The Form CMS-1500 Health Insurance Claim Form answers the needs of many health insurers. It is the paper claim form prescribed by the Centers for Medicare & Medicaid Services (CMS) for use by physicians and suppliers that qualify for an exemption from the mandatory electronic claims submission requirements set forth in the Administrative Simplification Compliance Act, Pub.L. 107-105 (ASCA) and the implementing regulation at 42 CFR 424.32.

The Form CMS-1500 was revised to accommodate the implementation of the National Provider Identifier (NPI). NPIs are to be used as the sole provider identifiers on all claims sent to a Medicare contractor.

The instructions for completing the Form CMS-1500 (08/05) were implemented by CMS in order to standardize claim submissions to Medicare Part B contractors. CMS requires that the Medicare carriers distribute an annual educational document with instructions for completing the CMS-1500 Claim Form. Please review this document in its entirety and make the necessary adjustments to your office protocol in order to comply with these instructions. If you use the service of an external agency or vendor for the preparation of your claim forms, please ensure that these instructions are available to them. Failure to do so can delay processing, and can cause denial or return of your claims.

You may purchase the Form CMS-1500 (08/05) claim forms by calling the U.S. Government Printing Office at (202) 512-1800 or for smaller quantities you may contact your local office supply vendor that provides the red dropout ink version of the form.

Key Points

• The Centers for Medicare & Medicaid Services (CMS) implemented the revised Form CMS-1500 (08/05), which accommodated the reporting of the National Provider Identifier (NPI). The Form CMS-1500 (08-05) version was effective July 1, 2007. The Form CMS-1500 (12/90) version will be rejected/returned on claims received on or after July 1, 2007.
• Providers are instructed to resubmit any rejected/returned claims using the the Form CMS-1500 (08/05) version.
• • A major difference between the Form CMS-1500 (08-05) and the prior form the Form CMS-1500 (12/90) is the split provider identifier fields. The split fields enable NPI reporting in the fields labeled as NPI.

Important considerations when completing the Form CMS-1500 (08/05)

• A photocopy of the form will not be accepted. Medicare no longer accepts super bill attachments for claims processing.
• The back of the form must not be blank.
• Providers and suppliers must report eight-digit dates in all date of birth fields (Items 3, 9b and 11a) and either six-digit or eight-digit dates in all other date fields (Items 11b, 12, 14, 16, 18, 19, 24A, and 31). Items 11b, 14, 16, 18, 19 and 24A must be consistent throughout with either six-digit or eight-digit date but not a combination of both. Items 12 and 31 are exempt for this requirement if using an alpha-numeric date.

Limits on the amount of information reportable.

• Six Lines of Service Limit: Report only one service per line for Items 24A through 24J. Do not exceed six lines of service per the Form CMS-1500 when submitting claims. Claims in excess of six lines will be returned unprocessed. If a claim requires more than six service lines then a separate complete form is required.
• Item 19 is limited to three elements per claim. If more than three elements need to be reported, due to multiple lines of service on the claim, report the additional lines of service on a separate claim form with the appropriate information in Item 19.

• Effective January 1, 2002, the phrase "Hospice-Employed" has been replaced by modifier GV.
• Effective April 1, 2002, the phrase "Not related to hospice patient's terminal condition" has been replaced by modifier GW.

• Item 23 is limited to one element per claim. Use a separate claim form for each service requiring the use of Item 23.

Total Charge for Each Claim Form:

• A Total Charge not to exceed six lines of service must be reported in Item 28 of each individual Form CMS-1500 claim form.
• Multiple Form CMS-1500 claim forms with "Continued…" or "See next page" or a single total in Item 28 for multiple Form CMS-1500 claim forms will be returned unprocessed.

