1. Title: Bill Spawning – HIPAA 837I and 837P Session: T-6-1100
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Title: Bill Spawning – HIPAA 837I and 837P
Session: T
A lot of you are coders, some are billers. But do you know how things go together to generate an electronic bill to a customer? This is about one of the standard HIPAA transactions, the 837I (from hospitals, with DRG billing). The 837P (professional services and other activities which bill using CPT codes) is very similar. But, in the interest of getting through this with some ability to understand, let’s just look at one standard.

2. Have a high level awareness
Objectives
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Have a high level awareness
of the HIPAA 837I standard transaction, to include being able to understand the concept of a data segment and a data element
of what will be available in the Central Billing Events Repository
of those financial elements that will be available in the Service Enterprise Resource Planning System (such as General Fund Enterprise Business System, or GFEBS)
Understand that billing is much more than coding (and that getting a bill in the mail is less than half the work of getting the money in the “bank”)
We are just getting our feet wet. It is like someone saying “let’s look at how the American Federal Income Tax System works.” Electronic billing works as well as can be expected with the convoluted requirements in Medicare and other payers.
Medicare is not an optimal healthcare program. It was not thoughtfully implemented as a whole concept. It is a program which has been expanded, transformed, and used in any manner possible in order to get Congressmen re-elected.
Insurance companies are not there to pay money on claims. They are there to pay CEOs and every-now-and-then, shareholders.
__________________
Next, the data collection systems in the MHS are not there to collect data for billing. Originally they were there for clinical support and decision making. Only this year did CPT quantities and modifiers become a permanent part of the M2 data repository in the form of the CAPER.

3. 2. All programs I’ve ever used had the same password requirements;
Pre-Test
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Raise your hand as I read the statements if the statement applies to you.
1. I’ve written computer programs such as “Grand Theft Auto” – it was a piece of cake and only took 2 million hours of detailed programming
2. All programs I’ve ever used had the same password requirements;
no special characters;
with special characters but only the !&()+*-?= ;
with special characters but
3. When doing my taxes, I have ALWAYS had all the information they wanted. It has ALWAYS been called the same thing on the W2 as on the tax form.
Right, and the other three programmers working with you tried to jump out of the window, but you were working in a basement so after a bit of therapy the guys are fine.
And every form wants “last name,” “first name,” “middle name” in that order;
--and everyone uses “military time”
--and when entering a date, the year comes before the day which comes before the month (which is always three letters)
3. And the MHS MEPRS system is a mirror image of the revenue code concept.

4. What You Need to Learn Prior to Falling Asleep
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The MHS does not collect some data needed for certain types of billing, and never will.
It is not cost effective.
The data would not be used by anyone else.
Get over it.
There is a lot of power in the HIPAA 837 electronic bill capability to do coordination of benefits, enter co-pay/ deductibles, and other civilian things.
We want billing and collections to be cost effective. We are NOT going to spend a gazillion dollars to collect surgical pre-authorizations, advance beneficiary notifications, condition codes…
A lot of power…BUT, the DoD has different LAWS, and needs to collect things civilians never dreamed of, such as interagency billing.
For years, the MHS has been trying to develop a “good” billing system. We have had the MSA module, TPOCS, and then the cosmetic billing program. None come close to meeting the billing standards of today. Staying with paper bills is not an option. The future of billing in the MHS is having central repositories of data, formatted in a manner close to the HIPAA transactions, which can be used to generate standard electronic bills. When you look at billable data in the future, you will see something like this.

5. Think of submitting your individual taxes [HIPAA 837I]
Standard HIPAA 837 I
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Think of submitting your individual taxes [HIPAA 837I]
Must be submitted with correct data in correct blanks
Taxpayer [Patient] name and demographic information
Earnings by W2 [rates for each CPT]
Deductions [co-pay, deductible]
What if you don’t have the information?
Which sections can you just skip?
Farm subsidies [type of currency]
How much does the Federal government [insurance company] owe you?
For paper or electronic, the correct data must be in the correct blanks. For instance, if you have 2 dependents, you need to enter “2,” not “2.00.” For your social security number you need numbers but no dashes.
You need to submit the forms in the correct order. You do not have the farm earnings with the deductions. You have the earnings all together, dividends, interest, etc., then deductions…
Sometimes you don’t know. For instance, what was the price you paid originally for a stock that just went bankrupt and you are taking a loss – can you say General Motors? Or does the amount you paid for a house include the realtor’s fees? The taxes, the PMI?
What sections can you skip? Buying or selling a house? Farm information?
BOTTOM LINE: Getting all the data together in the right place is like doing your taxes, but the second time (e.g., doing your daughter’s taxes) is easier.

6. HIPAA 837 I Transmission Control
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Communications Transport Protocol
Address of the entity sending the transmission and the address of the entity receiving the transmission
Example: Sent by central AF billing to a clearing house
Addresses are those the two parties agree upon
Matched as second to end of entire transmission by a “Communications Transport Trailer”
Let’s open up “Turbo-bill” and see what happens. Then next section of slides is the background stuff done without your seeing it to send the tax information to H&R block or Tax Slayer or TurboTax or Fidelity – whatever.
The Communications Transport Protocol is the beginning and the Communication Transport Trailer is the end of each transaction between you and the clearing house. This is your computer doing a “hand shake” with the internet service provider who will eventually move your tax electrons to the Federal government.
Clearing houses are like Internet service providers – they are excellent. They are like the US Postal Service or FedEx. You drop your data with them, and they get it to the other place. Otherwise, you would need to have couriers who take the data from you to the other end customer, such as Blue Cross/Blue Shield of Texas.
Addresses are the base address “1500 Pennsylvania Ave” and the drop location “suite 5C201” – only it is numbers used in the Internet to direct mail. Those the two parties agree upon, so the central AF billing may have 3 addresses from which they send bills:
-one address for medical/surgical insurance and
-another for pharmaceutical bills using the NCPDP and
-another for state workers’ compensation
Each of these types of bills may go to a different clearing house, because one clearing house is geared to medical/surgical insurance, another to pharmaceuticals, and the last is a Mom&Pop willing to hand massage workers’ comp bills.

