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CMS-1500 Claim Form Completion Instructions

General Information

When a provider qualifies for a waiver from the ASCA requirements, the CMS-1500 claim form is the standard claim form used by a noninstitutional providers or suppliers who submit claims to National Government Services.

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Claim Filing Instructions for Paper and Electronic Submission

Providers are required to submit claims to NGS Medicare Part B for their Medicare patients whether or not an assignment is taken. The provision requiring filing of the claim by providers also states that the provider(s) (see SE0908: Mandatory Claims Submission and its Enforcement):

  • is prohibited from charging for completing and filing the claim;
  • assigned claims not filed within one year of the service date are not beneficiary responsibility;
  • who fail to submit a claim are subject to sanctions;
  • must complete the claim form and must submit the claim to NGS;
  • provider(s) may not complete the claim and then ask the Medicare patient to submit the claim.

In order to stay in compliance with Medicare law, a physician who treats a Medicare beneficiary for a Medicare-covered service must either:

  1. enroll in Medicare and submit a claim on that beneficiary’s behalf for those services;
  2. opt out of Medicare and enter into a private contract with the beneficiary for those services; or
  3. furnish the Medicare-covered services for free.

A physician who wants to treat (and receive payment from) a Medicare beneficiary will stay in compliance with the law by either enrolling in Medicare and filing claims on the beneficiary’s behalf or by opting out of Medicare and entering into a private contract with the beneficiary.

Moreover, it is important to note that in order to receive a Medicare payment for covered items or services – whether directly from Medicare or from the beneficiary who is, in turn, reimbursed by Medicare, a provider or supplier must be enrolled in the Medicare Program. See the Code of Federal Regulations (CFR) Title 42, Part 424, Section 500 (270 KB) et seq. for the regulations regarding establishing and maintaining Medicare billing privileges.

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Regulations on Charging for Claim Form Completion

CMS has established Medicare policy concerning the practice by providers of charging Medicare patients for completion of Medicare forms.

When you furnish covered services to Medicare beneficiaries, providers are required to submit claims for your services and cannot charge beneficiaries for completing or filing Medicare claims. NGS will monitor compliance with these requirements and offenders may be subject to a Civil Monetary Penalty of up to $10,000 for each violation.

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Optical Character Recognition

For greater efficiency, accuracy and importantly reduce delays in processing your claims, we ask that paper claim forms are prepared so that our OCR system can handle your claims appropriately.

  • The form is designed for typewritten characters 10 or 12 pitch (pica)
  • Character fonts may not be mixed on the same form
  • Italics or script may not be used
  • Old or worn print bands or ribbons should be avoided
  • Use upper case (CAPITAL) letters for all alpha characters/li>
  • Do not use dollar signs, decimals or punctuation
  • Enter all information on the same horizontal plane
    Enter all information within the designated fields
  • Extraneous data may not be printed, handwritten or stamped on the form
  • Corrections may not be handwritten in any data field, pin feed edges are to be removed evenly at side perforations

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Missing, Incomplete, Insufficient or Invalid Claim Information

An unprocessable claim is any claim with incomplete or missing, required information or any claim that contains complete and necessary information; however, the information provided is invalid. Such information may either be required for all claims or required conditionally.

Important Note: There are no reopening or appeal rights on rejected claims (telephone or written); therefore, please do not send any form of correspondence into our office for unprocessable (MA130) claim(s) rejections.

Detailed information with regard to unprocessable claims can be reviewed for definitions and instructions concerning the handling of incomplete or invalid claims is available on the CMS website, CMS (Internet-Only Manual) IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 80.3.1 through 80.3.2.1.3, (1.7 MB) and CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10. (606 KB) A listing of the claim field requirements is also included.

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Health Insurance Claim CMS-1500 Form (02/12)

Providers and suppliers must report eight-digit dates in the date of birth fields Items 3 and 11a.

Providers and suppliers must report either six-digit or eight-digit dates in all other date fields (Items 11a, 14, 15, 16, 18, 19, 24A and 31), but we ask that you be consistent throughout the claim form.

