SV1 Professional Service

To specify the claim service detail for a Health Care professional

Position

Element

Name

Type

Requirement

Min

Max

Repeat

SV1-01 C003 Composite Medical Procedure Identifier Composite (composite) Mandatory

01 · 235 · Product/Service ID Qualifier · Identifier (ID) · Mandatory · 2 · 2 · -

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

02 · 234 · Product/Service ID · String (AN) · Mandatory · 1 · 48 · -

Identifying number for a product or service

03 · 1339 · Procedure Modifier · String (AN) · Optional · 2 · 2 · -

This identifies special circumstances related to the performance of the service, as defined by trading partners

C003-03 modifies the value in C003-02.

04 · 1339 · Procedure Modifier · String (AN) · Optional · 2 · 2 · -

This identifies special circumstances related to the performance of the service, as defined by trading partners

C003-04 modifies the value in C003-02.

05 · 1339 · Procedure Modifier · String (AN) · Optional · 2 · 2 · -

This identifies special circumstances related to the performance of the service, as defined by trading partners

C003-05 modifies the value in C003-02.

06 · 1339 · Procedure Modifier · String (AN) · Optional · 2 · 2 · -

This identifies special circumstances related to the performance of the service, as defined by trading partners

C003-06 modifies the value in C003-02.

07 · 352 · Description · String (AN) · Optional · 1 · 80 · -

A free-form description to clarify the related data elements and their content

C003-07 is the description of the procedure identified in C003-02.

SV1-02 · 782 · Monetary Amount · Decimal number (R) · Optional · 1 · 18 · -

Monetary amount

SV102 is the submitted charge amount.

SV1-03 · 355 · Unit or Basis for Measurement Code · Identifier (ID) · Conditional · 2 · 2 · -

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

P0304: If either SV1-03 or SV1-04 is present, then the other is required

SV1-04 · 380 · Quantity · Decimal number (R) · Conditional · 1 · 15 · -

Numeric value of quantity

SV1-05 · 1331 · Facility Code Value · String (AN) · Optional · 1 · 2 · -

Code identifying the type of facility where services were performed; the first and second positions of the Uniform Bill Type code or the Place of Service code from the Electronic Media Claims National Standard Format

SV105 is the place of service.

SV1-06 · 1365 · Service Type Code · Identifier (ID) · Optional · 1 · 2 · -

Code identifying the classification of service

SV1-07 C004 Composite Diagnosis Code Pointer Composite (composite) Optional

01 · 1328 · Diagnosis Code Pointer · Numeric (N0) · Mandatory · 1 · 2 · -

A pointer to the claim diagnosis code in the order of importance to this service

C004-01 identifies the primary diagnosis code for this service line.

02 · 1328 · Diagnosis Code Pointer · Numeric (N0) · Optional · 1 · 2 · -

A pointer to the claim diagnosis code in the order of importance to this service

C004-02 identifies the second diagnosis code for this service line.

03 · 1328 · Diagnosis Code Pointer · Numeric (N0) · Optional · 1 · 2 · -

A pointer to the claim diagnosis code in the order of importance to this service

C004-03 identifies the third diagnosis code for this service line.

04 · 1328 · Diagnosis Code Pointer · Numeric (N0) · Optional · 1 · 2 · -

A pointer to the claim diagnosis code in the order of importance to this service

C004-04 identifies the fourth diagnosis code for this service line.

SV1-08 · 782 · Monetary Amount · Decimal number (R) · Optional · 1 · 18 · -

Monetary amount

SV108 is the independent lab charges.

SV1-09 · 1073 · Yes/No Condition or Response Code · Identifier (ID) · Optional · 1 · 1 · -

Code indicating a Yes or No condition or response

SV109 is the emergency-related indicator; a "Y" value indicates service provided was emergency related; an "N" value indicates service provided was not emergency related.

SV1-10 · 1340 · Multiple Procedure Code · Identifier (ID) · Optional · 1 · 2 · -

Code indicating proper adjudication and payment determination in cases involving multiple surgical procedures during the same surgical session

SV1-11 · 1073 · Yes/No Condition or Response Code · Identifier (ID) · Optional · 1 · 1 · -

Code indicating a Yes or No condition or response

SV111 is early and periodic screen for diagnosis and treatment of children (EPSDT) involvement; a "Y" value indicates EPSDT involvement; an "N" value indicates no EPSDT involvement.

SV1-12 · 1073 · Yes/No Condition or Response Code · Identifier (ID) · Optional · 1 · 1 · -

Code indicating a Yes or No condition or response

SV112 is the family planning involvement indicator. A "Y" value indicates family planning services involvement; an "N" value indicates no family planning services involvement.

SV1-13 · 1364 · Review Code · Identifier (ID) · Optional · 1 · 2 · -

Code identifying extenuating circumstances or justifications which might assist any review of the medical necessity for this service

If SV113 is equal to "L" or "N", then SV114 is required.

SV1-14 · 1341 · National or Local Assigned Review Value · String (AN) · Optional · 1 · 2 · -

Value assigned by national or local organizations for various healthcare data elements

SV1-15 · 1327 · Copay Status Code · Identifier (ID) · Optional · 1 · 1 · -

Code indicating whether or not co-payment requirements were met on a line by line basis

SV1-16 · 1334 · Health Care Professional Shortage Area Code · Identifier (ID) · Optional · 1 · 1 · -

Code identifying the Health Care Professional Shortage Area Code (HPSA)

SV1-17 · 127 · Reference Identification · String (AN) · Optional · 1 · 30 · -

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SV117 is the health care manpower shortage area (HMSA) facility identification.

SV1-18 · 116 · Postal Code · Identifier (ID) · Optional · 3 · 15 · -

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

SV118 is the health care manpower shortage area (HMSA) zip code.

SV1-19 · 782 · Monetary Amount · Decimal number (R) · Optional · 1 · 18 · -

Monetary amount

SV119 is a noncovered charge amount.

SV1-20 · 1337 · Level of Care Code · Identifier (ID) · Optional · 1 · 1 · -

Code specifying the level of care provided by a nursing home facility

SV1-21 · 1360 · Provider Agreement Code · Identifier (ID) · Optional · 1 · 1 · -

Code indicating the type of agreement under which the provider is submitting this claim