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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

436-009-0004 Adoption of Standards 7 

Laboratory / Pathology

Facility - Outpatient

DME

Dispensed Pharmaceuticals

CMS-1500 Medical Bill

Required Documents

Treatment

All original medical provider billings must be accompanied by legible chart notes, which document the services that have been billed and identify the person performing the service.

PT / OT

For all time-based modalities and therapeutic procedures that require constant attendance, the chart notes must clearly indicate the time each modality or procedure begins and the time each modality or procedure ends or the amount of time spent providing each modality or procedure.

When multiple treatments are provided simultaneously by one machine, device, or table there must be a notation on the bill that treatments were provided simultaneously by one machine, device, or table and there must be only one charge.

Form

Timely Filing

Oregon Administrative Rules

Rule

Medical Bills

60 days

Oregon administrative rules, chapter 436.

436-009-0010 Medical Billing and Payment (2) Billing Timelines.

Items 0 through 10

Items 11 through 20

Items 21 through 33

CMS 1500 Box #

CMS 1500 (02/12) Field Description

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

Oregon 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

May be left blank

CMS 1500 Box #

CMS 1500 (02/12) Field Description

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

Oregon Workers' Compensation Instructions

11

INSURED'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

May be left blank

11b

OTHER CLAIM ID (Designated by NUCC)

N

May be left blank

11c

INSURANCE PLAN NAME OR PROGRAM NAME

N

May be left blank

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

May be left blank if box 17b contains the referring provider’s NPI

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

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

Oregon Workers' Compensation Instructions

21

ICD IND.

R

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

May be left blank

23

PRIOR AUTHORIZATION NUMBER

N

May be left blank

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

The provider must use the following codes to accurately describe the services rendered:

CPT® codes listed in CPT®2019;

Oregon Specific Codes (OSCs); or

HCPCS codes, only if there is no specific CPT® or OSC.

If there is no specific code for the medical service:

The provider should use an appropriate unlisted code from CPT® 2019 ( e.g., CPT® code 21299) or an unlisted code from HCPCS (e.g., HCPCS code E1399); and

The provider should describe the service provided.

Nurse practitioners and physician assistants must use modifier

“81” when billing as the surgical assistant during surgery.

24E

DIAGNOSIS CODE POINTER

R

CPT® codes listed in CPT®2019;

24F

$ CHARGES

R

Oregon Specific Codes (OSCs); or

24G

DAYS OR UNITS

R

HCPCS codes, only if there is no specific CPT® or OSC.

24H

EPSDT/FAMILY PLAN

N

If there is no specific code for the medical service:

24I Grey

ID QUAL

S

See under box 24J shaded area.

24J Grey

RENDERING PROVIDER ID. #

S

If the bill includes the rendering provider’s NPI in the non-shaded area of box 24J, the shaded area of box 24I and 24J may be left blank.

If the rendering provider does not have an NPI, then include the rendering provider’s state license number and use the qualifier “0B” in box 24I.

24J

NPI#

S

The rendering provider’s NPI.

24 Grey

GREY AREA SUPPLEMENTAL DATA

S

Nurse practitioners and physician assistants must use modifier

25

FEDERAL TAX ID. NUMBER

R

“81” when billing as the surgical assistant during surgery.

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

If the facility name and address are different than the billing provider’s name and address in box 33, fill in box 32.

32a

NPI #

R

If there is a name and address in box 32, box 32a must be filled in even if the NPI is the same as box 33a.

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.