For example:

If you choose to enter six-digit dates for Items 11a, 14, 15, 16, 18, 19 or 24A, you must enter six-digit dates for all these fields. The same applies to providers of service and suppliers who choose to submit eight-digit dates too.

Note: Items 12 and 31 are exempt from this requirement.

Legend Description

  • MM ‒ Month (e.g., December = 12)
  • DD ‒ Day (e.g., December 15 = 15)
  • YY ‒ two-position Year (e.g., 2020 = 20)
  • CCYY ‒ four-position year (e.g., 2020 = 2020)

(MM | DD | YY) or (MM | DD | CCYY)

A space must be reported between month, day and year (e.g., 12 | 15 | 18 or 12 | 15 | 2020). This space is delineated by a dotted vertical line on the CMS-1500 claim form.

(MMDDYY) or (MMDDCCYY)

No space between month, day and year (e.g., 121520 or 12152020). The date must be recorded as one continuous number.

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Patient and Insured Information

Select CMS-1500 Claim Form Item:

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33  
Item 1 (Required)

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

Note: When submitting your claims to Medicare, the Medicare box shall be checked; otherwise, your claim(s) will be rejected and returned.

Item 1a (Required)

Enter the patient’s Medicare HICN or MBI. The new term “Medicare number” and “Medicare ID” as it appears on the patient’s red, white and blue Medicare card for all Medicare claim submissions (primary or secondary). The MBI is 11 characters in length and made up only of numbers and uppercase letters (no special characters); if you use lowercase letters, our system will convert them to uppercase letters.MBIs are assigned by SSA and CMS.

Item 2 (Required)

Enter the patient’s last name, first name and middle initial (if any); list exactly as it appears on the patient’s red, white and blue Medicare card.

Item 3 (Required)

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

Item 4 (Leave blank when Medicare is primary)

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 Medicare is secondary payer (MSP), items 4, 6, 7 and 11 are required items.

-Or-

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

Item 5 (Required)

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 (Complete this item only when Items 4, 7 and 11 are completed.)

Check the appropriate box for the patient’s relationship to the insured.

Item 7 (Leave blank when Medicare is primary.)

Enter the insured’s address and telephone number. When Medicare is secondary payer, complete line item 7 only when items 4, 6 and 11 are completed.

-Or-

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

Item 8 (This field is reserved for NUCC use)

The NUCC will provide instructions for any use of this field.

Item 9 (Leave blank if no medigap benefits are assigned.)

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.

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.

Medigap crossover is the transfer of processed claim data from Medicare operations to private insurance companies that sell supplemental insurance benefits to Medicare beneficiaries.

For more information, refer to NGS Medigap, CMS Coordination of Benefits Overview and the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 28.

When applicable, on line item 9, enter the last name, first name and middle initial (if any) of the insured 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.

Item 9a (Leave blank if a medigap)

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 (This field is reserved for NUCC use.)

The NUCC will provide instructions for any use of this field.

Item 9c (Leave blank if a Medigap Payer ID is entered in Item 9d.)

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 identification card.

The city name should not be included:

1257 Anywhere Street
Baltimore, MD 21204

Shall be shown as:

1257 Anywhere St. MD 21204

Item 9d (Complete with medigap payer ID.)

Enter the five-digit claim-based Medigap Payer ID. You may refer to: CMS Trading Partners reference.

Under CMS’ national COBA claim-based medigap process, participating providers and suppliers that are exempted under the ASCA from having to bill electronically will be required to enter the CMS-assigned five-digit claim-based medigap COBA ID in Item 9d.

Otherwise, NGS cannot forward the claim information to the medigap insurer via the COBA claim-based medigap crossover process.

For more information, refer to CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 28. (600 KB)

Item 10a–10c (Required)

Check “YES” or “NO” 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.

Note: If any of these boxes are checked “YES,” identify primary insurance information in Item 11 through 11c.

Item 10d (Not required)

Crossover is the transfer of processed claim data from Medicare operations to Medicaid (or state) agencies. CMS COB program identifies the health benefits available to a Medicare beneficiary and coordinates the payment process to ensure appropriate payment of Medicare benefits. This is done automatically via the eligibility file-based crossover process, so most beneficiaries claims are automatically crossed over to state Medicaid agencies.

