CMS-1500 Claim Form Instructions

Disclaimer

This information release is the property of Noridian. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents.

The information is provided "as is" without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice.

All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian Healthcare Solutions (Noridian) and the CMS. The most current edition of the information contained in this release can be found on the Noridian website and the CMS website.

The identification of an organization or product in this information does not imply any form of endorsement.

The CMS-1500 Form (Health Insurance Claim Form) is sometimes referred to as the AMA (American Medical Association) form. The CMS-1500 Form is the prescribed form for claims prepared and submitted by physicians or suppliers, whether or not the claims are assigned. It can be purchased in any version required by calling the U.S. Government Printing Office at 202-512-1800.

The National Uniform Claim Committee (NUCC) changed the Form CMS-1500, and the revised form received White House Office of Management and Budget (OMB) approval on June 10, 2013. The revised form is version 02/12 and has replaced the previous version of the form 08/05.

The CMS Internet Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 26 was used to create this tutorial. The following instructions apply to the CMS-1500 Claim Form version 02/12. For complete information CMS-1500 claim form version 02/12, refer to http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c26.pdf.

Legend Description
MM Month (e.g., December = 12)
DD Day (e.g., Dec 15 = 15)
YY 2 position Year (e.g., 2006 = 06)
CCYY 4 position Year (e.g., 2006 = 2006)
(MM | DD | YY) or (MM | DD | CCYY) A space must be reported between month, day, and year (e.g., 12 | 15 | 06 or 12 | 15 | 2006). This space is delineated by the dotted vertical line on the CMS-1500 Form
(MMDDYY) or (MMDDCCYY) No space must be reported between month, day, and year (e.g., 121506 or 12152006). The date must be recorded as one continuous number.

 

Reminder: Providers and suppliers have the option of entering either a 6 or 8-digit date in items 11b, 14, 16, 18, 19, or 24A. The format chosen must be consistent throughout these items. Intermixing the two formats on the claim is not allowed. For instance, a provider of service or supplier will not be permitted to enter 8-digit dates for items 11b, 14, 16, 18, 19, and a 6-digit date for item 24A. Items 12 and 31 are exempt from this requirement.

NOTE: Throughout these instructions, you will notice that some items are bolded and some are in italics. Noridian has used boldface type to emphasize certain points and provided additional clarification on items through the use of italics.

X
 
Item Instructions
Item 1 Type of Health Insurance Coverage Applicable to the Claim
Show the type of health insurance coverage applicable to this claim by checking the appropriate box, e.g., if a Medicare claim is being filed, check the Medicare box.
Item 1a

Insured's ID Number
(Medicare ID)
This is a required field.
Enter the patient's Medicare ID whether Medicare is the primary or the secondary payer. An invalid Medicare ID will cause a claim to deny or be rejected as unprocessable.

Item 2 Patient's Name
This is a required field . Enter the patient's last name, first name, and middle initial, if any, as it appears on the patient's Medicare card (e.g., Jones John J). Include only one space between the last name, first name, and middle initial. If the name is not an identical match, the claim will be rejected as unprocessable. Do not submit extra spaces, nicknames, or descriptions such as Jr., Sr., deceased, or the estate of (unless indicated on the Medicare card).

Do not extend the beneficiary's name beyond the confines of this box.
Item 3 Patient's Birth Date and Sex
Enter the patient's 8-digit birth date (MM | DD | CCYY) and sex. Only one box should be indicated: either M or F. Marking both or neither will cause the claim to be rejected as unprocessable.
Item 4 Insured's Name
If Medicare is primary, leave blank . If there is insurance primary to Medicare, either through the patient's or spouse's employment or any other source, list the name of the insured here. When the insured and the patient are the same, enter the word SAME.
Item 5 Patient's Address and Telephone Number
This is a required field and must be filled in completely. Enter the patient's mailing address and telephone number. On the first line enter the street address; the second line, the city and state; the third line, the ZIP code and telephone number.
Item 6 Patient's Relationship to Insured
If Medicare is primary, leave blank. Check the appropriate box for the patient's relationship to the insured when item 4 is completed.
Item 7 Insurance Primary to Medicare, Insured's Address and Telephone Number
Complete this item only when items 4, 6, and 11 are completed. Enter the insured's address and telephone number. When the address is the same as the patient's, enter the word SAME.
Item 8 Reserved for NUCC Use
Leave blank.
Item 9 Medigap Benefits, Other Insured's Name
If no Medigap benefits are assigned, leave blank. Enter the last name, first name, and middle initial of the enrollee in a Medigap policy if it is different from that shown in item 2. Otherwise, enter the word SAME. This field may be used in the future for supplemental insurance plans.

