Claim Filing Instructions for Paper and Electronic Submission
Providers are required to submit claims to Medicare Part B for their Medicare patients whether or not an assignment is taken. The provision requiring mandatory filing of the claim by providers also states that:
The Centers for Medicare & Medicaid Services (CMS) has determined that it is more cost effective to process Medicare paper claims by means of the Optical Character Recognition (OCR) system. Forms not printed in accordance with Government Printing Office (GPO) specifications are being rejected from OCR processing. If claims do not conform to GPO specifications, they will be returned. Handwritten forms are not acceptable for OCR processing. The following will help ensure that providers’ paper claims can be handled by the OCR system:
Position on Charging for Claim Form Completion
The CMS has established the following Medicare policy concerning the practice by providers of charging Medicare patients for completion of Medicare forms, durable medical equipment (DME) recertifications, prescriptions, etc.
Medicare Part B reimburses providers for medically necessary professional services. Charges upon which reimbursement is based are assumed to include all the components of rendering medical services, such as overhead and completing necessary documents, prescription drugs, and insurance forms. Any provider who accepts assignment and makes an additional charge for filing insurance forms or preparing prescriptions violates his/her assignment agreement.
Providers who do not accept assignment and charge for completing documents may violate section 9331(b) of the Omnibus Budget Reconciliation Act (OBRA) of 1986.
Claims That are Incomplete or Contain Invalid Information
If a claim is submitted with incomplete or invalid information, it may be returned to the submitter as unprocessable. The CMS Internet-Only Manual (IOM) Publication 100-4, Medicare Claims Processing Manual, Chapter 1, (1 MB) can be reviewed for definitions and instructions concerning the handling of incomplete or invalid claims.
Timely Filing of Claims
Claims for services furnished on or after January 1, 2010, must be filed within one calendar year after the date of service.
The provider’s failure to file a claim timely will result in the claim being denied. The patient may then only be charged 20 percent of the amount that Medicare would have approved for the service.
Time Limits on Filing Part B Reasonable Charge and Fee Schedule Claims
Medicare law prescribes specific time limits within which claims for benefits may be submitted with respect to physician and other Part B services payable on a reasonable charge or fee schedule basis (including those services for which the charge is related to cost).
Regulations changed by the patient protection and Affordable Care Act (PPACA) signed into law on March 23, 2010, enacts a new one year timely filing rule for dates of service on/after January 1, 2010.
Whenever the last day for timely filing of a claim falls on a Saturday, Sunday, federal nonwork day or legal holiday, the claim will be considered filed timely if it is filed on the next workday.
Health Insurance Claim CMS-1500 Form
The CMS-1500 form (Health Insurance Claim Form) is sometimes referred to as the American Medical Association (AMA) form. The CMS-1500 form is the prescribed form for claims prepared and submitted by physicians or suppliers (except for ambulance suppliers), whether or not the claims are assigned. It can be purchased in any version required i.e., single sheet, snap-out, continuous, etc. To purchase them from the United States GPO, call (202) 512-1800.
The revised version of the form is CMS-1500 form (08/05) and is approved under the Office of Management and Budget (OMB) collection 0938-0999. The current claim form was revised to accommodate the implementation of the National Provider Identifier (NPI), which is scheduled for completion of the implementation in May 2007. Initially April 1, 2007, was the implementation date for the 08/05 version of the CMS 1500 form. The final implementation date was extended by CMS to July 2, 2007.
The CMS-1500 form answers the needs of many health insurers. It is the basic form prescribed by CMS for the Medicare and Medicaid programs for claims from physicians and suppliers. It has also been adopted by the TRICARE program and has received the approval of the AMA Council on Medical Services.
There are a number of Part B services that have special limitations on payments or that require special methods of benefit computation. Carriers should monitor their processing systems to insure that they recognize the procedure codes that involve services with special payment limitations or calculation requirements. They should be able to identify separately billed procedure codes for physician services which are actually part of a global procedure code to prevent a greater payment than if the procedure were billed globally.
The following instructions must be completed or are required for a Medicare claim. Carriers should provide information on completing the CMS-1500 form to all physicians and suppliers in their area at least once a year.
Providers may use these instructions to complete this form. The CMS-1500 form has space for physicians and suppliers to provide information on other health insurance. This information can be used by carriers to determine whether the Medicare patient has other coverage that must be billed prior to Medicare payment, or whether there is another insurer to which Medicare can forward billing and payment data following adjudication if the provider is a physician or supplier that participates in Medicare. (Refer to the CMS IOM Publication 100-05, Medicare Secondary Payer Manual, Chapters 3 and 28.)
