Understanding Health Insurance - Chapter 11: CMS-1500 and UB-04 (Learning Lab)

I would like someone to check my work before I submit it, please. If it is incorrect, please let me know so that I can fix it. I am not too sure about the diagnosis pointers?

Activity: Overview of the Physician or Supplier Information Part of the CMS-1500 Form Alice Jones had an EKG (93000) done during her office visit on 07/01/YY because she was complaining of chest pain that she started experiencing the day before. Fill in the missing information where indicated on the claim form below. Click submit when finished. Hint 14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP) 15. OTHER DATE MM DD YY 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION 06 30 YYYY QUAL| QUAL FROM TO 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DO MM DD YY 17 NPI FROM TO 19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC) 20. OUTSIDE LAB? $ CHARGES YES X NO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E) ICD Ind. 22. RESUBMISSION CODE ORIGINAL REF. NO. R07.9 B. C. L D. L E G. L 23. PRIOR AUTHORIZATION NUMBER F. L H. L J. K L LL 24. A. DATE(S) OF SERVICE B C. D. PROCEDURES, SERVICES, OR SUPPLIES E F. G. H. J. From To PLACE OF (Explain Unusual Circumstances) DIAGNOSIS EPODT OR Famly ID. RENDERING MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $ CHARGES UNITS Pan QUAL PROVIDER ID. 07 01 YY 11 99213 A NP 2 07 01 YY 11 93000 A NP Submit