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Segment
in
X12 Release 008010

SV1 Professional Service

To specify the service line item detail for a health care professional
Sequence
Element
Name
Type
Requirement
Min
Max
Repeat
01
C003
Composite Medical Procedure Identifier
Composite (composite)
Mandatory
1
01
Product/Service ID Qualifier
Identifier (ID)
Mandatory
2
2
-
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
C003-01 qualifies C003-02 and C003-08.
Codes (544)
02
Product/Service ID
String (AN)
Mandatory
1
80
-
Identifying number for a product or service
If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
03
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 and C003-08.
04
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 and C003-08.
05
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 and C003-08.
06
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 and C003-08.
07
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.
08
Product/Service ID
String (AN)
Optional
1
80
-
Identifying number for a product or service
C003-08 represents the ending value in the range in which the code occurs.
09
Procedure Modifier
String (AN)
Optional
2
2
-
This identifies special circumstances related to the performance of the service, as defined by trading partners
C003-09 modifies the value in C003-02 and C003-08.
10
Procedure Modifier
String (AN)
Optional
2
2
-
This identifies special circumstances related to the performance of the service, as defined by trading partners
C003-10 modifies the value in C003-02 and C003-08.
11
Procedure Modifier
String (AN)
Optional
2
2
-
This identifies special circumstances related to the performance of the service, as defined by trading partners
C003-11 modifies the value in C003-02 and C003-08.
12
Procedure Modifier
String (AN)
Optional
2
2
-
This identifies special circumstances related to the performance of the service, as defined by trading partners
C003-12 modifies the value in C003-02 and C003-08.
02
Monetary Amount
Decimal number (R)
Optional
1
18
1
Monetary amount
SV102 is the submitted service line item amount.
03
Unit or Basis for Measurement Code
Identifier (ID)
Conditional
2
2
1
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
P0304
Codes (925)
04
Quantity
Decimal number (R)
Conditional
1
15
1
Numeric value of quantity
05
Facility Code Value
String (AN)
Optional
1
3
1
Code identifying where services were, or may be, performed; the National Uniform Billing Committee (NUBC) Facility Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.
SV105 is the place of service.
06
Industry Code
String (AN)
Optional
1
30
1
Code indicating a code from a specific industry code list
SV106 is the Service Type (Code Source 958).
07
Diagnosis Code Pointer
Numeric (N0)
Optional
1
2
12
A pointer to the diagnosis code in the order of importance to this service
The first pointer designates the primary diagnosis and remaining diagnosis pointers indicate declining level of importance.
08
Monetary Amount
Decimal number (R)
Optional
1
18
1
Monetary amount
SV108 is the independent lab charges.
09
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
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.
Codes (9)
10
Multiple Procedure Code
Identifier (ID)
Optional
1
2
1
Code indicating proper adjudication and payment determination in cases involving multiple surgical procedures during the same surgical session
Codes (3)
11
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
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.
Codes (9)
12
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
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.
Codes (9)
13
Review Code
Identifier (ID)
Optional
1
2
1
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.
Codes (8)
14
National or Local Assigned Review Value
String (AN)
Optional
1
2
1
Value assigned by national or local organizations for various healthcare data elements
15
Copay Status Code
Identifier (ID)
Optional
1
1
1
Code indicating whether or not co-payment requirements were met on a line by line basis
Codes (4)
16
Health Care Professional Shortage Area Code
Identifier (ID)
Optional
1
1
1
Code identifying the Health Care Professional Shortage Area Code (HPSA)
17
Reference Identification
String (AN)
Optional
1
80
1
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.
18
Postal Code
Identifier (ID)
Optional
3
15
1
Code specifying international postal zone code excluding punctuation and blanks (zip code for United States)
SV118 is the health care manpower shortage area (HMSA) zip code.
19
Monetary Amount
Decimal number (R)
Optional
1
18
1
Monetary amount
SV119 is a non-covered service amount.
20
Level of Care Code
Identifier (ID)
Optional
1
1
1
Code specifying the level of care provided by a nursing home facility
Codes (8)
21
Provider Agreement Code
Identifier (ID)
Optional
1
1
1
Code indicating the type of agreement under which the provider is submitting this claim
Codes (7)
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Stedi is a registered trademark of Stedi, Inc. Stedi's EDI Reference and Mapping Guides are provided for marketing purposes and are free of charge. All names, logos, and brands of third parties listed on our site are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Our use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation.