Block-By-Block Instructions for completion of the CMS-1500 (02-12)
Block 10d: Workers' Compensation Claims:
A condition code is required when submitting a bill that is a duplicate (W2) or an appeal (W3=Level 1, W4=Level 2, W5=Level 3). ( The original reference number must be entered in Block 22 for these conditions.) Do not use condition codes when submitting a revised or corrected bill.
Block 19: Workers' Compensation Claims:
Additional claim information is required on Jurisdictional Workers' Compensation Guidelines.
Block 5:TRICARE Claim:
An APO/FPO (Army Post Office/Fleet Post Office) address should not be used unless that person is residing overseas. Enter the patient's actual place of residence and not a post office box number.
Block 5:CHAMPVA Claim :
An APO/FPO address should not be used unless that person is residing overseas. Enter the patient's actual place of residence and not a post office box number.
Block 6:Workers' Compensation Claims:
Check"Other"
Block 1a:Workers' Compensation Claim
Enter employee ID or workers' compensation claim number. If none is assigned the employer's policy number.
Block 7:TRICARE Claims, CHAMPVA Claims:
Enter sponsor's address (Ex: an APO/FPO, address, active duty sponsor's duty station, or the retiree's mailing address) if different from the patient's address
Block 11a: TRICARE Claims:
Enter sponsor's date of birth and gender if it is different from that listed in Block 3.
Block 11a:CHAMPVA Claims:
Enter sponsor's date of birth and gender if it is different from that listed in Block 3.
Block 1a:Property and Casual Claims
Enter the Federal Tax ID or SSN of the insured person or entity.
Block 7:Workers' Compensation Claims, Property and Casualty Claims:
Enter the employer's address. If required by a payer to report a telephone number, do not use a hyphen.
Block 4: Workers' Compensation Claims:
Enter the name of employer
Block 4: Property and Casualty Claims:
Enter the name of the insured person or entity.
Block 1a:TRICARE Claims
Enter the sponsor's SSN or Department of Veterans Affairs (VA) file number.
Block 1a:CHAMPVA Claims
Enter the sponsor's SSN or VA file number.
Block 11b: CHAMPVA Claims:
Enter the sponsor's branch of service, suing abbreviations.
Block 11b: TRICARE Claims:
Enter the sponsor's branch of service, using abbreviations ( Ex: Untied States Navy=USN).
Block 11:CHAMPVA Claims:
Enter the three-digit number of the VA station that issued the identification card.
Block 26: Patient's Account No:
Identifier assigned by the provider. Enter the patient's account number assigned by the provider of service's or supplier's accounting system.
Block 19: Additional Claim Information (Designated by NUCC): When reporting a second item of data, enter three blank spaces and then the next qualifier and number/code/ information. The NUCC defines the following qualifiers, since they are the same as those used in 5010A1: 0B State License Number 1G Provider UPIN Number G2 Provider Commercial Number LU Location Number (qualifier is used for Supervising Provider only.) N5 Provider Plan Network Identification Number SY SSN * may not be used for Medicare. X5 State Industrial Accident Provider Number ZZ Provider Taxonomy (qualifier in the 5010A1 for Provider Taxonomy is PXC, (but ZZ will remain the qualifier for the 1500 Claim Form. )
Identifies additional information about the patient's condition or the claim. Refer to the most current instructions from the public and private payer regarding the use of this field. Some payers ask for certain identifiers in this field. Ex: when modifiers 99 (multiple modifiers) is entered in Block 24D, an explanation of the modifiers might be inserted in Block 19. If identifiers are reported in this field, enter the appropriate qualifiers describing the identifier. Do not enter a space, hyphen, or other separator between the qualifier code and the number.
Block 23: Prior Authorization Number: No Hyphens, or spaces within the number.
Identifies the payer assigned number authorizing the service(s). Enter any of the following: prior authorization number, referral number, mammography pre-certification number, or Clinical Lab Improvement Amendments (CLIA) number, as assigned by the payer for the current service.
Block 4: Insured's Name
Identifies the person who holds the policy, which would be the employee for employer-provided health insurance. Enter the Insured's full last name, first name, and middle initial. If the insured uses a last name suffix (Jr., Sr.), enter it after the last name, and before the first name. Titles and professional suffixes should not be included with the name.