Round Trip Ambulance:

• Both initial pickup portion and the return portion of a round-trip ambulance service can be reported on the same Form CMS-1500 when the ZIP code reported in Item 23 and Item 32 match. Each portion of the round-trip ambulance service must be billed on separate lines with the appropriate modifiers. A separate and complete claim is required when the ZIP code in Item 23 and Item 32 do not match.
• The ZIP code will be reported in Item 23 where the pickup for the return trip occurred. The complete address, including ZIP code, of the destination must be entered in Item 32.

Attachments:

• When submitting attachment(s), staple the attachments to the top center of a single Form CMS-1500. If multiple claim forms require the same attachment(s), make photocopies of the attachments and include with each individual claim form.
• Required Attachments:
• For claims with Medicare Secondary Payment (MSP) involvement submit a complete and legible copy of the primary insurer Explanation of Benefits (EOB). A complete EOB contains an explanation of any codes or remarks for nonpayments of services and complete date(s) of service (i.e. month, day and year).
• Some modifiers require attachments. Refer to the list of modifiers, Local Medical Review policy and National Policy for attachment and documentation requirements.

Upper Right Margin of the Claim Form:

The upper right margin of the form above the line "HEALTH INSURANCE CLAIM FORM" is reserved for contractor’s administrative use. Any obstructions in this area will hinder timely and accurate processing of claims.

• Do not write, stamp or print in this area.
• Do not affix staples, labels or any other obstructions.

Readability of the Claim Form: Forms prepared in this manner reduce delays in processing claims.

• Stay within the lines: Report all information within the confines of the appropriate Item on the Form CMS-1500. Do not modify the form: Do not use a stamp, stickers, or write messages across the face of the claim form (e.g., RESUBMITTAL, EOB Attached etc.). Enclose a separate note. Do not use whiteout for corrections or make any marking that crosses multiple Items.
• Do not use any punctuation or symbols anywhere on the claim form (e.g., $105.35, should be reported as 10535.)
• Computer-generate or type all information in black ink.
• Preferred font is Arial, 10- or 11-point (no bolding, italics, or underlining).
• Laser jet printing is preferable, for computer-generated claims. Change cartridges and ribbons when necessary to ensure clear dark printing.

All paper claims submitted on behalf of your Medicare patients must be submitted using the Form CMS-1500 (08-05) in red dropout ink.

• Submit the original copy of printing.

How To Complete The Form CMS-1500

Item:

Item 1

Check the appropriate box for the type of health insurance coverage applicable to this claim.

Note: Check the Medicare box when filing to Medicare for processing.

Item 1a

Medicare requires completion of this Item. Enter the patient’s Medicare Health Insurance Claim Number (HICN) as it appears on the patient’s red, white, and blue Medicare card for all Medicare claim submissions (primary or secondary). The Medicare Health Insurance Claim Number is nine digits and an alpha or alphanumeric suffix.

Item 2

Medicare requires completion of this Item. Enter the patient’s last name, first name, and middle initial, if any, as it appears on the patient’s red, white, and blue Medicare card.

Item 3

Enter the patient’s eight-digit date of birth (MM DD CCYY) and check the appropriate box for the patient’s sex.

Item 4

Enter the name of the insured, if there is insurance primary to Medicare, either through the patient or spouse’s employment or any other source. When there is insurance primary to Medicare, Items 4, 6, 7, and 11 are required items.

OR

Enter the word, "SAME," when the insured is the same as the patient.

OR

Leave blank, when Medicare is primary.

Item 5

This Item is a carrier requirement.
Enter the patient’s mailing address and telephone number. Enter the street address on the first line, the city and state on the second line, and the ZIP code and phone number on the third line. Note: For Home Visits rendered in a state other than the patients mailing address: Enter in Item 5 the patient’s mailing address. Enter in Item 32 the complete address, including ZIP code, where the service was actually rendered.

Item 6

Check the appropriate box for the patient’s relationship to the insured. Complete this Item only when Items 4, 7, and 11 are completed.