Providers and suppliers must report 8-digit dates in all date of birth fields (Items 3, 9b, and 11a), and either 6-digit or 8-digit dates in all other date fields (Items 11b, 12, 14, 16, 18, 19, 24a, and 31).
Providers and suppliers have the option of entering either a 6- or 8-digit date in Items 11b, 14, 16, 18, 19, or 24a. However, if a provider of service or supplier chooses to enter 8-digit dates for Items 11b, 14, 16, 18, 19, or 24a, he or she must enter 8-digit dates for all these fields. For instance, a provider of service or supplier will not be permitted to enter 8-digit dates for Items 11b, 14, 16, 18, 19, and a 6-digit date for Item 24a. The same applies to providers of service and suppliers who choose to submit 6-digit dates too. Items 12 and 31 are exempt from this requirement.
| Legend | Description |
MM |
Month (e.g., December = 12) |
DD |
Day (e.g., Dec15 = 15) |
YY |
2 position Year (e.g., 1998 = 98) |
CCYY |
4 position Year (e.g., 1998 = 1998) |
(MM | DD | YY) or (MM | DD | CCYY)
A space must be reported between month, day, and year (e.g., 12 | 15 | 98 or 12 | 15 |1998). This space is delineated by a dotted vertical line on the CMS-1500 form.
(MMDDYY) or (MMDDCCYY)
No space must be reported between month, day, and year (e.g., 121598 or 12151998). The date must be recorded as one continuous number.
Items 1–11 Patient and Insured Information
Item 1
Show the type of health insurance coverage applicable to this claim by checking the appropriate box, e.g., if a Medicare claim is being filed, check the Medicare box.
Item 1a
Enter the patient’s Medicare Health Insurance Claim number (HICN) whether Medicare is the primary or secondary payer. This is a required field.
Item 2
Enter the patient’s last name, first name, and middle initial, if any, as shown on the patient’s Medicare card. This is a required field.
Item 3
Enter the patient’s 8-digit birth date (MM | DD | CCYY) and sex.
Item 4
If there is insurance primary to Medicare, either through the patient’s or spouse’s employment or any other source, list the name of the insured here. When the insured and the patient are the same, enter the word “same”. If Medicare is primary, leave blank.
Item 5
Enter the patient’s mailing address and telephone number. On the first line enter the street address; the second line, the city and state; the third line, the ZIP Code and phone number.
Item 6
Check the appropriate box for patient’s relationship to insured when Item 4 is completed.
Item 7
Enter the insured’s address and telephone number. When the address is the same as the patient’s, enter the word “same”. Complete this Item only when Items 4, 6, and 11 are completed.
Item 8
Check the appropriate box for the patient’s marital status and whether employed or a student.
Item 9
Enter the last name, first name, and middle initial of the enrollee in a Medigap policy if it is different from that shown in Item 2. Otherwise, enter the word “same”. If no Medigap benefits are assigned, leave blank. This field may be used in the future for supplemental insurance plans.
Note: Only participating physicians and suppliers are to complete Item 9 and its subdivisions and only when the beneficiary wishes to assign his/her benefits under a Medigap policy to the participating physician or supplier.
Participating physicians and suppliers must enter information required in Item 9 and its subdivisions if requested by the beneficiary. Participating physicians/suppliers sign an agreement with Medicare to accept assignment of Medicare benefits for all Medicare patients. A claim for which a beneficiary elects to assign his/her benefits under a Medigap policy to a participating physician/supplier is called a mandated Medigap transfer (Chapter 28 of the CMS IOM Publication 100-04, Medicare Claims Processing Manual).
Medigap
Medigap policy meets the statutory definition of a “Medicare supplemental policy” contained in Section 1882(g)(1) of title XVIII of the Social Security Act (the Act) and the definition contained in the NAIC Model Regulation that is incorporated by reference to the statute. It is a health insurance policy or other health benefit plan offered by a private entity to those persons entitled to Medicare benefits and is specifically designed to supplement Medicare benefits. It fills in some of the “gaps” in Medicare coverage by providing payment for some of the charges for which Medicare does not have responsibility due to the applicability of deductibles, coinsurance amounts, or other limitations imposed by Medicare. It does not include limited benefit coverage available to Medicare beneficiaries such as “specified disease” or “hospital indemnity” coverage. Also, it explicitly excludes a policy or plan offered by an employer to employees or former employees, as well as that offered by a labor organization to members or former members.