Block 9a: Other insured's Policy or Group Number: Do not use hyphen or space as a separator within the policy or group number.
Identifies the policy or group number for coverage of the insured as indicated in block 9. Enter the policy or group number of the other or secondary insured.
Block 5:Property and Casualty Claims:
If required by a payer to report a telephone number, do not use a hyphen or space as a separator within the telephone number.
Block 5:Workers' Compensation Claims:
If required by a payer to report a telephone number, do not use a hyphen or space as a separator within the telephone number.
Block 17: CHAMPVA Claims:
If the patient is referred from an MTF, enter the name of the MTF, and attach DD Form 2161 or SF 513, "Referral for Civilian Medical Care."
Block 17: TRICARE Claims:
If the patient is referring from a Military Treatment Facility (MTF), enter the name of the MTF and attach DD Form 2161 or SF 513, "Referral for Civilian Medical Care."
Block 24I: ID Qualifier (Lines 1-6)
If the provider does not have an NPI number, enter the appropriate qualifier and identifying number in the shaded area. Enter in the shaded area of Block 24I the qualifier identifying if the number is a non-NPI. The Other ID number of the rendering provider should be reported in Block 24J in the shaded area.
Carrier Block approved by theNUCC
In the upper right hand corner of the CMS-1500 (02-12) form
Block 13: Insured's or Authorized Person's Signature:
Indicates that there is a signature on file authorizing payment of medical benefits. Enter "Signature on File," " SOF," or legal signature. If there is no signature on file, then leave blank or enter, "NO Signature on File."
Block 16: Dates Patient Unable to Work in Current Occupation:
Indicates the time span the patient is or was unable to work. If the patient is employed and is unable to work in current occupation, a 6-digit (MMDDYY) or 8-digit (MMDDYYYY) date must be shown for the "from-to" dates that the patient is unable to work. An entry in this field may indicate employment-related insurance coverage.
Block 18: Hospitalization Dates Related to Current Services:
Information in this field refers to an impatient stay and indicates the admission an discharge dates associated with the service(s) on the claim. Enter the inpatient 6-digit or 8-digit hospital admission date followed by the discharge date (if discharge has occurred). If not discharged, subsequent to, a related hospitalization.
Block 5: Patient's Address Do not use punctuation (commas, periods) or other symbols in the address. Ex: 123 N Main Street 101 instead of 123 N. Main Street, #101.
Is the patient's permanent residence. A temporary address or school address should not be used. Enter the patient's mailing address and telephone number. The first line is for the street address; the second line is for the city and two-character state code; the third line is for the zip code and phone number.
Block 11: TRICARE Claim
Leave Blank
Block 11: Workers' Compensation Claim:
Leave Blank
Block 11a: Workers' Compensation Claims:
Leave Blank
Block 11c: Workers' Compensation Claim:
Leave Blank
Block 9a Worker's Compensation Claims:
Leave Blank
Block 9d: Workers' Compensation Claims:
Leave Blank
Block 24H: Private payers, Medicare, TRICARE, CHAMPVA, Workers' Compensation Claim:
Leave blank
Block 9:Workers' Compensation Claims:
Leave blank. If the case is pending and not yet declared workers' compensation, insert "other insurance."
Block 24D: Procedures, Services, or Supplies (Lines 1-6)
Medical services and procedures provided to the patient. Enter the CPT or HCPCS code 9(s) and modifier(s) (if applicable) from the appropriate code set in effect on the date of service. This field accommodates the entry of up to four two-digit modifiers. The specific procedure code(s) must be shown without a narrative description.
Block 32: Service Facility Location Information: 1st Line: Name 2nd Line: Address 3rd Line City,State, and Zip Code (no commas, periods) Enter a space between town name and state code, 9 digit zip code include hyphen.
Name and address of the facility where services were rendered identifies the site where services were provided. Enter the name, address, city, state, and zip code of the location where the services were rendered. Providers of services (name of physician) must identify the supplier's name, address, zip code, and NPI number when billing for purchased diagnostic tests. When more than one supplier is used, a separated 1500 Claim Form should be used to bill for each supplier.