Item 7

Enter the insured’s address and telephone number. Complete this Item only when Items 4, 6, and 11 are completed.

OR

Enter the word, "SAME," when the address is the same as the patient’s.

OR

Leave blank, when Medicare is primary.

Item 8

Check the appropriate box(es) for the patient’s marital status and whether employed or a student.

Item 9

Item 9 and its subdivision should only be completed when the provider is a participating physician or supplier, and when the beneficiary wishes to assign his/her benefits under a Medigap policy to the participating physician or supplier.

Participating physicians and 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 physicians and suppliers is called a mandated Medigap transfer.

Enter the last name, first name, and middle initial of the insured in a Medigap policy, if it is different from that shown in Item 2.

OR

Enter the word, “SAME,” when the patient’s name is the same, as it appears in Item 2.

OR

Item 9a

Enter the policy and/or group number of the Medigap insured preceded by MEDIGAP, MG, or MGAP.

Note: If you enter a policy and/or group number in Item 9a, then Item 9d and Item 13 must also be completed.

Item 9b

Enter the Medigap insured’s eight-digit birth date (MM DD CCYY) and check the appropriate box for the patient’s sex.

Item 9c

Leave blank if a Medigap Payer ID is entered in Item 9d. Otherwise, enter the claims processing address of the Medigap insurer. Use an abbreviated street address, two-letter state postal code, and ZIP code copied from the Medigap insured’s Medigap identification card. Note:
Disregard "employer’s name or school name" which is printed on the form.

Example:

The city name should not be included.

Item 9d

Under CMS’ national COBA claim based Medigap process, participating Part B and DME providers and suppliers that are exempted under the Administrative Simplification Compliance Act (ASCA) from having to bill electronically will be required to enter the CMS-assigned five-digit claim-based Medigap COBA ID in Item 9-D. Otherwise, the Medicare carrier cannot forward the claim information to the Medigap insurer via the COBA claim-based Medigap crossover process.

Item 10a through 10c

Check "YES" or "NO" to indicate whether employment, auto liability, or other accident involvement applies to one or more of the services described in Item 24.

Enter the two-letter state postal code for auto liability, when Item 10b is checked yes. 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

• Enter the patient’s Medicaid number, preceded by MCD.
• When the patient is entitled to Medicaid, also, check "YES" in Item 27.

Note: When physicians provide services to individuals dually entitled to Medicare and Medicaid, claims can only be paid on an assigned claim basis.

Item 11

If there is NO insurance primary to Medicare, enter the word “NONE” and proceed to Item 12. The only acceptable verbiage in Item 11 is “None” or the policy number of the insured. Entering any other information in this field will cause the claim to be returned unprocessed.

Medicare requires completion of this Item.

This item must be completed. By completing this item, the physician/supplier acknowledges having made a good faith effort to determine whether Medicare is the primary or secondary payer.

Medicare is primary: If there is no insurance primary to Medicare, enter the word "NONE" and proceed to Item 12.

Medicare is secondary: If there is insurance primary to Medicare, enter the insured’s policy or group number and proceed to Items 11a through 11c. When completing Items 11a – 11c also complete Items 4, 6, and 7.

Note:
For the Form CMS-1500 to be considered for Medicare Secondary Payer benefits, a copy of the primary payers explanation of benefits (EOB) notice must be forwarded along with the claim form.

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

Medicare Secondary Payer (MSP) Claims submitted by a Laboratory:

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 Form Form CMS-1500, 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.

Circumstances under which Medicare payment may be secondary to other insurance include beneficiary covered by:

• Group Health Plan Coverage:
• Working Aged;
• Disability (large group health plan);
• End Stage Renal Disease (ESRD);

• No fault and/or other liability
• Work-related illness/injury:
• Workers’ Compensation;
• Black Lung;
• Veterans benefits

Item 11a

Enter the insured’s eight-digit birth date (MM DD CCYY) and sex, if different from Item 3.

