837 Dental Transaction Mapping

837 Dental Transaction Mapping Exercise Example

837 Dental Transaction Mapping exercise gives a scenario of working with a 837 Dental Transaction file to complete the claim and send it to processing. 837 Dental Transaction Mapping exercise will be useful for insurance companies, providers and HIPAA specialists.

Scenario: Patient MINI DUCK dependent son of DONALD DUCK goes to the dental office OFFICE OF ANTHONY KRUZ DDS for some dental work. He saw Dr. ANTHONY CRUZ on May 16^th, 2018. The doctor performed two services,  one with code XXX and another one with code YYY. The office is working with a clearing house to generate a 837 file and assign a claim Number 494672314 for future reference. In this exercise you are going to fill in the blanks (from 1 to 26) to complete the claim, so it can be forwarded to MY BILLING SERVICE for processing.

Information for the 837 Dental Transaction Mapping

• 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 – OFFICE OF ANTHONY KRUZ DDS
  • NPI: 1122333344
  • Required tax ID for 1099 reporting: 111234567
• Subscriber – DONALD DUCK Member ID : 5554421
• Patient/Dependent – MINI DUCK
• Payer for this Claim – BLUE CROSS Payer ID: 741234
• Patient Account Number in the clinic is DDD0221111-02
• Rendering Provider – ANTHONY CRUZ, NPI: 1122333344
• The Invoice Number (or Patient Account Number) for the Claim: A126462967
• Principal Diagnosis Code: K00.1- SUPERNUMERARY TEETH
• Other Diagnosis Code: Z01.20 – ENCOUNTER DENTAL EXAM CLEANING W/O ABNORMAL FIND

Patient is also seen for Orthodontic treatment, scheduled for 24 months, 17 of which have been already consumed

The patient has a missing tooth  – Tooth # 8

One of the services is for initial installment of appliance (prosthesis) – Procedure code = 95010

The dentist will be working on the upper right corner (designation of the oral cavity)

Dentist will be also working on TOOTH # 12 on surfaces L (Lingual) and O (Occlusal)

• Date of Service(s): May. 16, 2018
• Services billed:
  • ADA procedure code, charge amount, units and diagnosis precedence
  • D0120- (Periodic Oral Evaluation – Established Patient – test)   $18, 1 unit, diagnosis pointers 1, 2
  • D0140- (Limited Oral Evaluation – Problem Focused)   $60, 1 unit, diagnosis pointers 1, 2

• Claim total: 0$ – Claim will be adjudicated and will be paid according to the fee for service.

In the following 837D transaction in version 005010X224A2, choose the “Best” answer for the incomplete sections:

ISA*00*          *00*          *ZZ*364187943      *ZZ*412014834      *160218*0157*^*00501*008817636*0*P*:~

GS*HC*__1__*FACELIFT*20160218*015725*8817636*X*005010X224A2~

ST*837*000000001*005010X224A2~

BHT*0019*00*00001*20160218*015725*CH~

NM1*41*2*PREMIER BILLING SERVICE*****46*__2__~

PER*IC*CUSTOMER SERVICE*TE*8775829188~

NM1*40*2* REPRICER XYZ *****46*__3__~

HL*1**20*1~

NM1*85*2*OFFICE OF ANTHONY KRUZ DDS*****XX*__4__~

N3*1200 E 12 MILE RD~

N4*MADISON*FL*480719998~

REF*EI*__5__~

HL*2*1*22*1~

SBR*P*18**UNION GROVE CAR*****15~

NM1*IL*1*DUCK*DONALD****MI*5554421~

N3*2800 SW 194TH AVE~

N4*PORTLAND*OR*27006~

DMG*D8*19691102*F~

NM1*PR*2*__6__*****PI*__7__~

HL*3*2*23*0~

PAT*__8__~

NM1*QC*1*DUCK*MINI~

DMG*D8*20100411*F~

CLM*__9__*78***11:B:1**C*Y*Y~

DN1*__10__*__11__~                 — treatment for orthodontic purposes     (24,17)

DN2*__12__*__13__****JP~     — Tooth status  (8 and M)