NOTE: Only participating physicians and suppliers are to complete item 9 and its subdivisions and only when the beneficiary wishes to assign his/her benefits under a MEDIGAP policy to the participating physician or supplier.

Participating physicians and suppliers must enter information required in item 9 and its subdivisions if requested by the beneficiary. Participating physicians/suppliers sign an agreement with Medicare to accept assignment of Medicare benefits for all Medicare patients. A claim for which a beneficiary elects to assign his/her benefits under a Medigap policy to a participating physician/supplier is called a mandated Medigap transfer. (See chapter 28 of the Medicare Claims Processing Manual.)

Medigap - Medigap policy meets the statutory definition of a "Medicare supplemental policy" contained in Section 1882(g)(1) of Title XVIII of the Social Security Act (the Act) and the definition contained in the NAIC Model Regulation that is incorporated by reference to the statute. It is a health insurance policy or other health benefit plan offered by a private entity to those persons entitled to Medicare benefits and is specifically designed to supplement Medicare benefits. It fills in some of the "gaps" in Medicare coverage by providing payment for some of the charges for which Medicare does not have responsibility due to the applicability of deductibles, coinsurance amounts, or other limitations imposed by Medicare. It does not include limited benefit coverage available to Medicare beneficiaries such as "specified disease" or "hospital indemnity" coverage. Also, it explicitly excludes a policy or plan offered by an employer to employees or former employees, as well as that offered by a labor organization to members or former members.

Do not list other supplemental coverage in item 9 and its subdivisions at the time a Medicare claim is filed. Other supplemental claims are forwarded automatically to the private insurer if the private insurer contracts with the carrier to send Medicare claim information electronically. If there is no such contract, the beneficiary must file his/her own supplemental claim.
Item 9a Medigap Benefits, Other Insured's Policy or Group Number
If no Medigap benefits are assigned, leave blank. Enter the policy and/or group number of the Medigap insured preceded by MEDIGAP, MG, or MGAP. Do not enter other types of insurance (e.g., supplemental).

NOTE: Item 9d must be completed if the provider enters a policy and/or group number in item 9a.
Item 9b Reserved for NUCC Use
Leave blank.
Item 9c Reserved for NUCC Use
Leave blank.
Item 9d Medigap Benefits, Insurance Plan/Program Name, PAYERID Number
Enter the nine-digit PAYERID number of the Medigap insurer. If no PAYERID number exists, then enter the Medigap insurance program or plan name.

If the beneficiary wants Medicare payment data forwarded to a Medigap insurer under a mandated Medigap transfer, the participating provider or supplier must accurately complete all of the information in items 9, 9a, 9b, and 9d.

A Medicare participating provider or supplier shall only enter the COBA Medigap claim-based ID within item 9d when seeking to have the beneficiary's claim crossed over to a Medigap insurer. If a participating provider or supplier enters the PAYERID or the Medigap insurer program or its plan name within item 9d, the Medicare Part B contractor or Durable Medical Equipment Medicare Administrative Contractor (DMAC) will be unable to forward the claim information to the Medigap insurer prior to October 1, 2007, or to the Coordination of Benefits Contractor (COBC) for transfer to the Medicare insurer on or after October 1, 2007. (See chapter 28 Section70.6.4 for more information concerning the COBA Medigap claim-based crossover process.)

NOTE: The configuration of the PAYERID is alpha numeric and up to 9 digits.
Items
10a-10c
Condition Relationship? Employment, Auto Liability, or Other Accident
Check "YES" or "NO" by placing an (X) in the center of the box to indicate whether employment, auto liability, or other accident involvement applies to one or more of the services described in item 24. Enter the State postal code. Any item checked "YES," indicates there may be other insurance primary to Medicare. Identify primary insurance information in item 11.
Item 10d Use this item exclusively for Medicaid (MCD) information. If the patient is entitled to Medicaid, enter the patient's Medicaid number preceded by MCD.
Item 11 Insured's Policy Group or FECA Number

THIS ITEM MUST BE COMPLETED, IT IS A REQUIRED FIELD. BY COMPLETING THIS ITEM, THE PHYSICIAN/SUPPLIER ACKNOWLEDGES HAVING MADE A GOOD FAITH EFFORT TO DETERMINE WHETHER MEDICARE IS THE PRIMARY OR SECONDARY PAYER.
If there is insurance primary to Medicare for the service date(s), enter the insured's policy or group number within the confines of the box and proceed to items 11a-11c. Items 4, 6, and 7 must also be completed. If item 11 is left blank, the claim will be denied as unprocessable.

