Difference Between 837 Institutional and 837 Professional

837 Professional

Professional billing is responsible for the billing of claims generated for work performed by physicians, suppliers and other non-institutional providers for both outpatient and inpatient services. Professional charges are billed on a CMS-1500 form. The electronic version of the CMS-1500 is called the 837-P, the P standing for the professional format.

837 Institutional
Institutional billing is responsible for the billing of claims generated for work performed by hospitals and skilled nursing facilities. Institutional charges are billed on a UB-04.
And also Hospital Billing uses Revenue Codes.

Revenue Codes

Revenue codes are 3-digit numbers that are used on hospital bills to tell the insurance companies either where the patient was when they received treatment, or what type of item a patient might have received as a patient. A medical claim will not be paid if this is missing from a bill.

Revenue codes go along with procedure codes. When putting them in a charge master, you would add the correct revenue code to the CPT code you were going to use for a particular department. It's the use of revenue codes which allows hospitals to use the same CPT code in multiple departments because it will show which department the services were provided in.

An easy example to use here would be to match up CPT code 99282, which is for an emergency room visit of low to moderate severity, and revenue code 450, which stands for emergency room. In this case, revenue code 450 is the only code that could be used for this CPT code, thus making this one easy to code.

In short, Revenue Codes are descriptions and dollar amounts charged for hospital services provided to a patient.  The revenue code tells an insurance company whether the procedure was performed in the emergency room, operating room or another department.For example, stitches may be given to a patient in the emergency room, or in a completely different area of the hospital like the maternity ward.

837 Specification

Both sets of 837 specifications are same. The only differences would be claim specific data that pertains to a single transaction. All three transactions contain ISA, GS and ST segments but some data and qualifying codes are specific to the type of 837. Another way to quickly identify which type of 837 is being encountered is by the codes sent in the GS-08 or in the ST-03. Professionals use a 005010X222, Institutional uses a 005010X223 and Dental uses a 005010X224.

837 Institutional Transaction Sample

Data Element	Value
Subscriber:	Clark Kent
Subscriber Address:	123 Fake St. Pittsburgh, PA 15123
Sex:	M
DOB:	May 3, 2006
Insurance ID#:	000000001-03
Payer ID #:	987654321
Patient:	Clark Kent
Primary Payer:	UPMC Health Plan
Submitter:	Line Medical Center
EDI #:	111111111
Receiver:	UPMC Health Plan
EDI #:	222222222
Billing Provider:	Line Medical Center
Provider #	111111111
Address:	123 Line Blvd. Pittsburgh, PA 15123
Contact Person and Number	Dr. J, 412-454-1000
Attending Physician:	William J. Line, MD
Attending Physician NPI:	2222222222
UPIN #	P97777
Patient Account Number:	333333
Date of Admission:	04/17/2011
Place of Service:	Hospital
Occurrence Codes and Dates:	41 on 5/1/2010 27 on 7/15/2010 33 on 4/15/2010 C2 on 4/10/2010
Value Code	30
Value Amount	$20.
Condition Codes:	01
ICD-9 Procedure Code and Date:	449.1, 7/30/2010
Principal Diagnosis Code:	250.00
Secondary Diagnosis Codes:	789.01
Revenue Codes	0300 0320 0270
Services:	HC
Institutional Services Rendered:	81000 76092 J1120
Line Item Charge Amounts	$120. $50. $30.
Total Charges:	$200.

 

 

Example 837 Data String
The following transmission sample illustrates the file format used for an EDI transaction, which includes delimiters and data segment symbols. The sample includes the ISA (Interchange Control) and GS (Functional Group) portions of a transmission, and only one ST/SE segment. This sample contains a line break after each tilde to provide an easy illustration of where a new data segment begins.

