OP6121 Modifier - 2 (HCPCS & CPT-4) 44 24D-3 837I/2400/SV2/HC/02-4 - 3 837P/2400/SV1/HC/01-4 OP6122 Service - 3 46 24G-3 837I/2400/SV2/DA/05 837I/2400/SV2/UN/05 837P/2400/SV1/UN/04 OP6123 Outpatient Total Charges - 3 47 24F-3 837I/2400/SV2/03 837P/2400/SV1/02 OP6124 Service Date - 3 45 24A-3 837/2400/DTP/472/D8/03 Reference ASC X12N/005010A1 UB-04 Transaction Set/Loop/ Data Form Segment ID/Code Value/ Element # Data Element Name Locator Reference Designator OP7001 Record Type NA NA NA OP7002 Sequence Number NA NA NA OP7003 Patient Control Number 3A 26 837/2300/CLM/01 OP7004 Principal Diagnosis Code 67 21A 837/2300/HI/BK/01-2 OP7005 Other Diagnosis Code 1 67A 21B 837I/2300/HI/BF/01-2 – 837P/2300/HI/BF/02-2 OP7006 Other Diagnosis Code 2 67B 21C 837I/2300/HI/BF/02-2 – 837P/2300/HI/BF/03-2
OP6121 Modifier - 2 (HCPCS & CPT-4) - 3 44 24D-3 837I/2400/SV2/HC/02-4 837P/2400/SV1/HC/01-4 OP6122 Service - 3 46 24G-3 837I/2400/SV2/DA/05 837I/2400/SV2/UN/05 837P/2400/SV1/UN/04 OP6123 Outpatient Total Charges - 3 47 24F-3 837I/2400/SV2/03 837P/2400/SV1/02 OP6124 Service Date - 3 45 24A-3 837/2400/DTP/472/D8/03 Data Element # Data Element Name UB-04 Form Locator Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator OP7001 Record Type NA NA NA OP7002 Sequence Number NA NA NA OP7003 Patient Control Number 3A 26 837/2300/CLM/01 OP7004 Principal Diagnosis Code 67 21A 837/2300/HI/BK/01-2 OP7005 Other Diagnosis Code – 1 67A 21B 837I/2300/HI/BF/01-2 837P/2300/HI/BF/02-2 OP7006 Other Diagnosis Code – 2 67B 21C 837I/2300/HI/BF/02-2 837P/2300/HI/BF/03-2
Chapter%20241_20170907_v2.docx