NOTE: Enter the appropriate information in item 11c if insurance primary to Medicare is indicated in item 11.

If there is no insurance primary to Medicare, do not enter "n/a," "not," etc., enter the word NONE within the confines of the box and proceed to item 12.

If the insured reports a terminating event with regard to insurance which had been primary to Medicare (e.g., insured retired), enter the word NONE and proceed to item 11b.

If a lab has collected previously and retained MSP information for a beneficiary, the lab may use that information for billing purposes of the non-face-to-face lab service. If the lab has no MSP information for the beneficiary, the lab will enter the word NONE in item 11 of the CMS-1500 Form, when submitting a claim for payment of a reference lab service. Where there has been no face-to-face encounter with the beneficiary the claim will then follow the normal claims process. When a lab has a face-to-face encounter with a beneficiary, the lab is expected to collect the MSP information and bill accordingly.

Insurance Primary to Medicare - Circumstances under which Medicare payment may be secondary to other insurance include:
  • Group Health Plan Coverage
    • Working Aged (Type 12);
    • Disability (Large Group Health Plan - Type 43); and
    • End Stage Renal Disease (ESRD - Type 13);
  • No Fault (Type 14) and/or Other Liability (Type 47); and
  • Work-Related Illness/Injury:
    • Workers' Compensation (Type 15);
    • Black Lung (Type 41); and
    • Veterans Benefits (Type 42).
NOTE: For a paper claim to be considered for Medicare secondary payer benefits, a policy or group number must be entered in this item. In addition, a copy of the primary payer's explanation of benefits (EOB) notice must be forwarded along with the claim form. (See Pub. 100-05, Medicare Secondary Payer Manual, Chapter 3.) Without an attached EOB from the primary insurance, the claim will be denied.
Item 11a Insured's Date of Birth and Sex
This item must be completed if a policy or group number is reported in item 11 AND is different from the date in item 3. Enter the insured's 8-digit birth date (MM | DD | CCYY) and sex if different from item 3.
Item 11b Insurance Primary to Medicare, Employer's Name
Provide this information to the right of the vertical dotted line: Enter employer's name, if applicable. If there is a change in the insured's insurance status, e.g., retired, enter either a 6-digit (MM|DD|YY) or 8-digit (MM|DD|CCYY) retirement date proceeded by the word "RETIRED."
Item 11c Insurance Plan/Program Name
This item must be completed if a policy or group number is submitted in item 11. Enter the nine-digit PAYERID number of the primary insurer. If no PAYERID number exists, then enter the complete primary payer's program or plan name. If the primary payer's EOB does not contain the claims processing address, record the primary payer's claims processing address directly on the EOB. Please include the telephone number of the primary payer. This is required if there is insurance primary to Medicare that is indicated in item 11.
Item 11d Leave blank. Not required by Medicare.
Item 12 Patient's or Authorized Person's Signature
The patient or authorized representative must sign and enter either a 6-digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY), or an alphanumeric date (e.g., January 1, 2006) unless the signature is on file. In lieu of signing the claim, the patient may sign a statement to be retained in the provider, physician, or supplier file in accordance with the Medicare Claims Processing Manual, Chapter 1, "General Billing Requirements." If the patient is physically or mentally unable to sign, a representative specified in the Medicare Claims Processing Manual, Chapter 1, "General Billing Requirements" may sign on the patient's behalf. In this event, the statement's signature line must indicate the patient's name followed by "by" the representative's name, address, relationship to the patient, and the reason the patient cannot sign. The authorization is effective indefinitely unless the patient or the patient's representative revokes this arrangement.

NOTE: This can be Signature on File and/or a computer generated signature. The patient's signature authorizes release of medical information necessary to process the claim. It also authorizes payment of benefits to the provider of service or supplier when the provider of service or supplier accepts assignment on the claim.

