.90 Card. Arrhythmia (Type) 427.9 Rheumatoid 714.0 Cardiomyopathy 425.4 Lupus 710.0 Cellulitis (Site) 682.9 DIAGNOSIS: (IF NOT CHECKED ABOVE) C.V.A. - Acute 436 Cere. Vas. Accid. (Old) 438 Cerumen 380.4 Chestwall Pain 786.59 Cholecystitis 575.0 Cholelithiasis 574.00 COPD 492.8 571.5 Cong. Heart Fail. 428.9 Conjunctivitis 372.30 Contusion (Sito) 924.9 Costochondritis 733.99 Depression 311. Dermatitis 692.9 Diabetes Mellitus 250.00 Diabetic Ketosis 250.1 Diverticulitis 562.11 Diverticulosis 562.10 Electrolyte Dis. Fatigue Fibrocys. Br. Dis Fracture (Site) Open/Close Fungal Infect. (Site) Gastric Ulcer Gastritis Gastroenteritis G.I. Bleeding Glomerulonephritis Headache Headache, Tension Migraine (Type) Hemorrhoids Hernia, Hiatal Inguinal Hepatitis 110.8 531.90 535.0 558.9 578.9 583.9 784.0 307.81 346.9 455.6 553.3 550.9 573.3 Herpes Simplex 054.9 Herpes Zoster Hydrocelo 603.9 Hyperlipidemia 272.4 Hypertension 401.9 Hyperthyroidism 242.9 Hypothyroidism 244.9 Labyrinthitis 386,30 Lipoma (Site) 214.9 Lymphoma 202.8 Mit. Valve Prolapse 424,0 Myocard. Infarction (Area) 410.9 M.I., Old 412 Myositis 729.1 Nausea/Vomiting 787.0 Neuralgia 729.2 Nevus (Site) 216.9 Obesity 278.0 SERVICES PERFORMED AT: Office OE.R. REFERRING PHYSICIAN & ID. NUMBER CLAIM CONTAINS NO ORDERED REFERRING SERVICE RETURN APPOINTMENT INFORMATION: 5. 10 - 15 - 20 - 30 - 40 - 60 NEXT APPOINTMENT M. T. W. TH.F.S DAYS) WKS.JI MOS.] PRN) DATE / TIME: INSTRUCTIONS TO PATIENT FOR FILING INSURANCE CLAIMS: 1. Complete upper portion of this form, sign, and date. 2. Attach this form to your own insurance company's form for direct reimbursement. MEDICARE PATIENTS - DO NOT SEND THIS TO MEDICARE. WE WILL SUBMIT THE CLAIM FOR YOU. ACCEPT DOCTOR'S SIGNATURE ASSIGNMENT? AM O YES PM O NO O CASH TOTAL TODAY'S FEE HECK # OLD BALANCE O VISA TOTAL DUE O MC COPAY AMOUNT REC'D. TODAY