Example: Chiropractic Spinal Manipulation with X-Ray

Example: Chiropractic Spinal Manipulation with X-Ray X12 Admin Wed, 05/13/2026 - 07:04 BUSINESS SCENARIO: Patient is an adult male receiving chiropractic spinal manipulation with X-Ray due to acute back pain. Subscriber is the Patient. The Payer is Medicare B and the encounter is billed directly to Medicare B. 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: MATTHEW J WILLIAMSON SUBSCRIBER ID: 9YJ9TE1GP41 SUBSCRIBER ADDRESS: 123 RAINBOW ROAD, KANSAS CITY, MO, 64105 SUBSCRIBER DOB: 03/03/1954 SUBSCRIBER SEX: M 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: $145.50 PLACE OF SERVICE CODE: 11 CLAIM FREQUENCY CODE: 1 INITIAL TREATMENT DATE: 01/12/2025 DATE OF LAST X-RAY: 01/12/2025 DIAGNOSIS CODE: M48.20 SERVICE LINE NUMBER: PROCEDURE CODE: 98940 PROCEDURE MODIFIER: AT LINE ITEM CHARGE AMOUNT: $145.50 UNIT OR BASIS FOR MEASURMENT CODE: UN SERVICE UNIT COUNT: 1 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 NM1IL1WILLIAMSONMATTHEWJMI9YJ9TE1GP41~ NM1 SUBSCRIBER NAME N3123 RAINBOW ROAD~ N3 SUBSCRIBER ADDRESS N4KANSAS CITYMO64105~ N4 SUBSCRIBER CITY, STATE, ZIP DMGD819540303~ DMG SUBSCRIBER DEMOGRAPHIC INFORMATION DMHM248152002~ DMH SUBSCRIBER EXTENDED DEMOGRAPHIC INFORMATION 2010BB PAYER NAME LOOP NM1PR2MEDICARE B~ NM1 PAYER NAME REF2U05440~ REF PAYER SECONDARY IDENTIFICATION 2300 CLAIM INFORMATION CLM153829140764352987432145.511:B:1YAYY~ CLM CLAIM INFORMATION DTP523D820250112~ DTP ORIGINAL CLAIM CREATION DATE DTP454D820250112~ DTP INITIAL TREATMENT DATE DTP455D820250112~ DTP LAST X-RAY DATE CR2**A**CHRONIC PAIN AND DISCOMFORT~ CR2 SPINAL MANIPULATION SERVICE INFORMATION HIABF:M4820~ HI DIAGNOSIS 2400 SERVICE LINE NUMBER LX1~ LX SERVICE LINE NUMBER SV1HC:98940:AT145.5UN11NNN~ SV1 PROFESSIONAL SERVICE DTP472D820250112~ DTP SERVICE DATE/TIME REF6R1~ REF LINE ITEM CONTROL NUMBER TRAILER SE30*0001~ SE TRANSACTION SET TRAILER