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CMS-1500 (HCFA)

Applicable Services

Required Reports

Forms & Attachments

Timely Filing

12 months from DOS

Filling out the Form

Instructions

Service

Rule

Physician Services

Billing and Reimbursement Manual Chapter 4

Laboratory / Pathology

DME

CMS-1500 Medical Bill

Required Documents

Treatment

Physician’s Report of Work Ability or narrative equivalent

Form

Timely Filing

Billing and Reimbursement Manual

Rule

Medical Bills

12 months

Billing and Reimbursement Manual

Billing and Reimbursement Manual Chapter 4 (PDF)

Item 0 through 10

Item 11 through 20

Item 21 through 33

CMS 1500 Box #

CMS 1500 (02/12) Field Description

Ohio Workers' Compensation Requirements (Required/ Situational/ Optional / Not Applicable)

Ohio Workers' Compensation Instructions

0

CARRIER NAME AND ADDRESS

1

MEDICARE, MEDICAID, TRICARE, CHAMPVA, GROUP HEALTH PLAN, FECA, BLACK LUNG, OTHER

R

Place an “X” in the “Other” box.

1a

INSURED’S I.D. NUMBER

R

Enter the patient's social security number.

2

PATIENT’S NAME (Last Name, First Name, Middle Initial)

R

Enter the patient’s first name. Periods are not allowed within the field; however, commas and hyphens may be used

3

PATIENT’S BIRTH DATE, SEX

R

Enter the patient’s 8-digit birthdate (MM|DD|YYYY).

4

INSURED’S NAME (Last Name, First Name, Middle Initial)

R

Enter the name of the employer.

5

PATIENT’S ADDRESS (No., Street), CITY, STATE, ZIP CODE, TELEPHONE

R

Enter the patient’s address. The first line is for the street address. If required by a payer to report a telephone number, do not use a hyphen or space as a separator within the telephone number

6

PATIENT RELATIONSHIP TO INSURED

N

7

INSURED'S ADDRESS (No., Street), CITY, STATE, ZIP CODE, TELEPHONE

R

Enter the address of the employer. If required by a payer to report a telephone number, do not use a hyphen or space as a separator within the telephone number.

8

RESERVED FOR NUCC USE

N

9

OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)

N

9a

OTHER INSURED'S POLICY OR GROUP NUMBER

N

9b

RESERVED FOR NUCC USE

N

9c

RESERVED FOR NUCC USE

N

9d

INSURANCE PLAN NAME OR PROGRAM NAME

N

10a

IS PATIENT'S CONDITION RELATED TO: EMPLOYMENT

Mark appropriate box or boxes with an “X”. The state postal code where the accident occurred must be reported if “YES” is marked in 10b for “Auto Accident”.

10b

IS PATIENT'S CONDITION RELATED TO: AUTO ACCIDENT _ PLACE (State)

Mark appropriate box or boxes with an “X”. The state postal code where the accident occurred must be reported if “YES” is marked in 10b for “Auto Accident”.

10c

IS PATIENT'S CONDITION RELATED TO: OTHER ACCIDENT

Mark appropriate box or boxes with an “X”. The state postal code where the accident occurred must be reported if “YES” is marked in 10b for “Auto Accident”.

10d

CLAIM CODES (Designated by NUCC)

S

Condition Codes are required when submitting a bill that is a duplicate or an appeal. (Original Reference Number must be entered in Box 22 for these conditions). NOTE: Do not use Condition Codes when submitting a revised or corrected bill

CMS 1500 Box #

CMS 1500 (02/12) Field Description

Ohio Workers' Compensation Requirements (Required/ Situational/ Optional / Not Applicable)

Ohio Workers' Compensation Instructions

11

ISURED'S POLICY GROUP OR FECA NUMBER

R

Enter the name of the workers’ compensation insurance carrier, self-insured employer or third party administrator

11a

INSURED'S DATE OF BIRTH, SEX

N

11b

OTHER CLAIM ID (Designated by NUCC)

N

11c

INSURANCE PLAN NAME OR PROGRAM NAME

N

11d

IS THERE ANOTHER HEALTH BENEFIT PLAN?

N

12

PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE

N

13

INSURED'S OR AUTHORIZED PERSONS' SIGNATURE

N

14

DATE OF CURRENT ILLNESS, INJURY OR PREGNANCY (LMP)

R

None

15

OTHER DATE

S

Complete if appropriate. Enter another date related to the patient’s condition or treatment. Enter the date in the 6-digit (MM|DD|YY) or 8- digit (MM|DD|YYYY) format. Enter the qualifier between the left-hand set of vertical, dotted lines.

Enter the applicable qualifier to identify which date is being reported:090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care) 304 Latest Visit or Consultation 439 Accident 444 First Visit or Consultation 453 Acute Manifestations of a Chronic Condition 454 Initial Treatment 455 Last X-ray 471 Prescription

16

DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

S

If the patient is unable to work in current occupation, a 6-digit (MM|DD|YY) or 8-digit (MM|DD|YYYY) date must be shown for the “from-to” dates that the patient is unable to work.

17

NAME OF REFERRING PROVIDER OR OTHER SOURCE

S

Enter the name (First, MI, Last) followed by the credentials of the professional who referred or ordered the service or supply. If multiple providers are involved, enter one provider using the following order: 1. Referring Provider (qualifier DN); 2. Ordering Provider (qualifier DK); 3. Supervising Provider (qualifier DQ). Do not use periods or commas. A hyphen can be used. Enter the qualifier to the left of the vertical, dotted line.

17a

OTHER ID #

N

17b

NPI #

S

Enter the National Provider Identifier (NPI) number of the referring, ordering or supervising provider

18

HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

S

If applicable, enter the inpatient 6-digit (MM|DD|YY) or 8-digit (MM|DD|YYYY) hospital admission date followed by the discharge date. If not discharged, leave discharge date blank. This date is when a medical service is furnished as a result of, or subsequent to, a related hospitalization.

19

ADDITIONAL CLAIM INFORMATION (Designated by NUCC)

N

20

OUTSIDE LAB?

S

Complete as appropriate

CMS 1500 Box #

CMS 1500 (02/12) Field Description

Ohio Workers' Compensation Requirements (Required/ Situational/ Optional / Not Applicable)

Ohio Workers' Compensation Instructions

21

ICD IND.

R

Enter the International Classification of Diseases-Clinical Modification(ICD-CM) code(s) that correspond(s) to the conditions treated, in accordance with National Correct Coding Initiative and ICD- CM coding guidelines. The billed diagnoses must be related to the services billed.

21.A

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

S

Enter the applicable International Classification of Diseases (ICD) indicator to identify the version of ICD codes being reported: (0= ICD10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Enter the codes to identify the patient’s diagnosis and/or condition. List no more than 12 ICD diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field.

21.B

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

S

Enter the applicable International Classification of Diseases (ICD) indicator to identify the version of ICD codes being reported: (0= ICD10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Enter the codes to identify the patient’s diagnosis and/or condition. List no more than 12 ICD diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field.

21.C

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

S

Enter the applicable International Classification of Diseases (ICD) indicator to identify the version of ICD codes being reported: (0= ICD10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Enter the codes to identify the patient’s diagnosis and/or condition. List no more than 12 ICD diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field.

21.D

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

S

Enter the applicable International Classification of Diseases (ICD) indicator to identify the version of ICD codes being reported: (0= ICD10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Enter the codes to identify the patient’s diagnosis and/or condition. List no more than 12 ICD diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field.

21.E

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

S

Enter the applicable International Classification of Diseases (ICD) indicator to identify the version of ICD codes being reported: (0= ICD10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Enter the codes to identify the patient’s diagnosis and/or condition. List no more than 12 ICD diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field.

21.F

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

S

Enter the applicable International Classification of Diseases (ICD) indicator to identify the version of ICD codes being reported: (0= ICD10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Enter the codes to identify the patient’s diagnosis and/or condition. List no more than 12 ICD diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field.

21.G

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

S

Enter the applicable International Classification of Diseases (ICD) indicator to identify the version of ICD codes being reported: (0= ICD10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Enter the codes to identify the patient’s diagnosis and/or condition. List no more than 12 ICD diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field.

21.H

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

S

Enter the applicable International Classification of Diseases (ICD) indicator to identify the version of ICD codes being reported: (0= ICD10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Enter the codes to identify the patient’s diagnosis and/or condition. List no more than 12 ICD diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field.

21.I

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

S

Enter the applicable International Classification of Diseases (ICD) indicator to identify the version of ICD codes being reported: (0= ICD10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Enter the codes to identify the patient’s diagnosis and/or condition. List no more than 12 ICD diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field.

21.J

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

S

Enter the applicable International Classification of Diseases (ICD) indicator to identify the version of ICD codes being reported: (0= ICD10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Enter the codes to identify the patient’s diagnosis and/or condition. List no more than 12 ICD diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field.

21.K

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

S

Enter the applicable International Classification of Diseases (ICD) indicator to identify the version of ICD codes being reported: (0= ICD10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Enter the codes to identify the patient’s diagnosis and/or condition. List no more than 12 ICD diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field.

21.L

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items A-L to service line below (24E)

S

Enter the applicable International Classification of Diseases (ICD) indicator to identify the version of ICD codes being reported: (0= ICD10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Enter the codes to identify the patient’s diagnosis and/or condition. List no more than 12 ICD diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field.

