ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X291
Example 8a: 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 for which the predetermination is requested 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*005010X291~
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*3698~
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**********08~
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
2400 SERVICE LINE
LX*2~
SV1*HC:J1550*53.37*UN*1*11**1~
SV1 PROFESSIONAL SERVICE
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*29*0711~
SE TRANSACTION SET TRAILER