Class # 6 "Understanding the CMS 1500 Form"
The CMS-1500 form, also known as the Healthcare Financing Administration (HCFA), and the Professional Paper Claim Form, is used for reimbursement from various government insurance plans including Medicare, Medicaid and Tricare. Although it was developed by The Centers for Medicare and Medicaid (CMS), it has become the standard form used by all insurance carriers. Typically it is what physicians and clinical practitioners use to submit claims for professional services, and hence is very important to the process of getting paid.
Let’s walk through the different sections and individual boxes on the CMS 1500 medical claim form:
Not including the space at the top for the carrier’s information, the form is divided into two sections: The top section (boxes 1–13) contains information about the subscriber and the patient. The bottom section (boxes 14–33) contains information about the provider and the patient’s treatment.
Located in the upper center and right margin of the form, you will find the section marked “Carrier.” This is where you enter the payer information including the insurance company name and address in the following format:
Line 1 Name
Line 2 First line of address
Line 3 Second line of address (if no second line, leave blank)
Line 4 City, state (two characters), and ZIP code
Please note: When entering a nine-digit ZIP code, include the hyphen. Do not use any other punctuation or symbols in the address (e.g., periods, commas, pound signs).
If there are four lines to the address, it will look like this:
ABC Insurance Company
567 Insurance Lane
Big City IL 60605
If there are three lines to the address, it will look like this:
ABC Insurance Company
567 Insurance Lane
Big City IL 60605
Patient and Insured/Subscriber Information
ITEM 1: TYPE OF COVERAGE: There are seven boxes to choose from. They are:
a. Medicare – patients over 65, disabled, handicapped
b. Medicaid – public assistance/welfare
c. TRICARE – active and retired armed forces personnel and their dependents
d. CHAMPVA – spouses and children of U.S. veterans
e. Group Health Plan
f. FECA/Black Lung – federal program
The first six boxes are for government programs and government employees. They are not checked for commercial claims. The last box, marked “Other,” is checked when you have a patient who carries a commercial plan, or for any claim involving liability insurance, an auto accident or workers’ compensation.
ITEM 1a: INSURED’S ID NUMBER: Report the number exactly as shown on the insured’s ID card.
FOR WORKERS’ COMPENSATION CLAIMS: Enter Employee ID number.
FOR PROPERTY AND CASUALTY CLAIMS: Enter Federal Tax ID or Social Security number of the insured person or entity.
ITEM 2: PATIENT’S NAME
• Enter as: LAST name, first name, middle initial
• Use commas to separate the last name, first name, and middle initial
• Hyphens can be used, but not periods
• If the subscriber uses a last name suffix (e.g., Jr, Sr, II, III), then it should be entered after the last name and before the first name: DOE Jr, John, J
ITEM 3: PATIENT’S DATE OF BIRTH AND SEX
• Enter date of birth only, in the format MMDDYYYY
• Enter an X in the correct box to indicate the sex of the patient. Only one box may be checked. If sex is unknown, leave blank.
ITEM 4: INSURED’S NAME
Enter the insured’s name according to Item 2 instructions, noting the following:
FOR WORKERS’ COMPENSATION CLAIMS: Enter the name of the employer.
FOR PROPERTY AND CASUALTY CLAIMS: Enter the name of the insured person or entity.
ITEM 5: PATIENT’S ADDRESS: If the patient’s address is the same as the insured’s address, then this section should remain blank. The patient’s address should correspond to the patient’s permanent residence. A temporary address or school address should not be used.
Note that no commas, periods or symbols are allowed in the address. There are no hyphens or spaces allowed in the phone number.
7803 S Market Street 203
Lincolnwood IL 60712
ITEM 6: PATIENT’S RELATIONSHIP TO INSURED: Enter an X in the correct box. The options are: Self, Spouse, Child, Other (employee, ward or dependent, as defined by the insured’s plan).