7. HIPAA 837I Transmission Control
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Interchange Control Header
Provides the security information, such as a password or other identifying information
Date and time of interchange
Which repetition separator will be used
Interchange version number
Interchange control number
If an interchange acknowledgement is needed
If this is a test or production data
Matched as second to end of entire transmission by a “Interface Control Trailer”
Just inside the Communications Transport Protocol is the:
Interchange control header – this part of the transaction holds information such as
-- a password. With all the PHI out there, these transactions would not be good going to the wrong organization.
-- Version of the file layout. For instance, most of us remember going from 4010 to We will be going from ICD-9-CM to ICD-10-CM. It is in the Interchange Control header that we enter stuff so the end user can translate it correctly.
--What version is the tax preparation form (2010 or 2009)? If you were a year late sending in your taxes, you need to be able to say these are last year’s or this year’s. But with all the little updates, even knowing the month and date of the last update is good.
_______________________________________
Do not discuss (just here in case)
Repetition separators are not the same as a
Data element separator,
Component element separator and the
Segment terminator

8. Functional Group Header and at the end Trailer
Transmission Control
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Functional Group Header and at the end Trailer
Says what kind of transaction, such as 837I, 837P,
HIPAA Health Care Claim (Professional, Institutional, Dental)
HIPAA Health Care Claim Payment/Advice Transaction
HIPAA Benefit Enrollment and Maintenance
HIPAA Health Care Eligibility/Benefit Inquiry
HIPAA Health Care Eligibility/Benefit Response
HIPAA Health Care Claim Status Request
HIPAA Health Care Claim Status Notification
HIPAA Health Care Review Information
HIPAA NCPDP DO – Retail Pharmacy
Just inside the interface control header is the:
The functional group header. This is a divider between the various clumps of HIPAA data being sent. It is like saying here are all the earnings [837I] enclosed by a functional group header at the start and a functional group trailer at the end. The next functional group is all the deductions [837P] with a functional group header and trailer.
Each different set of transactions, such as the HIPAA 837P and the HIPAA 270 needs its own separate functional group header. So, if you are just sending institutional bills, there would be just one functional group header. If you are sending professional bills, AND institutional bills all the professional bills would be between one functional group header and trailer, and another functional group header and trailer. Same if you were doing HIPAA 276 claim status request and professional bills, it would be the same, two different functional group headers and trailers.
This header contains which transactions will be in the clump, the sender’s and receiver’s codes, the date and time, and the group control number (which is assigned and maintained by the sender), “x” saying the standard is an X12 standard, and the industry identifier code – in this case X _ _ _.
The functional group trailer just has the number of transaction sets included and the group control number from the header.

9. How Does The OUTSIDE Fit Together?
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How Does The OUTSIDE Fit Together?
Communications Transport Protocol
Interchange Control Header
Functional Group Header
Detail Segment – 837P
Functional Group Trailer
Functional Group Header
Detail Segment – 837I
Functional Group Trailer
A data SEGMENT is a record – in our case a complete bill.
A data ELEMENT is a field – in our case the biller’s name, or some other single field.
The data elements are the W2s and all the INT and DIV. Other data elements are the deductions. The data segment would me my tax return. Another data segment would be my daughter’s tax return. Then another data segment would be my husband’s tax return.
The communications transport protocol is your computer working with the internet service provider. The Interchange control is your name and SSAN on the top front page and on every additional page, and at the bottom of the last page.
This is the easy part. All the sender and receiver have to do is agree to addresses. This could also be the clearing house sending stuff to Aetna, the first detail segment would be 837P from 20 different doctor’s offices, each with its own set of claims. The next detail segment would be 837I from 15 hospitals. And the last detail could be a bunch of 270 eligibility requests.
Functional Group Header
Detail Segment – 276
Functional Group Trailer
Interchange Control Trailer
Communications Transport Trailer

10. HIPAA 837 - Health Care Claim Institutional
Detail Segments
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HIPAA Health Care Claim
Institutional
Professional
Dental
HIPAA Health Care Claim Payment/Advice Transaction
HIPAA Benefit Enrollment and Maintenance
HIPAA Health Care Eligibility/Benefit Inquiry
HIPAA Health Care Eligibility/Benefit Response
HIPAA Health Care Claim Status Request
HIPAA Health Care Claim Status Notification
HIPAA Health Care Review Information
HIPAA NCPDP DO – Retail Pharmacy
Today – we will look at the Detail Segments for the 837I. In general, the 837P (professional) is the same concept. It is like saying:
837I is an E-Z 1040 tax return, the 837P is the individual tax return, the NCPDP is a business tax return.
Similar transaction sets (functional groups, such as multiple 837I is a transaction set) can be sent together in a transmission
Each different functional group begins with a “group start segment” and ends with a “group end segment”
A functional group (or multiple functional groups) are prefaced by an interchange header and followed with an interchange trailer

11. Basic “Penmanship” Rules
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BASIC A_Z (upper case) …9 (Arabic #s)
! & () + * , - . / : ; ? = space
Extended a-z (lower case)
% [ ] _ { } \ < > # $
Data element separator, asterisk (*)
Sub-element separator, colon (:)
Segment terminator, tilde (~)
If transmitting in USA, usually extended set is fine – could be problems with international partners, particularly with foreign languages
For the rest of this briefing, all the lower case letters should be upper case, but are lower so you can read them more easily
A couple of things to point out – the “*” is how we separate data elements. There is a list of letters, numbers and characters which can be used. The basic set includes ONLY upper case letters. The extended set permits lower case letters. Unless you specifically agree not to use the extended set, you get to use the extended set.
For is in the extended set. So, if you only could use the basic set, it is really hard to send addresses.
Extended sets usually only become a problem with international partners.

