Example: Anesthesia for Laser Eye Surgery

BUSINESS SCENARIO:

Patient is an adult female receiving anesthesia for laser eye surgery. This is the bill for the anesthesia service only. Subscriber is the Patient. The Payer is Medicare B and the encounter is billed directly to Medicare B.

DATA ELEMENTS:

Listed below are the data elements that are to be included in the claim (e.g. name of insurance company, identification numbers, subscriber name, address and demographic details, billing and other provider details and identifiers, service details and codes, etc.). This gives all the information that needs to be included in the claim.

Example:

SUBMITTER:
SUBMITTER NAME: PROVIDER MEDICAL GROUP
SUBMITTER ID: N305
SUBMITTER CONTACT NAME: NINA
SUBMITTER CONTACT NUMBER: 6155551212 ext. 911

RECEIVER:
RECEIVER NAME: MEDICARE B RECEIVER
RECEIVER ID: 05440

BILLING PROVIDER:
BILLING PROVIDER TAXONOMY: N/A
BILLING PROVIDER NAME: PROVIDER MEDICAL GROUP
BILLING PROVIDER NPI: 2366554859
BILLING PROVIDER ADDRESS: 123 MAIN STREET, KANSAS CITY, MO, 64105-1909
BILLING PROVIDER TIN: 756473826

SUBSCRIBER:
SUBSCRIBER NAME: MARGARET JONES
SUBSCRIBER ID: 9YJ9TE1GP41
SUBSCRIBER ADDRESS: 123 RAINBOW ROAD, KANSAS CITY, MO, 64105
SUBSCRIBER DOB: 03/03/1954
SUBSCRIBER SEX: F

DESTINATION PAYER:
PAYER NAME: MEDICARE B
PAYER SECONDARY IDENTIFICATION: 05440

PATIENT:
Same as Primary Subscriber

CLAIM INFORMATION:
ORIGINAL CLAIM CREATION DATE: 01/12/2025

PROVIDER ASSIGNED CLAIM IDENTIFIER: 153829140764352987432
TOTAL CHARGES: $827.00
PLACE OF SERVICE CODE: 22
CLAIM FREQUENCY CODE: 1

DIAGNOSIS CODES: H25.11, H25.811
ANESTHESIA RELATED PROCEDURE CODE: 66984

RENDERING PROVIDER:
RENDERING PROVIDER NAME: JACOB E. TOWNSEND
RENDERING PROVIDER NPI: 5678912345

SERVICE LOCATION:
SERVICE LOCATION NAME: PROVIDER OP HOSPITAL
SERVICE LOCATION ADDRESS: 345 MAIN DRIVE, KANSAS CITY, MO, 64105-1909
SERVICE LOCATION NPI: 43294867

SERVICE LINE NUMBER:
PROCEDURE CODE: 00142
PROCEDURE MODIFIERS: QK, QS, P1
LINE ITEM CHARGE AMOUNT: $827
UNIT OR BASIS FOR MEASURMENT CODE: MJ
SERVICE UNIT COUNT: 61
EMERGENCY INDICATOR: N
EPSDT INDICATOR: N
FAMILY PLANNING: N
DATE OF SERVICE: 01/12/2025