ITEM 7: INSURED’S ADDRESS: Enter the insured’s address by following the same instructions listed for Item 5. The insured’s address is the insured’s permanent residence, which may be different from the patient’s address in Item 5.
FOR WORKERS’ COMPENSATION CLAIMS: Enter the address of the employer.
FOR PROPERTY AND CASUALTY CLAIMS: Enter the address of the insured noted in Item 4.
ITEM 8: RESERVED FOR NUCC USE: Marital, employment and student status are no longer required and have been removed from this item.
ITEM 9: OTHER INSURED’S NAME: If additional group health coverage exists under a name that is different from that shown in Item 2, enter the other insured’s name according to Item 2 instructions. If Items 9, 9a and 9d are completed, then Item 11d should be marked as well. Otherwise leave blank.
ITEM 9a: OTHER INSURED’S POLICY OR GROUP NUMBER: Do not use hyphens or spaces within the policy or group number. If there is no policy or group number, state “NONE”.
ITEM 9b: RESERVED FOR NUCC USE: Other insured’s date of birth and sex are no longer required.
ITEM 9c: RESERVED FOR NUCC USE: Employer’s name or school name is no longer required.
ITEM 9d: OTHER INSURED’S PLAN OR PROGRAM NAME: Enter the secondary insurance plan name or program name.
ITEMS 10a-10c: IS PATIENT’S CONDITION RELATED TO: One or more categories can be checked, but only one box on each line may be checked.
a. Employment? (current or previous) – Mark “YES” or “NO”
b. Auto Accident? – Mark “YES” or “NO”
c. Other Accident? – Mark “YES” or “NO”
If a field is marked “YES,” then there may be other applicable insurance coverage that would be primary, such as auto insurance. Primary insurance information would then be stated in Item 11.
ITEM 10d: CLAIM CODES (Designated by NUCC): The most current instructions from the public or private payer dictate whether or not reporting Claim Codes is required. When applicable, use the NUCC Claim Codes to identify additional information about the patient’s condition or the claim.
If more than one code needs to be reported, enter one code followed by three blank spaces before entering the next code. Repeat as necessary.
FOR WORKERS’ COMPENSATION CLAIMS: When submitting a duplicate bill or an appeal, Condition Codes are required. The Original Reference Number must be recorded in Item 22 for these conditions. When submitting a revised or corrected bill, do not use Condition Codes.
The Condition Codes for workers’ compensation claims that are valid for use on the 1500 Health Insurance Claim Form are W2 (duplicate of original bill), W3 (Level 1 appeal), W4 (Level 2 appeal), and W5 (Level 3 appeal).
ITEM 11: INSURED’S POLICY, GROUP OR FECA NUMBER
Do not use hyphens or spaces, even if they appear in the number on the insurance card. It’s important to note that this applies to the number for health, auto or other coverage.
The FECA number is the nine-digit alphanumeric identifier assigned to a patient claiming work-related condition(s) under the Federal Employees Compensations Act 5 USC 8101.
ITEM 11a: INSURED’S DATE OF BIRTH AND SEX: Enter insured’s date of birth and sex according to Item 3 instructions.
ITEM 11b: OTHER CLAIM ID (Designated by NUCC): The qualifier and accompanying identifier below have been approved for use:
Y4 Property Casualty Claim Number
FOR WORKERS’ COMPENSATION OR PROPERTY AND CASUALTY CLAIMS: Enter the claim number assigned by the payer in the larger box (required, if known).
ITEM 11c: INSURANCE PLAN NAME OR PROGRAM NAME: List the name of the insurance plan or program. In some cases, payers require you to list the identification number of the primary insurer rather than the name in this field.
ITEM 11d: IS THERE ANOTHER HEALTH BENEFIT PLAN?: Enter X in the correct box. If marked “YES,” Items 9, 9a and 9d should also be completed. Note that secondary medical insurance takes precedence over dental insurance.