ISA*00* *00* *ZZ*111111111 *33*7306849549*110418*1336*^*00501*000000312*1*P*:~
GS*HC*111111111*7306849549*20110418*1336*312005010X223~
ST*837*0034*005010X223A1~
BHT*0019*00*3920394930203*20100816*1615*CH~
NM1*41*2* LINE MEDICAL CENTER*****46*111111111~
PER*IC*DR. J*TE*4124541000~
NM1*40*2*UPMCHP*****46*222222222~
HL*1**20*1~
NM1*85*2* LINE MEDICAL CENTER*****XX*1111111111~
N3*123 LINE BLVD~
N4*PITTSBURGH*PA*15123~
REF*EI*111111111~
PER*IC*CLARK KENT*TE*00000000101*FX*6145551212~
HL*2*1*22*0~
SBR*P*18*XYZ1234567******BL~
NM1*IL*1*KENT*CLARK*S**MI*00000000101~
N3*123 FAKE ST~
N4*PITTSBURGH*PA*15123~
DMG*D8*19820503*M~
NM1*PR*2*UPMCHP*****PI*222222222~
CLM*333333 *200***13:A:1***A**Y*Y~
DTP*434*RD8*20110417-20110417~
CL1*1*9*01~
REF*F8*ASD0000123~
HI*BK:25000~
HI*BF:78901~
HI*BR:4491:D8:20100730~
HI*BH:41:D8:20100501*BH:27:D8:20100715*BH:33:D8:20100415*BH:C2:D8:20100410~
HI*BE:30:::20~
HI*BG:01~
NM1*71*1*LINE*WILLIAM*AL***34*2222222222~
REF*1G*P97777~
LX*1~
SV2*0300*HC:81000*120*UN*1~
DTP*472*D8*20100730~
LX*2~
SV2*0320*HC:76092*50*UN*1~
DTP*472*D8*20100730~
LX*3~
SV2*0270*HC:J1120*30*UN*1~
DTP*472*D8*20100730~
SE*41*0001~
GE*1*312~
IEA*1*000000312~

SQL Server Stored Procedure for EDI 837 P 5010 Version

Here is a sample Stored Procedure which is used to generate Loop 2010BB. For complete List, please email me at vbsenthilinnet@gmail.com

 

set ANSI_NULLS ON
set QUOTED_IDENTIFIER ON
GO



/********************************************************************************
      Page No			: 130
	  Purpose           : PAYER NAME
********************************************************************************/
 
ALTER PROCEDURE [dbo].[ProcHCEDI_Loop2010BB]
       @plngClaimNo						   Bigint = NULL,
       @pstrSegDelim                        VARCHAR(1) = Null,
	   @plngInsPlanRowID					   Bigint		= NULL
      
AS
DECLARE
	@strValidText				VARCHAR(8000),
	@strInValidText				VARCHAR(8000),
	@StrInsName					VARCHAR(100),
	@strAddress1				VARCHAR(100),
	@strAddress2				VARCHAR(100),
	@strCity					VARCHAR(50),
	@strState					VARCHAR(50),
	@strZip						VARCHAR(50),
	@strPayerID					VARCHAR(50),
	@strNHPI					VARCHAR(80)



BEGIN

	SET @strValidText = ''
	SET @strInvalidText = ''
	SELECT @pstrSegDelim = IsNull(@pstrSegDelim,'*')

	SET @strValidText = 'NM1' + @pstrSegDelim


	/*
		 Page No		:	131
		 Loop No		:	2010BB
		 Loop Name		:	PAYER NAME
		 Segment Name	:	NM1 Individual or Organizational Name
		 Data Element	:   NM101 - Entity Identifier Code
	*/

	SET @strValidText = @strValidText + 'PR' + @pstrSegDelim


	/*
		 Page No		:	131
		 Loop No		:	2010BB
		 Loop Name		:	PAYER NAME
		 Segment Name	:	NM1 Individual or Organizational Name
		 Data Element	:   NM102 - Entity Type Qualifier
	*/

	SET @strValidText = @strValidText + '2' + @pstrSegDelim


	SELECT
			@StrInsName			= LTRIM(RTRIM(ISNULL(InsuranceName,''))),
			@strAddress1		= LTRIM(RTRIM(ISNULL(Address1,''))),
			@strAddress2		= LTRIM(RTRIM(ISNULL(Address2,''))),
			@strCity			= LTRIM(RTRIM(ISNULL(City,''))),
			@strState			= LTRIM(RTRIM(ISNULL(State,''))),
			@strZip				= LTRIM(RTRIM(ISNULL(Zip,''))),
			@strPayerID			= LTRIM(RTRIM(ISNULL(PayerID,'')))
	FROM
			ViewHCInsurance
	WHERE 
			Code = (SELECT InsCode   From ViewHCPatientPolicy Where InsPlanRowID =@plngInsPlanRowID)



	SELECT	@strNHPI			= LTRIM(RTRIM(ISNULL(NHPI,'')))

