EDI 837 Professional. Version 005010X222A1
Billing for Physician Administered Drugs and NDC Reporting
Providers are required to report the National Drug Code (NDC) supplemental information in addition to the procedure
code (CPT or HCPCS) when billing for a physician administered drug on the electronic and paper claim formats.
When billing physician administered drugs, in addition to the appropriate CPT or HCPCS codes, the following must be
reported on the claim:
• the 11-digit NDC number;
• the unit price (EDI only);
• the 2-digit unit of measure code, e.g. GR (Gram), ML (Milliliter), UN (Unit); and
• the quantity dispensed.
LIN Segment
| LIN02 | N4 | N4 Qualifier identifies the NDC being billed |
| LIN03 | Actual NDC e.g., 01234567891 | Report the NDC in the 11 digit format.Do not use hyphens or spaces |
CTP Segment
| CTP03 | Unit Price | e.g., 2.50 |
| CTP04 | Dispensing Quantity | e.g., 2 |
| CTP05 | Unit of Measure Value | Values are: |
Example EDI 837
Please note : All the information used in this example are dummy data.
ISA*00* *00* *ZZ*ukgesglgpa *01*bxwtirveg *220622*0410*^*00501*999 *1*P*:
GS*HC*ukgesglgpa*bxwtirveg*20220622*0410*999*X*005010X222A1
ST*837*0001*005010X222A1
BHT*0019*00*999*20220622*0410*CH
NM1*41*2*Richey*****46*1070414647
PER*IC*Padgett Gilles*TE*1013444785*FX*1027086334
NM1*40*2*Barlow*****46*394332591
HL*1**20*1
PRV*BI*PXC*193200000X
NM1*85*2*Demo LLC*****XX*1306854021
N3*762 Broad Fifth
N4*Whitehouse*IL*246181682
REF*EI*775925470
HL*2*1*22*0
SBR*P*18*******ZZ
NM1*IL*1*Soileau*Sheela****MI*327383761
N3*P.O. Box 86570
N4*Hufman*IL*11909
DMG*D8*19920608*M
NM1*PR*2*AETNA BETTER HEALTH OF ILLINOIS*****PI*68024
CLM*FR100110*509.00***11:B:7*Y*A*Y*Y
REF*F8*1347204412
HI*ABK:R079*ABF:R0600*ABF:Z308
NM1*82*1*Webster*Niel****XX*1049086189
PRV*PE*PXC*207Q00000X
NM1*77*2*Krieger*****XX*1167726079
N3*346 Cotton Common Crossroad
N4*Soileau*IL*163417061
LX*1
SV1*HC:99214:25*209.00*UN*1***1:2:3
DTP*472*RD8*20210602-20210602
REF*6R*163038
LX*2
SV1*HC:J1050*300.00*UN*150***3
DTP*472*RD8*20210602-20210602
REF*6R*163039
LIN**N4*00009737611
CTP****150.00*ML
SE*37*0001
GE*1*999
IEA*1*999
Interchange Control Header
| Authorization Qualifier | 00 |
| Security Qualifier | 00 |
| Interchange ID Qualifier Sender | ZZ |
| Submitter ID | ukgesglgpa |
| Interchange ID Qualifier Receiver | 01 |
| Receiver ID | bxwtirveg |
| Interchange Date | 06/22/2022 |
| InterChange Time (HHMM) | 04:10 |
| Repetition Seperator | ^ |
| Control Number | 999 |
| Acknowledgement Requested | 1 |
| Usage Indicator | P |
Functional Group Header
| Application Sender Code | ukgesglgpa |
| Application Receiver Code | bxwtirveg |
| Group Transaction Date | 06/22/2022 |
| Group Transaction Time (HHMM) | 04:10 |
| Group Control Number | 999 |
| EDI Version | 005010X222A1 |
Transaction Set Header
| Transaction set | 837 |
| Transaction Control Number | 0001 |
Hierarchical Transaction
| Application Transaction Number | 999 |
| Transaction Date | 06/22/2022 |
| Transaction Time (HHMM) | 0410 |
| Submitter Entity | Organization |
| Organization Name | Richey |
| Etin Number | 1070414647 |
| Contact Name | Padgett Gilles |
| Contact Phone | 1013444785 |
| Contact Fax | 1027086334 |
| Receiver Name | Barlow |
| Receiver Etin Number | 394332591 |
Billing Provider
| Entity Type | 2 |
| Last or Organization Name | Demo LLC |
| Address1 | 762 Broad Fifth |
| City | Whitehouse |
| State | IL |
| Zip | 246181682 |
| NPI | 1306854021 |
| Tax ID | 775925470 |
| Taxonomy Code | 193200000X |
Subscriber information
| Payer Responsbility | P |
| Insured Relationship | 18 |
| Claim Filling Indicator | ZZ |
Subscriber Name
| Entity Type | 1 |
| Last or Organization Name | Soileau |
| First Name | Sheela |
| DOB | 06/08/1992 |
| Gender | M |
| Policy No | 327383761 |
| Address1 | P.O. Box 86570 |
| City | Hufman |
| State | IL |
| Zip | 11909 |
Payer
| Name | AETNA BETTER HEALTH OF ILLINOIS |
| Payer ID | 68024 |
Claim Information
| Claim No | FR100110 |
| Billed Amount | 509.00 |
| Claim Type | 7 |
| Provider Sign Indicator | Y |
| Provider Accept Assignment Code | A |
| Benefits Assignment Indicator | Y |
| Release of information | Y |
| Payer Claim Number | 1347204412 |
ICD Information
| ICD Code 1 | R079 |
| ICD Code 2 | R0600 |
| ICD Code 3 | Z308 |
Rendering Provider
| Entity Type | 1 |
| Last or Organization Name | Webster |
| First Name | Niel |
| NPI | 1049086189 |
| Taxonomy Code | 207Q00000X |
Facility
| Name | Krieger |
| Address1 | 346 Cotton Common Crossroad |
| City | Soileau |
| State | IL |
| Zip | 163417061 |
| NPI | 1167726079 |
Line Item : 1
| Line Item ID | 163038 |
| Procedure Code | 99214 |
| Modifier 1 | 25 |
| Units Code | UN |
| Units | 1 |
| Charges | 209.00 |
| ICD Pointers | 1,2,3 |
| Service From Date | 06/02/2021 |
| Service To Date | 06/02/2021 |
Line Item : 2
| Line Item ID | 163039 |
| Procedure Code | J1050 |
| Units Code | UN |
| Units | 150 |
| Charges | 2.00 |
| ICD Pointers | 3 |
| Service From Date | 06/02/2021 |
| Service To Date | 06/02/2021 |
| Drug Product ID | N4 |
| NDC Code | 00009737611 |
| Drug Unit | 150.00 |
| Drug UOM | ML |
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