X12 Version: 008060 | Transaction Set: 837 | TR3 ID: 008060X323
Example: Chiropractic Spinal Manipulation with X-Ray
BUSINESS SCENARIO:
Patient is an adult male receiving chiropractic spinal manipulation with X-Ray due to acute back pain. Subscriber is the Patient. The Payer is Medicare B and the encounter is billed directly to Medicare B.
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: MATTHEW J WILLIAMSON
SUBSCRIBER ID: 9YJ9TE1GP41
SUBSCRIBER ADDRESS: 123 RAINBOW ROAD, KANSAS CITY, MO, 64105
SUBSCRIBER DOB: 03/03/1954
SUBSCRIBER SEX: M
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: $145.50
PLACE OF SERVICE CODE: 11
CLAIM FREQUENCY CODE: 1
INITIAL TREATMENT DATE: 01/12/2025
DATE OF LAST X-RAY: 01/12/2025
DIAGNOSIS CODE: M48.20
SERVICE LINE NUMBER:
PROCEDURE CODE: 98940
PROCEDURE MODIFIER: AT
LINE ITEM CHARGE AMOUNT: $145.50
UNIT OR BASIS FOR MEASURMENT CODE: UN
SERVICE UNIT COUNT: 1
EMERGENCY INDICATOR: N
EPSDT INDICATOR: N
FAMILY PLANNING: N
DATE OF SERVICE: 01/12/2025
Transmission Explanation
HEADER
ST*837*0001*008060X323~
ST TRANSACTION SET HEADER
BHT*0019*00*12345*20250112*1549*CH~
BHT BEGINNING OF HIERARCHICAL TRANSACTION
1000A SUBMITTER NAME
NM1*41*2*PROVIDER MEDICAL GROUP*****46*N305~
NM1 SUBMITTER NAME
PER*IC*NINA*TE*6155551212*EX*911~
PER SUBMITTER EDI CONTACT INFORMATION
1000B RECEIVER
NM1*40*2*MEDICARE B RECEIVER*****46*05440~
NM1 RECEIVER NAME
2000A BILLING PROVIDER
HL*1**20*1~
HL - BILLING PROVIDER HIERARCHICAL LEVEL
2010AA BILLING PROVIDER NAME
NM1*85*2*PROVIDER MEDICAL GROUP*****XX*2366554859~
NM1 BILLING PROVIDER NAME
N3*123 Main Street~
N3 BILLING PROVIDER ADDRESS
N4*KANSAS CITY*MO*641051909~
N4 BILLING PROVIDER LOCATION
REF*EI*756473826~
REF BILLING PROVIDER TAX IDENTIFICATION
2000B SUBSCRIBER HL LOOP
HL*2*1*22*0~
HL - SUBSCRIBER HIERARCHICAL LEVEL
SBR*P*18*******MB~
SBR SUBSCRIBER INFORMATION
2010BA SUBSCRIBER NAME LOOP
NM1*IL*1*WILLIAMSON*MATTHEW*J***MI*9YJ9TE1GP41~
NM1 SUBSCRIBER NAME
N3*123 RAINBOW ROAD~
N3 SUBSCRIBER ADDRESS
N4*KANSAS CITY*MO*64105~
N4 SUBSCRIBER CITY, STATE, ZIP
DMG*D8*19540303~
DMG SUBSCRIBER DEMOGRAPHIC INFORMATION
DMH*M*248152002~
DMH SUBSCRIBER EXTENDED DEMOGRAPHIC INFORMATION
2010BB PAYER NAME LOOP
NM1*PR*2*MEDICARE B~
NM1 PAYER NAME
REF*2U*05440~
REF PAYER SECONDARY IDENTIFICATION
2300 CLAIM INFORMATION
CLM*153829140764352987432*145.5***11:B:1*Y*A*Y*Y~
CLM CLAIM INFORMATION
DTP*523*D8*20250112~
DTP ORIGINAL CLAIM CREATION DATE
DTP*454*D8*20250112~
DTP INITIAL TREATMENT DATE
DTP*455*D8*20250112~
DTP LAST X-RAY DATE
CR2********A**CHRONIC PAIN AND DISCOMFORT~
CR2 SPINAL MANIPULATION SERVICE INFORMATION
HI*ABF:M4820~
HI DIAGNOSIS
2400 SERVICE LINE NUMBER
LX*1~
LX SERVICE LINE NUMBER
SV1*HC:98940:AT*145.5*UN*1***1***N**N*N~
SV1 PROFESSIONAL SERVICE
DTP*472*D8*20250112~
DTP SERVICE DATE/TIME
REF*6R*1~
REF LINE ITEM CONTROL NUMBER
TRAILER
SE*30*0001~
SE TRANSACTION SET TRAILER