CMS-1500 (02/12) data element requirements – all field update
The National Uniform Claim Committee (NUCC) has created a presentation that reviews the changes to the revised form in detail. Click here to view the NUCC presentation on the CMS-1500 (02/12) paper claim form.
Status Key:
R = Completion of this item is required by Medicare for every claim
C = Completion of this item is conditionally required based on certain circumstances
NR = Completion of this item is not required by Medicare Claims missing, or containing incomplete, or invalid information for any required or conditionally required item will be returned as unprocessable.
Note: Providers can utilize the First Coast Service Options Inc. (First Coast) PC-ACE Pro32™ software to submit claims electronically. PC-ACE Pro32™ software has built-in edits to avoid submitting claims without required information being included. Some item numbers contain links to
Item Number Item Description and Guidance Requirement Status
1 Type of insurance R
1a Patient’s Medicare Health Insurance Claim (HIC) number R
2 Enter the patient’s last name, first name, and middle initial (if any), as shown on patient’s Medicare card. R
3 Enter the patient’s eight digit birth date (MM/DD/CCYY) and sex. R
4 Insured’s name
(Complete item only if there is insurance primary to Medicare. Complete this item only when items 6, 7, and 11a-c are completed.) C
5 Patient’s mailing address, city, state, and phone number R
6 Check appropriate box for patient’s relationship to insured.
(Complete item only if there is insurance primary to Medicare. Complete this item only when items 4, 7, and 11a-c are completed.) C
7 Insured’s address and telephone number.
Note: When address is the same as patient’s, enter the word SAME.
(Complete item only if there is insurance primary to Medicare. Complete this item only when items 4, 6, and 11a-c are completed.) C
8 Leave blank — Medicare Part B Providers are not required to complete. NR
9-9d Medigap information (Leave Items 9b and 9c blank) C
10a-c Employment/accident indicators R
10d Medicaid ID C
11 Primary insurance policy number
Note: Enter the word NONE if Medicare is primary R
11a-c Insured’s birth date, employer, plan name (Item 11b — provide this information to the right of the vertical line.) C
11d Another health benefit plan
Leave blank — Medicare Part B Providers are not required to complete. NR
12 Patient’s signature and date R
13 Patient signature — Medigap authorization
Note: Must be completed if information contained in 9-9d. C
14 Date of current illness, injury, or pregnancy
Note: Although space for a qualifier is included, Medicare does not use this information; do not enter a qualifier in item 14. C
15 Leave blank — Medicare Part B Providers are not required to complete. NR
16 If patient is employed, enter dates patient will be unable to work in current occupation. C
17 Enter the name and qualifier of the referring, ordering or supervising physician if the item or service was ordered, supervised or referred by a physician.
• The qualifiers appropriate for identifying an ordering, referring, or supervising role are as follows:
• DN — referring provider
• DK — ordering provider
• DQ — supervising provider
• Enter the qualifier to the left of the dotted vertical line on item 17.
Note: Claims submitted with a national provider identifier (NPI) and without one of the qualifiers notated above or an invalid qualifier will be returned as an unprocessable claim (RUC).
See Claim completion FAQs on the First Coast provider website for additional details for reporting referring/ordering providers.
See also the Ordering/referring provider FAQs for additional guidance. C
Required if services are ordered, referred or supervised
17a DO NOT complete NR
17b If the service is referred or ordered, enter the national provider identifier (NPI) of the referring/ordering individual provider only.
(Click here to verify the provider’s NPI is eligible to order or refer services.) C
Required if services are ordered, referred or supervised
18 Hospitalization dates C
19 Additional claim information
See CMS IOM Pub 100-04, Chapter 26, Section 10.4 for guidance on completion of Item 19 C
20 Outside lab
See Claim completion FAQs on the First Coast provider website for additional details for reporting purchased services. C
21
Report up to twelve primary diagnosis codes
• For dates of service prior to October 1, 2014 — report ICD-9-CM codes. Enter the ICD indicator 9 as a single digit between the vertical, dotted lines.
