Medicare claim (MS014)

Medicare Claim (MS014) **Patient Information** * **Patient Name:** John Smith * **Date of Birth:** 12/05/1958 * **Medicare Number:** 123-456-7890A * **Date of Service:** 01 November 2024 **Provider Information** * **Provider Name:** Dr. Eleanor Vance * **NPI Number:** 1234567890 * **Tax ID:** 12-3456789 * **Address:** 10 Downing Street, London, SW1A 2AA **Diagnosis Codes** * **Primary Diagnosis:** I10 (Essential (primary) hypertension) * **Secondary Diagnosis:** E11.9 (Type 2 diabetes mellitus without complications) **Procedure Codes** * **CPT Code:** 99214 (Office or other outpatient visit for the evaluation and management of an established patient) * **Modifiers:** 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) **Charges** * **Total Charge:** £150.00 **Supporting Documentation** * **Medical Record Number:** 12345 * **Referring Physician (if applicable):** N/A * **Notes:** Patient presents with stable hypertension and type 2 diabetes. Medication review and adjustment. Patient advised on lifestyle modifications. Follow-up in 3 months.