22

RESUBMISSION CODE

S

List the original reference number for resubmitting claims. Please refer to the most current instructions from the payer regarding the use of this field (e.g., code). 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.) This Item Number is not intended for use for original claim submissions.

23

PRIOR AUTHORIZATION NUMBER

N

24A

DATE(S) OF SERVICE

R

(Lines 1-6). Enter date(s) of service, both the “From” and “To” dates. If there is only one date of service, enter that date under “From”. Leave “To” blank or reenter “From” date

24B

PLACE OF SERVICE

R

Enter the appropriate two-digit code from the Place of Service Code list for each item used or service performed. The Place of Service Codes are available at: https://www.cms.gov/

24C

EMG

N

24D

PROCEDURES, SERVICES, OR SUPPLIES

R

Enter the CPT code(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.

24E

DIAGNOSIS CODE POINTER

R

Enter the diagnosis code reference letter 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 letter for each service should be listed first, other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. Do not enter ICD diagnosis codes in Item Number 24E; entered in Item Number 21 only

24F

$ CHARGES

R

Enter your usual, customary and reasonable charge for the procedure performed. If more than one unit of service is billed, make sure your charges reflect this in the total.

24G

DAYS OR UNITS

R

Enter the number of days or units. This field is most commonly used for multiple visits, units of supplies, anesthesia units or minutes, or oxygen volume. If only one service is performed, the number 1 must be entered.

24H

EPSDT/FAMILY PLAN

N

24I Grey

ID QUAL

S

If using the 11-digit BWC provider number, use qualifier G2 or LU in the non-National Provider Identifier qualifier field.

24J Grey

RENDERING PROVIDER ID. #

S

The MCO and BWC can only accept one rendering provider ID per bill.

24J

NPI#

S

Report the Identification Number in Items 24i and 24j only when different from data recorded in items 33a and 33b. The individual performing/rendering the service is listed in 24J and the qualifier indicating if the number is a non-NPI is reported in 24I. The non- NPI ID number of the rendering provider refers to the payer assigned unique identifier of the professional.

24 Grey

GREY AREA SUPPLEMENTAL DATA

S

25

FEDERAL TAX ID. NUMBER

R

Enter the Provider’s “Federal Tax ID Number” of the Billing Provider identified in Item Number 33. Enter an X in the appropriate box to indicate which number is being reported. Only one box can be marked. Do not enter hyphens with numbers. Enter numbers left justified in the field.

26

PATIENT'S ACCOUNT NO.

O

Optional; Enter the patient’s account number assigned by the provider. Do not use hyphens with numbers. Enter numbers left justified in the field.

27

ACCEPT ASSIGNMENT?

N

28

TOTAL CHARGE

R

Enter total charges for the services (i.e., total of all charges in 24F). Enter the number right justified in the dollar area of the field. Do not use commas when reporting dollar amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter 00 in the cents area if the amount is a whole number.

29

AMOUNT PAID

O

This section may be used to indicate any agreed upon discount amount or rate.

30

RSVD FOR NUCC USE

N

31

SIGNATURE OF PHYSICIAN OR SUPPLIER

R

Enter the signature of the practitioner or supplier or their representative, “Signature on File,” or “SOF.” Enter either the 6- digit date (MM|DD|YY), 8- digit date (MM|DD|YYYY), or alpha-numeric date that the form was signed. In addition, provide degree, credentials or title as appropriate.

32

SERVICE FACILITY LOCATION INFORMATION

R

Use the following format to enter the location where the services were rendered: 1st Line – Name of Service Facility 2nd Line – Address 3rd Line – City, State and ZIP code Do not use punctuation (i.e., commas and periods) or other symbols in the address. Enter a space between town name and state code. Do not include a comma. Report a 9-digit zip code, including the hyphen.

32a

NPI #

R

Enter the NPI number of the service facility location in 32.

32b

OTHER ID #

S

Enter the 2-digit qualifier identifying the non-NPI number followed by the ID number. Do not enter a space, hyphen, or other separator between the qualifier and number: (0B = State License Number; G2 = Provider Commercial Number; LU = Location Number).

33

BILLING PROVIDER INFO & PH #

R

Enter the Provider’s or supplier’s billing name, physical billing address, zip code, and phone number as follows: 1st Line – Name of Provider 2nd Line – Address 3rd Line – City, State and zip code The phone number is to be entered in the area to the right of the field title.

33a

NPI #

R

Enter the NPI number of the billing provider in 33a.

33b

OTHER ID #

S

Enter the billing provider’s 11-digit BWC Provider Number.