Notes: When the patient is entitled to Medicaid, also, check “YES” in Item 27.

When physicians provide services to individuals dually entitled to Medicare and Medicaid, claims can only be paid on an assigned claim basis. For more information on QMB, please refer to MLN Matters Articles MM9817. (224 KB)
Item 11 (Required)

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

When Medicare is Primary: 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 reject.

When 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.

When multiple payers exist, it is imperative that all explanation of benefits accompany the paper CMS-1500 claim form.

MSP Claims Submitted by a Laboratory

If a laboratory has collected previously and retained MSP information for a beneficiary, the laboratory may use that information for billing purposes of the non face-to-face laboratory service.

If the laboratory has no MSP information for the beneficiary, the laboratory will enter the word “None” in Item 11 of CMS-1500 claim form when submitting a claim for payment of a reference laboratory service. Where there has been no face-to-face encounter with the beneficiary, the claim will then follow the normal claims process. When a laboratory has a face-to-face encounter with a beneficiary, the laboratory 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
    • ESRD
  • Nongroup health plan coverage:
    • Auto no fault
    • Liability
  • Work-related insurance:
    • Workers’ compensation
  • Government programs:
    • Black Lung
    • Veterans benefits

For more information, refer to CMS IOM Publication 100-05, Medicare Secondary Payer Manual, Chapter 3. (477 KB)

Item 11a (If Medicare is the Secondary Payer, complete this line item.)

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

Item 11b (Leave blank. Not required by Medicare.)

Item 11c (If Medicare is the Secondary Payer, complete this line item.)

Enter the complete primary payer’s 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. 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 (Required)

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, 2020).

-Or-

Enter: “Signature on file” (SOF).

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 contractor. 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)

Name of Patient: Health Insurance Claim Number (HICN):
____________________________________ _________________________________
I request that payment of authorized Medicare benefits be made either to me or on my behalf to ______________________________________ for services furnished to me by the provider. I authorize any holder of medical information about me to release to the Centers for Medicare & Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related service.
____________________________________ _________________________________
Patient Signature Date

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

Item 13 (Required signature when beneficiary 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 COB trading partners (i.e., supplemental insurers) with whom CMS has a payer-to-payer COB 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)

Name of Patient: Health Insurance Claim Number (HICN):
____________________________________ _________________________________
I request that payment of authorized Medigap benefits be made either to me or on my behalf to the provider of service and (or) supplier for any services furnished to me by the provider of service and (or) supplier. I authorize any holder of Medicare information about me to release to ____________________________ any information needed
(Name of Medigap Insurance) to determine these benefits payable for related services.
____________________________________ _________________________________
Patient Signature Date

 


Note: Items 14–33 Address 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 (Required for pregnancy and chiropractor claims.)

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 initial treatment or date of exacerbation of the existing condition.

When x-ray is used to demonstrate subluxation, enter an eight-digit (MM/DD/CCYY) or six-digit (MM/DD/YY) date of the x-ray in Item 19 of the CMS-1500 claim form or the electronic equivalent.

Note: Effective for claims with dates of service on and after 1/1/2000, the x-ray is no longer required.

Though CMS-1500 claim form (02/12) 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 (Not required, but may be completed at provider discretion.)

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 (Required)

Enter the legal name of the referring ordering or supervising physician/NPP (first name, last name) who are of a type/specialty that is legally eligible to order and refer Part B clinical laboratory and imaging services.

All physicians or NPP who order services or refer Medicare beneficiaries must report this data.

When a claim involves multiple referring, ordering, or supervising physicians, use a separate CMS-1500 claim form for each ordering, referring, or supervising physician.

Additional instructions for CMS-1500 claim form (02/12): Enter one of the following qualifiers as appropriate to identify the role that this physician or NPP is performing:

Qualifier Provider Role
DN Referring physician
DK Ordering physician
DQ Supervising physician

Enter the qualifier to the left of the dotted vertical line on Item 17.

Ensure you are correctly spelling the ordering/referring provider’s name.