ITEM 12: PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE
• If available, enter original patient signature. If a signed document with the patient’s authorization for release of information is in the chart, “Signature on file” or “SOF” is permissible.
• If original signature is entered, the date signed must be stated as MMDDYY or MMDDYYYY
ITEM 13: INSURED’S OR AUTHORIZED PERSON’S SIGNATURE
• If available, enter original signature of the insured. If a signed document with the insured’s authorization for payment of benefits to the provider’s office is in the chart, “Signature on file” or “SOF” is permissible.
• If original insured’s signature is entered, the date signed must be stated as MMDDYY or MMDDYYYY
Physician or Supplier Information
ITEM 14: DATE OF CURRENT ILLNESS OR INJURY: State the date of the examination. Whether it is an initial exam or a repeat visit, the date when the patient first developed symptoms or the date the diagnosis was made is required. Also, enter the three-digit qualifier 431 (onset of current symptoms or illness).
ITEM 15: OTHER DATE
Enter an additional date related to the patient’s condition or prior treatment. State in either MMDDYY or MMDDYYYY format.
Enter the appropriate three-digit qualifier to define which date is being reported:
454 Initial treatment
304 Latest visit or consultation
453 Acute manifestation of a chronic condition
455 Last X-ray
090 Report start (assumed care date)
091 Report end (relinquished care date)
444 First visit or consultation
ITEM 16: DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION: Typically, this is only indicated for accidents rendering the patient unable to work.
ITEM 17: NAME OF REFERRING PROVIDER OR OTHER SOURCE
When multiple providers are involved in treating the patient, identify one provider using the following priority order: (1) referring provider, (2) ordering provider, (3) supervising provider. Enter the applicable qualifier to identify which provider is being reported: DN (referring provider), DK(ordering provider), DQ (supervising provider).
• Enter as: first name, middle initial, last name and university-bestowed credentials (e.g., MD) of the referring provider
• Note: If filing electronically, the degree(s) cannot be stated
• Do not use periods or commas in the name or in the degree(s)
ITEMS 17a AND 17b: ID NUMBER OF PROVIDER
• Item 17a is no longer used, unless required by an individual insurance company. If necessary, only one of these numbers would be requested: 0B (state license number), 1G (provider UPIN number), G2 (provider commercial number), LU (location number).
• In Item 17b, enter 10-digit NPI number, which can be looked up on the NPPES website
ITEM 18: HOSPITALIZATION DATES RELATED TO CURRENT SERVICES: For patients that were treated in a hospital, enter the admission and discharge dates in either MMDDYY or MMDDYYYY format.
ITEM 19: RESERVED FOR LOCAL USE/REPORTING ATTACHMENTS: When attaching necessary documentation to a claim, it is important that descriptions not be used. Instead, the documents must be coded as follows:
Step 1: State the letters PWK
Step 2: Indicate the attachment/report submitted
Step 3: Indicate the transmission code
REPORT TYPE CODES
04 Drugs administered
05 Treatment diagnosis
06 Initial assessment (e.g., head and neck evaluation from first encounter)
08 Plan of treatment
09 Progress report
10 Continued treatment
13 Certified test report (e.g., sleep study)
A3 Allergies/sensitivities document
B3 Physician order
B4 Referral form
CK Consent form(s)
DA Dental models
DB Durable medical equipment prescription (e.g., request for fabrication of sleep apnea appliance from a referring M.D.)
DG Diagnostic report (e.g., TMD report)
DS Discharge summary (from hospital or ER)
EB Explanation of benefits (coordination of benefits or Medicare secondary payer)
LA Laboratory results (from brush biopsy or smear, blood/genetic testing)
M1 Medical record attachment (M.D. progress notes)
OB Operative note
OE Objective physical examination (including vital signs) document
OZ Support data for claim (police report)
P4 Pathology report
P5 Patient medical history document
PN Physical therapy notes
PY Physician’s report (DDS or DMD SOAP notes, LMN from an M.D.)