Do not list other supplemental coverage in Item 9 and its subdivisions at the time a Medicare claim is filed. Other supplemental claims are forwarded automatically to the private insurer if the private insurer contracts with the carrier to send Medicare claim information electronically. If there is no such contract, the beneficiary must file his/her own supplemental claim.
Item 9a
Enter the policy and/or group number of the Medigap insured preceded by MEDIGAP, MG, or MGAP.
Note: Item 9d must be completed, even when the provider enters a policy and/or group number in Item 9a.
Item 9b
Enter the Medigap insured’s 8-digit birth date (MM | DD | CCYY) and sex.
Item 9c
Leave blank if a Medigap PAYERID is entered in Item 9d. Otherwise, enter the claims processing address of the Medigap insurer. Use an abbreviated street address, two-letter postal code, and ZIP Code copied from the Medigap insured’s Medigap identification card. For example:
1257 Anywhere Street
Baltimore, MD 21204
is shown as “1257 Anywhere St. MD 21204.”
Item 9d
Enter the 9-digit PAYERID number of the Medigap insurer. If no PAYERID number exists, then enter the Medigap insurance program or plan name.
If the beneficiary wants Medicare payment data forwarded to a Medigap insurer through the Medigap claim-based crossover process, the participating provider of service or supplier must accurately complete all of the information in Items 9, 9a, 9b, and 9d.
A Medicare participating provider or supplier shall only enter the COBA Medigap claim based ID within Item 9d when seeking to have the beneficiary’s claim crossed over to a Medigap insurer. If a participating provider or supplier enters the PAYERID or the Medigap insurer program or its plan name within Item 9d, the Medicare Part B contractor or DME Medicare administrative contractor (MAC) will be unable to forward the claim information to the Medigap insurer prior to October 1, 2007, or to the Coordination of Benefits Contractor (COBC) for transfer to the Medicare insurer on or after October 1, 2007. (See Chapter 28, Section 70.6.4 of the CMS IOM Publication 100-04, Medicare Claims Processing Manual, (672 KB) for more information concerning the COBA Medigap claim-based crossover process.)
Items 10a–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 State postal code. Any Item checked “yes” indicates there may be other insurance primary to Medicare. Identify primary insurance information in Item 11.
Item 10d
Use this Item exclusively for Medicaid (MCD) information. If the patient is entitled to Medicaid, enter the patient’s Medicaid number preceded by MCD.
Item 11
This Item must be completed, it is a required field. By completing this Item, the physician/supplier acknowledges having made a good faith effort to determine whether Medicare is the primary or secondary payer.
If there is insurance primary to Medicare, enter the insured’s policy or group number and proceed to Items 11a-11c. Items 4, 6, and 7 must also be completed.
Note: Enter the appropriate information in Item 11c if insurance primary to Medicare is indicated in Item 11.
If there is no insurance primary to Medicare, enter the word “none” and proceed to Item 12.
If the insured reports a terminating event with regard to insurance which had been primary to Medicare (e.g., insured retired), enter the word “none” and proceed to Item 11b.
If a lab has collected previously and retained Medicare Secondary Payer (MSP) information for a beneficiary, they 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 CMS-1500 form, when submitting a claim for payment of a reference lab service. Where there has been no face-to-face encounter with the beneficiary, the claim will then follow the normal claims process. When a lab has a face-to-face encounter with a beneficiary, the lab is expected to collect the Medicare Secondary Payer (MSP) information and bill accordingly.
Insurance Primary to Medicare—Circumstances under which Medicare payment may be secondary to other insurance include:
Note: For a paper claim to be considered for MSP benefits, a copy of the primary payer’s explanation of benefits (EOB) notice must be forwarded along with the claim form. (Refer to the CMS IOM Publication 100-05, Medicare Secondary Payer Manual, Chapter 3.) (272 KB)
Items 11a–13 Patient and Insured Information
Item 11a
Enter the insured’s 8-digit birth date (MM | DD | CCYY) and sex if different from Item 3.
Item 11b
Enter employer’s name, if applicable. If there is a change in the insured’s insurance status, e.g., retired, enter either a 6-digit (MM | DD | YY) or 8-digit (MM | DD | CCYY) retirement date preceded by the word “RETIRED.”
