SV5 Durable Medical Equipment Service

To specify the claim service detail for durable medical equipment

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Position
Element
Name
Type
Requirement
Min
Max
Repeat
SV5-01
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.
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.
SV5-02
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
Quantity
Decimal number (R)
Mandatory
1
15
1
Numeric value of quantity
SV503 is the length of medical treatment required.
SV5-04
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
Monetary Amount
Decimal number (R)
Conditional
1
18
1
Monetary amount
SV505 is the purchase price.
SV5-06
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
Prognosis Code
Identifier (ID)
Optional
1
1
1
Code indicating physician's prognosis for the patient

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