RB Radiology films
RR Radiology reports
XP Clinical photographs
TRANSMISSION TYPE CODES
AA Available on request at provider site
BM By mail
IMPORTANT: Three spaces are required between each set of data reported. Thus, if you are, for example, going to be providing a head and neck evaluation, SOAP notes, and an operative report, this information would be entered in Item 19 as follows:
PWK06BM PWKPYBM PWKOBBM
If the information will not be sent with the claim (for electronic filing and Medicare claims), then the information would be entered like this:
PWK06AA PWKPYAA PWKOBAA
ITEM 20: OUTSIDE LAB AND RELATED CHARGES: Note that if multiple labs are used, separate claim forms are required for each purchased service. For purchased services:
• Enter the amount in the field to the left of the vertical line
• Use 00 for the cents if the amount is a whole number
• Do not report anything in the right-hand field next to the “$ Charges” column (leave blank)
• Do not use commas, decimal points, or dollar signs, e.g., $1125.00 should be stated as 112500 to the left of the vertical line
Indicate the name and address of the independent provider (lab name, if the lab is billing the office — this includes pathology and prosthetic labs) from whom services were purchased in Item 32.
ITEM 21: DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
In the parentheses in the upper right corner of this box, enter the applicable single-digit ICD indicator to identify which version of ICD codes is being reported. This will be either 9 (ICD-9-CM) or 0 (ICD-10-CM).
CORRECT DIAGNOSIS CODING ORDER
• Prioritization of diagnoses is very important: A maximum of 12 codes is allowed
• ICD codes should be prioritized from the most important problem being treated to the least significant one affecting the patient’s condition
• V codes next (describing patient history factors affecting treatment)
• E codes should be last (side effects of medications, descriptors, or how an accident occurred). If the claim is for any type of accident, then there must be at least one E code indicating how the accident occurred listed.
• When identifying a screening code, it is always stated first, followed by other diagnoses in the above order
ITEM 22: RESUBMISSION AND ORIGINAL REFERENCE NUMBER: If resubmitting a claim, state the original reference or claim number. The single-digit bill frequency code should be entered either as 7 (replacement of prior claim) or 8 (void/cancel prior claim), left-justified in the left-hand side of the field.
ITEM 23: PRIOR AUTHORIZATION NUMBER
• A reference/authorization number is provided when a phone pre-authorization is called in for a CT scan or other service after approval by a registered nurse
• A number is also provided by medical/pharmacy review when a written pre-authorization has been submitted and approved. Online and written pre-authorizations are recommended. If checking benefits by phone, the reference number that you receive is not an authorization number.
• Prior authorization is required for the following elective (nonemergency) services: CT scans, diagnostic tests, Botox, and surgical procedures
• Not required for diagnostic or therapeutic procedures
ITEM 24a: DATES OF SERVICE: Stated in chronological order (separate claims are recommended for each date of service). The same date appears in both columns.
ITEM 24b: PLACE OF SERVICE: The Place of Service codes most commonly used by dentists are 11 (office), 22 (outpatient, hospital), and 24 (ambulatory surgical facility).
ITEM 24c: EMERGENCY TREATMENT: Enter Y for “yes” next to each medically billable procedure provided on an emergency basis. This is not only for traumatic injuries, but can also be used in situations such as an emergency curettage of a periodontal abscess, an incision and drainage procedure, removal of a painful impacted wisdom tooth, and removal of a fractured tooth. Any patient with pain, swelling, discomfort, infection or inflammation is considered an emergency patient.
ITEM 24d: CODING SERVICES
• Code every billable service
• Do not unbundle procedures
• Up to four modifiers are allowed to further describe surgical procedures
LISTING THE PROCEDURES ON THE CLAIM FORM:
• List all diagnostic and therapeutic services in the order in which they were performed
• List surgical procedures from highest cost to lowest cost in each jaw
• Add modifiers to further define procedures
COMMONLY USED MODIFIERS:
22 Procedure performed was more extensive or complicated than the CPT description. For example, when used with code 21249, this modifier indicates that seven or more fixtures were placed in the same jaw and requires documentation in the form of details in the operative report.
