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CMS-1500 (HCFA)

Applicable Services

Required Reports

Reporting Forms & Attachments

Filling out the Form

Instructions

CMS-1500 Medical Bill

Required Document

Psychology

Report of psychiatric evaluation and tests

MMI

Clinical notes for a visit to determine Maximum Medical Improvement (MMI) and Permanent Impairment Rating

Per Manual

Any report required by procedure code descriptors

PT / OT

A plan of care for physical medicine therapy

Surgery

An operative report for a surgical procedure

Neuromuscular Testing

Results of neuromuscular testing procedures

Items 0 through 10

Items 11 through 20

Items 21 through 33

CMS 1500 Box #

CMS 1500 (02/12) Field Description

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

South Carolina Workers' Compensation Instructions

0

CARRIER NAME AND ADDRESS

1

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

R

Mark the "OTHER" box

1a

INSURED’S I.D. NUMBER

R

Enter the patient's Social Security Number or other identifier number.

2

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

R

Enter patient’s last name, first name, and middle initial.

3

PATIENT’S BIRTH DATE, SEX

R

Enter month, day and year of the patient's date of birth (MMDDYY).

4

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

R

Enter the business name for the patient’s employer on the date entered in Field 14.

5

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

R

Enter the patient’s complete mailing address and telephone number for identification purposes:

6

PATIENT RELATIONSHIP TO INSURED

N

Not applicable

7

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

R

Enter the employer's complete address and telephone number:

Line 1 – Enter the street address, including suite number if applicable;

Line 2 – Enter the city and state;

Line 3 – Enter the zip code and telephone number.

8

RESERVED FOR NUCC USE

N

Not applicable

9

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

S

If known, enter the insurance carrier's 3-digit code.

9a

OTHER INSURED'S POLICY OR GROUP NUMBER

N

Not applicable

9b

RESERVED FOR NUCC USE

N

Not applicable

9c

RESERVED FOR NUCC USE

N

Not applicable

9d

INSURANCE PLAN NAME OR PROGRAM NAME

N

Not applicable

10a

IS PATIENT'S CONDITION RELATED TO: EMPLOYMENT

R

Mark the appropriate box.

10b

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

R

Mark the appropriate box.

10c

IS PATIENT'S CONDITION RELATED TO: OTHER ACCIDENT

R

Mark the appropriate box.

10d

CLAIM CODES (Designated by NUCC)

N

Not applicable

CMS 1500 Box #

CMS 1500 (02/12) Field Description

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

South Carolina Workers' Compensation Instructions

11

ISURED'S POLICY GROUP OR FECA NUMBER

R

Enter the name of the workers' compensation insurance carrier. If the employer in Element 4 is self-insured, enter the nae of the employer or the name of the employer's claims administration division. If you are unsure of the carrier you may call the employer, or contact the SCWCC Coverage Division at coverage@wcc.sc.gov. To obtain this information from the SCWCC you will need to have the patient's name, social security number, date of injury, and employer name.

11a

INSURED'S DATE OF BIRTH, SEX

N

Not applicable

11b

OTHER CLAIM ID (Designated by NUCC)

R

Enter the worker's compensation file number (WCC#).

11c

INSURANCE PLAN NAME OR PROGRAM NAME

R

List the insurance carrier name or employer's name if self-insured.

11d

IS THERE ANOTHER HEALTH BENEFIT PLAN?

N

Not applicable

12

PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE

N

Not applicable

13

INSURED'S OR AUTHORIZED PERSONS' SIGNATURE

N

Not applicable

14

DATE OF CURRENT ILLNESS, INJURY OR PREGNANCY (LMP)

R

If the patient presents as a result of an accident, enter the date the accident occured. If the patient presents as a result of an illess, enter the date of first symptoms. Date must be in MM/DD/YY, format.

15

OTHER DATE

S

Provider should give dates (MM/DD/YY) only if the patient had symptoms the same as or similar to those for which the current claim is being submitted.

16

DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

S

If the claim is being filed by the primary physician responsible for the patient, enter the dates during which that physician expects the patitne to be unable to return to work. Dates must be in MM/DD/YY format.

17

NAME OF REFERRING PROVIDER OR OTHER SOURCE

S

If appicable, enter the referring physician's name and professional title (e.g., M.D.).

