provider identifying qualifiers box 17

This MLN Matters® Article is intended for physicians and other providers submitting claims to Medicare contractors (carriers, A/B Medicare Administrative Contractors (A/B MACs), and Durable Medical Equipment Medicare Administrative Contractors
(DME/MACs)) for services provided to Medicare beneficiaries.

This change request (CR) 8509 revises the current CMS 1500 claim form instructions to
reflect the revised CMS 1500 claim form, version 02/12.

The National Uniform Claim Committee (NUCC) recently revised the CMS 1500 claim form. On June 10, 2013, the White House Office of Management and Budget (OMB) approved the revised form, 02/12. The revised form has a number of changes. Those most notable for Medicare are new indicators to differentiate between ICD-9 and ICD-10 codes on a claim, and qualifiers to identify whether certain providers are being identified as having performed an ordering, referring, or supervising role in the furnishing of the service. In addition, the revised form uses letters, instead of numbers, as diagnosis code pointers, and expands the number of possible diagnosis codes on a claim to 12.The qualifiers that are appropriate for identifying an ordering, referring, or supervising role are as follows:

• DN – Referring Provider
• DK – Ordering Provider
DQ – Supervising Provider

Providers should enter the qualifier to the left of the dotted vertical line on item 17.