25 Exam performed on same day as a therapeutic or surgical procedure and not recently performed when the diagnosis to treat was made. Without this modifier, an exam performed on the same day as any surgical or therapeutic treatment, such as a pain relief orthotic, a biopsy when referred from another, or an emergency extraction, will not be paid as a separate procedure, and reimbursement will only be provided for the treatment.
47 Sedation or nitrous oxide analgesia
50 Bilateral procedure, i.e., same procedure performed on both sides of the same jaw. Note that this cannot be reported with modifier 59.
51 Additional procedure. Use this modifier for all additional procedures in the same site (e.g., at the same incision site) as that of the main procedure.
52 Procedure performed was less involved than the CPT code description. For example, when used with code 21210 or 21215, both of which signify autogenous harvesting, this modifier indicates that demineralized freeze-dried bone allograft was used instead of the patient’s own bone taken from another site.
59 Distinct and separate procedure. Note that this modifier can no longer be reported with modifier 50.
99 When two or more modifiers are needed to describe a surgical procedure, they must be preceded by the modifier 99.
ITEM 24e: DIAGNOSIS POINTER: Enter the diagnosis code reference letter(s) from Item 21 that correspond with the service performed, noting the following:
• Each procedure must relate to at least one, but no more than four, diagnoses
• Radiographic codes will only relate to those codes that describe problems that can be seen on a radiograph, e.g., hard-tissue problems (teeth, or problems in the bone/jaw)
• Enter diagnosis code reference letter(s) in alphabetical order, without spaces or commas (e.g., ABCD)
ENTERING INFORMATION IN THE SHADED AREA OF SECTION 24
The following are the types of supplemental information that should be entered by the dentist in the shaded areas of section 24:
• Narrative descriptions for codes ending in 89 or 99
• Tooth numbers and areas of the oral cavity
• National Drug Codes (NDC) for drugs administered orally, subcutaneously, intramuscularly or intravenously
• Contracted rates for participating providers of medical plans
Only the following qualifiers can be used when reporting these services. Do not enter a space between the qualifier and the explanation. Do not enter hyphens or spaces within the number/code. More than one qualifier can be used. Enter the first qualifier and number/code/information. After the first item, leave three blank spaces, and then enter the next qualifier and number/code/information.
ZZ Narrative description of unspecified codes, ending in 89 or 99
JO Dentistry designation system for tooth and areas of the oral cavity
JP Universal/National Tooth Designation System
CTR Contracted rate
ITEM 24f: PROVIDER’S FEES: Enter the fee for each service, noting the following:
• No dollar signs, commas or periods are allowed when reporting fees
• For surgical fees only, the charges decrease down the column as the importance of the procedure decreases; the most extensive procedure in each jaw has the highest fee and the fees go down from there. When you switch to the other jaw, the fees again start with the highest and go down to the lowest fee.
• It is not illegal to have different fees in different practice locations
• Procedures are assigned fee ranges based on the ZIP codes of where the services were performed
ITEM 24g: DAYS OR UNITS: Enter the appropriate number of days or units, noting the following:
• When multiples of the same procedure are performed, such as biopsies and extractions, the code is stated once and the number of times that exact procedure was performed is stated here
• The total charge is then stated in Item 24f
• If only one service is performed, the number 1 must be entered
• Anesthesia services must be reported as minutes
ITEM 24h: EARLY & PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) FAMILY PLAN: This item is not relevant to oral/dental claim submissions.
ITEM 24i: ID QUALIFIER: This is not required unless a provider is participating in a medical plan. If the rendering provider has a medical participating provider ID number, then it should be stated here, with the following ID Qualifier: 1G (provider UPIN number). If the rendering provider is a participating or contracted medical provider with BCBS, then the code 1B should be used, followed by the provider’s UPIN.