Signature by Mark (X) - When an illiterate or physically handicapped enrollee signs by mark, a witness must enter his/her name and address next to the mark.
Item 13 Medigap Benefits, Insured's/Authorized Person's Signature
The patient's signature or the statement "signature on file" in this item authorizes payment of medical benefits to the physician or supplier. The patient or his/her authorized representative signs this item or the signature must be on file separately with the provider as an authorization. However, note that when payment under the Act can only be made on an assignment-related basis or when payment is for services furnished by a participating physician or supplier, a patient's signature or a "signature on file" is not required in order for Medicare payment to be made directly to the physician or supplier.

The presence of or lack of a signature or "signature on file" in this field will be indicated as such to any downstream Coordination of Benefits trading partners (supplemental insurers) with whom CMS has a payer-to-payer coordination of benefits relationship. Medicare has no control over how supplemental claims are processed, so it is important that providers accurately address this field as it may affect supplemental payments to providers and/or their patients.

In addition, the signature in this item authorizes payment of mandated Medigap benefits to the participating physician or supplier if required Medigap information is included in item 9 and its subdivisions. The patient or his/her authorized representative signs this item or the signature must be on file as a separate Medigap authorization. The Medigap assignment on file in the participating provider of service/supplier's office must be insurer specific. It may state that the authorization applies to all occasions of service until it is revoked.
Item 14 Date of Current Illness/Injury/Pregnancy
  • For current illness, injury, or pregnancy, enter either an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date.
  • For chiropractic services, enter an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date of the initiation of the course of treatment and enter an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date of x-ray (if used to demonstrate subluxation) in item 19.
Form version 02/12: Although this version of the form includes space for a qualifier, Medicare does not use this information; do not enter a qualifier in Item 14.
Item 15 Leave blank. Not required by Medicare.
Item 16 Dates Patient Unable to Work in Current Occupation
If the patient is employed and is unable to work in his/her current occupation, enter an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date when the patient is unable to work.

An entry in this field may indicate employment related insurance coverage.
Item 17

Name of the Referring or Ordering Physician
Enter one of the following qualifiers to the left of the dotted vertical line, as appropriate, to identify the role that the physician (or non-physician practitioner) is performing:

DN = Referring Provider
DK = Ordering Provider
DQ = Supervising Provider

Item 17a Leave blank
Item 17b NPI of the Referring/Ordering Physician
Enter the NPI of the referring, ordering, supervising physician or non-physician practitioner listed in item 17. All physicians and non-physician practitioners who order services or refer Medicare beneficiaries must report this data.
Item 18 Service Furnished as a Result of, or Subsequent to, a Related Hospitalization
Enter either a 6-digit (MM | DD | YY) or an 8-digit (MM | DD | CCYY) date when a medical service is furnished as a result of, or subsequent to, a related hospitalization.
Item 19 Narrative Field
This is a required field for the purposes outlined below.
  • Enter either a 6-digit (MM | DD | YY) or an 8-digit (MM | DD | CCYY) date the patient was last seen and the UPIN (NPI when it becomes effective) of his/her attending physician when a physician providing routine foot care submits claims.
  • For physical therapy, occupational therapy, and speech-language pathology services, effective for claims with dates of service on or after June 6, 2005, the date last seen and the UPIN/NPI of an ordering/referring/attending/certifying physician or non-physician practitioner are not required. If this information is submitted voluntarily, it must be correct or it will cause rejection or denial of the claim. However, when the therapy service is provided incident to the services of a physician or nonphysician practitioner, then incident to policies continue to apply. For example, for identification of the ordering physician who provided the initial service, see item 17 and 17a and/or 17b, and for the identification of the supervisor, see item 24Jof this section.
NOTE: Effective May 23, 2008, all identifiers submitted on the Form CMS-1500 MUST be in the form of an NPI.
  • Enter either a 6-digit (MM | DD | YY) or an 8-digit (MM | DD | CCYY) x-ray date for chiropractor services (if an x-ray, rather than a physical examination was the method used to demonstrate the sublaxation). By entering an x-ray date and the initiation date for course of chiropractic treatment in item 14, the chiropractor is certifying that all the relevant information requirements (including level of sublaxation) of Pub. 100-02, Medicare Benefits Policy Manual, Chapter 15, are on file, along with the appropriate x-ray and all are available for carrier review.
  • Enter the drug's name, strength, and dosage when submitting a claim for Not Otherwise Classified (NOC) drugs.
  • Enter a concise description of an "unlisted procedure code" or a "not otherwise classified" (NOC) code within the confines of this box. An attachment may also need to be submitted to help expedite claim processing. If more than one unlisted procedure code is reported on the claim, precede each description in item 19 with the line item number that corresponds to the line that contains the NOC code. This will enable claims processing staff to determine the correct description for each unlisted procedure code. If billing the same unlisted procedure code more than once on the claim, you may need to indicate the charges of the procedure codes to indicate which description belongs to each line.
  • Enter all applicable modifiers when modifier 99 (multiple modifiers) is entered in item 24D. If modifier 99 is entered on multiple line items of a single claim form, all applicable modifiers for each line item containing a 99 modifier should be listed as follows: 1=(mod), where the number 1 represents the line item and "mod" represents all modifiers applicable to the referenced line item. Modifier 99 is only appropriate when more than four modifiers are necessary per claim line. When four or less modifiers apply, each modifier can be entered in the existing space in item 24D on the CMS-1500 Form.
  • Enter the statement "Homebound" when an independent laboratory renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient. (See Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, "Covered Medical and Other Health Services," and Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, "Laboratory Services from Independent Labs, Physicians, and Providers," and Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, "Definitions," respectively for the definition of "homebound" and a more complete definition of a medically necessary laboratory service to a homebound or an institutional patient.)
  • Enter the statement, "Patient refuses to assign benefits" when the beneficiary absolutely refuses to assign benefits to a non-participating provider/supplier who accepts assignment on a claim. In this case, payment can only be made directly to the beneficiary.
  • Enter the statement, "Testing for hearing aid" when billing services involving the testing of a hearing aid(s) is used to obtain intentional denials when other payers are involved.
  • When dental examinations are billed, enter the specific surgery for which the exam is being performed.
  • Enter the specific name and dosage amount when low osmolar contrast material is billed, but only if HCPCS codes do not cover them.
  • Enter a 6-digit (MM | DD | YY) or an 8-digit (MM | DD | CCYY) assumed and/or relinquished date for a global surgery claim when providers share postoperative care.
  • Enter demonstration ID number "30" for all national emphysema treatment trial claims.
  • Enter the NPI/PIN of the physician who is performing a purchased interpretation of a diagnostic test. (See Pub. 100-04, Chapter 1, Section 30.2.9.1 for additional information.)
NOTE: Effective May 23, 2008, all identifiers submitted on the Form CMS-1500 MUST be in the form of an NPI.
  • Method II suppliers shall enter the most current HCT value for the injection of Aranesp for ESRD beneficiaries on dialysis (See Pub. 100-04, Chapter 8, Section 60.7.2).
Item 20 Diagnostic and Purchased Tests
Enter the purchase price under charges if the "yes" block is checked. A "yes" check indicates that an entity other than the entity billing for the service performed the diagnostic test. A "no" check indicates "no purchased tests are included on the claim." When "yes" is annotated, item 32 must be completed. When billing for multiple purchased diagnostic tests, each test must be submitted on a separate CMS-1500 Form.

NOTE: This is a required field when billing for diagnostic tests subject to purchase price limitations.
Item 21

Patient's Diagnosis/Condition
Enter the patient's diagnosis/condition to the highest level of specificity for the date of service. Reminder: Enter the applicable ICD indicator as a single digit between the vertical, dotted line.

To avoid a claim denial, the ICD-10 diagnosis indicator of 0 (zero) must be included, in ICD Ind. section of this Item. If the indicator field is blank, the claim will deny as unprocessable. It must be updated to include the indicator and submitted as a new claim.

Reminder: Do not report ICD-10-CM codes for claims with dates of service prior to implementation of ICD-10-CM, on either the old or revised version of the CMS-1500 claim form.

Enter up to 12 diagnosis codes. Note that this information appears opposite lines with letters A-L. Relate lines A- L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field.

Do not insert a period in the ICD-10-CM code.
Item 22 Leave blank. Not required by Medicare
Item 23 Prior Authorization Number
This is a required field for the purposes outlined below.
  • Enter the Quality Improvement Organization (QIO) prior authorization number for those procedures requiring QIO prior approval.
  • Enter the Investigational Device Exemption (IDE) number when an investigational device is used in an FDA-approved clinical trial. Post Market Approval number should also be placed here when applicable.
  • Enter the 10-digit Clinical Laboratory Improvement Act (CLIA) certification number for laboratory services billed by an entity performing CLIA covered procedures.
NOTE: Item 23 can contain only one condition. Any additional conditions should be reported on a separate CMS-1500 Form.
Item 24 Service Line
The six service lines in section 24 have been divided horizontally to accommodate submission of both the NPI and legacy identifier during the NPI transition and to accommodate the submission of supplemental information to support the billed service. The top portion in each of the six service lines is shaded and is the location for reporting supplemental information. It is not intended to allow the billing of 12 service lines.