• For dates of service on and after October 1, 2014 — report ICD-10-CM codes. Enter the ICD indicator 0 as a single digit between the vertical, dotted lines.
• If submitting a claim with a span of dates for a service, use the “from” date to determine which ICD code set to use. R
22 Leave blank — Medicare Part B Providers are not required to complete. NR
23 Prior authorization number C
24A Date(s) of service (DOS) R
24B
Place of service (POS)
See CMS IOM Pub 100-04, Chapter 26, Section 10.5 for codes and definitions. R
24C Leave blank — Medicare Part B Providers are not required to complete. NR
24D Procedure code/applicable modifiers R
24E-Diagnosis pointer
Note: the reference will be a letter from A-L. This information appears opposite the diagnosis codes in Item 21. Relate lines A- L to lines of service in 24E by the letter of the line. R
24F Charge (in dollars) for service R
24G Days/Units R
24H Leave blank — Medicare Part B Providers are not required to complete. NR
24I – Leave blank — Medicare Part B Providers are not required to complete. NR
24J-Enter the NPI of the rendering provider in the lower non-shaded portion.
Do not report anything in the upper shaded portion of item 24J. C
25 Federal tax identification number (TIN) C
26 Patient’s account number C
27 Assignment
See CMS IOM Pub 100-04, Chapter 1, Section 30.3.1 for list of provider and claim types for which assignment must always be accepted. R
28 Total Charges R
29 Enter amount collected from patient, if any.
Note: Please review When not to show patient paid amounts on claims article before collecting payments from patients.
C
30 Leave blank — Medicare Part B Providers are not required to complete. NR
31 Provider signature and date
Note: “Signature on File” and/or a computer generated signature are acceptable. See section 10.4 Item 32 for details R
32-For services payable under the Medicare Physician Fee Schedule (MPFS) and anesthesia services:
Name, address and ZIP of location where services were rendered for all locations.
Note: As of January 1, 2011, all locations (including patient’s home) must be reported. R
32a-If reporting anti-markup services (formerly purchased diagnostic services), enter the NPI of the provider who performed the service.
Note: DO NOT report for providers outside of local jurisdiction. Instead, you are required to report the NPI of the provider who purchased the service. C
32b-DO NOT complete NR
33-Billing provider’s name, address, ZIP and telephone number R
33a-Enter the NPI of the billing provider or group. R
33b -DO NOT complete NR
The National Uniform Claim Committee (NUCC) has created a presentation that reviews the changes to the revised form in detail. Click here to view the NUCC presentation on the CMS-1500 (02/12) paper claim form.
Status Key:
R = Completion of this item is required by Medicare for every claim
C = Completion of this item is conditionally required based on certain circumstances
NR = Completion of this item is not required by Medicare Claims missing, or containing incomplete, or invalid information for any required or conditionally required item will be returned as unprocessable.
Note: Providers can utilize the First Coast Service Options Inc. (First Coast) PC-ACE Pro32™ software to submit claims electronically. PC-ACE Pro32™ software has built-in edits to avoid submitting claims without required information being included. Some item numbers contain links to
Item Number Item Description and Guidance Requirement Status
1 Type of insurance R
1a Patient’s Medicare Health Insurance Claim (HIC) number R
2 Enter the patient’s last name, first name, and middle initial (if any), as shown on patient’s Medicare card. R
3 Enter the patient’s eight digit birth date (MM/DD/CCYY) and sex. R
4 Insured’s name
(Complete item only if there is insurance primary to Medicare. Complete this item only when items 6, 7, and 11a-c are completed.) C
5 Patient’s mailing address, city, state, and phone number R
6 Check appropriate box for patient’s relationship to insured.
(Complete item only if there is insurance primary to Medicare. Complete this item only when items 4, 7, and 11a-c are completed.) C
7 Insured’s address and telephone number.
Note: When address is the same as patient’s, enter the word SAME.
