This identifier indicates the payer responsible for the reimbursement described in this iteration of the 2430 loop. The identifier indicates the Other Payer by matching the appropriate Other Payer Primary Identifier (Loop ID-2330B, element NM109).
SVD02 782 Monetary Amount M R 1/18 Required 1
Zero “0" is an acceptable value for this element.
SVD03 C003 Composite Medical Procedure Identifier
O Comp Situational 1
Situational Rule: Required when a line level procedure code other than a revenue code was returned on the 835 remittance advice (SVC01).
If not required by this implementation guide, do not send.
This element contains the procedure code that was used to adjudicate this service line.
SVD03-01 235 Product/Service ID Qualifier M ID 2/2 Required 1
Code Name
ER Jurisdiction Specific Procedure and Supply Codes CODE SOURCE:
576: Workers Compensation Specific Procedure and Supply Codes
HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
Because the AMA’s CPT codes are also level 1 HCPCS codes, they are reported under HC.
CODE SOURCE:
130: Health Care Financing Administration Common Procedural Coding System HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate
Code
CODE SOURCE:
716: Health Insurance Prospective Payment
System (HIPPS) Rate Code for Skilled Nursing Facilities IV Home Infusion EDI Coalition (HIEC) Product/Service Code
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Home Infusion EDI Coalition Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.
CODE SOURCE:
513: Home Infusion EDI Coalition (HIEC) Product/Service Code List WK Advanced Billing Concepts (ABC) Codes
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Complimentary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA,
OR
5010X837IA2.ecs 175 For internal use only The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.
CODE SOURCE:
843: Advanced Billing Concepts (ABC) Codes
SVD03-02 234 Product/Service ID M AN 1/48 Required 1
ExternalCodeList
Name: 576
Description: Workers Compensation Specific Procedure and Supply Codes
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 716
Description: HIPPS Rate Code for Skilled Nursing Facilities
ExternalCodeList
Name: 843
Description: Advanced Billing Concepts (ABC) Codes
SVD03-03 1339 Procedure Modifier O AN 2/2 Situational 1 Situational Rule: Required when a modifier clarifies or improves the reporting accuracy of the associated
procedure code. This is the first procedure code modifier. If not required by this implementation guide, do not send.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 576
Description: Workers Compensation Specific Procedure and Supply Codes
ExternalCodeList
Name: 843
Description: Advanced Billing Concepts (ABC) Codes
SVD03-04 1339 Procedure Modifier O AN 2/2 Situational 1
Situational Rule: Required when a second modifier clarifies or improves the reporting accuracy of the associatedprocedure code. If not required by this implementation guide, do not send.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 576
Description: Workers Compensation Specific Procedure and Supply Codes
ExternalCodeList
Name: 843
Description: Advanced Billing Concepts (ABC) Codes
Situational Rule: Required when a third modifier clarifies or improves the reporting accuracy of the associated procedure code. If not required by this implementation guide, do not send.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 576
Description: Workers Compensation Specific Procedure and Supply Codes
ExternalCodeList
Name: 843
Description: Advanced Billing Concepts (ABC) Codes
SVD03-06 1339 Procedure Modifier O AN 2/2 Situational 1
Situational Rule: Required when a fourth modifier clarifies or improves the reporting accuracy of the associated procedure code. If not required by this implementation guide, do not send.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 576
Description: Workers Compensation Specific Procedure and Supply Codes
ExternalCodeList
Name: 843
Description: Advanced Billing Concepts (ABC) Codes
SVD03-07 352 Description O AN 1/80 Situational 1
Situational Rule: Required when SVC01-7 was returned in the 835 transaction. If not required by this implementation guide, do not send.
SVD04 234 Product/Service ID O AN 1/48 Required 1
Industry: Service Line Revenue Code
ExternalCodeList
Name: 132
Description: National Uniform Billing Committee (NUBC) Codes
SVD05 380 Quantity O R 1/15 Required 1
This is the number of paid units from the remittance advice. When paid units are not present on the remittance advice, use the original billed units.
The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
SVD06 554 Assigned Number O N0 1/6 Situational 1 Situational Rule: Required when payer bundled this service line. If not required by this implementation
guide, do not send.
Situational Rule:
Required when claim has been previously adjudicated by payer identified in Loop 2330B and service line has adjustments applied to it. If not required by this implementation guide, do not send.
TR3 Notes:
1. To show unbundled lines: If, in the original claim, line 3 is unbundled into (for example) 2 additional lines, then the SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more times for the additional unbundled lines.
5010X837IA2.ecs 177 For internal use only
TR3 Example:
SVD*11122333*50.5**0305*1~