Section title: X12 EDI Examples
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ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X222

Example 10b: Home Infusion Therapy Pharmacy (Adjudicated with NDC in Loop 2410)

Example of services from a home infusion therapy pharmacy, which includes the billing for the drugs delivered for administration in the home and where adjudication will be from NDC number provided in Loop 2410

SUBSCRIBER/PATIENT: Steve A. Smith

ADDRESS: 15210 Juliet Lane, Libertyville, IL 60048

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: PLANID1234

SUBMITTER: Quality Billing Service Corporation

ETIN: 587654321

CONTACT PERSON AND PHONE NUMBER: Bud Holly, (801)726-8899

BILLING PROVIDER/SENDER: Professional Home IV, LLC

ADDRESS: 1500 Industrial Drive, Libertyville, IL 60048

TIN: 10-1234567

NATIONAL PROVIDER IDENTIFIER: 1234567893

CONTACT PERSON AND PHONE NUMBER: Brenda Holly, (801)999-9999

PAY-TO PROVIDER: Professional Home IV, LLC

ORDERING PROVIDER: Marcus Welby

NATIONAL PROVIDER IDENTIFIER: 1112223338

PATIENT ACCOUNT NUMBER: CLMNO12345

DIAGNOSIS: 465.9

CASE: The service is provided over a date span from 2/1/2004 to 2/7/2004 for prescriptions that the physician prescribed on 1/30/2004.

Provided is ceftriaxone, 2 gm IV, q24h over 7 days for gravity infusion through PICC line to treat an acute upper respiratory infection. 20mls sterile water is the diluent for reconstitution of the ceftriaxone which is compounded into 100ml saline IV mini-bags. Also provided are all administration supplies and the pole necessary for the ceftriaxone infusion. Additionally, provided are all administration supplies, and flushing solutions (sodium chloride and heparin) prepackaged by the manufacturer in pre-filled syringes

Drug service lines in this example begin after submission of a daily per diem charge of $200 per day of therapy, coded with HCPCS S9500 in the LX*1 service line. Drugs are precisely coded with NDC numbers, and the HCPCS provided are S5000 and S5001 for a generic drug and brand drug, respectively. The quantity and unit of measure sent for each pair of NDC and HCPCS is the same, and the practice used for infusion therapy claims is to provide a count of containers used, e.g. number of vials, number of bags, etc.

The health plan adjudicates the drug claim using the NDC in the 2410 LIN segment, quantity and unit of measure in the 2410 CTP segment, and charges in the 2400 SV1 segment. For example, in the LX*2 service line, 7 units of ceftriaxone (NDC of 00004-1965-01 which is for Rocephin®) is billed by the provider for total charge amount of $682.50.We note that as 00004-1965-01 Rocephin comes in a physical container of 2gm vials, this means that the provider’s charge per vial of Rocephin is $97.50.

As S5000 and S5001 are used to map claim translation directly to the NDC coding for adjudication, payers should not reject occurrences of S5000 or S5001 because of overlapping dates.

Service lines LX*2, LX*3 and LX*4 contain the drugs that are elements of the compound. Service lines LX*5 and LX*6 are for non-compounded prescription drugs.

The primary purpose of this example is to demonstrate how drugs are billed along with services when provided by a home infusion therapy pharmacy. Billing for the drugs is found in segments #25-64 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