Block 11b: Property and Casualty Claims:
Required if known. Enter the claim number assigned by the payer.
Block 11b: Workers Compensation Claims:
Required if known. Enter the claim number assigned by the payer.
Block 9b: Reserved for NUCC Use:
Reserved for NUCC use. The NUCC will provide instructions for any use of this field.
Block 9c: Reserved for NUCC Use:
Reserved for NUCC use. The NUCC will provide instructions for any use of this field.
Block 10d: Claim codes(designated by NUCC) When required by payers to provide the sub-set of condition codes approved by the NUCC, enter the "Condition Code" in the field.
The "Claim Codes" identify additional information about the patient's condition or the claim. When applicable use the report "Claim Codes" designated by the NUCC. Refer to the most current instructions from the public or private payer regarding the need to report claim codes.
Block 24E: Diagnosis Pointer (Lines 1-6): The reference letter(s) should be A-L or multiple letters as applicable. ICD-9-CM or ICD-10-Cm diagnosis codes must be entered in Item Number 21 only. Do not enter them in Block 24E. Enter number left justified in the field. Do not use commas between the numbers.
The "Diagnois Pointer" is the line letter from Item Number 21 that relates to the reason the service(s) was performed. In Block 24E, enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference number for each service should be listed first, other applicable services should follow.
Block 21: Diagnosis of Nature of Illness or Injury: 9 ICD-9-CM 0 ICD-10-CM Enter the indicator between the vertical, dotted lines. Enter the patient's diagnosis and/or condition codes. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the latter of the line. Use the highest level of specificity. Do not provide narrative description in this field
The "ICD indicator" identifies the version of the ICD code set being reported. The "Diagnosis of Nature of Illness or Injury" is the sign, symptom, complaint, or condition of the patient relating to the service(s) on the claim. Enter the applicable ICD indicator to identify which version of ICD codes is being reported.
Block 15:Other Date 454 Initial Treatment 444 First Visit or Consultation 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-ray 471 Prescription 090 Report Start 091 Report End
The "Other Date" identifies additional date information about the patient's condition or treatment. Enter an "Other Date" related to the patient's condition or treatment. Enter the date in the 6-digit (MMDDYY) or 8-digit (MMDDYYYY) format. Previous pregnancies are not a similar illness. Leave blank if unknown. Enter the applicable qualifier between the vertical, dotted lines to identify which date is being reported.
Block 9: Other Insured's Name:
The "Other Insured's Name" indicates that there is a holder of another policy that may cover the patient. If Item Number 11d is marked YES, complete fields 9,9a, and 9d; otherwise, leave field 9,9a,and 9d blank. When additional group health coverage exists, enter other insured's full last name, first name, and middle initial of the enrollee in another health plan if it is different from that shown in Block 2.
Block 33a: NPI#:
The NPI # refers to the HIPAA National Provider Identifier # Enter the NPI# of the billing provider in Block 33a.
Block 32a: NPI# National Provider Identifier#:
The NPI number refers to the HIPAA NPI# if a service facility is entered in Block 32, enter the NPI# of the service facility location in BLock 32a.
Block 17b: NPI
The NPI number refers to the HIPAA National Provider Identifier number. Enter the NPI number of the referring, ordering, or supervising provider in Block 17b.
Block 8L Reserved for NUCC Use:
The NUCC will provide instructions for any use of this field.
Block 33: Billing Provider Info & Ph#: Identifies the provider requesting to be paid for the service rendered and should always be completed.
The billing provider's or supplier's billing name, address, zip code, and phone number is the billing office location and telephone number of the provider and supplier. Enter the provider's or supplier's billing name, address, zip code, phone number. The phone number is to be entered in the area to the right of the field title. Name line one, 2nd line address 3rd line city, state, and zip code.
Block 24J: Rendering Provider ID. # (Line 1-6): Enter numbers left justified in the block. Report the identification number of the rendering provider in Block 24I and 24J only when different from data recorded in Blocks 33a and 33b. Enter numbers left justified in the block.
The individual performing/rendering the service should be reported in Block 24J, and the qualifier indicating if the number is a non-NPI goes in Block 24J. The non-NPI ID number of the rendering provider refers to the payer-assigned unique identifier of the professional. The individual rendering the service should be reported in Block 24J. Enter the non-NPI ID number in the shaded area of the field. Enter the NPI in the unshaded area of the field.