12. Begin hierarchical transaction – BHT*0019*00*0123*20110309*0932*CH~
1000 Header
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HEADER
ST*837* *00510X223~
Begin hierarchical transaction – BHT*0019*00*0123* *0932*CH~
BHT – Beginning of hierarchical transaction
“0019” – Information Source, Subscriber, Dependent
“00” – original transmission (not sent to receiver before)
0123 – submitter’s batch control number
– date of transmission in CCYYMMDD
0932 – time in HHMM, so 9:32 am
“CH” – chargeable
Remember, we are looking at what an electronic transaction would look like. But, we are also looking at what would be in the billing events repository. This submitter information would be on an electronic bill, but it would not be in the BER because the CBER would not be actually generating the transaction – just providing the data to be able to submit a bill. So the CBER will not have the Communication transport protocol/trailer, the interchange group header/trailer, or the functional group header/trailer.
“ST” is the identifier which says “hey, we are starting a group of detail segments all about…”
“837” is the transaction set identifier
Then comes the control number – let’s make one up –
Then the implementation convention reference “005010x223” – which is Oct I transaction code number. This will be matched by an SE segment with the same set number.
--- “BHT” says “here comes transactions ‘00’ which means original transmission, a batch control number we make up, the date, time and “CH” meaning chargeable, that this is a fee-for-service claim with at least one chargeable line item. We would use “RP” for capitated encounters.
___________________________

13. NM1*41*2*AF Central Billing*****46*164.65.172.66~
1000A Submitter
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1000A Submitter
NM1*41*2*AF Central Billing*****46* ~
NM1 – a name element
“41” means submitter
“2” means non-person entity
Last name
**** means I’m not using a bunch of fields, in this case the first name, middle name, prefix, suffix
“46” means Electronic Transmitter Identification Number
“ ” – our address
PER*IC*Fred Darcy*TE* ~
PER – submitter EDI contact information
“IC” means Information Contact
Fred Darcy is the free-form name
“TE” means telephone and then the number
This would not be in the BER because the CBER would not be actually generating the transaction – just providing the data to be able to submit a bill.
Submitter - who actually is sending the Detail Segments – the entity responsible for the creation and formatting of this transaction
“NM1” is a name element; “41” means this is a submitter name; “2” is non-person; then name of company; then some blanks; then “46” at this place means “the Electronic transmitter identification is coming” and the “ ” is the ETInumber I made up.
“PER” is person info coming; IC is information contact; TE is telephone
- EM – electronic mail; FX – facsimile; TE - telephone;
Every device connected to the public Internet is assigned a unique number known as an Internet Protocol (IP) address. IP addresses consist of four numbers separated by periods (also called a 'dotted-quad') and look something like )
____________________
A couple of things to point out – the “*” is how we separate data elements. There is a list of letters, numbers and characters which can be used. The basic set includes ONLY upper case letters. The extended set permits lower case letters. Unless you specifically agree not to use the extended set, you get to use the extended set. For is in the extended set. So, if you only could use the basic set, it is really hard to send addresses.
BASIC – Upper Case, 0..9, ! & ()+*,-./:;?= space
Extended – a-z % [ ] _ { } \ < > # $
Extended sets usually only become a problem with international partners

14. NM1*40*2*AF Clearing House*****46*127.0.0.1~
1000B Receiver
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1000B Receiver
NM1*40*2*AF Clearing House*****46* ~
NM1 – a name element
“40” means RECEIVER
“2” means non-person entity
Last name
**** means I’m not using a bunch of fields, in this case the first name, middle name, prefix, suffix
“46” means Electronic Transmitter Identification Number
“ ” – address for where we are sending the package
Receiver – notice the “40” after the NM1 segment type name. 40 means “receiver” name. There are lots of NM1 but the next number tells what kind of name. This is strictly a “who is physically sending the transmission”
Looks like the other NM1 elements – the second variable tells “whose” name
_____________________
A couple of things to point out – the “*” is how we separate data elements. There is a list of letters, numbers and characters which can be used. The basic set includes ONLY upper case letters. The extended set permits lower case letters. Unless you specifically agree not to use the extended set, you get to use the extended set. For is in the extended set. So, if you only could use the basic set, it is really hard to send addresses.
BASIC – Upper Case, 0..9, ! & ()+*,-./:;?= space
Extended – a-z % [ ] _ { } \ < > # $
Extended sets usually only become a problem with international partners

15. 2000A Billing – Hierarchical and Billing Provider
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HL – Billing Provider Hierarchical Level
HL*1**20*1~ notice this is the 1st “HL”
2000A Billing Provider Specialty
PRV*BI*PXC*261QM1100X~
PRV – Billing Provider Specialty Information segment
“BI” means billing
“PXC” means health care provider taxonomy code
the HIPAA Health Care Provider Taxonomy
Segment details – the letters at the beginning are the code names for the segment, such as HL for Hierarchial level or BI for billing or NM for name. The “20” is defined as “information source”
Loop 2000A – PRV*BI*PXC*261QM1100X (PRV billing provider specialty segment; BI – billing; PXC – health care provider taxonomy code; the code for MHS outpatient)

