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 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 - 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
- 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*M~
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 ~
DN2*_12* 13 ****JP~
REF*D9*494672314~
HI*ABK: 14 *ABF: 15 *ABF:Z0121*ABF:Z0121~
NM1*82*1* 16 * 17 *N***XX* 18 ~
PRV*PE*PXC*1223G0001X~
SBR*P*18**BLUE CROSS******CL~
AMT*D*57~
OI***Y***Y~
NM1*IL*1*DUCK*DONALD*****MI*5554421~
NM1*PR*2*BLUE CROSS*****PI*12345~
LX*1~
SV3*AD: 19 *18*** 20 *1**** 21 ~
TOO*JP* 22 * 23 ~
DTP*472*D8* 24 ~
DTP*452*D8* 25 ~
SVD*12345*12*AD:D0120**1~
DTP*573*D8*20180520~
CAS*PR*3*6~
LX*2~
SV3*AD:D0140*60**10**1****1:2~
DTP*472*D8*20180516~
SVD*12345*45*AD:D0140**1~
CAS*PR*2*10~
CAS*CO*45*5~
DTP*573*D8*20180520~
SE*47*000000001~
GE*1*8817636~
IEA*1*008817636~
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)
9. Claim Submitter ID (CLM02 also called Patient Account Number)
10. Treatment for orthodontic purposes
11. Remaining months
12. Tooth Status – Tooth Number
13. Tooth Status – Tooth Status Code
14. Principal Dental Diagnosis Code (HI01-2 where HI01-1 = ABK principle diagnosis code ICD-10)
15. Other Dental Diagnosis Code (HI02-2 where HI02-1 = ABF diagnosis code ICD-10)
16. Rendering Provider Last Name (NM103 where NM101 = 82 rendering and NM102 = 1 person)
17. Rendering Provider First Name (NM104 where NM101 = 82 rendering and NM102 = 1 person)
18. Rendering Provider ID (NM109 where NM101 = 82 rendering and NM108 = XX NPI)
19. Service Code (SV301-2 where SV301-1 = ADA code on line #1)
20. Prosthesis, Crown or Inlay code
21. Diagnosis Code Pointer(s) (SV311) line #1
22. Tooth Information Tooth Number
23. Tooth Information – Tooth Surface
24. Service Date (DTP03 where DTP01 = 472 service date and DTP03 = D8 CCYYMMDD format)
25. Appliance placement Date (DTP03 where DTP01 = 452 qualifier and DTP03 = D8 CCYYMMDD format) – it must be the same date as date of service
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