When required to submit NDC drug and quantity information for Medicaid rebates, submit the NDC code in the red shaded portion of the detail line item in positions 01 through position 13. The NDC is to be preceded with the qualifier N4 and followed immediately by the 11 digit NDC code (e.g., N499999999999). Report the NDC quantity in positions 17 through 24 of the same red shaded portion. The quantity is to be preceded by the appropriate qualifier: UN (units), F2 (international units), GR (gram) or ML (milliliter). There are six bytes available for quantity. If the quantity is less than six bytes, left justify and space fill the remaining positions (e.g. UN2 or F2999999).
Item 24A Date of Service
This is a required field. Enter a 6-digit (MMDDYY) or 8-digit (MMDDCCYY) date for each procedure, service, or supply within the confines of this box. When "from" and "to" dates are shown for a series of identical services, enter the number of days or units in column G. Return as unprocessable if a date of service extends more than 1 day and a valid "to" date is not present.
Item 24B Place of Service
This is a required field. Enter the appropriate 2-digit place of service code(s) from the list provided in Section 10.5 of the Medicare Claims Processing Manual, Chapter 26. Identify the location, using a place of service code, for each item used or service performed.

NOTE: When a service is rendered to a hospital inpatient, use the "inpatient hospital" code.

Enter only one place of service code per CMS-1500 Form, unless the second place of service code is 12 (patient's home).
Item 24C Leave blank. Not required by Medicare.
Item 24D Procedures, Services, or Supplies Code
This is a required field. Enter the procedures, services, or supplies using the CMS Healthcare Common Procedure Coding System (HCPCS) code. When applicable, show HCPCS code modifiers with the HCPCS code. The CMS-1500 Form has the ability to capture up to four modifiers.

Enter the specific procedure code without a narrative description. However, when reporting an "unlisted procedure code" or a "not otherwise classified" (NOC) code, include a narrative description in item 19 if a coherent description can be given within the confines of that box. Otherwise, an attachment must be submitted with the claim.

Noridian will return as unprocessable if an "unlisted procedure code" or a "not otherwise classified" (NOC) code is indicated in item 24D, but an accompanying narrative is not present in item 19 or on an attachment.

Modifiers must be two alpha/numeric characters. Do not place extra narrative after, under, or above the procedure code. Pricing modifiers should be placed in the first modifier position. Procedure codes should not be placed in the first modifier position. Be sure to distinguish between zeros and the letter "O". Hyphens or any other separators should not be used between procedure codes and modifiers. Only uppercase characters should be used for procedure codes and modifiers.
Item 24E Diagnosis Code Reference Number

This is a required field. Enter the diagnosis code reference number or letter (as appropriate, per form version) as shown in Item 21 to relate the date of service and the procedures performed to the primary diagnosis. Enter only one reference number/letter per line item. When multiple services are performed, enter the primary reference letter for each service. This will be a letter from A-L.

If a situation arises where two or more diagnoses are required for a procedure code (e.g., pap smears), the provider shall reference only one of the diagnoses in item 21.

Item 24F Charge Amount
Enter the charge for each listed service. Include the cents with dollar amounts. For example, $24.00 must be entered as 2400 rather than 24 or 24-. Do not use dollar signs, decimals, dashes, commas, or lines. Negative dollar amounts are not allowed.
Item 24G Days or Units
Enter the number of days or units. This field is most commonly used for multiple visits, units of supplies, anesthesia minutes, or oxygen volume. If only one service is performed, the numeral 1 must be entered.

Some services require that the actual number or quantity billed be clearly indicated on the claim form (e.g., multiple ostomy or urinary supplies, medication dosages, or allergy testing procedures). When multiple services are provided, enter the actual number provided.

For anesthesia, show the elapsed time (minutes) in item 24G. Convert hours into minutes and enter the total minutes required for this procedure (e.g., 2 hours and 10 minutes would be reported as 130. One hour and 10 minutes would be reported as 70).

For instructions on submitting units for oxygen claims, see Chapter 20, Section 130.6 of the Medicare Claims Processing Manual.

Do not place zeros before or after the number of units (e.g., a service of 1 should not be billed as 010; it should be billed as 1. Indicate only whole numbers, e.g., do not bill 1.5).