16. 2000A Foreign Currency Information
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Situational
This will not be in the Central Billing Events Repository and probably will not be used by the billing organization
Used to specify the currency (e.g., Euro, pounds UK, dollars Canadian) used in the transaction
CUR*85*CAD~
CUR means Currency
“85” means billing provider
“CAD” means Canada (CA is Canada, D is dollar)
Situational – use if you need to, otherwise, do not include
Notice the “85.” We have used that before for the billing provider.
Currency Code is NOT the Country Code.
Would not expect to use this. Would be if we were billing another country. Seeing as these are USA HIPAA standard electronic transmissions, they are not an international concept. Shoot, CPT is not an international concept.
- Usually based on the 2 letter country code and the name of the currency, e.g.,
AFN Afghanistan, Afghanis ALL Albania, Leke
DZD Algeria, Dinars USD America (United States of America), Dollars
USD American Samoa, United States Dollars
USD American Virgin Islands, United States Dollars
EUR Andorra, Euro AOA Angola, Kwanza
XCD Anguilla, East Caribbean Dollars
XCD Antigua and Barbuda, East Caribbean Dollars
ARS Argentina, Pesos
AMD Armenia, Drams
AWG Aruba, Guilders (also called Florins)
AUD Australia, Dollars
EUR Austria, Euro
AZN Azerbaijan, New Manats
EUR Azores, Euro
BSD Bahamas, Dollars BHD Bahrain, Dinars
EUR Baleares (Balearic Islands),
Euro BDT Bangladesh, Taka BBD Barbados, Dollars XCD Barbuda and Antigua, East Caribbean Dollars BYR Belarus, Rubles EUR Belgium, Euro BZD Belize, Dollars XOF Benin, Communauté Financière Africaine Francs (BCEAO) BMD Bermuda, Dollars BTN Bhutan, Ngultrum INR Bhutan, India Rupees BOB Bolivia, Bolivianos

17. 2010AA Billing Provider Name
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NMI*85*2*56th Medical Group Luke*****XX* ~
NM1 – segment name
“85” means billing
“2” means non-person entity
56th Medical Group Luke – last name
***** not used first name, middle name, prefix, suffix
“XX” National Provider Identifier
– NPI for Luke
N3*7219 North Litchfield Road~
N4*Luke AFB*AZ*85309~
I hope this is beginning to look familiar – the NM1 segments are all over.
Luke AFB AZ 85309
7219 North Litchfield Road Luke AFB, AZ 85309

18. 2010AA Billing Provider Name
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REF*EI*as if I can even guess~
REF – billing provider tax ID
“EI” – employer tax number
Spot for the number
PER*IC*Dane I-forget* *ex*56~
PER – billing provider contact info segment, situational, if different from submitting info
“IC” means information contact
I hope this is beginning to look familiar – the NM1 segments are all over.
Luke AFB AZ 85309
7219 North Litchfield Road Luke AFB, AZ 85309

19. 2010AA Billing, Pay-to Address
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NM1*87*2~
“87” means “Pay-to provider” *
N3*5109 Leesburg Parkway*Suite 701*~
N3 is the address segment detail code *
Address line
Second address line
N4*Falls Church*VA*22041~
N4 is a city/state/zip segment detail
City
State
Zip
Pay-to address could be a PO Box or a lock box or a street address.
As you can see, just like for coding when you see you think diabetes, when you send electronic bills, the NM1 is a name of some kind, the N3 is an address. When you work with these, you can start being able to see unusual things like for coders you don’t expect to see technicians coding

20. notice this is the 2nd “HL” in the ST segment *
2000B Subscriber Loops
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2000B Subscriber HL Loop
HL*2*1*22*0~
notice this is the 2nd “HL” in the ST segment *
the HL loop to which this one is subordinate *
22 means “subscriber” *
0 means the subscriber is the patient and this is the only claim
Now the Subscriber information Loops
The 2000B subscriber information is sent once. The subscriber could be the patient or it could be the patient’s spouse or parent.
The subscriber loop has two parts, the subscriber data in 2010BA and the payer data in 2010BB.

21. Central Billing Events Repository Data Start HERE
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Central Billing Events Repository Data Start HERE

22. NM1*IL*1*Doe*John*T**Jr*MI*123456~ N3*123 Main Street~
2000B Subscriber Loops
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2010BA Subscriber
SBR*P*18*GRP ******CI~
2010BA Subscriber name
NM1*IL*1*Doe*John*T**Jr*MI*123456~
N3*123 Main Street~
N4*Phoenix*AZ*85309~
DMG*D8* *M~
REF*SY* ~ (subscriber 2nd ID {SY is “SSAN is next”}, situational, not required)
Now the Subscriber information Loops
The 2000B subscriber information is sent once. The subscriber could be the patient or it could be the patient’s spouse or parent.
The subscriber loop has two parts, the subscriber data in 2010BA and the payer data in 2010BB.
SBR is the subscriber information segment
P is primary payer (which is usual; there could be a secondary but that is highly unusual)
18 means the patient is the subscriber (the person whose name is on the policy as owning the policy)
GRP is an example of a policy or group number
If there was not a group number, after the asterisk would be the free-form name of the plan
CI the claim filing indicator code is “Commercial Insurance” – other types would be Blue Cross/Blue Shield
---Then the usual subscriber name NM1, N3, N4.
NM1 – IL means “insured or subscriber”; MI is the member identification number which follows – 12345
----
DMG is the subscriber demographic information segment
-----John Doe was born 15 Aug 1968 (the D8 is for the birthday), he is Male
REF is the subscriber secondary identification, in this case SY is social security number
REF is the property and casualty claim number which will never be in the CBER (Y4 is the agency claim number)

23. 2000B Subscriber Payer Loops
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2010BB Payer Name
NM1*PR*2*Health Inc Insurance*****PI*1234~
PR is payer
PI is payer identification
N3*123 Main Street~
N4*Phoenix*AZ*85309~
REF*FY*1234~ (Reference – Payer 2nd ID, situational, not required)
FY means “claim office number”
REF*G2*1234~ (Reference – Billing Provider 2nd ID, situational, not required)
G2 means provider commercial number
Payer name and mailing address –
In the NM1, the “PR” means payer
In REF, the FY means “claim office number” and the “G2” means
“provider commercial number