CMS order and referring data file contain NPI and legal name (last name, first name) of all physicians and nonphysicians who are of a type/specialty that is legally eligible to order and refer in the Medicare program and who have current enrollment records in Medicare (i.e., they have enrollment records in PECOS) at https://data.cms.gov/.

Line Item 17 of CMS-1500 claim form or the electronic equivalent, only include the first and last name as it appears on the Ordering and Referring file found on CMS Medicare IPPS Hospital Lookup Tool page.

Do not enter “nicknames”, credentials (e.g., “Dr.,” “MD,” “RPNA,” etc.) or middle names (initials) in the Ordering/Referring name field, as their use could cause the claim to fail the edits.

Ensure that the name and the NPI you enter for the ordering/referring provider belong to a physician or NPP and not to an organization, such as a group practice that employs the physician or NPP who generated the order or referral.

For more information on ordering and referring, refer to Medicare Learning Network (MLN) Matters article SE1305 Revised.

For additional information you may refer to CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15,  (1 MB) for nonphysician practitioner rules. Also, for claim form requirements, refer to CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 26. (606 KB)

Item 17a and 17b (Leave Item 17a blank. Not required by Medicare. Completion of Item 17b is required by Medicare.)

Enter the NPI of the referring, ordering, or supervising physician or NPP listed in Item 17.

All physicians and NPPs who refer, order or supervise services to Medicare beneficiaries must report the NPI in Item 17b.

Line Item 17b of CMS-1500 claim form or the electronic equivalent, only include the NPI as it appears on the ordering and referring file found on https://data.cms.gov/.

Item 18 (Not required, but may be used to report hospitalization dates.)

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 (Required for specific claims. Please review the following list. If your claim includes any of the elements listed, enter the required information in this Item.)

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.

Administrations of ESAs or Part B antianemia drugs not self-administered (other than ESAs) in the treatment of cancer: Individuals 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 three numeric and a decimal point [xx.x]). Example for hemoglobin tests: TR/R1/9.0, Example for hematocrit tests: TR/R2/27.0.

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. For more information, refer to CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 8, Section 60.7.2. (1.8 MB)

Beneficiary Refuses to Assign Benefits when the beneficiary absolutely refuses to assign benefits to a nonparticipating provider or supplier who accepts assignment on a claim. In this case, payment can only be made directly to the beneficiary.

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 CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, (1.33 MB) is on file, along with the appropriate x-ray and all are available for contractor review.

Clinical Trial: Effective 1/1/2014, as a result of Change Request 8401, enter the eight-digit clinical trial number preceded by “CT Clinical Trial Identifier Number (CT99999999) for clinical trials, clinical studies or registries. The NCT number, also called the ClinicalTrials.gov Identifier, is assigned after the protocol information has been released (that is, submitted) by the responsible party and passed review by ClinicalTrials.gov staff.

Clinical Trials billing requirements for Special Services can be found in the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 32, Section 68 and 69.

Note: Also required on the claim for clinical trials clinical studies or registries are modifiers and appropriate diagnosis:

  • Q0= Investigational clinical service provided in a clinical research study that is in an approved clinical research study
  • Q1= Routine clinical service provided in a clinical research study that is in an approved clinical research study
  • ICD-10 replaced with code Z00.6

Demonstration: Enter the demonstration ID number “56” for all national Laboratory Affordable Care Act Section 113 Demonstration Claims.

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

Drugs: Enter the drug’s name and dosage when submitting a claim for drugs.

Indicate the exact name of the drug and the dosage shall be documented on line Item 19 or the electronic equivalent.

Example:

  • DOSAGE: 80,000 MCG
  • DRUG: LIORSEAL
  • INVOICE PRICE: $2,376.37

Global Surgery Claim when Providers Share Postoperative 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 postoperative care.

Homebound: Enter the statement “Homebound” when an independent laboratory renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient.

For the definition of “homebound” and a more complete definition of a medically necessary laboratory service to a homebound or an institutional patient, please refer to the links below:

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.

Modifiers: 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.

National Emphysema Treatment Trial (NETT): Enter demonstration ID number “30” for all national emphysema treatment trial claims in Item 19.