Item 11b

Enter the employer’s name, if applicable. If there is a change in the insured’s insurance status, e.g., retired, enter the eight-digit retirement date (MM DD CCYY) preceded by the word "Retired."

Item 11c

Enter the complete primary payer’s plan name. If the primary payer’s Explanation of Benefits (EOB) does not contain the claims processing address, record the primary payer’s claims processing address directly on the EOB. 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

Medicare requires completion of this Item.

The patient or authorized representative must sign and enter either a six-digit date (MM/DD/YY), eight-digit date (MM/ DD/CCYY). or an alphanumeric date (e.g., January 1, 2007).

OR

Enter: "Signature on file" (SOF).

The patient’s authorization must be obtained prior to billing Medicare for all services for which the patient is physically present. The only exempt services are diagnostic tests or test interpretations, when the patient neither visits the provider or supplier nor is visited by a representative of the provider in connection with the services.

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.

Physically or mentally unable to sign:
If the patient is physically or mentally unable to sign, a representative may sign on the patient’s behalf. In this event, the statement’s signature line must indicate the patient’s name, followed with "by" and the representative’s name, address, relationship to the patient, and the reason the patient cannot sign. If the patient does not have a representative present, and a verbal consent may be obtained, the medical personnel obtaining the verbal consent may sign.

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.

Signature on File (SOF):
Providers who are submitting Medicare claims for a patient over an extended period, or electronically, have the option to make a one time signature authorization agreement with the patient. This will spare the inconvenience of obtaining the patient’s signature for each claim filed with Medicare.

The statement or a copy of the statement should not be sent to the Medicare carrier.
The signed agreement(s) should be kept with the patient’s records in the provider’s files.

The authorization may be on a lifetime basis. It need not be a specific period of time and the patient can cancel it at any time. This agreement is effective with the date of the signing, and 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 written statement should be similar to the sample agreement provided below.

SAMPLE
(Signature on File Authorization on Provider’s Letterhead)

During an audit, Medicare may request that you provide them with a Signature on File or patient signature.

Item 13

The patient’s signature or the statement “signature on file” in this item authorizes payment of medical benefits to the physician or suppler. 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.

NOTE: This can be “Signature on File” signature and/or a computer generated signature.

SAMPLE
(Medigap Authorization on Provider’s Letterhead)

ITEMS 14-33 Provider of Service or Supplier Information

REMINDER: For date fields other than date of birth, all fields shall be one or the other format, six-digit: (MM/DD/YY or eight-digit (MM/DD/CCYY). Intermixing the two formats on the claim is not allowed.

Item 14

Enter either a six-digit (MM/DD/YY) or eight-digit (MM/DD/CCYY) date of current illness, injury, or pregnancy. For Chiropractic services, enter an eight-digit (MM/DD/CCYY) or six-digit (MM/DD/YY) date of the initiation of the course of treatment and enter an eight-digit (MM/DD/CCYY) or six-digit (MM/DD/YY) date in item 19.

Item 15

Leave blank. Not required by Medicare.

Item 16

Enter a six-digit date (MM/DD/YY) or eight-digit date (MM/DD/CCYY) when the patient is employed and unable to work in his/her current occupation. An entry in this field may indicate employment-related insurance coverage (e.g., MSP Workers’ Compensation).

Item 17

Enter the name of the referring or ordering physician in Item 17 and his/her CMS-assigned six-character Unique Provider Identification Number (UPIN) (one (1) alpha + five (5) numeric) in Item 17a, if the service or item was ordered or referred by a physician.

Referring Physician: A physician who requests an Item or service for the beneficiary for which payment may be made under the Medicare program.

Ordering Physician: A physician or, when appropriate, a nonphysician practitioner who orders nonphysician services for the patient. Examples of services that might be ordered include diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, durable medical equipment and services incident to that physician’s or nonphysician practitioner’s service.