24. 2000C Patient Loops 2000C Patient HL Loop HL*3*2*23*0~ PAT*01~
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2000C Patient HL Loop
HL*3*2*23*0~
PAT*01~
01 is a spouse
NM1*QC*1*Doe*Sally*J~
QC is that this person is the patient
N3*123 Main Street
N4*Phoenix*AZ*85309
DMG*D8* *F~
In the patient demographic segment, the date is the birth date
F means female
Now the Patient information Loops
This is not logical with my having “18” for self on the subscriber information. If that had been blank, then this would make sense as in this case the patient is not the policy holder. This loop would not be here if the policy holder was the patient.
This hierarchical segment is dependent on the subscriber in loop 2000B. There are no hierarchical levels dependent on this one. So, this is HL number 3, it is dependent on HL 2 and in this case, the “23” means the patient is a dependent of the subscriber. The 0 at the end says – no subordinates to this.
In the PAT patient information segment, the “01” means spouse, a “19” would be a child and a “53” is a life partner.
In the NM1 patient name segment, the “QC” means this person is the patient, and the “1” means it is a person.
In the DMG patient demographic information segment, the D8 says “here comes the patient’s birthday” which is 7 Jun 1970, and the person is a female.

25. 2310C Other Operating Physician 2310D Rendering Provider
2300 Claim
Track x – xxx day –
2300 Claim
Diagnoses!
2310A Attending Provider
2310B Operating Physician
2310C Other Operating Physician
2310D Rendering Provider
2310E Service Facility Location
Other Subscriber Information
2330A Other Subscriber Name
This is what the coders have been waiting for - the claim stuff. Up to now it has been demographic stuff, insurance company stuff, and where to send the money.
Remember, this is the 837 Institutional, so it will be a lab test or a radiology exam, or the institutional component of an ER or SDS.

26. CLM*0009OUT201103010111*500***11:A:1*Y*A*Y*I~
2300 Claim Information
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CLM*0009OUT *500***11:A:1*Y*A*Y*I~
0009OUT (DMIS ID 0009; outpatient;1 Mar 2010; 111th claim) is an example of a Claim Submitter’s identification of this claim, it is the patient control number, the number used to track this claim through the biller’s system
500 is an example of the total amount of all submitted charges of service segments for this claim; this number must match the sum of all the SV2 segments
This is the start of the claim segment.
The number is red is the number which will identify the encounter throughout the billing process. In the example I started with Luke’s DMIS ID, then that it was outpatient, then the date and a series number. I don’t remember how these numbers are assigned in TPOCS or in the MSA module. In the CBER it will probably be the appointment IEN or inpatient hospital number, or whatever the UBO team decides for each type of encounter. Lab may use accession number? Who knows.
“The maximum number of characters to be supported for this field is 20. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system.”

27. CLM*0009OUT201103010111*500***11:A:1*Y*A*Y*I~
2300 Claim Information
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CLM*0009OUT *500***11:A:1*Y*A*Y*I~
11 is an example of a Facility Code Value (think Place of Service, in this case 11 is the doctor’s office)
A is the facility code qualifier for the Uniform Billing Claim Form Bill Type
1 is the frequency of the claim (the only bill for the encounter, it covers the entire encounter)
“Y” is there for entertainment value and to confuse people, the guidance says “not used” but the example shows it
“A” the provider accepts assignment from the payer
“Y” means the patient has assigned benefits to the provider
“I” means federal law permits release of diagnosis info
Notice the “11:A:1” that is CLM05-1, -2 and -3
CLM is the next “A” for the provider accepting assignment from the payer. It is not if the patient has or has not assigned benefits to the provider
CLM is if the patient has assigned benefits to be paid directly to the provider, in this example the response is “Y” for yes
CLM is Release of Information, “I” means “informed consent to release medical information for conditions or diagnoses regulated by Federal statutes (the “I” is used because we do not collect if the patient has signed, and due to HIPAA business use we are authorized to release this information to the insurer)

28. DTP – Date or Time or Period DTP*096*TM*1130~
2300 Claim Information
DTP – Date or Time or Period
DTP*096*TM*1130~
DTP – Date or time or period
“096” means “discharge”
“TM” means the time will be expressed in Format HHMM
1130 is an example of 11:30 am
DTP*434*RD8* ~
“434” means “statement”
“RD8” means time will be CCYYMMDD-CCYYMMDD
means 1 Mar 11-5 Mar 11

29. DTP – Date or Time or Period DTP*435*DT*201103011242~
2300 Claim Information
DTP – Date or Time or Period
DTP*435*DT* ~
DTP – Date or time or period
“435” means “admission”
“DT” means the time will be expressed in Format CCYYMDDHHMM
is an example of 1 Mar :42 pm

30. CL1 – Institutional Claim Code CL1*1*7*30~
2300 Claim Information
Track x – xxx day –
CL1 – Institutional Claim Code
CL1*1*7*30~
CL1 – institutional claim code
1 – an admission type code (1 = emergent; 2 = urgent; 3 = elective; 4 = newborn)
7 – an admission source code (7 = ER; 2 = clinic; 1=nonhealthcare facility point of origin)
30 – a patient status code (see list at end of briefing)
REF*LU*MD~
REF is a Reference identification qualifier
LU is location number for an auto accident state or province code
REF*EA*4444MN~
EA is a medical record identification number
Type of Admission or Service For inpatient hospital services, enter the one (1)-digit code to indicate type of service. Use one of the following codes (see OAR for definitions): Emergent ; 2 – Urgent ; 3 – Elective ; 4 - Newborn
____
Source of Admission
1 = Nonhealthcare Facility Point of origin
2 = Clinic
4 = Transfer from a Hospital (Different Facility)
5 = Transfer from a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF)
6 = Transfer from Another Healthcare Facility
7 = Emergency Room
8 = Court/Law Enforcement
9 = Information Not Available
B = Transfer from another Home Health Agency
C = Readmission to same Home Health Agency
D = Transfer from one distinct unit of the hospital to another distinct unit of the same hospital resulting in a separate claim to the payer
E = Transfer from Ambulatory Surgery Center
F = Transfer from Hospice and is under a hospice plan of care or enrolled in a hospice program
NEWBORNS
5 = Born inside this hospital
6 = Born outside of this hospital