NOC Drugs: When reporting an NOC drug, follow the instructions below.

  • Enter the name of the drug, NDC number and dosage administered in the claim narrative.
  • Enter the most appropriate NOC code in the “Procedure Code” field.
  • Enter a quantity of “1” in the “Quantity Billed” field.

    Radiopharmaceuticals/Radionuclides: When reporting radiopharmaceuticals/radionuclides, follow the instructions below:
  • Enter the total 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.

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.

Also, please refer to the NGS LCD for Routine Foot Care and Debridement of Nails (L33636).

Technical or Professional anti-markup: Enter the physician who is performing the technical or professional component of a diagnostic test that is subject to the anti-markup payment limitation.

Also, please refer to the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 30.2.9 for additional information.

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.

Unlisted Procedures or 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.

You may refer to Instructions for Use of Not Otherwise Classified or Unlisted Codes.

Item 20 (Complete this item when billing for diagnostic tests subject to antimarkup price limitations.)

Check a NO to indicate “no antimarkup tests are included on the claim.”

Check a “YES to indicate that an entity other than the entity billing for the service performed the diagnostic test.

Enter the antimarkup price under charges. In addition complete Items 24J and 33 as noted below:

  • Item 20 indicate yes if purchased a test
  • Item 24J is the rendering provider of the billing group
  • Item 32 is complete name, address and the NPI of the provider the tests were purchased from
  • Item 33 is the billing provider

When billing for multiple antimarkup diagnostic tests, each test shall be submitted on a separate CMS-1500 claim form. Multiple antimarkup 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.

Note: This is a required field when billing for diagnostic tests subject to antimarkup price limitations. When submitting claims for Modifier 90 (Reference (outside) laboratory) is also used on line item 24D. Only independent billing clinical laboratories (specialty 69) can bill with the 90 modifier.

For more information, refer to CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 30.2.9. (1.7 MB)

Item 21 (Required)

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 12 diagnoses in priority order (primary, secondary condition).

The information appears opposite lines with letters A‒L. Relate lines A‒L to the lines of service in Item 24E by the letter of the line.

Use the highest level of specificity. Do not provide narrative description in this field. Line Item 24E shall report the primary diagnosis code letter by listing either an A, or a B or a C, or a D or an E, etc., as the pointer.

Truncated diagnosis codes are not acceptable. Many Medicare policies are diagnosis-specific. 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 ICD-10-CM 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 resources in your office.

It is recommended that you bill the ICD-10-CM code(s) that you are treating at the time of the visit. All other conditions should be noted in the medical record.

The “ICD Indicator” identifies the ICD code set being reported.

Indicator Code Set
0 ICD-10-CM Diagnosis

Enter the zero “0” indicator as a single digit between the vertical, dotted lines.

Additional ICD-10 References

Item 22 (Leave blank. Not required by Medicare.)

Item 23 (Required for specific claims.)

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

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

Ambulance Suppliers: Enter the ZIP code, of the location where the patient was picked up (POP).

  • One-way trip:
    • Enter the ZIP code, of the location where the patient was picked up.
    • This ZIP code must match the ZIP code entered in Item 32
  • Round trip:
    • Enter the ZIP code, of the location where the patient was picked up for the round trip.
    • Enter each portion of the round trip on a separate line with the appropriate modifiers (Item 24A–Item 24G of the claim form).

Note: A separate claim form for each portion of a round trip service is required when the ZIP code of the initial pick up point in Item 23 is not equal to the ZIP code of the return trip pick up point in Item 32.

For more information, please refer to: CMS IOM Publication 100-02, Medicare Benefits Policy Manual, Chapter 10 and CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 15, Section 30.1.2.

CLIA: Enter the ten-digit CLIA certification number for laboratory services billed by an entity performing CLIA-covered procedures.

For more information, please refer to: Clinical Laboratory Improvement Amendments (CLIA).

HHA Hospice Facility: Enter the NPI of the HHA or hospice facility when CPT code G0181 (HH) or G0182 (hospice) is billed for physicians performing CPO services.

IDE Number: Enter the seven-digit 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.

