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Scenario:

Patient Daisy Duck was referred to Dr. Ben Kildare by her doctor, Dr. Marcus Welby, MD. She saw Dr. Kildare, a skin specialist, on Nov. 16, 2015. She paid her co-pay of $10, at the front desk when she checked in. In addition to the office visit, 3 procedures were performed and are to be billed on using their respective CPT codes as service lines within the claim.

Daisy is a dependent (wife) on Donald Duck’s plan with BCBS. Each has their own Member ID.

The Group Practice is working with a Billing Service (Clearinghouse) to creating an 837 and submit it to a Repricer, who then sends it on to the Payer, BCBS. So the trading partners are the Billing Service and Repricer for the 837.

In this exercise, you are a mapper for the Billing Service and will be creating a single claim to send to the repricer.

Information for the transaction/claim

  • Submitter - PREMIER BILLING SERVICE, Trading Partner ID (ETIN – Electronic Transmitter Identification Number): PBS5747 also GS02 Sender ID
  • Receiver - REPRICER XYZ, Trading Partner ID (ETIN): 66783JJT
  • Billing Provider - ABUNCHA PHYSICIANS
  • NPI: 4121212121
  • Required tax ID for 1099 reporting: 111234567
  • Subscriber - DONALD DUCK Member ID: DDD0221111-01
  • Patient/Dependent - DAISY DUCK
  • Payer for this Claim - BLUE CROSS Payer ID: 741234
  • Rendering Provider - BEN KILDARE, NPI: 1122333344
  • The Invoice Number (or Patient Account Number) for the Claim: A126462967
  • Principal Diagnosis Code: R21 - SKIN ERUPT
  • Other Diagnosis Code: Z1159 - SCREEN OTH SPCF VIRAL
  • Date of Service(s): Nov. 16, 2015
  • Services billed. CPT code, charge amount, units and diagnosis precedence:
    99213 - (Office Visit) $40, 1 unit, diagnosis pointers 1, 2
    95010 - (Scratch Test) $15, 1 unit, diagnosis pointers 1, 2
    87072 - (Culture Microbiology) $35, 1 units, diagnosis code pointers 2, 1
    86663 – (Epstein-Barr virus, early antigen) $10, 1 unit, diagnosis code pointers 1, 2
  • Claim total: $40 + 15 + 35 + 10 = $100
  • CO-Pay of $10

In the following 837P version 005010X222A1, choose the "Best" answer for the incomplete transaction:

ISA*00* *00* *ZZ*PBS5747 *ZZ*66783JJT *110110*1453*^*00501*000000001*0*P*:~
GS*HC* 1 *66783JJT*20110110*1153*1*X*005010X222A1~
ST*837*0001*005010X222A1~
BHT*0019*00*0123*20151224*1023*CH~
NM1*41*2*PREMIER BILLING SERVICE*****46* 2 ~
PER*IC*CUSTOMER SERVICE*TE*8885552222*EX*231~
NM1*40*2*REPRICER XYZ*****46* 3 ~
HL*1**20*1~
NM1*85*2*ABUNCHA PHYSICIANS*****XX* 4 ~
N3*123 MAIN ST~
N4*MIAMI*FL*33111~
REF*EI* 5 ~
HL*2*1*22*1~
SBR*P**GROUP-A******BL~
NM1*IL*1*DUCK*DONALD*D***MI*DDD0221111-01~
NM1*PR*2* 6 *****PI* 7 ~
HL*3*2*23*0~
PAT* 8 ~
NM1*QC*1*DUCK*DAISY~
N3*1253 DISNEY ST~
N4*ORLANDO*FL*33413~
DMG*D8*19450612*F~
CLM* 9 *100***11::1*Y*A*Y*Y*C~
AMT*F5* 10 ~
REF*D9*1731234~ Claim Number
REF*EA*11223344~ Medical Record Number
HI*ABK: 11 *ABF: 12 ~
NM1*DN*1*WELBY*MARCUS*W**JR~ Referring Provider Name
NM1*82*1* 13 * 14 ****XX* 15 ~
PRV*PE*PXC*203BF0100Y~
NM1*77*2*KILDARE CLINIC~
N3*2345 OCEAN BLVD~
N4*MIAMI*FL*33111~
LX*1~
SV1*HC:99213*40*UN*1***1:2**N~
DTP*472*D8* 16 ~
REF*6R*20001~ Line item control number
LX*2~
SV1*HC: 17 * 18 *UN*1***1:2**N~
DTP*472*D8*20151116~
REF*6R*20002~
LX*3~
SV1*HC:87072*35*UN*1*** 19 **N~
DTP*472*D8*20151116~
REF*6R*20003~
LX*4~
SV1*HC:86663*10*UN*1***1:2**N~
DTP*472*D8*20151116~
REF*6R*20004~
SE*48*0001~
GE*1*1~
IEA*1*000000001~

Select the best answer for each question:

1. Group Sender ID ( GS02)



 
2. Transaction Submitter ETIN (NM109 where NM108 = 46)



 
3. Transaction Receiver ETIN (NM109 where NM108 = 46)



 
4. Billing Provider ID (NM109 where NM108 = XX for NPI)



 
5. Billing Provider's required tax ID (REF02 where REF01 = EI Employer's ID number)



 
6. Payer Name (NM103 where NM101 = PR Payer and NM102 = 2 Non-person entity)



 
7. Payer ID (NM109 where NM108 = PI)



 
8. Patient Relationship to Subscriber (PAT02) (Code-Description)



 
9. Claim Submitter ID (CLM02 also called Patient Account Number)



 
10. Patient Paid Amount (AMT02 where AMT01 = F5 patient paid amt)



 
11. Principal Diagnosis Code (HI01-2 where HI01-1 = BK principle diagnosis code ICD-9)



 
12. Other Diagnosis Code (HI02-2 where HI02-1 = BF diagnosis code ICD-9)



 
13. Rendering Provider Last Name (NM103 where NM101 = 82 rendering and NM102 = 1 person)



 
14. Rendering Provider First Name (NM104 where NM101 = 82 rendering and NM102 = 1 person)



 
15. Rendering Provider ID (NM109 where NM101 = 82 rendering and NM108 = XX NPI)



 
16. Service Date (DTP03 where DTP01 = 472 service date and DTP03 = D8 CCYYMMDD format)



 
17. Service Code (SV101-2 where SV101-1 = HC HCPCS or CPT code on line #2)



 
18. Line Item Charge Amount (SV102) line #2



 
19. Diagnosis Code Pointer(s) (SV107) line #3


 

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