31. HI – Diagnosis information HI*ABK:T8731*Y~
2300 Claim Information
Track x – xxx day –
HI – Diagnosis information
HI*ABK:T8731*Y~
“ABK” is ICD-10-CM principal diagnosis
“BK” is ICD-9-CM principal diagnosis
T8731 is the diagnosis for neuroma of amputation stump, right upper extremity
Y” is “yes” in the Present on Admission Indicator
HI*ABJ:T8741*Y~
“ABJ” is ICD-10-CM admitting diagnosis
“BJ” is ICD-9-CM admitting diagnosis
HI*APR:R110~
“APR” is ICD-10-CM reason for outpatient visit
The decimal point for ICD codes is implied and not transmitted

32. HI*ABN*T560X1*Y*ABN*W3301*Y~
2300 Claim Information
Track x – xxx day – HI
HI*ABN*T560X1*Y*ABN*W3301*Y~
“ABN” is ICD-10-CM external cause of injury
T560X1 is Toxic effect of lead and its compounds, accidental
“Y” is yes for the Present on Admission Indicator
“ABN” is for the additional ICD-10-CM external cause of injury
W3301 is Accidental discharge of shotgun
“Y” is yes for the POA indicator
HI*DR:123~
“DR” is diagnosis related group
HI*ABF:J151*Y~
“ABF” is ICD-10-CM other diagnosis
Looks like there can be up to 10 external causes of injury – a bit more than I have ever seen…
J151 is pneumonia due to Pseudomonas

33. “BBR” is the ICD-10-PCS principal procedure
2300 Claim Information
Track x – xxx day –
HI*BBR:0B110F4:D8: ~
“BBR” is the ICD-10-PCS principal procedure
0B110F4 is Tracheostomy device inserted to trachea, open, to outside (cutaneous)
D8 is that a date in the CCYYMMDD format follows
HI*BBQ:02130KF:D8: *BBQ:4A023N8:D8: ~
BBQ is other ICD-10-PCS procedures
02130KF is Bypass of 4 or more coronary artery sites via open procedure using nonautologous tissue substitute to the abdominal artery
4A023N8 is measurement of the cardiac system via percutaneous approach of sampling and pressure, bilaterally

34. 2300 Claim Information NOT in CBER
Segments that are available but would not be in the Central Billing Events Repository
PWK – Claim supplemental information (paperwork)
AMT – Patient estimated amount due
REF – Service authorization exception code (for example if it was an emergency which is why there was no pre-authorization
REF – Referral number (for example a payer provided a referral number for so many physical therapy encounters)

35. 2300 Claim Information NOT in CBER
Track x – xxx day –
Segments that are available but would not be in the Central Billing Events Repository
REF – Prior authorization (for example for major surgery)
REF – Investigational device exemption number
REF – Demonstration Project Identifier
REF – Peer Review Organization Approval Number
NTE – Claim note or a Billing Note (used when the provider wants to indicate there is additional information needed to substantiate medical treatment)

36. 2300 Claim Information NOT in CBER
Track x – xxx day –
Segments that are available but would not be in the Central Billing Events Repository
HI*BI – Occurrence span information
HI*BH – Occurrence information
HI*BE – Value information
HI*BG – Condition information HI*TC – Treatment code condition (used for home health agencies)
Value codes would be things like “02 hospital has no semi-private rooms”
Condition codes would be things like
-02 Condition is Employment Related
Patient alleges that the medical condition causing this episode of care is due to environment/events resulting from the patient’s employment.
-03 Patient Covered by Insurance Not Reflected Here
Indicates that patient/patient representative has stated that coverage may exist beyond that reflected on this bill.
-04 Information Only Bill
Indicates bill is submitted for informational purposes only. Examples would include a bill submitted as a utilization report, or a bill for a beneficiary who is enrolled in a risk-based managed care plan and the hospital expects to receive payment from the plan.
-05 Lien Has Been Filed
The provider has filed legal claim for recovery of funds potentially due to a patient as a result of legal action initiated by or on behalf of a patient.

37. 2310A Attending Provider Name
Track x – xxx day –
NM1*71*Jones*John****XX* ~
“71” in this position is “attending physician”
XX is “the NPI is next”
PRV*AT*PXC*208D00000X~
PRV is attending provider specialty segment
“AT” is attending
“PXC” is “the HIPAA Health Care Provider Taxonomy is next”

38. 2310 Additional Providers
2310B NM1*72*1*Meyers*Jane*****XX* ~
“72” is operating physician
XX is “the NPI is next”
Is only used if there is a surgical procedure on the claim
2310C NM1*ZZ*1*Doe*John*A***XX* ~
“ZZ” is mutually defined to indicate “other operating physician”
Usually not needed, usually only one surgeon
2310D NM1*82*1*Doe*Jane*C***XX* ~
“82” is rendering provider

39. 2310E Service Facility
2310E
NM1*77*2*Bolling Clinic*****XX* ~
“77” is Service Location (other than the doctor’s office)
“2” is non-person entity
N3*1300 Angell Street~
N4*Bolling AFB*DC*20032~

40. 2310F Referring Provider NOT in CBER
Track x – xxx day –
NOT in the Central Billing Event Repository, but could be for civilian sector
NM1*DN*1*Welby*Marcus*W**Jr*XX* ~
“DN” is referring provider
“1” is a person
XX is “the NPI is next”
Done with provider information, on to other subscriber information

41. 2320 Other Subscriber Information
Track x – xxx day –
SBR*S*01*GR00786******13~
SBR is a subscriber information segment
“S” is secondary coverage
“01” is that the spouse is the one with the coverage
“GR00786” is an example of a insured group or policy number
“13” is a claim filing indicator code representing “point of service” – eventually this will go away when HIPAA National Plan IDs are fielded
This is ONLY used if the person has a secondary coverage – which is unusual.