Block 17: Name of Referring Provider or Other Source: If multiple providers are involved, enter one provider using the following priority order: 1. Referring provider 2. Ordering provider 3. Supervising provider Do not use periods periods or commas within the name. A hyphen can be used for hyphenated names. Enter the applicable qualifier to the left of the vertical, dotted lines to identify which provider is being reported. DN Reffering provider DK Ordering provider DQ Supervising provider
The name entered is the referring provider, ordering provider, or supervising provider who referred, ordered, or supervised the service(s) or supply(ies) on the claim. The qualifier indicates the role of the provider being reported. Enter the name (first name, middle initial, last name) and credentials of the professional who referred, ordered, or supervised the service(s) or supply(ies) on the claim.
Block 17a: Other ID Number: The NUCC defines the following qualifiers used in 5010AI: 0B State License Number 1G Provider UPIN Number G2 Provider Commercial Number LU Location Number (This qualifier is used for Supervising Provider only.)
The non-NPI ID number of the referring, ordering, or supervising provider is the unique identifier of the professional or provider designated taxonomy code. The other ID number of the referring, ordering, or supervising, provider is reported in 17a. The shade area. The qualifier indicated what the number represents is reported in the qualifier field to the immediate right of 17a.
Block 32b: Other ID#: 0B: State License Number G2: Provider Commercial Number LU: Location Number
The non-NPI ID number of the service facility is the payer-assigned unique identifier of the facility. Enter the two-digit qualifier identifying the non-NPI # followed by the ID number: Do not enter a space, hyphen, or other separator between the qualifer and the number.
Block 33b: Other ID#:
The non-NPI number of the billing provider refers to the payer assigned unique identifier of the professional. Enter the two digit qualifier identifying the non-NPI number following the ID#. No space, hyphen, or separator between the qualifier and the number.
Block 3: Patient's BirthDate, Sex Birth: Newborn diagnosis Birth to 17 years: Pediatric diagnosis 12-55 years:Maternity diagnosis 15-124 years: Adult diagnosis
The patient's birthdate and sex (gender) is information that will identify the patient, and it distinguishes persons with similar names. Enter each patient's 8-digit birth date (MM/DD/YYYY). Enter an X in the correct box to indicate sex of the patient. Only one box can be marked. If gender is unknown leave blank.
Block 1: Medicare, Medicaid, TRICARE, CHAMPVA, Group, Health Plan, FECA, Black Lung, Other
This Block is used to identify the insurance type to whom the claim is being submitted and may establish primary liability. Indicate the type of health insurance coverage applicable to this claim by placing an X in the appropriate box. Only one box can be marked. "Other" indicates health insurance including HMO's , commercial insurance, automobile accidents, liability, or workers' compensation.
Block 12: Patient's or Authorized Person's Signature:
This box indicates there is an authorization on file for the release of any medical or other information necessary to process and/or adjudicate the claim. Enter "Signature on File", "SOF," or legal signature. When legal signature is entered, enter the date signed in 6-digit (MMDDYY) or 8-digit (MMDDYYYY) format. If there is no signature on file, leave blank or enter "No Signature on File."
Block 30: Reserved for NUCC Use:
This field is reserved for NUCC use. THe NUCC will provide instruction for any use of this field.
Block 24F: $Charges (Lines 1-6):
Total bill amount for each service line. Enter the charge for each listed service. Enter numbers right justified in the dollar area of the field. Do not use commas when reporting dollar amounts.
Quick Response (QR) code symbol, date
Upper left hand corner of the form.
Block 29: Amount Paid:
block indicates payment received from the patient or other payers. Enter the total amount the patient and/or other payers paid on the covered service only. Enter the number right justified in the dollar area of the field. Do not use commas when reporting dollar amounts.
