ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X222
Example 10a: Drug administered in the Physician Office
Example of service in a physician office, which includes the billing for a drug administered in the office.
SUBSCRIBER/PATIENT: Steve R. Vaughn
ADDRESS: 236 Diamond St., Las Vegas, NV 89109
SEX: M
DOB: 5/1/1943
SUBSCRIBER IDENTIFICATION #: MBRID12345
GROUP #: GRP01020102
DESTINATION RECEIVER: XYZ Receiver
ETIN: 369852758
DESTINATION PAYER: R&R Health Plan
NATIONAL PLAN IDENTIFIER: PLANID12345
BILLING PROVIDER/SENDER: Associates in Medicine
ADDRESS: 1313 Las Vegas Blvd., Las Vegas, NV 89109
TIN: 587654321
NATIONAL PROVIDER IDENTIFIER: 1234567893
CONTACT PERSON AND PHONE NUMBER: Bud Holly, (801)726-8899
PAY-TO PROVIDER: Associates in Medicine
RENDERING PROVIDER: Jim Hendrix
NATIONAL PROVIDER IDENTIFIER: 1122333341
TAXONOMY IDENTIFIER: 208D00000X
PATIENT ACCOUNT NUMBER: CLMNO12345
DIAGNOSIS: 0359.1
CASE: The service provided on 7/11/2004 is that the patient received an injection of immune globulin during an office visit. The service is billed with procedure code 90782.
Coding for the drug is accomplished with a HCPCS procedure code of J1550 (injection, gammablobulin, intramuscular, 10 cc). And, the drug is also coded with NDC of 00026-0635-12 (BayGam® SDV, PF 10 ML).
Place of service is an office. Total billed charges are $103.37. Sales tax is $3.37.
The primary purpose of this example is to demonstrate how drugs are billed along with services when provided by a physician office. Billing for the drug is found in segments #25-30 below.
Transmission Explanation
HEADER
ST*837*0711*005010X222A1~
ST TRANSACTION SET HEADER
BHT*0019*00*0013*20040801*1200*CH~
BHT BEGINNING OF HIERARCHICAL TRANSACTION
1000A SUBMITTER
NM1*41*2*Associates in Medicine*****46*587654321~
NM1 SUBMITTER
PER*IC*Bud Holly*TE*8017268899~
PER SUBMITTER EDI CONTACT INFORMATION
1000B RECEIVER
NM1*40*2*XYZ Receiver*****46*369852758~
NM1 RECEIVER NAME
2000A BILLING PROVIDER HL LOOP
HL*1**20*1~
HL - BILLING PROVIDER
2010AA BILLING PROVIDER
NM1*85*2*Associates in Medicine*****XX*1234567893~
NM1 BILLING PROVIDER NAME
N3*1313 Las Vegas Boulevard~
N3 BILLING PROVIDER ADDRESS
N4*Las Vegas*NV*89109~
N4 BILLING PROVIDER CITY/STATE/ZIP
REF*EI*587654321~
REF BILLING PROVIDER SECONDARY IDENTIFICATION
2000B SUBSCRIBER HL LOOP
HL*2*1*22*0~
HL - SUBSCRIBER
SBR*P*18*GRP01020102******CI~
SBR SUBSCRIBER INFORMATION
2010BA SUBSCRIBER
NM1*IL*1*Vaughn*Steve*R***MI*MBRID12345~
NM1 SUBSCRIBER NAME
N3*236 Diamond ST~
N3 SUBSCRIBER ADDRESS
N4*Las Vegas*NV*89109~
N4 SUBSCRIBER CITY
DMG*D8*19430501*M~
DMG SUBSCRIBER DEMOGRAPHIC INFORMATION
2010BB SUBSCRIBER / PAYER
NM1*PR*2*R&R Health Plan*****XV*PLANID12345~
NM1 PAYER NAME
2300 CLAIM
CLM*CLMNO12345*103.37***11:B:1*Y*A*Y*Y~
CLM CLAIM LEVEL INFORMATION
HI*BK:03591~
HI HEALTH CARE DIAGNOSIS CODE
2310B RENDERING PROVIDER
NM1*82*1*Hendrix*Jim****XX*1122333341~
NM1 RENDERING PROVIDER NAME
PRV*PE*PXC*208D00000X~
PRV RENDERING PROVIDER INFORMATION
2400 SERVICE LINE
LX*1~
LX SERVICE LINE COUNTER
SV1*HC:90782*50*UN*1***1~
SV1 PROFESSIONAL SERVICE
DTP*472*D8*20040711~
DTP DATE - SERVICE DATE(S)
2400 SERVICE LINE
LX*2~
SV1*HC:J1550*53.37*UN*1***1~
SV1 PROFESSIONAL SERVICE
DTP*472*D8*20040711~
DTP DATE - SERVICE DATE(S)
AMT*T*3.37~
AMT SALE TAX AMOUNT
2410 DRUG IDENTIFICATION
LIN**N4*00026063512~
LIN DRUG IDENTIFICATION
CTP****10*ML~
CTP DRUG QUANTITY
TRAILER
SE*31*0711~
SE TRANSACTION SET TRAILER