Section title: X12 EDI Examples
back to previous

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*005010X222~

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*587654321~

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*11**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*11**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