17a

OTHER ID #

N

Not applicable

17b

NPI #

S

If applicable, enter the referring physician's national provider identifier (NPI) number.

18

HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

S

If the service is billed is rendered as a result of, or subsequent to, a related hospitalization, enter the appropriate dates. Dates must be in MM/DD/YY format.

19

ADDITIONAL CLAIM INFORMATION (Designated by NUCC)

S

List any permanent injuries sustained by the worker.

20

OUTSIDE LAB?

S

If laboratory work is being charged on this bill, this elelment must be completed. If the work was performed outside of the physician's office, mark "YES" and enter the amount charged for the service.

CMS 1500 Box #

CMS 1500 (02/12) Field Description

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

South Carolina Workers' Compensation Instructions

21

ICD IND.

R

Enter the ICD-10 diagnosis code in order of primary importance. (Use the appropriate ICD-10-CM diagnosis code adopted by CMS as determined by the date of service.) For each diagnosis indicated on the claim form, reference the alpha character A-L not the ICD-10-CM code in Element 24E. This entry should substantiate the relationship between the diagnosis entered in Element 21 and the procedure code entered in Element 24D.

21.A

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

S

Enter the ICD-10 diagnosis code in order of primary importance. (Use the appropriate ICD-10-CM diagnosis code adopted by CMS as determined by the date of service.) For each diagnosis indicated on the claim form, reference the alpha character A-L not the ICD-10-CM code in Element 24E. This entry should substantiate the relationship between the diagnosis entered in Element 21 and the procedure code entered in Element 24D.

21.B

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

S

21.C

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

S

21.D

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

S

21.E

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

S

21.F

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

S

21.G

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

S

21.H

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

S

21.I

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

S

21.J

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

S

21.K

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

S

21.L

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

S

22

RESUBMISSION CODE

N

Not applicable

23

PRIOR AUTHORIZATION NUMBER

S

If applicable, enter the prior authorization number from the carrier or employer.

24A

DATE(S) OF SERVICE

R

“FROM” and “TO” dates in (MMDDYY) may be utilitzed when the same service is provided on consecutive days.Otherwise, serivces must be itemized on a separate line for each date of serice.

24B

PLACE OF SERVICE

R

Enter the place of service code for each procedure performed.

24C

EMG

N

Not applicable

24D

PROCEDURES, SERVICES, OR SUPPLIES

R

Enter the approriate CPT or HCPCS procedure code from the Medical Services Provider Manual or the CPT book. When appropriate, the CPT or HCPCS two-digit modifier code must follow the procedure code.

24E

DIAGNOSIS CODE POINTER

R

Enter the diagnosis reference alpha characters A-L from Element 21 that correspond to the service entered in 24D.

24F

$ CHARGES

R

For each service rendered, enter either the provider's usual charge or the MAP amount listed in the Sechdule, whichever is less.

24G

DAYS OR UNITS

R

Enter the number of units of service.

24H

EPSDT/FAMILY PLAN

N

Not applicable

24I Grey

ID QUAL

N

Not applicable

24J Grey

RENDERING PROVIDER ID. #

N

Not applicable

24J

NPI#

R

Enter the NPI for the rendering provider.

24 Grey

GREY AREA SUPPLEMENTAL DATA

N

Not applicable

25

FEDERAL TAX ID. NUMBER

R

Enter the provider's Federal Employer Identification Nuber (FEIN) and mark the "EIN" box. If the provider does not have a FEIN number, enter th eprovider's social security number and mark the "SSN" box.

26

PATIENT'S ACCOUNT NO.

O

Providers may wish to enter their ow patient account number for identification purposes.

27

ACCEPT ASSIGNMENT?

N

Not applicable

28

TOTAL CHARGE

R

Enter the total of all charges listed in Element 24E. Do not carry charges from one claim form forward to another claim form.

29

AMOUNT PAID

N

Not applicable

30

RSVD FOR NUCC USE

N

Not applicable

31

SIGNATURE OF PHYSICIAN OR SUPPLIER

R

Enter the provider signature and the date the claim was prepared.

32

SERVICE FACILITY LOCATION INFORMATION

R

Self-explanatory

32a

NPI #

N

Not applicable

32b

OTHER ID #

N

Not applicable

33

BILLING PROVIDER INFO & PH #

R

Self-explanatory

33a

NPI #

N

Not applicable

33b

OTHER ID #

R

Not applicable