Neck and Arm Pain

Neck and Right Arm Pain

Medicare and Keystone Blue

Full Case Study ? CS12

Mr. James L. Makis , an established patient, arrives at the medical office complaining of neck and right arm pain. His neck pain has been worsening over the last two years. Recently, he has been experiencing some numbness and a tingling sensation in his right arm going down to his thumb. He has no other symptoms or pertinent medical history. His primary insurance is Medicare and his secondary insurance is Keystone Blue. Medicare applies the $100.00 charge for the office visit to Mr. Makis' deductible. There is no copayment with Medicare, but Keystone Blue requires a $25.00 copayment. Medicare will pay part of the bill as will Keystone Blue. Mr. Makis will pay the remaining balance.

Development Lab 1847 Ruddiman Drive, North Muskegon, MI 49445 231.744.4759

James L Makis - Neck and Right Arm Pain

Medical Care Offices

Patient Registration Form

Social Security Number

721 - 33 - 6056

Name & Address

Prefix (Mr., Mrs., Mr.) First name Middle initial Last name Suffix (Jr. Sr. II, III) Address line 2 Address line 3 Address line 4 City State Zip

Mr. James L Makis

544 River Road

Springtown CO 80002

Other Information

Home phone Alternate phone Work phone Date of birth Gender Marital Status Preferred language Race Ethnicity

(970) 555-5050

01/21/1951 Male Married English Black Not Hispanic or Latino

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James L Makis - Neck and Right Arm Pain

Patient Registration (Chapter 7)

Add James L. Makis from patient registration using the demographic information from the previous page. (After submitting the new patient information, the Company: Select screen appears.)

Select Patient Responsibility because the charges for this visit will be paid by the patient, a guarantor, or the patient's insurance company. (After selecting Patient Responsibility, the New Case screen appears.)

Record the complaint of Neck and right arm pain. (After adding the case, the Entity / Payers: Select screen appears.)

Select Medicare as the primary payer. Mr. Makis is the subscriber to the insurance policy (select Self). The effective date of the policy is January 1st, 2016. The policy has no coinsurance or copayment. (The insurance ID number is 543168542, the group name is Medicare, and the group number is 5625. The plan type is Medicare.)

Select Keystone Blue as the secondary payer. Mr. Makis is the subscriber to the insurance policy (select Self). The effective date of the policy is January 1st, 2010. The policy has a $25.00 copayment. (The insurance ID number is 689235120, the group name is Keystone Blue, and the group number is 5456. The plan type is PPO The copayment amount is $25.00.)

Confirm the payers. (After confirming the payers, the Visit Add screen will appear.)

Complete the required fields on the Visit Add screen. This is a Doctor visit. (After adding the visit, the Clinical Note Add screen appears.)

Select "Injury-Bones/Jts" as the presenting problem. On the body part screen, select both "Neck" and "Arm ? Rt (upper)". (Mr. Makis is now on the Clinic Status screen.)

Patient Intake (Chapter 9)

Move Mr. Makis to any vacant room on the Clinic Status screen.

Answer the following clinical notes for Mr. Makis.

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James L Makis - Neck and Right Arm Pain

CURRENT PROBLEM Chief Complaint

History Chief Complaint History of Injury Symptoms

Pain scale

My neck hurts and I have a tingling sensation down my right arm.

none Numbness and tingling sensation down the right arm. 7 (7/10)

PATIENT HISTORY

Medications

Prescription Meds

None

Over-the-counter substances ALLERGIES

Aspirin 01/22/14 Take 80mg once per day

Medication Allergies PAST MEDICAL HISTORY

Penicillin Rash Active

Significant condition

High blood pressure

PAST SURGICAL HISTORY

Cervical / Disc surgery

No

Upper extremity surgery

No

PREVIOUS INJURIES

Neck injury

No

Upper arm injury

No

MUSCULOSKELETAL HISTORY

Arthritis, joint problem

Arthritis in right shoulder

Muscle pain stiffness

No

Tendinitis

No

Back or disc problems

Degenerative disc disease in spine due to osteoarthritis.

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James L Makis - Neck and Right Arm Pain

BODY STATISTICS (US) Height Weight BMI (body mass index)

VITAL SIGNS Blood Pressure Systolic Diastolic Pulse Respirations Temperature

5 feet 10 inches 205 pounds (calculated by MedTrak)

190 100 86 12 98.6

Put the chart in the Rack for Mr. Makis.

Provider Initial Contact (Chapter 10)

Sign out the chart to change the Rack workflow status to Examine. (Place the cursor next to Mr. Makis' name and click the Examine Patient button.)

Place an order for the following X-ray, found in the following category sequence: X-RAY C-SPINE (COMPLETE) in Radiology Head & Neck

Open Orders (Chapter 11)

Document the answers for the x-ray personnel part of the order in Open Orders as follows:

X-RAY C-SPINE (COMPLETE)

Notes X-ray number

none 36727

Completed by

(your initials)

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