MEMORANDUM FOR: (check one)
[ ]
[ ]
FROM: CSC Bill Payer
SUBJECT: Payment of Service for a Metastasized Cancer
EMPLOYEE:____________________________ FILE NUMBER_______---______---________
In accordance with our established procedures, on __________ (date), the bill payer has paid for medical services related to the following metastasized cancer(s) listed below. Please update ECMS and inform beneficiary of accepted condition.
Primary/Accepted
Metastatic Cancer (s) ICD-9 Code Diagnosis Date (if known) Cancer (ICD9 code)
1.
2.
3.
The following medical reports and/or resources were used to make this determination (see attachments): Check each that are appropriate.
[ ] Medical report or bill ___________________________, dated: __________________
(report or bill is attached)
[ ] WEB MD Internet Site
[ ] OWCP Medical Director
[ ] Merck Manual
[ ] Staff Nurse
[ ] NIOSH Primary/Secondary Cancer Tables
[ ] CPT/ICD-9 Utility Table provided by OWCP Medical Director
[ ] Other (describe):
Number of documents attached: _________
___________________________ ______________________
Signature of CSC Bill Payer Date