Example: Anesthesia for Laser Eye Surgery

Example: Anesthesia for Laser Eye Surgery X12 Admin Tue, 05/12/2026 - 12:26 BUSINESS SCENARIO: Patient is an adult female receiving anesthesia for laser eye surgery. This is the bill for the anesthesia service only. Subscriber is the Patient. The Payer is Medicare B and the encounter is billed directly to Medicare B. DATA ELEMENTS: Listed below are the data elements that are to be included in the claim (e.g. name of insurance company, identification numbers, subscriber name, address and demographic details, billing and other provider details and identifiers, service details and codes, etc.). This gives all the information that needs to be included in the claim. Example: SUBMITTER: SUBMITTER NAME: PROVIDER MEDICAL GROUP SUBMITTER ID: N305 SUBMITTER CONTACT NAME: NINA SUBMITTER CONTACT NUMBER: 6155551212 ext. 911 RECEIVER: RECEIVER NAME: MEDICARE B RECEIVER RECEIVER ID: 05440 BILLING PROVIDER: BILLING PROVIDER TAXONOMY: N/A BILLING PROVIDER NAME: PROVIDER MEDICAL GROUP BILLING PROVIDER NPI: 2366554859 BILLING PROVIDER ADDRESS: 123 MAIN STREET, KANSAS CITY, MO, 64105-1909 BILLING PROVIDER TIN: 756473826 SUBSCRIBER: SUBSCRIBER NAME: MARGARET JONES SUBSCRIBER ID: 9YJ9TE1GP41 SUBSCRIBER ADDRESS: 123 RAINBOW ROAD, KANSAS CITY, MO, 64105 SUBSCRIBER DOB: 03/03/1954 SUBSCRIBER SEX: F DESTINATION PAYER: PAYER NAME: MEDICARE B PAYER SECONDARY IDENTIFICATION: 05440 PATIENT: Same as Primary Subscriber CLAIM INFORMATION: ORIGINAL CLAIM CREATION DATE: 01/12/2025 PROVIDER ASSIGNED CLAIM IDENTIFIER: 153829140764352987432 TOTAL CHARGES: $827.00 PLACE OF SERVICE CODE: 22 CLAIM FREQUENCY CODE: 1 DIAGNOSIS CODES: H25.11, H25.811 ANESTHESIA RELATED PROCEDURE CODE: 66984 RENDERING PROVIDER: RENDERING PROVIDER NAME: JACOB E. TOWNSEND RENDERING PROVIDER NPI: 5678912345 SERVICE LOCATION: SERVICE LOCATION NAME: PROVIDER OP HOSPITAL SERVICE LOCATION ADDRESS: 345 MAIN DRIVE, KANSAS CITY, MO, 64105-1909 SERVICE LOCATION NPI: 43294867 SERVICE LINE NUMBER: PROCEDURE CODE: 00142 PROCEDURE MODIFIERS: QK, QS, P1 LINE ITEM CHARGE AMOUNT: $827 UNIT OR BASIS FOR MEASURMENT CODE: MJ SERVICE UNIT COUNT: 61 EMERGENCY INDICATOR: N EPSDT INDICATOR: N FAMILY PLANNING: N DATE OF SERVICE: 01/12/2025 Transmission Explanation HEADER ST8370001008060X323~ ST TRANSACTION SET HEADER BHT00190012345202501121549CH~ BHT BEGINNING OF HIERARCHICAL TRANSACTION 1000A SUBMITTER NAME NM1412PROVIDER MEDICAL GROUP**46N305~ NM1 SUBMITTER NAME PERICNINATE6155551212EX911~ PER SUBMITTER EDI CONTACT INFORMATION 1000B RECEIVER NM1402MEDICARE B RECEIVER4605440~ NM1 RECEIVER NAME 2000A BILLING PROVIDER HL1201~ HL - BILLING PROVIDER HIERARCHICAL LEVEL 2010AA BILLING PROVIDER NAME NM1852PROVIDER MEDICAL GROUP**XX2366554859~ NM1 BILLING PROVIDER NAME N3123 Main Street~ N3 BILLING PROVIDER ADDRESS N4KANSAS CITYMO641051909~ N4 BILLING PROVIDER LOCATION REFEI756473826~ REF BILLING PROVIDER TAX IDENTIFICATION 2000B SUBSCRIBER HL LOOP HL21220~ HL - SUBSCRIBER HIERARCHICAL LEVEL SBRP18**MB~ SBR SUBSCRIBER INFORMATION 2010BA SUBSCRIBER NAME LOOP NM1IL1JONESMARGARETMI9YJ9TE1GP41~ NM1 SUBSCRIBER NAME N3123 RAINBOW ROAD~ N3 SUBSCRIBER ADDRESS N4KANSAS CITYMO64105~ N4 SUBSCRIBER CITY, STATE, ZIP DMGD819540303~ DMG SUBSCRIBER DEMOGRAPHIC INFORMATION DMHF248152002~ DMH SUBSCRIBER EXTENDED DEMOGRAPHIC INFORMATION 2010BB PAYER NAME LOOP NM1PR2MEDICARE B~ NM1 PAYER NAME REF2U05440~ REF PAYER SECONDARY IDENTIFICATION 2300 CLAIM INFORMATION CLM15382914076435298743282722:B:1YAYY~ CLM CLAIM INFORMATION HIABF:H2511ABF:H25811~ HI DIAGNOSIS HIBP:66984~ HI ANESTHESIA RELATED PROCEDURE CODE 2310B RENDERING PROVIDER NAME LOOP NM1821TOWNSENDJACOBEXX5678912345~ NM1 RENDERING PROVIDER NAME 2310C SERVICE LOCATION NAME LOOP NM1772PROVIDER OP HOSPITAL**XX43294867~ NM1 SERVICE LOCATION NAME N3345 MAIN DRIVE~ N3 SERVICE LOCATION ADDRESS N4KANSAS CITYMO641051909~ N4 SERVICE LOCATION CITY, STATE, ZIP 2400 SERVICE LINE NUMBER LX1~ LX SERVICE LINE NUMBER SV1HC:00142:QK:QS:P1827MJ6112NNN~ SV1 PROFESSIONAL SERVICE DTP472D820250112~ DTP SERVICE DATE/TIME REF6R1~ REF LINE ITEM CONTROL NUMBER TRAILER SE310001~ SE TRANSACTION SET TRAILER