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:

Select the best answer for each question: