EDI 5010 Documentation 837 Professional - Loop 2400 Service Line

2400 Service Line
        

2400 Service Line LX
We need to repeat this loop for each line item in the claim
Loop Seg ID Segment Name Format Length Ref# Req Value
2400 LX Service Line ID 2 R LX
Element Separator AN 1 *
LX01 Assigned Number N0 1/6 554 R Print Service Line Number
Segment Terminator ~
2400 Professional Service SV

Loop Seg ID Segment Name Format Length Ref# Req Value
2400 SV1 Professional Service ID 3 R SV1
Element Separator AN 1 *
SV101-1 Product/Service ID Qualifier ID 2 235 R HC
Component Element Separator 1 :
SV101-2 Product/Service ID AN 1/48 234 R Print the Procedure Code
Component Element Separator 1 :
SV101-3 Procedure Modifier AN 2 1339 S Modifier 1
Component Element Separator 1 :
SV101-4 Procedure Modifier AN 2 1339 S Modifier 2
Component Element Separator 1 :
SV101-5 Procedure Modifier AN 2 1339 S Modifier 3
Component Element Separator 1 :
SV101-6 Procedure Modifier AN 2 1339 S Modifier 4
Element Separator AN 1 *
SV102 Monetary Amount R 1/18 782 R Line Item Charge Amount
Element Separator AN 1 *
SV103 Unit ID 2 335 R Unit (UN or MJ)
Element Separator AN 1 *
SV104 Quantity R 1/15 380 R Service Unit Count
Element Separator AN 1 *
SV105 Facility Code Value AN 1/2 1331 R Place of Service Code
Element Separator AN 1 *
SV106 Service Type Code ID 1/2 1365 Not Used
Element Separator AN 1 *
SV107-1 Diagnosis Code Pointer N0 1/2 1328 S first diagnosis code pointer
Component Element Separator 1 :
SV107-2 Diagnosis Code Pointer N0 1/2 1328 S Second diagnosis code pointer
Component Element Separator 1 :
SV107-3 Diagnosis Code Pointer N0 1/2 1328 S Third diagnosis code pointer
Component Element Separator 1 :
SV107-4 Diagnosis Code Pointer N0 1/2 1328 S Fourth diagnosis code pointer
Element Separator AN 1 *
SV108 Monetary Amount R 1/18 782 Not Used
Element Separator AN 1 *
SV109 Yes/No : Emergency Indicator ID 1 1073 S Y or N
Element Separator AN 1 *
SV110 Multiple Procedure Code ID 1/2 1340 Not Used
Element Separator AN 1 *
SV111 Yes/No : EPSDT Indicator ID 1 1073 S Y or N
Element Separator AN 1 *
SV112 Yes/No : Family Planning Indicator ID 1 1073 S Y or N
Element Separator AN 1 *
SV113 Review Code ID 1/2 1364 Not Used
Element Separator AN 1 *
SV114 National or Local Assigned Review Value AN 1/2 1341 Not Used
Element Separator AN 1 *
SV115 Copay Status Code ID 1/1 1327 Not Used
Element Separator AN 1 *
Segment Terminator ~

2400 Service Date – DTP

Loop Seg ID Segment Name Format Length Ref# Req Value
2400 DTP Service Date ID 3 R DTP
Element Separator AN 1 *
DTP01 Date/Time Qualifier ID 3 374 R 472
Element Separator AN 1 *
DTP02 Date time Period Format Qualifier ID 2/3 1250 R D8 or RD8
Element Separator AN 1 *
DTP03 Date time Period ID 1/35 1251 R CCYYMMDD or CCYYMMDD-CCYYMMDD
Segment Terminator ~

2400 Line Item Control Number

Loop Seg ID Segment Name Format Length Ref# Req Value
2400 REF Line Item Control Number ID 3 R REF
Element Separator AN 1 *
REF01 Control Number ID 2/3 128 R 6R
Element Separator AN 1 *
REF02 Line Item Control Number AN 1/50 127 R Line Item control Number
Segment Terminator ~
 
Example

LX*1~
SV1*HC:99214*60*UN*1*11**1~
DTP*472*RD8*20120921-20120921~
REF*6R*1134~

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Example 2:
Claim Setup
Field Value
Claim No 252
Claim Location NY Office
Place of Service 11 - Office
Rendering Provider David Mark
ICD Code 410,415, 368.34, 522.3


Line items
Procedure Code Mod1 Mod2 Mod3 Mod4 ICD FromDOS ToDOS Units Unit Charges
99214 1,2,3,4 01/09/2012 01/09/2012 1 40
92570 1 01/09/2012 01/09/2012 1 180.04
90371 3,4 01/09/2012 01/09/2012 1 83

LX*1~
SV1*HC:99214*40*UN*1*11**1:2:3:4~
DTP*472*RD8*20120109-20120109~
REF*6R*1140~
LX*2~
SV1*HC:92570*180.04*UN*1*11**1~
DTP*472*RD8*20120109-20120109~
REF*6R*1141~
LX*3~
SV1*HC:90371*83*UN*1*11**3:4~
DTP*472*RD8*20120109-20120109~
REF*6R*1142~

Now edit the claim and add the Modifiers as follows

Line items
Procedure Code Mod1 Mod2 Mod3 Mod4 ICD FromDOS ToDOS Units Unit Charges
99214 25 1,2,3,4 01/09/2012 01/09/2012 1 40
92570 26 51 1 01/09/2012 01/09/2012 1 180.04
90371 51 59 26 RT 3,4 01/09/2012 01/09/2012 1 83
LX*1~
SV1*HC:99214:25*40*UN*1*11**1:2:3:4~
DTP*472*RD8*20120109-20120109~
REF*6R*1140~
LX*2~
SV1*HC:92570:26:51*180.04*UN*1*11**1~
DTP*472*RD8*20120109-20120109~
REF*6R*1141~
LX*3~
SV1*HC:90371:51:59:26:RT*83*UN*1*11**3:4~
DTP*472*RD8*20120109-20120109~
REF*6R*1142~




        
 
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