The ordering/referring requirement became effective January 1, 1992, and is required by §1833(q) of the Act. All claims for Medicare-covered services and Items that are the result of a physician’s order or referral must include the ordering/referring physician’s name and National Provider Identifier (NPI). This includes:

• Medicare-covered services and items that are the result of a physician’s order or referral;
• Parenteral and enteral nutrition;
• Immunosuppressive drug claims;
• Hepatitis B claims;
• Diagnostic laboratory services;
• Diagnostic radiology services;
• Portable X-ray services;
• Consultative services;
• Durable medical equipment;
• When the ordering physician is also the performing physician (as often is the case with in –office clinical laboratory tests). When a service is incident to the service of a physician or nonphysician practitioner, the name of the physician or nonphysician practitioner who performs the initial service and orders the nonphysician service must appear in Item 17;
• When a physician extender or other limited licensed practitioner refers a patient for consultative service, submit the name of the physician who is supervising the limited licensed practitioner.

Item 17a

Note: Effective May 23, 2008, 17a is not to be reported but 17b MUST be reported when a service was ordered or referred by a physician.

Item 17a Form CMS-1500 (08/05) – – Effective May 23, 2008, 17a is not to be reported but 17b MUST be reported when a service was ordered or referred by a physician.

Item 17b Form CMS-1500 (08-05) – Enter the NPI of the referring/ordering physician listed in Item 17. All physicians who order services or refer Medicare beneficiaries must report this data.

Multiple Referring/Ordering Physicians:
When a claim involves multiple referring and/or ordering physicians, a separate Form Form CMS-1500 shall be used for each ordering/referring physician. All physicians who order or refer Medicare beneficiaries for services must report an NPI.

Item 18

Enter a six-digit date (MM/DD/YY) or eight-digit date (MM DD CCYY) when a medical service is furnished as a result of, or subsequent to, a related hospitalization.

Item 19

Please review the following list. If your claim includes any of the elements listed, enter the required information in this Item.

There is a limit of three elements per claim form in Item 19.

Physical Therapy, Occupational Therapists or Speech-Language Pathology:
For physical therapy, occupational therapy or 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 nonphysician 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 17b, and for the identification of the supervisor, see Item 24J of this section.

NOTE: Effective May 23, 2008, all identifiers submitted on the Form Form CMS-1500 MUST be in the form of an NPI.

Routine foot care submitted by a physician:
Enter either a six-digit (MM/DD/YY) or eight-digit date (MM/DD/CCYY) the patient was last seen and the NPI of his/her attending physician when a physician providing routine foot care submits claims.

Chiropractic services:
Enter a six-digit date (MM/DD/YY) or an eight-digit date (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 subluxation). 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 subluxation) of Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, is on file, along with the appropriate X-ray and all are available for carrier review.

Not otherwise classified (NOC) drugs:

When reporting an NOC drug, follow the instructions below:

1. Enter the name of the drug, National Drug Code (NDC) number and dosage administered in the claim narrative.
2. Enter the most appropriate NOC code in the Procedure Code field.
3. Enter a quantity of one (1) in the Quantity Billed field.

Unlisted procedures or not otherwise classified (NOC):
Enter a concise description of an “unlisted procedure code” or an NOC code if one can be given within the confines of this Item. Otherwise an attachment shall be submitted with the claim.

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 modifier 99 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.

When submitting for services that have up to four modifiers on the line of service:
Indicate pricing modifiers in the first two positions and processing or informational modifiers in the third and fourth positions.

Homebound:
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.)

Beneficiary refuses to assign benefits to a participating provider:
Enter PATIENT REFUSES TO ASSIGN BENEFITS in when the beneficiary absolutely refuses to assign benefits to a nonparticipating physician/supplier who accepts assignment on a claim. In this case, payment can only be made directly to the beneficiary.

Testing for Hearing Aid:

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.