NOTE: This field should contain at least 1 day or unit. The carrier should program their system to automatically default "1" unit when the information in this field is missing to avoid returning as unprocessable.
Item 24H Leave blank. Not required by Medicare. Entering information in this item may cause delays in claims processing.
Item 24I ID Qualifier
Enter the ID qualifier 1C in the shaded portion when submitting the rendering supplier's NSC in 24J.
Item 24J PIN/NPI of the Rendering Provider
NOTE: DME suppliers are not mandated to report a supplier identifier, such as the NSC number, legacy number or NPI in item 24J on the CMS-1500 claim form.

Enter the rendering provider's PIN in the shaded portion. In the case of a service provided incident to the service of a physician or non-physician practitioner, when the person who ordered the service is not supervising, enter the PIN of the supervisor in the shaded portion. Enter the rendering provider's NPI number in the lower unshaded portion. In the case of a service provided incident to the service of a physician or non-physician practitioner, when the person who ordered the service is not supervising, enter the NPI of the supervisor in the lower unshaded portion.

NOTE: Effective May 23, 2008, the shaded portion of 24J is not to be reported.

Information must be submitted within the confines of this box. Be sure to distinguish between zeros and the letter "O". Do not enter provider names, UPIN numbers, or state postal codes in this item.
Item 25 Provider or Supplier Federal Tax ID (Employer Identification Number)
Enter the provider of service or supplier Federal Tax ID (Employer Identification Number) or Social Security Number. Enter an (X) in the appropriate box to indicate which number is being reported. Only one box can be marked. Do not enter hyphens or spaces. Medicare providers are not required to complete this item for crossover purposes since the Medicare contractor will retrieve the tax identification information from their internal provider file for inclusion on the COB outbound claim. However, tax identification information is used in the determination of accurate National Provider Identifier reimbursement. Reimbursement of claims submitted without tax identification information will/may be delayed.
Item 26 Patient's Account Number
This field is optional to assist the provider in patient identification. Enter the patient's account number assigned by the provider's of service or supplier's accounting system. As a service, any account numbers entered here will be returned to the provider. If an account number is entered in this item, it will appear on the provider remittance notice/advice.
Item 27 Accept Assignment?
This is a required field, even if you are a participating provider. Check the appropriate box with an (X) to indicate whether the provider of service or supplier accepts assignment of Medicare benefits or not. If Medigap is indicated in item 9 and Medigap payment authorization is given in item 13, the provider of service or supplier shall also be a Medicare participating provider of service or supplier and accept assignment of Medicare benefits for all covered charges for all patients.

The following providers of service/suppliers and claims can only be paid on an assignment basis:
  • Clinical diagnostic laboratory services;
  • Physician services to individuals dually entitled to Medicare and Medicaid;
  • Participating physician/supplier services;
  • Services of physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives, certified registered nurse anesthetists, clinical psychologists, and clinical social workers;
  • Ambulatory surgical center services for covered ASC procedures;
  • Home dialysis supplies and equipment paid under Method II;
  • Ambulance services;
  • Drugs and biologicals; and
  • Simplified Billing Roster for influenza virus vaccine and pneumococcal vaccine.
Item 28 Total charges for services on claim
Enter the total charges for the services (i.e., total of all charges in 24F). Include the cents with dollar amounts. For example, $24.00 must be entered as 2400 rather than 24 or 24-. Do not use dollar signs, decimals, dashes, commas, or lines. Negative dollar amounts are not allowed. Do not mark as continued or the claim will be rejected as unprocessable; each CMS-1500 Form should have its own total.
Item 29 Total amount the patient paid on the covered services only
Enter the total amount the patient paid on the covered services only. Include the cents with dollar amounts. For example, $24.00 must be entered as 2400 rather than 24 or 24-. Do not use dollar signs, decimals, dashes, commas, or lines. Negative dollar amounts are not allowed. Do not mark as continued or the claim will be rejected as unprocessable; each CMS-1500 Form should have its own total.

Do not include the amount paid by the primary insurance, co-insurance, deductibles, account balance, or payments on previous claims in this item.

NOTE: If any dollar amount is entered here, part or all of the payment will go directly to the patient, even if you are a participating provider.
Item 30 Leave blank. Not required by Medicare.
Item 31 Signature of Provider of Service or Supplier
This is a required field. Enter the signature of the provider of service or supplier, or his/her representative, and either the 6-digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY), or alpha-numeric date (e.g., January 1, 2006) the form was signed.

