Section title: Requests for Interpretation
835 response to an 837i containing no procedure codes

If an 837i claim is submitted without any CPT or HCPCS codes and only revenue codes, where in the 835 is payment information sent? Would the SV1 segment be absent entirely?


A UB04 is submitted via 837i transaction. The UB04 has no CPT nor HCPCS codes on any service lines; it only contains Revenue codes. Where is the remittance information expected in an 835 file? Since the SV1 segment in the 835 is situational and would require a CPT or HCPCS code, it follows that the SV1 segment would be absent. Where then is payment information for the service line expected to be reported in the 835?

RFI Response

The X12N/005010X221 TR3 guide defines the code sources that may be used for each data element. The Qualifier in SVC01-1 defines the code source that is used in SVC01-2. 

The SVC01-2 is defined: “This is the adjudicated procedure code or revenue code as identified by the qualifier in SVC01-1.” If a revenue code is the only code considered in adjudication, then the revenue code would be populated in the SVC01-2 and SVC01-1 would have the NU qualifier pointing to code source 132.  

If a procedure code and revenue code were both considered during adjudication, the procedure code will be populated in the SVC01-2 and the revenue code in the SVC04.