Dental examinations:
Enter the specific surgery for which the exam is being performed

Low Osmolar Contrast Material:
Enter the specific name and dosage amount when low osmolar contrast material is billed, but only if HCPCS codes do not cover them.

Radiopharmaceuticals/Radionuclides:
When reporting Radiopharmaceuticals/Radionuclides, follow the instructions below:

• Enter theTotal Acquisition Cost in the claim narrative.
• Enter a quantity of one (1) in the Quantity Billed field.

NOTE: When reporting NOC Radiopharmaceutical procedure codes A4641 and A9999, enter the name of the radioactive drug and the Total Acquisition Cost in the claim narrative. Enter a quantity of one (1) in the Quantity Billed field.

Global surgery claim when providers share post-operative care:
Enter a six-digit (MM/DD/YY) or eight-digit date (MM/DD/CCYY) assumed and/or relinquished date(s) for global surgery, when providers share post-operative care.

National Emphysema Treatment Trial (NETT):
Enter demonstration ID number "30" for all national emphysema treatment trial claims in Item 19. Portable X-ray Supplier:
Enter the six-digit PIN of the physician who provided the interpretation.

Aranesp for ESRD beneficiaries on dialysis:
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)

Administrations of ESAs or Part B anti-anemia drugs not self-administered (other than ESAs) in the treatment of cancer: Individuals and entities who bill for administrations of ESAs or Part B anti-anemia drugs not self-administered (other than ESAs) in the treatment of cancer must enter the most current hemoglobin or hematocrit test results. The test results shall be entered as follows: TR= test results (backslash), R1=hemoglobin, or R2=hematocrit (backslash), and the most current numeric test result figure up to 3 numerics and a decimal point [xx.x]). Example for hemoglobin tests: TR/R1/9.0, Example for Hematocrit tests: TR/R2/27.0.

Enter the NPI 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.)

Competitive Acquisition Program (CAP) Drugs
Enter the prescription number (which is an alpha-numeric number 30 characters in length and consists of the vendor ID, HCPCs code, and the vendor controlled prescription number.

Item 20

Complete this Item when billing for diagnostic tests subject to purchase price limitations. 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 shall be completed.

When billing for multiple purchased diagnostic tests, each test shall be submitted on a separate claim Form Form CMS-1500. Multiple purchased tests may be submitted on the ASC X12 837 electronic format as long as appropriate line level information is submitted when services are rendered at different service facility locations. See Chapter 1.

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

Item 21

Medicare requires completion of this Item for all physicians.

Enter the patient’s diagnosis/condition. With the exception of claims submitted by Ambulance suppliers (specialty type 59), all physician and nonphysician specialties (i.e., PA, NP, CNS, CRNA) use an ICD-9-CM code number and code to the highest level of specificity for the date of service. Enter up to four diagnoses in priority order (primary, secondary condition). All narrative diagnoses for nonphysician specialties shall be submitted on an attachment. An independent laboratory shall enter a diagnosis only for limited coverage procedures.

Truncated diagnosis codes are not acceptable. Many Medicare policies are diagnosis-specific. ICD-9-CM code listings cover a range and include truncated codes. It is the provider’s responsibility to avoid truncated codes by selecting a code(s) carried out to the highest level of specificity and selected from the ICD-9-CM codebook appropriate to the year in which the claim is submitted. Many diagnosis codes are deleted, added or made more specific each year. It is very important that you have the current ICD-9-CM book in your office.

It is recommended that you bill the ICD-9 CM code(s) that you are treating at the time of the visit. All other conditions should be noted in the medical record.

Item 22

Leave blank. Not required by Medicare.

Item 23

Please review the following list. If your claim includes any of the elements listed, enter the required information in this Item.

NOTE: Item 23 can contain only one condition. Any additional conditions should be reported on a separate Form CMS-1500.

Quality Improvement Organization (QIO) prior authorization number:
Enter the Quality Improvement Organization (QIO) prior authorization number for those procedures requiring QIO prior approval.

