ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X291
Example 8b: 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 for which the predetermination is requested will be provided over a date span from 2/1/2004 to 2/7/2004 for prescriptions that the physician prescribed on 1/30/2004. In this case, the payer needs the drug duration to process the predetermination request.
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*005010X291~
ST TRANSACTION SET HEADER
BHT*0019*00*0013*20040301*1200*CH~
BHT BEGINNING OF HIERARCHICAL TRANSACTION
1000A SUBMITTER
NM1*41*2*Quality Billing Service Corporation*****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*Professional Home IV, LLC*****XX*1234567893~
NM1 BILLING PROVIDER NAME
N3*1500 Industrial Drive~
N3 BILLING PROVIDER ADDRESS
N4*Libertyville*IL*60048~
N4 BILLING PROVIDER CITY
REF*EI*10-1234567~
REF BILLING PROVIDER SECONDARY IDENTIFICATION
PER*IC*Brenda Holly*TE*8019999999~
PER BILLING PROVIDER CONTACT INFORMATION
2000B SUBSCRIBER HL LOOP
HL*2*1*22*0~
HL - SUBSCRIBER
SBR*P*18*GRP01020102******CI~
SBR SUBSCRIBER INFORMATION
2010BA SUBSCRIBER
NM1*IL*1*Smith*Steve*A***MI*MBRID01234~
NM1 SUBSCRIBER NAME
N3*15210 Juliet Lane~
N3 SUBSCRIBER ADDRESS
N4*Libertyville*IL*60048~
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*2232.93***12:B:1*Y*A*Y*Y**********08~
CLM CLAIM LEVEL INFORMATION
HI*BK:4659~
HI HEALTH CARE DIAGNOSIS CODE
2400 SERVICE LINE
LX*1~
LX SERVICE LINE COUNTER
SV1*HC:S9500*1400.00*UN*7*12**1~
SV1 PROFESSIONAL SERVICE
2420E ORDERING PROVIDER NAME
NM1*DK*1*Welby*Marcus****XX*1112223338~
NM1 ORDERING PROVIDER NAME
2400 SERVICE LINE
LX*2~
LX SERVICE LINE COUNTER
SV1*HC:S5001*682.50*UN*7*12**1~
SV1 PROFESSIONAL SERVICE
DTP*472*RD8*20040201-20040207~
DTP DATE - SERVICE DATE(S)
DTP*471*D8*20040130~
DTP DATE – PRESCRIPTION DATE
2410 DRUG IDENTIFICATION
LIN**N4*00004196501~
LIN DRUG IDENTIFICATION
CTP****7*UN~
CTP DRUG QUANTITY
REF*XZ*2530001~
REF PRESCRIPTION NUMBER
2420E ORDERING PROVIDER NAME
NM1*DK*1*Welby*Marcus****XX*1112223338~
NM1 ORDERING PROVIDER NAME
2400 SERVICE LINE
LX*3~
LX SERVICE LINE COUNTER
SV1*HC:S5000*15.12*UN*14*12**1~
SV1 PROFESSIONAL SERVICE
DTP*472*RD8*20040201-20040207~
DTP DATE - SERVICE DATE(S)
DTP*471*D8*20040130~
DTP DATE – PRESCRIPTION DATE
2410 DRUG IDENTIFICATION
LIN**N4*63323024910~
LIN DRUG IDENTIFICATION
CTP****14*UN~
CTP DRUG QUANTITY
REF*XZ*2530001~
REF PRESCRIPTION NUMBER
2420E ORDERING PROVIDER NAME
NM1*DK*1*Welby*Marcus****XX*1112223338~
NM1 ORDERING PROVIDER NAME
2400 SERVICE LINE
LX*4~
LX SERVICE LINE COUNTER
SV1*HC:S5000*67.69*UN*7*12**1~
SV1 PROFESSIONAL SERVICE
DTP*472*RD8*20040201-2004020~
DTP DATE - SERVICE DATE(S)
DTP*471*D8*20040130~
DTP DATE – PRESCRIPTION DATE
2410 DRUG IDENTIFICATION
LIN**N4*00338004938~
LIN DRUG IDENTIFICATION
CTP****7*UN~
CTP DRUG QUANTITY
REF*XZ*2530001~
REF PRESCRIPTION NUMBER
2420E ORDERING PROVIDER NAME
NM1*DK*1*Welby*Marcus****XX*1112223338~
NM1 ORDERING PROVIDER NAME
2400 SERVICE LINE
LX*5~
LX SERVICE LINE COUNTER
SV1*HC:S5000*57.12*UN*14*12**1~
SV1 PROFESSIONAL SERVICE
DTP*472*RD8*20040201-20040207~
DTP DATE - SERVICE DATE(S)
DTP*471*D8*20040130~
DTP DATE – PRESCRIPTION DATE
2410 DRUG IDENTIFICATION
LIN**N4*08290033010~
LIN DRUG IDENTIFICATION
CTP****14*UN~
CTP DRUG QUANTITY
REF*XZ*2530002~
REF PRESCRIPTION NUMBER
2420E ORDERING PROVIDER NAME
NM1*DK*1*Welby*Marcus****XX*1112223338~
NM1 ORDERING PROVIDER NAME
2400 SERVICE LINE
LX*6~
LX SERVICE LINE COUNTER
SV1*HC:S5000*10.50*UN*7*12**1~
SV1 PROFESSIONAL SERVICE
DTP*472*RD8*20040201-20040207~
DTP DATE - SERVICE DATE(S)
DTP*471*D8*20040130~
DTP DATE – PRESCRIPTION DATE
2410 DRUG IDENTIFICATION
LIN**N4*08290038005~
LIN DRUG IDENTIFICATION
CTP****7*UN~
CTP DRUG QUANTITY
REF*XZ*2530003~
REF PRESCRIPTION NUMBER
2420E ORDERING PROVIDER NAME
NM1*DK*1*Welby*Marcus****XX*1112223338~
NM1 ORDERING PROVIDER NAME
TRAILER
SE*64*0711~
SE TRANSACTION SET TRAILER