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Patient Inpatient Face Sheet

A young female Dora Max was a driver involved in a car accident on 5/22/2015 when she rear-ended by another driver. She was seen in ER complaining of pain in the arm and neck. She was brought to "Help Me" hospital. She was evident that compound fractures were present. She was admitted to the hospital for open reduction, internal fixation of the type II fractures of radius and ulna. The patient had internal bleeding and lost unknown amount of blood.

Patient Name and address:

Dora Max
1 Test Lane, Will NY 10148
Patient Hospital/Account Number aka CLAIM ID: 123456789
DOB: 09/09/1955

Primary insurance and Guarantor information:

Policyholder: Patient (Self-insured)
Primary carrier name: Blue of Florida
Policy number/ Member ID: FL1443119

Admission Date: 05/22/2015 2pm
Source of admission: Admitted thru Emergency (CL101,02)
DOS: 05/22/2015

Attending Physician: Ahi, Ama,NPI: 1999955501
Billing Provider: Radiology Specialists, Group NPI: 0199999999, TAX ID: 133333333
TAXONOMY CODE 282N00000X
Service Facility: Help Me, 900 Hospital Ave, Island NY 10300

Admission Diagnosis: S52.201B
Discharge Diagnosis (principal Diagnosis) :S52.201B
Principal Diagnosis: S52.201B (POA=Y)
Patient reason for visit diagnosis: S52.301B,S13.4XXA
External Cause of Injury diagnosis: V43.52XA (POA=N)
Secondary (other) Diagnosis: S52.301B(POA=Y), S14.0XXA (POA=Y), R58 (POA=N)
Procedure Code for blood work requested by attending physician: 85027
Attending Physician ordered a complete CBC with automated Hgb, Hct, RBC count, WBC count and platelet count – cpt code 80027.

EDI trading partner information:

Group Control Number: 111111111
Submitter Name: Billing Company 1, Trading partner (submitter id) : 222222222 ALSO GS02
Receiver Name : WEBMD, Receiver ID: 111111111 ALSO GSO03
Payer: Blue of Florida, Payer ID: SB590

Billing company "Billing Company 1" is submitting an institutional claim for doctor Ahi, Ama for lab work her ordered to "Blue of Florida" thru a clearinghouse "WebMD".

ISA*00* *00* *ZZ*222222222 *ZZ*111111111 *150521*0007*^*00501*000000001*1*P*:~
GS*HC* 1 *111111111*20150521*0007* 2 *X*005010X223A2~
ST*837*0001*005010X222A1~
BHT*0019*00*00000001*20160523*000437*CH~
NM1*41*2* 3 *****46*222222222~
PER*IC*MATT BILL*TE*9999999999~
NM1*40*2*WEBMD*****46* 4 ~
HL*1**20*1~
PRV*BI*PXC* 5 ~
NM1*85*2*RADIOLOGY SPECIALISTS*****XX* 6 ~
N3*1 LOST LANE 1~
N4*MAINE*NY*112050000~
REF*EI* 7 ~
HL*2*1*22*0~
SBR*P*18*******BL~
NM1*IL*1*MAX*DORA****MI* 8 ~
N3*1 TEST LANE~
N4*WILL*NY*10148~
DMG*D8*19550909*F~
NM1*PR*2* 9 *****PI* 10 ~
N3*PAYER ADDRESS~
N4*HOUSE OF BLUES*FL*37419~
CLM* 11 *152***21:A:1**A*Y*Y~
DTP*434*RD8*20150522-20150522~
DTP*435*DT* 12 13 ~
DTP*096*TM*1130~ -> Discharge hour needed if CLM05-3 = 1(Final)
CL1*1*7*09~
NTE*ADD*Emergency Case~
HI*ABK: 14 :::::::Y~
HI*ABJ:S52201B~
HI*APR:S52301B*APR:S134XXA~ -> Not allowed on inpatient claims, only for outpatient
HI*ABN:V4352XA::::::: 15 ~
HI*ABF:S52301B:::::::Y*ABF:S140XXA:::::::Y*ABF: 16 :::::::N~
NM1*71*1*AHI*AMA****XX* 17 ~
PRV*AT*PXC*281N00000X~
NM1*77*2* 18 ~
N3*900 HOSPITAL AVENUE~
N4*STATEN ISLAND*NY*103001664~
LX*1~
SV2*0311*HC: 19 *152*UN*1~
DTP*472*RD8* 20 ~
REF*6R*123456789001~
SE*40*001~
GE*1*1~
IEA*1*000000001~

Select the best answer for each question:

1. Group Sender ID (GS02)


 
2. Group control number (GS06)


 
3. Transaction Submitter Name (NM103 where NM101 is 41)


 
4. Receiver ID (NM109 where NM101 is 40)


 
5. Group Taxonomy code


 
6. Billing Provider ID (NM109 where NM108 is XX for NPI)


 
7. Billing Provider TAX ID (REF02 where REF01 is EI)


 
8. Member identification code (NM109 where NM101 is IL (Subscriber))


 
9. Payer Name (NM103 where NM101 is PR (payer))


 
10. Payer ID (NM109 where NM108 is PI (Plan ID))


 
11. Patient account number called Claim submitter identifier (CLM01)


 
12. Admission Date (DTP03 where DTP01 is 435)


 
13. Admission Time (DTP03 where DTP01 is 435)


 
14. Principal Diagnosis (HI01-02 where HI01-01 qualifier is ABK)


 
15. External cause of injury present on admission indicator ((HI01-09 ) where HI01-01 is ABN)


 
16. Other (secondary ) diagnosis code not present on admission (where HI01-01 is ABF)


 
17. Attending physician billing id (NPI) (NM1-09 where NM101 is 71 and NM108 is XX for NPI)


 
18. Service facility location name (NM103 where NM101 is 77)


 
19. Service code (procedure code) (SV2-02-02)


 
20. Date of service (DTP03 where DTP01 is 472)


 

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