	FROM
			ViewHCInsurancePlan
	WHERE 
			PlanRowID = (SELECT PlanRowID   From ViewHCPatientPolicy Where InsPlanRowID =@plngInsPlanRowID)


	
	IF @StrInsName= ''
		SET @strInValidText = @strInValidText + 'E2010BB_NM103' + @pstrSegDelim
    ELSE IF LEN(@StrInsName) > 35
		SET @strInValidText = @strInValidText + 'E2010BB_NM103_01' + @pstrSegDelim
	ELSE
		SET @StrValidText = @strValidText + @StrInsName + @pstrSegDelim 
	

	/*
		 Page No		:	131
		 Loop No		:	2010BB
		 Loop Name		:	PAYER NAME
		 Segment Name	:	NM1 Individual or Organizational Name
		 Data Element	:   NM104,NM105,NM106,NM107  
		 NOT USED
	*/
	
    SET @StrValidText = @strValidText + @pstrSegDelim + @pstrSegDelim + @pstrSegDelim + @pstrSegDelim

	/*
		 Page No		:	131
		 Loop No		:	2010BB
		 Loop Name		:	PAYER NAME
		 Segment Name	:	NM1 Individual or Organizational Name
		 Data Element	:   NM108,NM109
	*/

	
	IF @strPayerID = '' AND @strNHPI = ''
		SET @strInValidText = @strInValidText + 'E2010BB_NM109' + @pstrSegDelim
	ELSE
	BEGIN
		IF @strNHPI <> '' 
			SET @StrValidText = @strValidText + 'XV' + @pstrSegDelim + @strNHPI
		ELSE IF @strPayerID <> '' 
			SET @StrValidText = @strValidText + 'PI' + @pstrSegDelim + @strPayerID
	END


	SELECT @strValidText as EDIinfo, @strInvalidText as ErrInfo,1 as RowNum,'2010BB - Payer Name' +space(200) AS LoopNo,'NM1' as SegmentName, '130' as PageNo  into #temp
	--**************************************************************************************************

	/*
		 Page No		:	134
		 Loop No		:	2010BB
		 Loop Name		:	PAYER NAME
		 Segment Name	:	N3 Address Information
	*/


	SET @strValidText = ''
	SET @strInvalidText =''

	/*
		 Page No		:	134
		 Loop No		:	2010BB
		 Loop Name		:	PAYER NAME
		 Segment Name	:	N3 Address Information
		 Data Element   :   N301 - ALIAS: Payer Address 1
	*/

	SET @strValidText = 'N3' + @pstrSegDelim

	IF @strAddress1 =''
		SET @strInValidText = @strInValidText + 'E2010BB_N301' + @pstrSegDelim
	ELSE
		SET @StrValidText = @strValidText + @strAddress1


	/*
		 Page No		:	134
		 Loop No		:	2010BB
		 Loop Name		:	PAYER NAME
		 Segment Name	:	N3 Address Information
		 Data Element   :   N302 - ALIAS: Payer Address 2
	*/

	IF @strAddress2   <> '' 
		SET @StrValidText = @strValidText +  @pstrSegDelim + @strAddress2 
	Insert into #temp SELECT @strValidText as EDIinfo, @strInvalidText ,2,'2010BB - Payer Name Address','N3', '134'
	--**************************************************************************************************

	
	/*
		 Page No		:	135
		 Loop No		:	2010BB
		 Loop Name		:	PAYER NAME
		 Segment Name	:	N4 Geographic Location PAYER CITY/STATE/ZIP CODE
	*/

	SET @strValidText = ''
	SET @strInvalidText =''

    SET @StrValidText  = 'N4' + @pstrSegDelim
	
	
	-- Page No 135
	IF @strCity = ''
		SET @strInValidText = @strInValidText + 'E2010BB_N401' + @pstrSegDelim
     ELSE
		SET @StrValidText = @strValidText + @strCity + @pstrSegDelim 
	
	-- Page No 135
	IF @strState = ''
		SET @strInValidText = @strInValidText + 'E2010BB_N402' + @pstrSegDelim
     ELSE
		SET @StrValidText = @strValidText + @strState + @pstrSegDelim 

	if @strZip <> '' 
		SET @strZip = REPLACE(@strZip,'-','')
	