Block 24H: EPSDT/Family Plan (Lines 1-6) AV Available -not used (patient refused referral.) S2 Under Treatment (Patient is currently under treatment for referred diagnostic or corrective treatment/scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial periodic screening service, not including dental referrals.) NU Not Used (Used when no EPSDT patient referral was given.)
certain services that may be covered under some state Medicaid plans. For Early and Periodic Screening, Diagnosis, and Treatment related services, enter the response in the shaded portion of the field. If there is a requirement to report a reason code for EPDST, enter the appropriate reason code as noted below. (A Y or N response is not entered with the code.) the two-character code is right justified in the shaded area of the field. If service is Family Planning ,enter Y or N in the bottom, unshaded area of the field.
Block 24B: Place of Service (Lines 1-6)
identifies the location where the service was rendered. In block 24B, enter the appropriate two-digit code from the Place Of Service Codes list for each item used or service performed. www.cms.gov/physicanfeesched/downloads/Website_POS_database.pdf
Block 9d: Insurance Plan Name or Program Name:
identifies the name of the plan or program of the other insured as indicated in Item Number 9. Enter the other or secondary insured's insurance plan or program name.
Block 6: Patient Relationship to Insured
indicates how the patient is related to the insured. "self" would indicate that the insured is the patient. "spouse" would indicate that the patient is the husband of the wife or qualified partner as defined by the insured's plan. "Other" may include employee, ward, or dependent as defined by the insured's plan. Enter X in the correct box to indicate the patient's relationship to the insured when Item Number 4 is completed Only one box can be marked.
Block 20: Outside Lab? $ Charges: Enter charge amount in the field to the left of the vertical line. Enter 00 for cents line if the amount is a whole number. Negative dollar amounts are not allowed. Leave right-hand field blank.
indicates that services have been rendered by an independent provider as indicated in Block 32 and the related costs. Complete this field when billing for purchased services by entering an X in "YES" If a "YES" is annotated, enter the purchase price under "$Charges, " and complete Block 32. Each purchased service must be reported on a separate claim form because only one charge can be entered.
Block 11d: Is there another Health Benefit Plan?
indicates that the patient has insurance coverage other than the plan indicated in Block 1. When appropriate, enter an X in the correct box. If marked "YES," complete 9,9a, and 9d. Only one box can be marked. (For Medicare leave blank)
Block 27: Accept Assignment?
indicates that the provider agrees to accept assignment under the terms of the payer's program. Enter an X in the correct box. Only one box can be marked.
Block 10a-10c: Is patient's Condition Related To: State postal code where the accident occurred must be reported if "YES" is marked in 10b for "Auto accident." Any item marked "YES" indicates there may be other applicable insurance coverage that would be primary, such as automobile liability insurance. Primary insurance information must be shown in Block 11.
indicates whether the patient's illness or injury is related to employment, auto accident, or other accident. When appropriate enter X in the correct box to indicate whether one or more service described in Box 24 are for a condition or inure that occurred on the job or as a result of an automobile or other accident. Only one box on each line can be marked.
Block 7: Insured's Address: If reporting a foreign address, contact payer for specific reporting instructions. "Insured's Telephone" does not exist in 5010A1.
insured's permanent residence, which may be different from the patient's address in block 5. Enter the insured's address and telephone number. If Block 4 is completed, this field should be completed. The first line is for the street address; the second line is for the city and state; the third line is for the zip code and phone number.
Block 11b: Other Claim ID (Designated by NUCC) Y4 Property Casualty Claim Number
is another identifier applicable to the claim. Enter the "Other Claim ID." Applicable claim identifiers are designated by the NUCC. Enter the qualifier to the left of the vertical, dotted line. Enter the identifier number to the right of the vertical, dotted line.
Block 11: Insured's Policy, Group, or FECA Number: Do not use a hyphen or a space as a separator within the policy or group number.
is the alphanumeric identifier for the health, auto, or other insurance plan coverage. The FECA number is a 9-digit alphanumeric identifier assigned to a practice claiming work-related condition(s) under the Federal Employees Compensation Act 4 USC 8101. Enter the insured's policy or group number as it appears on the insured's health care identification card. If Block 4 is completed, then this field should be completed.
Block 11a: Insured's Date of Birth, Sex:
is the birthdate and gender of the insured as indicated in Block 1a. Enter the 8-digit date of birth of the insured and an X to indicate the sex of the insured.
Block 1a: The "Insured's ID Number"
is the identification number of the insured and identifies the insured to the payer. Enter the "Insured's ID Number" as shown on the insured's ID card for the payer to which the claim is being submitted.