For more information, please refer to: Medicare Coverage Related to Investigational Device Exemption (IDE) Studies and Reminder: Investigational Device Exemption Studies.

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

Item 24A through 24J

The top portion in each of the six service lines is shaded and shall not be used. The claim was not intended to allow the billing of 12 service lines. When billing more than six lines of service, you must submit another completed CMS-1500 claim form (02/12).

Item 24A (Required)

Enter a six-digit (MM/DD/YY) or an eight-digit date (MMDDCCYY) for each procedure, service, or supply.

When “from” and “to” dates are shown for a series of identical services:

  1. Enter the number of days or units in Item 24G.
  2. 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.
  3. “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.

Submit your claims within the timely filing limits. Medicare law prescribes specific time limits within which claims for benefits may be submitted. As a result of the PPACA, all claims with dates of services on or after 1/1/2010 must be filed within one calendar year after the date of service.

Claims with Dates of Service: Claims Must Be Filed By:
01/01/2010 and later 365 days/one calendar year from the date of service

For more information, please refer to Time Limits for Filing Medicare Fee-For-Service Claims.

Item 24B (Required)

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

A separate claim must be submitted for each POS this applies to paper claims.

Effective 1/1/2011, for claims processed on or after 1/1/2011, submission of the location where the service was rendered (Item 32) will be required for all POS codes.

How to Use the Mobile Unit Code (POS 15): Effective 1/1/2003 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 SNF.

  • 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.

You may refer to CMS website for Place of Service Codes for Professional Claims.

Item 24C (Leave blank. Not required by Medicare.)

Item 24D (Required)

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

Enter the appropriate CMS CPT/HCPCS code. When applicable, show CPT/HCPCS code modifiers with the CPT/HCPCS code. The CMS-1500 claim form (02/12) has the ability to capture up to four modifiers.

Enter the specific procedure code without a narrative description.

Paper claims: when reporting an unlisted procedure code” or an 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 a paper 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.

Electronic claims: when reporting an “unlisted procedure code” or an NOC code, include PWK segment to be populated. NGS Medicare providers shall follow NGS policies at Medicare Part B PWK Fax.

Note: PWK is for all JK and J6 providers. The PWK segment is within the 2300/2400 Loop of the 837 Professional and Institutional electronic transactions. NGS providers have the option of mailing or faxing documentation for electronically-submitted claims. Additional documentation should only be submitted when NGS requires it to process your claim; NGS will only review additional documentation when it is necessary to process your claim.

Modifier: When applicable, show CPT/HCPCS code modifiers with the CPT/HCPCS code. The CMS-1500 claim form (02/12) has the ability to capture up to four modifiers. When reporting more than four modifiers, refer to the instructions for Item 19.

Billing NGS: 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.

For more information, please refer to Policy Education Topics.

Item 24E (Required)

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 Letter Per Line Item: When multiple services are performed, enter the primary reference number for each service, enter A, B, C, D, etc.

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-10-CM codes may result in either a claim return or medical necessity denial.

Additional ICD-10 References

Item 24F (Required)

Enter the charge for each listed service. If there are no cents in the charge amount, enter “00” in the cents field. 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.

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

You may refer to our NGS Fee Schedule Lookup for fees in your jurisdiction.

Item 24G (Required)

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.

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.

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, please refer to the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 20, Section 130.6. (547 KB)

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.

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 injectables.

Units Exceeding 999: Use the following table to determine the number of lines required:

If the number of services fall between: Enter the following units of service in Item 24G: Detail line number:
1–999 1–999 1
1000–1997 Difference in number (up to 998) 2
1998–2994 Difference in number (up to 997) 3
2995–3990 Difference in number (up to 996) 4
3991–4985 Difference in number (up to 995) 5

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 (Leave blank. Not required by Medicare.)

Item 24J (Required)

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 NPP, 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.

If the billing provider is a group, the rendering provider NPI must go in Item 24J.

If the billing provider is a solo practitioner, Item 24J is left blank.

Note: The shaded portion of 24J is not intended to be additional lines. Do not enter data in the shaded portion.

Item 25 (Required)

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

Item 26 (Medicare providers are not required to complete this item.)