Item 11c
Enter the 9-digit PAYERID number of the primary insurer. If no PAYERID number exists, then enter the complete primary payer’s program or plan name. If the primary payer’s EOB does not contain the claims processing address, record the primary payer’s claims processing address directly on the EOB. 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
The patient or authorized representative must sign and enter either a 6-digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY), or an alpha-numeric date (e.g., January 1, 1998) unless the signature is on file. In lieu of signing the claim, the patient may sign a statement to be retained in the provider, physician, or supplier file in accordance with Chapter 1, “General Billing Requirements.” If the patient is physically or mentally unable to sign, a representative specified in Chapter 1, “General Billing Requirements” may sign on the patient’s behalf. In this event, the statement’s signature line must indicate the patient’s name followed by “by” the representative’s name, address, relationship to the patient, and the reason the patient cannot sign. The authorization is effective indefinitely unless patient or the patient’s representative revokes this arrangement.
Note: This can be “Signature on File” and/or a computer generated signature. The patient’s signature authorizes release of medical information necessary to process the claim. It also authorizes payment of benefits to the provider of service or supplier when the provider of service or supplier accepts assignment on the claim.
Signature by Mark (X)
When an illiterate or physically handicapped enrollee signs by mark, a witness must enter his/her name and address next to the mark.
Item 13
The patient’s signature or the statement “signature on file” in this item authorizes payment of medical benefits to the physician or supplier. The patient or his/her authorized representative signs this item or the signature must be on file separately with the provider as an authorization. However, note that when payment under the Act can only be made on an assignment-related basis or when payment is for services furnished by a participating physician or supplier, a patient’s signature or a “signature on file” is not required in order for Medicare payment to be made directly to the physician or supplier.
The presence of or lack of a signature or “signature on file” in this field will be indicated as such to any downstream Coordination of Benefits trading partners (supplemental insurers) with whom CMS has a payer-to-payer coordination of benefits relationship. Medicare has no control over how supplemental claims are processed, so it is important that providers accurately address this field as it may affect supplemental payments to providers and/or their patients.
In addition, the signature in this Item authorizes payment of mandated Medigap benefits to the participating physician or supplier if required Medigap information is included in Item 9 and its subdivisions. The patient or his/her authorized representative signs this Item or the signature must be on file as a separate Medigap authorization. The Medigap assignment on file in the participating provider of service/supplier’s office must be insurer specific. It may state that the authorization applies to all occasions of service until it is revoked.
Note: This can be “Signature on File” signature and/or a computer generated signature.
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, 6-digit: (MM | DD | YY) or 8-digit: (MM | DD | CCYY); intermixing the two formats on the claim is not allowed.
Item 14
Enter either an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date of current illness, injury, or pregnancy. For chiropractic services, enter an 8-digit (MM |DD | CCYY) or 6-digit (MM | DD | YY) date of the initiation of the course of treatment and enter an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date in Item 19.
Item 15
Leave blank. Not required by Medicare.
Item 16
If the patient is employed and is unable to work in his/her current occupation, enter an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date when patient is unable to work. An entry in this field may indicate employment related insurance coverage.
Item 17
Enter of the referring or ordering physician if the service or Item was ordered or referred by a physician. All physicians who order services or refer Medicare beneficiaries must report this data. When a claim involves multiple referring and/or ordering physicians, a separate Form CMS-1500 shall be used for each ordering/referring physician.
The term “physician” when used within the meaning of Section 1861(r) of the Act and used in connection with performing any function or action refers to:
Referring physician– is a physician who requests an Item or service for the beneficiary for which payment may be made under the Medicare program.
Ordering physician–is a physician or, when appropriate, a nonphysician practitioner who orders nonphysician services for the patient. Refer to the CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, (1 MB) for nonphysician practitioner rules. Examples of services that might be ordered include diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, DME, 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 Section 1833(q) of the Act. All claims for Medicare covered services and Items that are the result of a physician’s order or referral shall include the ordering/referring physician’s name. See Items 17a and 17b below for further guidance on reporting the referring/ordering provider’s NPI. The following services/situations require the submission of the referring/ordering provider information:
Item 17a
Not required
Item 17b
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.
Item 18
Enter either an 8-digit (MM | DD | CCYY) or a 6-digit (MM | DD | YY) date when a medical service is furnished as a result of, or subsequent to, a related hospitalization.
Item 19
Enter either a 6-digit (MM | DD | YY) or an 8-digit (MM | DD | CCYY) date patient was last seen and the NPI of his/her attending physician when a physician providing routine foot care submits claims.
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 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.