42. Claim Adjustments, Repricing…NOT in CBER
Claim adjustments, repricing, coordination of benefits (COB) payer paid amount, remaining patient liability, adjudication information, check remittance date, and other post bill generation activities will not appear in the Central Billing Events Repository (CBER).
These activities will be done by the Service billing/collections activity.
Collections, adjustments, repricing, co-pays, deductibles etc., will be tracked in the Service Enterprise Resource Planning (ERP) system.

43. NM1*PR*2*Another Insurance Group*****PI*1123344~ “PR” is payer
2330B Other Payer Name
Track x – xxx day –
NM1*PR*2*Another Insurance Group*****PI* ~
“PR” is payer
“2” is non-person entity
“PI” is payer identification
N3*100 N Broadway*Suite 10B~
N4*New York City*NY*10008~
Other payer information such as provider name, operating physician and service facility will not be in the CBER as these data elements are not collected and stored centrally

44. 2400 Loops
2400 Service Line
2420C Rendering Provider
2420D Referring Provider

45. LX is a service line number segment SV2*0300*HC:81099*73.42*UN*1~
2400 Services Provided
Track x – xxx day –
LX*1~
LX is a service line number segment
SV2*0300*HC:81099*73.42*UN*1~
SV2 is a institutional service line segment
0300 is an example of a revenue code for the laboratory
“HC” is a HCPCS code (includes CPT)
“81099” is a HCPCS lab unspecified code
“73.42” is the price billed
“UN” is “unit”
“1” is a quantity
LX begins with 1 and is incremented by one for each additional service line of a claim
Revenue code 300 is laboratory, general
After the you could have a :modifier such as HC:81099:QW
As well as the free text description (up to 80 characters)
Charge include base charge and applicable tax amounts, “0” is acceptable value;
Only DA for days and UN for unit are acceptable “unit or basis for measurement code”
Quantity can be up to 8 characters, a decimal can be used

46. 2400
DTP*472*D8* ~
DTP is date or time or period segment
“472” is a service
D8 indicates date format will be CCYYMMDD
is 2 Mar 11

47. Transaction Set Trailer NOT in CBER
Would not be in the CBER, this is done when the HIPAA transaction is sent to the clearing house
SE*1230* ~
SE is a transaction set trailer
1230 is the number of segments included in the transaction including ST and SE segments
is the same transaction set control number in the ST02 that began the transaction

48. Transaction Set Trailer NOT in CBER
Again, this would not be in the Central Billing Events Repository – it is something used by the billing organization to make sure the “box of bills” are sent to the correct clearing house (e.g., FedEx)
Then the clearing house re-directs the data to the payer

49. Coordination of Benefits
Business Usage
Track x – xxx day –
Coordination of Benefits
The CBER will list all the known possible payers based on what is in the Other Health Insurance file and the PATCAT (patient category, such as Coast Guard)
Billing entity needs to determine when there is a primary and secondary payer, will the bill go to
The first payer who enters what he paid, and the first payer send it directly to the second payer
The first payer send back his remittance, then you need to enter the 1st payer’s input and send to the second payer
The first payer who enters what he paid, and the first payer send it directly to the second payer (for instance, send to automobile insurance company who enters payment information and sends to medical insurance company)
The first payer send back his remittance, then you need to enter the 1st payer’s input and send to the second payer
(for instance, send to medical insurance company, then when it comes back, send it off to the Coast Guard)

50. Capturing The Data Encounter Data Patient Registration
Track x – xxx day –
Encounter Data
Patient Registration
At the MTF entering the patient initially in the CHCS registration module will “bring down” the patient data (e.g., birthday, gender, EDI-PN) from DEERs
Appointment Module
To make an appointment there must be a “file and table build” where the provider data (e.g., NPI and HIPAA taxonomy) are stored
Also will collect the date/time of the scheduled appointment and the DMIS ID
Inpatient Module
Assigns the medical record number, links the provider file information
Let’s look at what is currently collected – if we don’t collect something that is needed, we need to
Figure out how to derive it from what we have
Figure out how to do the process without it
Figure out how to collect it or collect something that could be used as a surrogate
There are different ???

51. Ambulatory Data Module
Capturing The Data
Track x – xxx day –
Encounter Data
Ambulatory Data Module
Where outpatient coded data are collected
Can come from AHLTA or be entered directly in ADM
Coding Compliance Editor
Where all inpatient coded data are entered
Patient Demographics
DEERS
Insurance Information
DEERS Standard Insurance Tables/Other Health Insurance
PATCAT – patient categories
Let’s look at what is currently collected – if we don’t collect something that is needed, we need to
Figure out how to derive it from what we have
Figure out how to do the process without it
Figure out how to collect it or collect something that could be used as a surrogate
There are different ???