Block 11c: Insurance Plan Name or Program Name:
is the name of the plan or program of the insured as indicated in Block 1a. Enter the "Insurance Plan Name or Program Name" of the insured. Some payers require an identification number of the primary insurer rather than the name in this field.
Block 31: Signature of Physician or Supplier Including degrees or Credentials:
refers to the authorized or accountable person and the degree, credentials, or title. Enter the legal signature of the practitioner or supplier representative, "Signature on File," or "SOF," Enter either the 6-digit date, 8-digit date, or alphanumeric date that the form was signed.
Block 24A: Date(s) of Service (Lines 1-6) Number of days must correspond to the number of units in Block 24G. When required by payers to provide additional anesthesia services information Ex: begin and end times., narrative description of an unspecified code, NDC, VP - HIBCC codes, OZ-GTIN codes, contract rate, or toth numbers and area of the oral cavity, enter the applicable qualifier and number/code/ information starting with the first space in the shaded line of this field.
the actual month, day, and year the service(s) was provided. Grouping services refers to a charge for a series of identical services without listing each date of service. Enter date(s) of service, both the "From" and "To" dates. If there is only one service enter the "From" date leave the "To" date blank., or re'enter "from" date. If grouping services, the place of service, procedure code, charges, and individual provider for each line must be identical for that service. Grouping is allowed only for services on consecutive days.
Block 14: Date of Current Illness, Injury, or Pregnancy (LMP): 421 Onset of Current Symptoms or Illness 484 Last Menstrual Period
the first date of onset of illness, the actual date of injury, or the last menstrual period (LMP) for pregnancy. Enter the 6-digit (MMDDYY) or 8-digit (MMDDYYYY) date of the first date of the present illness, injury, or pregnancy, use the date of the LMP as the first date. Enter the applicable qualifier to identify which date is being reported:
Block 2: Patient's Name Surname Format: Smith-White =SMITH-WHITE Prefixed name: MacIverson=MACIVERSON Seniority name with numeric suffix: John R. Ellis, III= ELLIS III JOHN R
the name of the person who received the treatment or supplies. Enter the patient's full last name and middle initial. If the patient uses a suffix enter it after the last name and before the first name. Titles and professional suffixes should not be included with the name. Use commas to separate the last name, first name, and middle initial.
Block 24G: Days or Units ( Lines 1-6): Anesthesia services must be reported as minutes. Units may only be reported for anesthesia services when the codes description includes a time period. ("daily management")
the number of days corresponding to the dates entered in Block 24A or units as defined in CPT or HCPCS coding manual(s). Enter the number of days or units. This block is most common used for multiple visits, units of supplies, anesthesia unis or minutes, or oxygen volume. If only one service is performed, the numeral 1 must be entered. Enter numbers left justified in this block. No leading, zeros are required. If reporting fraction of a unit, use the decimal point.
Block 28: Total Charge:
the total billed amount for all services entered in Block 24F (Lines 1-6). Enter the total charges for the services( that is, total of all charges to in Block 24F).
Block 25: Federal Tax ID Number:
the unique identifier assigned by a federal or state agency. Enter the "Federal Tax ID Number" (EIN or SSN) of the billing provider identified in Block 33. This is the tax ID number intended to be used for 1099 reporting purposes. Enter an X in the appropriate box to indicate box to indicate which number is being reported. Only one box can be marked. No hyphens with numbers. Enter numbers left justified in the field
Block 22: Re-submission and/ or Original Reference Number: This block is not intended for use of original claim submissions.
" Resubmission"means the code and original reference number assigned by the destination payer or receiver to indicate a previously submitted claim or encounter. List the original reference number for resubmitted claims. When resubmitting a claim, enter the appropriate bill frequency code left justified in the left-hand side of the field. 7 Replacement of prior claim 8 Void/cancel of prior claim
Block 24C: EMG (Lines 1-6)
"EMG" identifies if the service was an emergency. Check with payer to determine if this element is necessary. If required, enter Y for "YES" or leave blank if "NO," in the bottom , unshaded area of the field. The definition of an emergency would be either defined by federal or state regulations or programs, payer contract, or as defined in 5010A1.
