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CMS-1500 (HCFA)

Applicable Services

Reporting Requirements

Forms & Attachments

Timely Filing

12 months from DOS

Filling out the Form

Instructions

Service

Rule

Physician Services

PART 9. BILLING SUBPART A. PRACTITIONER BILLING R 418.10901 General information (PDF) 

Laboratory / Pathology

DME

Ambulance Services

Vision Services

Hearing Services

CMS-1500 Medical Bill

Required Documents

Initial Evaluation

A copy of the medical report for the initial visit.

Progress Report

An updated progress report if treatment exceeds 60 days.

Surgery

A copy of the operative report or office report if billing surgical procedure codes 10021-69990.

Radiology

The x-ray report is required when the professional component of an x-ray is billed

Anesthesia

A copy of the anesthesia record if billing anesthesia codes 00100-01999

PT / OT

A copy of the initial evaluation and a progress report every 30 days of physical treatment, physical or occupational therapy, or manipulation services.

“By Report”

A report describing the service if submitting a bill for a "by report" procedure.

Unusual Circumstances

A  copy of the medical report if a modifier is applied to a procedure code to explain unusual billing circumstances.

Functional Capacity

A functional capacity or work evaluation.

When Indicated

When the procedure code descriptor states, “includes a written report.”

Form

Timely Filing

Department of Licensing and Regulatory Affairs Workers’ Compensation Agency Rules

Rule

Medical Bills

12 months

Current Health Care Services Rules (R 418.10101 - 418.101504)

R 418.10102 Claim filing limitations

CMS 1500 Box #

CMS 1500 (02/12) Field Description

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

Michigan Workers' Compensation Instructions

1a

INSURED’S I.D. NUMBER

R

Patient's Claim number (if known) or Social Security number (SSN)

2

Patient's Name

R

Name of the patient.

3

Patient's Birth Date and Sex

R

Patient's sex and date of birth.

4

Insured's Name

R

Name of the employer.

5

Patient’s Address (multiple fields)

R

Patient's complete address omitting the telephone number

6

Patient's Relationship to Insured

R

Check other.

7

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

R

Employer address. Omit the telephone number.

8

Reserved for NUCC Use

N

Omit

9

Other Insured’s Name

N

Omit

9a

Other Insured’s Policy or Group Number

N

Omit

9b

Reserved for NUCC Use

N

Omit

9c

Reserved for NUCC Use

N

Omit

9d

Insurance Plan Name or Program Name

N

Omit

10a-c

Is Patient’s Condition Related To:

R

Mark the appropriate boxes.

10d

CLAIM CODES (Designated by NUCC)

S

Condition codes if applicable

CMS 1500 Box #

CMS 1500 (02/12) Field Description

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

Michigan Workers' Compensation Instructions

11

InSURED'S POLICY GROUP OR FECA NUMBER

N

Omit

12

PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE

R

Signature on file is acceptable per Chris Clock at WCA

13

INSURED'S OR AUTHORIZED PERSONS' SIGNATURE

R

Signature on file is acceptable per Chris Clock at WCA

14

Date of Current Illness, Injury, or Pregnancy (LMP)

R

Date of the work-related accident or the first symptoms of work-related illness.

15

Other Date

S

Complete if appropriate.

16

DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

S

Enter the month, day, and year if applicable

18

HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

S

Date if applicable

19

Additional Claim Information (Designated by NUCC)

Additional claim information, if applicable. When reporting supplemental claim information, use the qualifier PWK for data, followed by the appropriate Report Type Code, the appropriate Transmission Type code, then the Attachment Control Number

20

Outside Lab? $Charges

Mark appropriate box

CMS 1500 Box #

CMS 1500 (02/12) Field Description

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

Michigan Workers' Compensation Instructions

21

Diagnosis or Nature of Illness or Injury

Diagnostic numeric or alpha code. Enter the applicable ICD indicator to identify which version of ICD codes is being reported

22

Resubmission and/or Original Reference Number

Resubmission and/or Original Reference Number if applicable

23

Prior Authorization Number

Enter the ZIP code for point of pickup for ambulance claims if applicable

24

GENERAL

Each of the six lines is split length-wise and is shaded on the top portion for reporting supplemental information if applicable, such as a narrative description of unspecified codes, NDC for drugs, Device Identifier of the Unique Device Identfier (sic) for supplies, contract rate, or tooth numbers and areas of the oral cavity.

The upper shaded portion shall be used to report the NDC if required. When entering supplemental information for NDC, add in the following order: qualifier, NDC code, one space, unit/basis of measurement qualifier, quantity. If reporting both the repackaged NDC and the original NDC of a drug, used (sic) the shaded area to report the information n the following order: qualifier (N4), NDC code, one space, unit//basis of measurement qualifier, quantity, one space ORIG, qualifier (N4), NDC code

24a

Date(s) of Service [lines 1–6]

R

Date for each service, "from/to" dates may be utilized.

24b

Place of Service [lines 1–6]

R

Place of service code.

24c

EMG [lines 1–6]

N

Omit.

24d

Procedures, Services, or Supplies [lines 1–6]

S

Enter the procedure code and modifier if appropriate. Attach documentation to explain unusual circumstances

24e

Diagnosis Pointer [lines 1–6]

R

Diagnosis code reference letter (pointer) from item number 21 as appropriate.

24f

$Charges [lines 1–6]

R

Charge for each procedure billed.

24g

Days or Units [lines 1–6]

R

Complete this column for number of days or units. Anesthesia services must be reported in minutes

24h

EPSDT/Family Plan [lines 1–6]

N

Omit

24I Grey

ID QUAL

N

Omit

24J

RENDERING PROVIDER ID. #

S

Rendering Provider ID#, enter the NPI number in unshaded area of the field

24 Grey

GREY AREA SUPPLEMENTAL DATA

S

25

Federal Tax ID Number

R

Enter the billing provider’s FEIN.

26

Patient's Account Number

R

Enter the patient's account or case number

27

Accept Assignment?

N

Omit

28

Total Charge

R

Enter the total charges.

29

Amount Paid

N

Omit

30

Reserved for NUCC Use

N

Omit

31

Signature of Physician or Supplier Including Degrees or Credentials

R

Signature of Physician or supplier, including degrees or credentials

32

Service Facility Location Information

S

Complete if applicable.

32a

NPI#

S

NPI of service facility if appropriate.

32b

Other ID#

S

Reporting of other ID numbers if applicable.

33

Billing Provider Info & Ph #

R

Billing provider’s name, address, zip code, and telephone number.

33a

NPI#

R

Billing provider’s NPI number.

33b

Other ID#

S

Other ID # if applicable.