	-- Page No 135
	IF @strZip = ''
		SET @strInValidText = @strInValidText + 'E2010BB_N403' + @pstrSegDelim
    ELSE
		SET @StrValidText = @strValidText + @strZip  
	
	Insert into #temp SELECT @strValidText as EDIinfo, @strInvalidText ,3,'2010BB - Payer City/State/ZipCode','N4', '135'
	--**************************************************************************************************

	
	SELECT EDIinfo, ErrInfo,LoopNo,SegmentName,PageNo FROM #temp order by RowNum

	IF @@ERROR = 0  
		RETURN 0
	ELSE
		RETURN 1

END

EDI 835 Health Care Claim Payment/Advice

Looking for best Practice Management software ? Please email at vbsenthilinnet@gmail.com

If you are new to Medical Billing, then please read this article first.
If you are new to EDI, then  read the following articles

1. What is an EDI ?
2. EDI Transactions 
3. Understanding EDI Structure
4. EDI Instruction

EDI 835 Health Care Claim Payment/Advice

The 835 is used primarily by Healthcare insurance plans to make payments to healthcare providers, to provide Explanations of Benefits (EOBs), or both. When a healthcare service provider submits an 837 Health Care Claim, the insurance plan uses the 835 to detail the payment to that claim, including:

• What charges were paid, reduced or denied
• Whether there was a deductible, co-insurance, co-pay, etc.
• Any bundling or splitting of claims or line items
• How the payment was made, such as through a clearinghouse

A particular 835 document may not necessarily match up one-for-one with a specific 837. In fact, it is not uncommon for multiple 835 transactions to be used in response to a single 837, or for one 835 to address multiple 837 submissions. As a result, the 835 is important to healthcare providers, to track what payments were received for services they provided and billed. And also one EDI 835 File, may contain multiple Checks i.e Multiple EOBs

Before going into detail, Let us understand how insurance Payer make the Payment. Please understand and have good understanding on the following topics.

1. What is Copay, Co Insurance and Deductible in  Insurance Payment Posting ?
2. EOB – Explanation of Benefits

 

I have developed a small Parsing tool in VB.NET/VB.6/Java . This tool will take the EDI File and convert into PDF File as shown here.

 

Looking for best Practice Management software ? Please email at vbsenthilinnet@gmail.com 

Questions or feedback are always welcome. You can email me at vbsenthilinnet@gmail.com

271–5010 Health Care Eligibility Benefit Response - Subscriber Demographic Information and Subscriber Date –Loop 2100C

        

Subscriber Demographic Information.

Loop	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
2100C	DMG	Demographic Information	ID	3		S	DMG
		Element Separator	AN	1			*
	DMG01	Date Time Period format Qualifier	ID	2	1250	S	D8 = Date format
		Element Separator	AN	1			*
	DMG02	Date Time Period	AN	8	1251	S	<CCYYMMDD - Recipient Date of Birth>
		Segment Terminator					~

Sample
DMG*D8*19571112

Loop	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
2100C	DTP	Subscriber Date	ID	3		R	DTP
		Element Separator	AN	1			*
	DTP01	Date Time Qualifier	ID	2	374	R	See values below
		Element Separator	AN	1			*
	DTP02	Date Time Period Format Qualifier	ID	2/3	1250	R	D8 or RD8
		Segment Terminator					~

DTP 01 – Date Time Qualifier

 

Code	Definition
096	Discharge
102	Issue
152	Effective Date of Change
291	Plan
307	Eligibility
340	Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin
341	Consolidated Omnibus Budget Reconciliation Act (COBRA) End
342	Premium Paid to Date Begin
343	Premium Paid to Date End
346	Plan Begin
347	Plan End
356	Eligibility Begin
357	Eligibility End
382	Enrolment
435	Admission
442	Date of Death
458	Certification
472	Service
539	Policy Effective
540	Policy Expiration
636	Date of Last Update
771	Status

DTP 02 – Date Time Period Qualifier

Code	Definition
D8	Date Expressed in Format CCYYMMDD
RD8	Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Sample

DTP*356*D8*20110101
DTP*346*D8*20140101
DTP*347*D8*20141231

        

Questions or feedback are always welcome. You can email me at vbsenthilinnet@gmail.com. 