OR

Investigational Device Exemption (IDE) number:
Enter the seven-digit Investigational Device Exemption number when an investigational device is used in an FDA-approved clinical trial. Post Market Approval number should also be placed here when applicable.

OR

Home Health Agency (HHA) Hospice Facility:
Enter the NPI of the home health agency (HHA) or hospice facility when CPT code G0181 (HH) or G0182 (Hospice) is billed for physicians performing care plan oversight (CPO) services.

OR

Item 24

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 position 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

Medicare requires completion of this Item. Enter a six-digit (MM/DD/YY) or an eight-digit date (MMDDCCYY) for each procedure, service, or supply.

Note:
When "from" and "to" dates are shown for a series of identical services:

• Enter the number of days or units in Item 24G. The submitted charge that is reported in Item 24F should be the total charges for all of the days or units reported in Item 24G to reflect the proper number of services being billed. “From” and “to” dates should be consecutive and should equal the number of days or units in Item 24G. Claims will be returned as unprocessable if a date of service extends more than one day and a valid “to” date is not present.
• Dates on one line may not overlap months or years.

More than six (6) lines of service: When billing more than six (6) lines of service, you must submit another completed Form CMS-1500.

Claim Filing Time Limits:

Item 24B

Medicare requires completion of this Item.

Enter the appropriate two-position place of service code (POS) to identify the location where the Item is used or the service is performed.

When reporting a place of service other than home (12), Item 32 is also required. A separate claim must be submitted for each place of service (POS) this applies to paper claims.

Note: How to Use the Mobile Unit Code (15): Effective January 1, 2003 and subsequent, when services are furnished in a mobile unit, they are often provided to serve an entity for which another POS code exists.

For example, a mobile unit may be sent to a physician’s office or a skilled nursing facility.

• If the mobile unit is serving an entity for which another POS code already exists, providers should use the POS code for that entity.
• If the mobile unit is not serving an entity which could be described by an existing POS code, the providers are to use the Mobile Unit POS code 15.

Click here for a complete list of Alphabetic Place of Service.

Item 24C

Leave blank. Not required by Medicare.

Item 24D

CPT/HCPCS: Medicare requires completion of this portion of the Item.

Enter the appropriate CMS Healthcare Common Procedure Coding System (HCPCS) code. When applicable, show HCPCS code modifiers with the HCPCS code. The Form Form CMS-1500 (08-05) 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 shall be submitted with the claim.

Note: Claims will be returned as unprocessable if an "unlisted procedure code" or an (NOC) code is indicated in Item 24D, but an accompanying narrative is not present in Item 19 or on an attachment.

MODIFIER:
When applicable, show HCPCS code modifiers with the HCPCS code. The Form Form CMS-1500 (08-05) has the ability to capture up to four modifiers. When reporting more than four modifiers, refer to the instructions for Item 19.

Billing National Government Services:
When reporting modifiers 22, 52, 53 or 66 attach a copy of the Operative or Procedure Report with your claim form. If this information is not included, processing of your claim may be delayed or the claim may be denied.

Click here for a complete Modifier list.

Item 24E

Medicare requires completion of this Item. (The only exception to this is Ambulance Providers).

Enter the reference number of the diagnosis code(s) shown in Item 21 to relate the date of service and the procedures performed to the primary diagnosis.

Enter only one reference number per line Item. When multiple services are performed, enter the primary reference number for each service, either a 1, or a 2, or a 3, or a 4.

Enter the reference number for the primary diagnosis for that detail line, 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.

Note: Improper submission of the ICD-9 CM codes may result in either a claim return or medical necessity denial. Remember to link the ICD-9-CM code to the line of coding.

Item 24F

This Item is a carrier requirement.  (The only exception to this is HMO Copay)

Enter the charge for each listed service. The submitted charge that is reported in Item 24F should be the total charges for all of the days or units reported in Item 24G.