Enter either a 6-digit (MM | DD | YY) or an 8-digit (MM | DD | CCYY) x-ray date for chiropractor services (if an x-ray, rather than a physical examination was the method used to demonstrate the 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 MB) are on file, along with the appropriate x-ray and all are available for carrier review.
Enter the drug’s name and dosage when submitting a claim for Not Otherwise Classified (NOC) drugs.
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.
Enter the statement “Homebound” when an independent laboratory renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient. (See CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, (1 MB) “Covered Medical and Other Health Services,” and CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 16, (450 KB) Laboratory Services from Independent Labs, Physicians and Providers, and CMS IOM Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, (233 KB) Definitions, respectively for the definition of “homebound” and a more complete definition of a medically necessary laboratory service to a homebound or an institutional patient.)
Enter the statement, “Patient refuses to assign benefits” when the beneficiary absolutely refuses to assign benefits to a nonparticipating physician/supplier who accepts assignment on a claim. In this case, payment can only be made directly to the beneficiary.
Enter the statement, “Testing for hearing aid” when billing services involving the testing of a hearing aid(s) is used to obtain intentional denials when other payers are involved.
When dental examinations are billed, enter the specific surgery for which the exam is being performed.
Enter the specific name and dosage amount when low osmolar contrast material is billed, but only if HCPCS codes do not cover them.
Enter a 6-digit (MM | DD | YY) or an 8-digit (MM | DD | CCYY) assumed and/or relinquished date for a global surgery claim when providers share postoperative care.
Enter demonstration ID number “30” for all national emphysema treatment trial claims.
Enter the NPI of the physician who is performing a purchased interpretation of a diagnostic test. (Refer to the CMS IOM Publication 100-04, Chapter 1, Section 30.2.9.1 for additional information.)
Method II suppliers shall enter the most current HCT value for the injection of Aranesp for end-stage renal disease (ESRD beneficiaries on dialysis. (Refer to the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 8, Section 60.7.2.) (1 MB)
Individuals and entities who bill carriers or A/B MACs 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.
Item 20
Complete this Item when billing for diagnostic tests subject to anti-markup payment limitations (fomerly known as 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 CMS- 1500 form. 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. Refer to the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 1. (1 MB)
Note: This is a required field when billing for diagnostic tests subject to anti-markup limitations.
Item 21
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. All narrative diagnoses for nonphysician specialties shall be submitted on an attachment.
Item 22
Leave blank. Not required by Medicare.
Item 23
Enter the quality improvement organization (QIO) prior authorization number for those procedures requiring QIO prior approval.
Enter the Investigational Device Exemption (IDE) number when an investigational device is used in an FDA-approved clinical trial. The Post Market Approval number should also be placed here when applicable. For physicians performing care plan oversight services, enter the NPI of the home health agency (HHA) or hospice when CPT code G0181 (HH) or G0182 (Hospice) is billed.
Enter the 10-digit Clinical Laboratory Improvement Act (CLIA) certification number for laboratory services billed by an entity performing CLIA-covered procedures.
Note: Item 23 can contain only one condition. Any additional conditions should be reported on a separate CMS-1500 form.
Item 24
The six service lines in section 24 have been divided horizontally to accommodate 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 line item in positions 01 through position 13. The NDC is to be preceded with the qualifier N4 and followed immediately by the 11 digit NDC code (e.g. N499999999999). Report the NDC quantity in positions 17 through 24 of the same red shaded portion. The quantity is to be preceded by the appropriate qualifier: UN (units), F2 (international units), GR (gram) or ML (milliliter). There are six bytes available for quantity. If the quantity is less than six bytes, left justify and space-fill the remaining positions (e.g. UN2 or F2999999).
Item 24A
Enter a 6- or 8-digit (MMDDCCYY) date for each procedure, service, or supply. When “from” and “to” dates are shown for a series of identical services, enter the number of days or units in column G. This is a required field. Return as unprocessable if a date of service extends more than one day and a valid “to” date is not present.
Item 24B
Enter the appropriate place of service code(s) from the list provided in the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Section 10.5. Identify the location, using a place of service code, for each Item used or service performed. This is a required field.
Note: When a service is rendered to a hospital inpatient, use the “inpatient hospital” code.
Item 24C
Medicare providers are not required to complete this Item.
Item 24D
Enter the procedures, services, or supplies using the CMS Healthcare Common Procedure Coding System (HCPCS) code. When applicable, show HCPCS code modifiers with the HCPCS code. The CMS-1500 form (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. This is a required field.
Return as unprocessable if an “unlisted procedure code” or a NOC code is indicated in Item 24d, but an accompanying narrative is not present in Item 19 or on an attachment.