In the case of a service that is provided incident to the service of a physician or non-physician practitioner, when the ordering physician or non-physician practitioner is directly supervising the service as in 42 CFR 410.32, the signature of the ordering physician or non-physician practitioner shall be entered in item 31. When the ordering physician or non-physician practitioner is not supervising the service, then enter the signature of the physician or non-physician practitioner providing the direct supervision in item 31.

NOTE: This is a required field, however the claim can be processed if the following is true. If a physician, supplier, or authorized person's signature is missing, but the signature is on file; or if any authorization is attached to the claim or if the signature field has "Signature on File" and/or a computer generated signature. Noridian is unable to process claims without the required signature and date listed in item 31. If left blank, the claim will be rejected as unprocessable.

The signature and date must be completely within the confines of this box. Additional acceptable signatures include: Signature stamp and computer generated signature.
Item 32 Name and Address of Facility Where Services Were Rendered
Enter the name, address, and ZIP code of the facility if the services were furnished in a physician's office, hospital, clinic, laboratory, or facility other than the patient's home. Only one name, address, and ZIP code may be entered in the box. If additional entries are needed, separate claim forms shall be submitted.

Enter the name and address information in the following format:
1st Line - Name
2nd Line - Address
3rd Line - City, State Postal Code, and ZIP Code

NOTE: Enter a complete address for the location where the services were performed. A PO Box is not acceptable. Do not include telephone numbers, commas, periods, or other punctuation in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Enter a space between the city and the state postal code. When entering a 9-digit ZIP code, include the hyphen.

Providers of service (namely physicians) shall identify the supplier's name, address, and ZIP code when billing for purchased diagnostic tests. When more than one supplier is used, a separate CMS-1500 Form shall be used to bill for each supplier.

For foreign claims, only the enrollee can file for Part B benefits rendered outside of the United States. These claims will not include a valid ZIP code. When a claim is received for these services on a beneficiary submitted Form CMS-1490S, before the claim is entered in the system, it should be determined if it is a foreign claim. If it is a foreign claim, follow instructions in Chapter 1 of the Medicare Claims Processing Manual for disposition of the claim. The carrier processing the foreign claim will have to make necessary accommodations to verify that the claim is not returned as unprocessable due to the lack of a ZIP code.

For durable medical, orthotic, and prosthetic claims, the name and address of the location where the order was accepted must be entered (DMERC only). This field is required. When more than one supplier is used, a separate CMS-1500 Form shall be used to bill for each supplier. This item is completed whether the supplier's personnel performs the work at the physician's office or at another location.

If a modifier is billed, indicating the service was rendered in a Health Professional Shortage Area (HPSA) or Physician Scarcity Area (PSA), the physical location where the service was rendered shall be entered if other than the patient's home.

If the supplier is a certified mammography screening center, enter the 6-digit FDA approved certification number.

Complete this item for all laboratory work performed outside a physician's office. If an independent laboratory is billing, enter the place where the test was performed.
Item 32a NPI of Service Facility
If required by Medicare claims processing policy, enter the NPI of the service facility.
Item 32b ID Qualifier and PIN
If required by Medicare claims processing policy, enter the PIN of the service facility. Be sure to precede the PIN with the ID qualifier of 1C. There should be one blank space between the qualifier and the PIN.

NOTE: Effective May 23, 2008, Item 32b is not to be reported.
Item 33 Provider's/ Supplier's Telephone Number, Billing Name, Address, and ZIP Code.
Enter the provider of service/supplier's billing name, address, ZIP Code, and telephone number. This is a required field.

Enter the name and address information in the following format:
1st Line - Name
2nd Line - Address
3rd Line - City, State Postal Code, and ZIP Code
Item 33a NPI of Billing Provider (Supplier) or Group
Enter the NPI of the billing provider or group. This is a required field.

NOTE: Submitting an invalid NPI in this item will cause the claim to be rejected as unprocessable.
Item 33b ID Qualifier and PIN
Enter the ID qualifier 1C followed by one blank space and then the PIN of the billing provider or group. Suppliers billing the DME MAC will use the National Supplier Clearinghouse (NSC) number in this item.

NOTE: Effective May 23, 2008, Item 33b is not to be reported.

To purchase claim forms, contact the U.S. Government Printing Office at 1-866-512-1800, local printing companies, and/or office supply stores.

 

Last Updated Sep 25, 2018