Non participating providers may not exceed the limiting charge fee for each service.

Note:
When billing National Government Services, Inc. of New Jersey (NJ):

Leave blank, when submitting an HMO Copayment Receipt.

Item 24G

This Item is a carrier requirement.  (The only exception to this is HMO Copay)

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.

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

Note:The designated span of dates for consecutive dates of care billed in Item 24A and the number of services entered in Item 24G should be equal.

For injections, and/or injectables:
Review the specific dosage to ensure that you are billing the appropriate number of services in Item 24G. Units (number of services) are defined in the respective HCPCS code for the injections and/or injectibles.

For units Exceeding 999, use the following table to determine the number of lines required:

Note: If needed, use the sixth detail line to submit any remaining units of service.

Item 24H

Leave blank. Not required by Medicare.

Item 24I

Item 24I

Item 24J

IItem 24J

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.

This unprocessable instruction does not apply to influenza virus and pneumococcal vaccine claims submitted on roster bills as they do not require a rendering provider NPI.

Item 25

This Item is a carrier requirement.  (The only exception to this is HMO Copay)

Enter the provider of service or supplier Federal Tax ID (Employer Identification Number or Social Security Number) and check the appropriate check box.

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

Enter the patient’s account number assigned by the provider’s of service or supplier’s accounting system. This field is optional to assist the provider in patient identification. As a service, any account numbers entered here will be returned to the provider.

Item 27

Check the appropriate block to indicate whether the provider of service or supplier accepts assignment of Medicare benefits.

Note:
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 physician 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.

Participating providers have signed agreements with their carrier to always accept assignment of Medicare benefits for all covered charges for all patients when Medicare services are rendered. Non participating providers accept or decline assignment of Medicare benefits on a case-by-case basis.

Note:

The carrier will automatically assume that the claim is assigned or unassigned whenever a provider makes no entry in Item 27 as follows:

• The carrier will automatically assume the claim is assigned for claim submissions from participating providers.
• The carrier will automatically assume that the claim is unassigned whenever a nonparticipating provider makes no entry in Item 27.
• The carrier will automatically assume the claim is assigned for Mandatory assignment situations.

Item 28

This Item is a carrier requirement.  (The only exception to this is HMO Copay)

Enter total charges for the services. (i.e., total of all charges in Item 24F).

Note:
When billing National Government Services, Inc. of New Jersey (NJ):
Leave blank, when submitting an HMO Copayment Receipt.

Item 29

Enter the total amount the patient paid on the covered services only. This applies to deductible and or any amount over and above the coinsurance.

Note: Do not enter a previously paid amount by Medicare in this Item. Leave blank when there is insurance primary to Medicare and complete Items 4, 6, 7, and 11.

Item 30

Leave blank. Not required by Medicare.

Item 31

Enter the signature of the provider of service or supplier, or his or her representative and the six-digit (MM/DD/YY) or eight-digit date (MM/DD/CCYY) or alphanumeric date (e.g., January 1, 2007) the form was signed.

In the case of a service that is provided incident to the service of a physician or nonphysician practitioner, when the ordering physician or nonphysician practitioner is directly supervising the service, the signature of the ordering physician or nonphysician practitioner shall be entered in Item 31.

When the ordering physician or nonphysician practitioner is not supervising the service, then enter the signature of the physician or nonphysician 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.

Item 32

This Item is conditional by Place of Service. When required, enter the name and complete address including ZIP code.

Item 32 - Enter the name and address, and ZIP code if the service(s)  were furnished in an office, hospital, clinic, laboratory, physician’s office or facility other than the patient’s home (place of service 12).  Note:  For home visits rendered in a state other than the patient's mailing address, enter the patient's mailing address in item 5 and the complete address, including zip code to reflect where the service was rendered. 

Effective for claims received on or after April 1, 2004,