Item 24E
Enter the diagnosis code reference number as 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. This is a required field.
If a situation arises where two or more diagnoses are required for a procedure code (e.g., pap smears), the provider shall reference only one of the diagnoses in Item 21.
Item 24F
Enter the charge for each listed service.
Item 24G
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, refer to CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 20, Section 130.6. (631 KB)
Beginning with dates of service on and after January 1, 2011, for ambulance mileage, enter the number of loaded miles traveled rounded up to the nearest tenth of a mile up to 100 miles. For mileage totaling 100 miles and greater, enter the number of covered miles rounded up to the nearest whole number miles. If the total mileage is less than 1 whole mile, enter a “0” before the decimal (e.g. 0.9). See CMS IOM Publication 100-04, Chapter 15, (733 KB) §20.2 for more information on loaded mileage and §30.1.2 for more information on reporting fractional mileage.
Note: This field should contain an appropriate numerical value. The B/MAC should program their system to automatically default "1" unit when the information in this field is missing to avoid returning as unprocessable, except on claims for ambulance mileage. For ambulance mileage claims, contractors shall automatically default “0.1” unit when total mileage units are missing in this field.
Item 24H
Leave blank. Not required by Medicare.
Item 24I
Enter the ID qualifier 1C in the shaded portion.
Item 24J
Enter the rendering provider’s National Provider Identifier (NPI) in the lower unshaded portion. In the case of a service provided incident to the service of a physician or nonphysician practitioner, when the person who ordered the service is not supervising, enter the NPI of the supervisor.
This 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
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 coordination of benefits (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. If Medigap is indicated in Item 9 and Medigap payment authorization is given in Item 13, the provider of service or supplier shall also be a Medicare participating provider of service or supplier and accept assignment of Medicare benefits for all covered charges for all patients.
The following providers of service/suppliers and claims can only be paid on an assignment basis:
Item 28
Enter total charges for the services (i.e., total of all charges in Item 24f).
Item 29
Enter the total amount the patient paid on the covered services only.
Item 30
Leave blank. Not required by Medicare.
Item 31
Enter the signature of provider of service or supplier, or his/her representative, and either the 6-digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY), or alphanumeric date (e.g., January 1, 1998) 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 as in 42 Code of Federal Regulation 410.32, 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
Enter the name and address, and ZIP Code of the facility when the services are furnished in any service location other than the patient’s home (12). Only one name, address and ZIP Code may be entered in this Item. If additional entries are needed, separate claim forms shall be submitted. Effective January 1, 2011, for claims processed on or after January 1, 2011, submission of the location where the service was rendered will be required for all POS codes.
Providers of service (namely physicians) shall identify the supplier’s name, address, and ZIP Code when billing for anti-markup tests. When more than one supplier is used, a separate CMS-1500 form must be used to bill for each supplier.
For foreign claims, only the enrollee can file for Part B benefits rendered outside of the United States. These claims will not include a valid ZIP Code. When a claim is received for these services on a beneficiary submitted 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 in CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 1, (1 MB) for disposition of the claim. The carrier processing the foreign claim will have to make necessary accommodations to verify that the claim is not returned as unprocessable due to the lack of a ZIP Code.
For DME orthotic and prosthetic claims, the name and address of the location where the order was accepted must be entered (DME MAC only). This Item is required. When more than one supplier is used, a separate CMS-1500 form shall be used to bill for each supplier. This Item is completed whether the supplier’s personnel performs the work at the physician’s office or at another location.
If the supplier is a certified mammography screening center, enter the 6-digit Federal Drug Administration (FDA)-approved certification number.
Complete this Item for all laboratory work performed outside a physician’s office. If an independent laboratory is billing, enter the place where the test was performed.
Item 32a
If required by Medicare claims processing policy, enter the NPI of the service facility.
Item 32b
Not required.
Item 33
Enter the provider of service/supplier’s billing name, address, ZIP Code, and telephone number. This is a required field.
Item 33a
Enter the NPI of the billing provider or group. This is a required Item.
Item 33b
Not required.
This information is from the National Government Services web site and was last updated 6/13/2011.
Disclaimer: National Government Services makes no representation, warranty, or guarantee that the compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this information. Although every reasonable effort has been made to ensure accuracy of the information on this page at the time of publication, the Medicare program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare program requirements. Any regulations, policies and/or guidelines cited on this page are subject to change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid Services Web site at http://www.cms.gov.
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