Enter the patient’s account number assigned by the providers of service or suppliers 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 (Required)

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 PAs, NPs, CNSs, nurse midwives, CRNAs, 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

For more information on Mandatory Assignment, please refer to CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 30.3.1.

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

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

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

CMS instructs NGS to conduct an enrollment period on an annual basis in order to provide eligible physicians, practitioners and suppliers with an opportunity to make their calendar year Medicare participation decision by December 31. Open enrollment is mid-November through December 31st each year.

For more information on Participation Agreements, please refer to: CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 15, Section 15.14.6.

Item 28 (Required)

A “Total Charge” not to exceed six lines of service must be reported in Item 28 of each individual CMS-1500 claim form.

Multiple CMS-1500 claim forms with “continued…” or “see next page” or a single total in Item 28 for multiple CMS-1500 claim forms will be returned as unprocessed.

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

Item 29 (Leave blank when there is insurance primary to Medicare and complete Items 4, 6, 7 and 11.)

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 (Required)

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, 2020) the form was signed.

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

When the ordering physician or NPP is not supervising the service, then enter the signature of the physician or NPP providing the direct supervision in Item 31.

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 (Required)

Location where the service was rendered (Item 32) will be required for all POS codes on claims for anesthesia services and every service payable under the MPFS, for services provided in all places of service, including home.

On the CMS-1500 claim form, only one name, address and ZIP code may be entered. If additional entries are needed, separate claim forms shall be submitted.

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 CMS-1490S form, 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 for disposition of the claim. The A/B MACs 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.

HPSA: The complete address, including the ZIP code of the physical location where the service was rendered, shall be entered if other than home.

Certified Mammography Screening Center: Enter the six-digit FDA-approved certification number, when the supplier is a certified mammography-screening center.

Laboratory work performed outside the physician’s office: Enter the facility name and complete address, including the ZIP code. Complete this Item for all laboratory work performed outside the physician’s office.

Independent Laboratory: Enter the place where the test was performed, and the NPI.

Outside Agreements: Providers of service (namely physicians) shall identify the supplier's name, address, ZIP code and NPI when billing for antimarkup tests.

Antimarkup Tests: Providers of service (namely physicians) shall identify the supplier's name, address, ZIP code and NPI when billing for antimarkup tests.

Physicians/Suppliers Billing for Out-of-Jurisdiction Antimarkup Tests/Interpretations: Enter your facility address in Item 32. Do not report the address of the facility where the antimarkup test/interpretation was actually performed.

Note: Physicians/suppliers are not to report the NPI (Item 32b) of the out-of-jurisdiction physician/supplier when submitting a claim for an antimarkup test outside of the local contractor’s jurisdiction.

For more information on reporting the service location NPI on anti-markup and reference laboratory claims, refer to MLN Matters MM8806 Revised.

Supplier Personnel: Enter the physical location whether the supplier personnel perform the work at the physician’s office, or at another location.

Item 32a (If required by Medicare claims processing policy; enter the NPI of the service facility.)

Note: The facility NPI in Item 32a is only required in limited situations such as antimarkup tests or independent laboratory services.

When submitting claims for antimarkup, complete line Items 24J and 33 as noted below: 

  • Item 20 indicate yes if purchased a test
  • Item 24J is the rendering provider of the billing group
  • Item 32 is complete name, address and NPI of provider the test were purchased from
  • Item 33 is the billing provider

When billing for multiple antimarkup diagnostic tests, each test shall be submitted on a separate CMS-1500 claim form. Multiple antimarkup 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.

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

For more information, refer to CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 30.2.9. (1.70 MB)

Item 32b (Leave blank. Not required by Medicare.)

Item 33 (Required)

Enter the provider/supplier of service legal billing name, address, ZIP code and telephone number.

The medical billing is practicing in the regions of Jurisdictions 6 and K:

  • J6 (IL, MN, WI)
  • JK (CT, MA, ME, NH, NY, RI, VT)
Item 33a (Required)

Enter the NPI of the billing provider, group, clinic or organization.

Item 33b (Leave blank. Not required by Medicare.)

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CMS-1500 Claim Form Completion Instructions
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