52. Insurance and Interagency
Capturing The Data
Track x – xxx day –
Rates
Insurance and Interagency
Inpatient – Diagnosis related group based
Place of service 11 – outpatient doctor’s office professional
Place of service 23 – hospital emergency room institutional
Place of service 22 – outpatient hospital (same day surgery institutional)
Ambulance
Laboratory
Diagnostic Imaging
Pharmaceutical
Dental
Anesthesia
To Patient
Cosmetic
Family member inpatient rate
Let’s look at what is currently collected – if we don’t collect something that is needed, we need to
Figure out how to derive it from what we have
Figure out how to do the process without it
Figure out how to collect it or collect something that could be used as a surrogate
There are different

53. APVs, Observation, Emergency Department
MHS Limitations
Track x – xxx day –
Do not collect a separate institutional encounter for outpatient services done somewhere other than the doctor’s office
APVs, Observation, Emergency Department
Do not collect anesthesia minutes of service
Do not collect the venipunctures (collection of specimen in the laboratory)
Do not collect ambulance mileage

54. MHS Limitations
Do not have standardized dental encounter data information (each Service has own collection system which does not feed data centrally)
Not all laboratory services are collected in CHCS – CoPath
Do not collect the exact pharmaceutical dispensed
Coding
Do not collect if it is workers’ compensation and many other issues (condition, occurrence, and value codes)

55. MHS Limitations
Poor understanding of assignment of PATCATs – BASED ON ELIGIBILITY OF THAT CARE ON THAT DATE
No “incident to” concept – encounters are collected based on the individual who did the service, not in the name of the physician
Otherwise, physician assistants and nurse practitioners could not treat new problems – they could only see “follow-up” patients and do services already ordered by physicians
Possible suboptimal pursuit of Other Health Insurance
In some cases, limited staffing to do accounts receivable

56. MHS Limitations
Need to receive daily CHCS Provider File update – no central repository with every provider NPI type I
Do not have patient level cost accounting
Do not have standard Revenue Codes
MEPRS is non-standard and inconsistent (e.g., code where work is done, but physical therapy is done on the wards)
Cannot do DRG cost outliers

57. Have a high level awareness
Objectives
Track x – xxx day –
Have a high level awareness
of the HIPAA 837I standard transaction, to include being able to understand the concept of a data segment and a data element
of what will be available in the Central Billing Events Repository
of those financial elements which will be available in the Service Enterprise Resource Planning System (such as General Fund Enterprise Business System, or GFEBS)
Understand that billing is much more than coding (and that getting a bill in the mail is less than half the work of getting the money in the “bank”)

58. Is it time to wake up now? Yes.
Questions
Track x – xxx day –
Is it time to wake up now? Yes.
Where am I? The same place you were when you fell asleep.
Is this Kansas? Don’t you wish.

59. Patient Status Examples:
Track x – xxx day –
Required. (For all Part A inpatient, SNF, hospice, home health agency (HHA) and outpatient hospital services.) This code indicates the patient’s status as of the “Through” date of the billing period (FL 6).
Code/Structure
01 Discharged to home or self care (routine discharge)
02 Discharged/transferred to a short-term general hospital for inpatient care.
03 Discharged/transferred to SNF with Medicare certification in anticipation of covered skilled care (effective 2/23/05). See Code 61 below.
04 Discharged/transferred to an Intermediate Care Facility (ICF)
05 Discharged/transferred to another type of institution not defined elsewhere in this code list (effective 2/23/05). Usage Note: Cancer hospitals excluded from Medicare PPS and children’s hospitals are examples of such other types of institutions.
Definition Change Effective 4/1/08: Discharged/Transferred to a Designated Cancer Center or Children’s Hospital.
06 Discharged/transferred to home under care of organized home health service organization in anticipation of covered skills care (effective 2/23/05).
07 Left against medical advice or discontinued care
08 Reserved for National Assignment
*09 Admitted as an inpatient to this hospital
From a CMS Manual System update (transmittal 1718, dated 24 Apr 2009, CR 6385)
Pub Medicare Claims Processing

60. Patient Status Examples:
Track x – xxx day –
10-19 Reserved for National Assignment
20 Expired (or did not recover - Religious Non Medical Health Care Patient)
21 Discharged/transferred to Court/Law Enforcement
22-29 Reserved for National Assignment
30 Still patient or expected to return for outpatient services
31-39 Reserved for National Assignment
40 Expired at home (Hospice claims only)
41 Expired in a medical facility, such as a hospital, SNF, ICF or freestanding hospice (Hospice claims only)
42 Expired - place unknown (Hospice claims only)
43 Discharged/transferred to a federal health care facility. (effective 10/1/03)
Usage note: Discharges and transfers to a government operated health care facility such as a Department of Defense hospital, a Veteran’s Administration (VA) hospital or VA hospital or a VA nursing facility. To be used whenever the destination at discharge is a federal health care facility, whether the patient lives there or not.
44-49 Reserved for national assignment
50 Discharged/transferred to Hospice - home
51 Discharged/transferred to Hospice - medical facility
52-60 Reserved for national assignment

61. Patient Status Examples:
Track x – xxx day –
61 Discharged/transferred within this institution to a hospital based Medicare approved swing bed.
62 Discharged/transferred to an inpatient rehabilitation facility including distinct part units of a hospital
63 Discharged/transferred to long term care hospitals
64 Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare
65 Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital.
66 Discharged/transferred to a Critical Access Hospital (CAH). (effective 1/1/06)
67-69 Reserved for national assignment
70 Discharge/transfer to another type of health care institution not defined elsewhere in the code list. (effective 4/1/08)
71-99 Reserved for national assignment
*In situations where a patient is admitted before midnight of the third day following the day of an outpatient diagnostic service or service related to the reason for the admission, the outpatient services are considered inpatient. Therefore, code 09 would apply only to services that began longer than 3 days earlier or were unrelated to the reason for admission, such as observation following outpatient surgery, which results in admission