Section title: X12 EDI Examples
back to previous

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