Request interpretation of SV107-1: "This first pointer designates the primary diagnosis for this service line. Remaining diagnosis pointers indicate declining level of importance to service line. Acceptable values are 1 through 12 and correspond to Composite Data Elements 01 through 12 in the Health Care Diagnosis Code HI segment in the Claim Loop ID-2300."
Can the number of Diagnosis Pointers exceed the number of Diagnosis Codes present on a single claim submission?
A single claim is populated with valid Diagnosis Codes in HI01-1 and HI01-2 (two codes) and Diagnosis Pointer values of SV107-1=1, SV107-2=2, SV107-3=3, and SV107-4=4. Assuming all other required/situational data elements are present, does this scenario meet X12 compliance standard?
The definition for Data Element 1328, which is what makes up each of the 4 parts of SV107 composite data element, is “A pointer to the diagnosis code in the order of importance to this service.” The Semantic Notes for C004, which is used in SV107, identify the third sub-element “C004-03 identifies the third diagnosis code for this service line” and the fourth sub-element “C004-04 identifies the fourth diagnosis code for this service line.” Since there are only 2 Diagnosis Codes in the HI segment, there are no third or fourth diagnosis codes to point to.
Therefore, it is not compliant for the number of Diagnosis Pointers to exceed the number of Diagnosis Codes on a claim.