ITEM 24j: RENDERING PROVIDER ID NUMBER: Required on all claims.
ITEM 25: FEDERAL TAX ID NUMBER
• State either the practice’s federal EIN or the doctor’s SSN without using hyphens, e.g., 321984567
• Check the appropriate box
ITEM 26: PATIENT’S ACCOUNT NUMBER
• The patient may have an account number with your office
• Not necessary to indicate
• For quick reference when check is issued
ITEM 27: ACCEPT ASSIGNMENT
COMMERCIAL CLAIM: Entering an X in the “YES” box indicates that the provider agrees to accept assignment under the terms of the payer’s program.
MEDICARE: Check the appropriate box to indicate whether the provider accepts assignment of Medicare benefits. Participating providers can only select “YES.” Nonparticipating providers who have a UPIN can select either “YES” or “NO” on a claim-by-claim basis. Reimbursement amounts and billing balance will be affected by the provider’s selection. If Medigap (supplemental Medicare insurance) is indicated in Item 9d and Medigap payment authorization is given in Item 13, the provider must also be a Medicare participating provider and accept assignment of Medicare benefits for all covered charges for all patients. Providers that have opted out of Medicare cannot bill Medicare for their services. In addition, the patient cannot submit a bill for services from a provider who has opted out.
ITEMS 28-30: CHARGES AND PAYMENTS
Item 28: Total of all fees being charged
Item 29: Payments made by patient or other payers (attach EOB)
Item 30: Reserved for NUCC use. Leave blank.
ITEM 31: SIGNATURE OF PROVIDER: The forms of acceptable signature include the legal signature of the doctor, the signature of a provider representative, “Signature on File”, and “SOF”. When filing electronically, the degree(s) cannot be stated. Doing so will cause the clearing house software to declare the claim “invalid.”
ITEM 32: SERVICE FACILITY LOCATION INFORMATION: Enter the name, address, city, state and ZIP code of the location where the services were rendered, noting the following:
• If payment was made to a supplier, such as a laboratory that billed the office (not the patient or insurance company), then the supplier’s name, address, ZIP code and NPI number must be provided
• If the location is a part or subdivision of the billing provider and has its own NPI number that is reported on the claim, then the subdivision is reported as the billing provider under Item 33 and the service facility location is not indicated
• When reporting the service facility location, the entity must be an external organization to the billing provider. Only report the facility if it is different from the billing provider location. The exception is BCBS plans, which require the same information in both Items 32 and 33 if there was no lab used.
• For diagnostic testing, state the name and location of the laboratory and its NPI number
• The Federal Tax ID number can no longer be used if the lab or service facility does not have an NPI number. Instead, enter one of the following two-digit qualifiers in Item 32b along with the corresponding number: 0B (state license number), G2 (provider commercial number), LU (location number). For example, a lab with no NPI number would have its information entered like this: 0B983435678 (with Item 32a left blank).
ITEM 33: PROVIDER BILLING INFORMATION
For an individual provider:
Line 1: Individual billing provider name
Line 2: Address
Line 3: City, state, nine-digit ZIP code
For a group practice or corporation:
Line 1: Individual billing provider name
Line 2: Address
Line 3: City, state, nine-digit ZIP code
ITEM 33a: Enter the billing provider’s NPI number.
ITEM 33b: The non-NPI ID number of the billing provider refers to either the state license number or the payer-assigned unique identifier for the professional, if it is different from the rendering provider non-NPI ID number stated in Item 24j.
0B State license number
G2 Provider commercial number (assigned by third-party payer, e.g., BCBS)
Note that in some states, Blue Cross and Blue Shield require a provider ID number even if the doctor is not a participating provider. Apply for it by completing a simple form.
Please view the videos below.
Optional reading assignment:
(Understanding Health Insurance, by Green and Rowell. 10th Edition)
"Essential CMS-1500 Claim Instruction", pages 371-392.