271–5010 Health Care Eligibility Benefit Response – Loop 2100C Subscriber Name

 

        

Use this segment to identify an entity by name and/or identification number. Use this NM1 loop to identify the insured or subscriber

 

Loop	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
2100C	NM1	Subscriber Name	ID	3		R	NM1
		Element Separator	AN	1			*
	NM101	Entity Identifier Code	ID	2/3	98	R	IL
		Element Separator	AN	1			*
	NM102	Entity Type qualifier	ID	1/1	1065	R	1
		Element Separator	AN	1			*
	NM103	Name Last or Organization Name	AN	1/60	1035	R	Insured Person Last Name
		Element Separator	AN	1			*
	NM104	Name First	AN	1/35	1036	S	Insured Person First Name
		Element Separator	AN	1			*
	NM105	Name Middle	AN	1/25	1037	S	Insured Person Middle Name
		Element Separator	AN	1			*
	NM106	Name Prefix	AN	1/10	1038	Not used
		Element Separator	AN	1			*
	NM107	Name Suffix	AN	1/10	1039	S	Insured Person Suffix
		Element Separator	AN	1			*
	NM108	Identification code Qualifier	ID	1/2	66	R	MI
		Element Separator	AN	1			*
	NM109	Identification code	AN	2/80	67	R	Insured Policy No
		Segment Terminator					~

 

 

NM102 - Entity Type Qualifier

Code qualifying the type of entity

Code	Definition
1	Person
2	Non-Person Entity

 

Sample
NM1*IL*1*MULLIN*DANIEL****MI*XJBH12345678~

Segment Structure



SUBSCRIBER Additional identification

Loop	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
2100C	REF	Reference Identification	ID	3		R	REF
		Element Separator	AN	1			*
	REF01	Reference Identification qualifier	ID	2/3	128	R	See below for valid values
		Element Separator	AN	1			*
	REF02	Reference Identification	AN	1/50	127	R	Identification value
		Element Separator	AN	1			*
	REF03	Description	AN	1/80	352	S	Free form description as optional

REF01- Reference Identification Type Qualifier

 

Code	Definition
18	Plan Number
1L	Group Policy Number
1W	Member Identification Number
3H	Case Number
49	Family Unit Number
6P	Group Number
CE	Class of Contract
CT	Contract Number
EA	Medical Record  Identification Number
EJ	Patient Account Number
F6	Health Insurance Claim (HIC) Number
GH	Identification Card Serial Number
HJ	Identify Card Number
IF	Issue Number
IG	Insurance Policy Number
N6	Plan Network Identification Number
NQ	Medicaid Recipient Identification Number
Q4	Prior Identifier Number
SY	Social Security Number
Y4	Agency Claim Number

Sample
REF*6P*1111119*XXXXXXX XXXXXXXXXX XXXXXXXXX, INC.
REF*EJ*660415~

2100C Subscriber Address

 

Loop	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
2100C	N3	Subscriber Address	AN	2		R	N3
		Element Separator	AN	1			*
	N301	Address Line 1	AN	1/55	166	R	Insured Person Address Line 1
		Element Separator	AN	1			*
	N302	Address Line 2	AN	1/55	166	S	Insured Person Address Line 2 if exists
		Segment Terminator					~

 

2100C Subscriber City/State/Zip code

Loop	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
2100C	N4	Subscriber City / State / Zip Code	AN	2		R	N4
		Element Separator	AN	1			*
	N401	City Name	AN	2/30	19	R	Insured Person City Name
		Element Separator	AN	1			*
	N402	State or Province Code	ID	2/2	156	R	Insured Person State Code
		Element Separator	AN	1			*
	N403	Postal Code	ID	3/15	116	R	Insured Person Zip Code
		Segment Terminator					~

2100C Subscriber Demographic Information.

Loop	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
2100C	DMG	Subscriber Demographic	ID	3		R	DMG
		Element Separator	AN	1			*
	DMG01	Date time Period Format Qualifier	ID	2/3	1250	R	D8
		Element Separator	AN	1			*
	DMG02	Date time Period	AN	1/35	1251	R	Insured Date of birth in the Format CCYYMMDD
		Element Separator	AN	1			*
	DMG03	Gender Code	ID	1	1068	R	Print M for Male Print F for Female Print U for unknown
		Segment Terminator

Sample

N3*254 Holly ST
N4*HYDE PARK*NY*011111117
DMG*D8*19521212*M

 

        

Questions or feedback are always welcome. You can email me at vbsenthilinnet@gmail.com.