REF*D9*494672314~       — Claim number assigned by Clearing House

HI*ABK:__14__*ABF:__15__~

NM1*82*1*__16__*__17__*N***XX*__18__~

PRV*PE*PXC*1223G0001X~

LX*1~

SV3*AD:__19__*18***__20__*1****__21__~

TOO*JP*__22__*__23__~           — tooth information  12 and L:O

DTP*472*D8*__24__~

DTP*452*D8*__25__~  —- Appliance placement

LX*2~

SV3*AD:D0140*60**__26__**1****1:2~ — this is the designation of the Oral cavity

DTP*472*D8*20180516~

SE*35*000000001~

GE*1*8817636~

IEA*1*008817636~

For the questions under the designated number in the above information, select one of the answers to be considered the ‘best’ :

1 – Group Sender ID ( GS02)

1. PBS5747
2. 66783JJT
3. 1122333344
4. 111234567
5. None of the above

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

1. 66783JJT
2. 1122333344
3. PBS5747
4. 111234567
5. None of the above

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

1. PBS5747
2. 66783JJT
3. 1122333344
4. 111234567
5. None of the above

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

1. 4121212121
2. 74123
3. 1122333344
4. 111234567
5. None of the above

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

1. 4121212121
2. 74123
3. 1122333344
4. 111234567
5. None of the above

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

1. BEN KILDARE
2. 74123
3. BLUE CROSS
4. 111234567
5. None of the above

7 – Payer ID (NM109 where NM108 = PI)

1. DDD0221111-01
2. 1122333344
3. 741234
4. 111234567
5. None of the above

8 – Patient Relationship to Subscriber   (PAT02) (Code – Description)

1. 18 Self
2. 19  Child
3. 53 Life Partner
4. G8 Other Relationship
5. 01 Spouse

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

1. 4121212121
2. A1264629007
3. DDD0221111-02
4. 111234567
5. None of the above

10 – Treatment for orthodontic purposes

1. 1
2. 12
3. 24
4. 36
5. None of the above

11 –  Remaining months

1. 12
2. 13
3. 17
4. None of the above

12 – Tooth Status – Tooth Number

1. 5
2. 6
3. 12
4. 8
5. None of the above

13 – Tooth Status – Tooth Status Code

1. A
2. B
3. M
4. E
5. None of the above

14 – Principal Dental Diagnosis Code (HI01-2 where HI01-1 = ABK principle diagnosis code ICD-10)

1. 99213
2. 74123
3. 1
4. R21
5. None of the above

15 – Other Dental Diagnosis Code (HI02-2 where HI02-1 = ABF diagnosis code ICD-10)

1. 99213
2. 74123
3. Z1159
4. 20
5. None of the above

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

1. WELBY
2. KILDARE
3. ABUNCHA PHYSICIANS
4. CRUZ
5. None of the above

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

1. WELBY
2. KILDARE
3. ANTHONY
4. BEN
5. DOCTOR

18 – Rendering Provider ID (NM109 where NM101 = 82 rendering and NM108 = XX  NPI)

1. 4121212121
2. KILDARE
3. 1122333344
4. D72365
5. Not required

19 – Service Code (SV301-2 where SV301-1 = ADA code on line #1)

1. 99213
2. 74123
3. Z1159
4. D020
5. None of the above

20 – Prosthesis, Crown or Inlay code

1. A
2. B
3. I – this is the right code as it is related to DTP*452
4. R
5. None of the above

21 – Diagnosis Code Pointer(s) (SV311) line #1

1. 1:2
2. 2
3. 35
4. 2:1
5. None of the above

22 – Tooth Information Tooth Number

1. 1
2. 2
3. 12
4. 78
5. None of the above

23 – Tooth Information – Tooth Surface

1. A
2. A:B
3. L>O – incorrect delimiter
4. L:O – correct answer
5. None of the above

24– Service Date (DTP03 where DTP01 = 472 service date and DTP03 = D8  CCYYMMDD format)

1. 11162015
2. 16, 2015
3. 101116
4. 20180516
5. 11/16/2015

25 – Appliance placement Date (DTP03 where DTP01 = 452 qualifier and DTP03 = D8  CCYYMMDD format) – it must be the same date as date of service

1. 11162015
2. 16, 2015
3. 101116
4. 20180516
5. 11/16/2015

26 – Oral cavities

Possible valid codes:

ORAL_CAVITY_ID	DESCRIPTION
00	entire oral cavity
01	maxillary arch
02	mandibular arch
10	upper right quadrant
20	upper left quadrant
30	lower left quadrant
40	lower right quadrant