SV5 Durable Medical Equipment Service

To specify the claim service detail for durable medical equipment

Position

Element

Name

Type

Requirement

Min

Max

Repeat

SV5-01 C003 Composite Medical Procedure Identifier Composite (composite) Mandatory 1

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.

SV5-02 · 355 · Unit or Basis for Measurement Code · Identifier (ID) · Mandatory · 2 · 2 · 1

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

SV5-03 · 380 · Quantity · Decimal number (R) · Mandatory · 1 · 15 · 1

Numeric value of quantity

SV503 is the length of medical treatment required.

SV5-04 · 782 · Monetary Amount · Decimal number (R) · Conditional · 1 · 18 · 1

Monetary amount

R0405: At least one of SV5-04 or SV5-05 is required

SV504 is the rental price.

SV5-05 · 782 · Monetary Amount · Decimal number (R) · Conditional · 1 · 18 · 1

Monetary amount

SV505 is the purchase price.

SV5-06 · 594 · Frequency Code · Identifier (ID) · Optional · 1 · 1 · 1

Code indicating frequency or type of activities or actions being reported

C0604: If SV5-06 is present, then SV5-04 is required

SV506 is the frequency at which the rental equipment is billed.

SV5-07 · 923 · Prognosis Code · Identifier (ID) · Optional · 1 · 1 · 1

Code indicating physician's prognosis for the patient