(Complete item only if there is insurance primary to Medicare. Complete this item only when items 4, 6, and 11a-c are completed.) C
8 Leave blank — Medicare Part B Providers are not required to complete. NR
9-9d Medigap information (Leave Items 9b and 9c blank) C
10a-c Employment/accident indicators R
10d Medicaid ID C
11 Primary insurance policy number
Note: Enter the word NONE if Medicare is primary R
11a-c Insured’s birth date, employer, plan name (Item 11b — provide this information to the right of the vertical line.) C
11d Another health benefit plan
Leave blank — Medicare Part B Providers are not required to complete. NR
12 Patient’s signature and date R
13 Patient signature — Medigap authorization
Note: Must be completed if information contained in 9-9d. C
14 Date of current illness, injury, or pregnancy
Note: Although space for a qualifier is included, Medicare does not use this information; do not enter a qualifier in item 14. C
15 Leave blank — Medicare Part B Providers are not required to complete. NR
16 If patient is employed, enter dates patient will be unable to work in current occupation. C
17 Enter the name and qualifier of the referring, ordering or supervising physician if the item or service was ordered, supervised or referred by a physician.
• The qualifiers appropriate for identifying an ordering, referring, or supervising role are as follows:
• DN — referring provider
• DK — ordering provider
• DQ — supervising provider
• Enter the qualifier to the left of the dotted vertical line on item 17.
Note: Claims submitted with a national provider identifier (NPI) and without one of the qualifiers notated above or an invalid qualifier will be returned as an unprocessable claim (RUC).
See Claim completion FAQs on the First Coast provider website for additional details for reporting referring/ordering providers.
See also the Ordering/referring provider FAQs for additional guidance. C
Required if services are ordered, referred or supervised
17a DO NOT complete NR
17b If the service is referred or ordered, enter the national provider identifier (NPI) of the referring/ordering individual provider only.
(Click here to verify the provider’s NPI is eligible to order or refer services.) C
Required if services are ordered, referred or supervised
18 Hospitalization dates C
19 Additional claim information
See CMS IOM Pub 100-04, Chapter 26, Section 10.4 for guidance on completion of Item 19 C
20 Outside lab
See Claim completion FAQs on the First Coast provider website for additional details for reporting purchased services. C
21
Report up to twelve primary diagnosis codes
• For dates of service prior to October 1, 2014 — report ICD-9-CM codes. Enter the ICD indicator 9 as a single digit between the vertical, dotted lines.
• For dates of service on and after October 1, 2014 — report ICD-10-CM codes. Enter the ICD indicator 0 as a single digit between the vertical, dotted lines.
• If submitting a claim with a span of dates for a service, use the “from” date to determine which ICD code set to use. R
22 Leave blank — Medicare Part B Providers are not required to complete. NR
23 Prior authorization number C
24A Date(s) of service (DOS) R
24B
Place of service (POS)
See CMS IOM Pub 100-04, Chapter 26, Section 10.5 for codes and definitions. R
24C Leave blank — Medicare Part B Providers are not required to complete. NR
24D Procedure code/applicable modifiers R
24E-Diagnosis pointer
Note: the reference will be a letter from A-L. This information appears opposite the diagnosis codes in Item 21. Relate lines A- L to lines of service in 24E by the letter of the line. R
24F Charge (in dollars) for service R
24G Days/Units R
24H Leave blank — Medicare Part B Providers are not required to complete. NR
24I – Leave blank — Medicare Part B Providers are not required to complete. NR
24J-Enter the NPI of the rendering provider in the lower non-shaded portion.
Do not report anything in the upper shaded portion of item 24J. C
25 Federal tax identification number (TIN) C
26 Patient’s account number C
27 Assignment
See CMS IOM Pub 100-04, Chapter 1, Section 30.3.1 for list of provider and claim types for which assignment must always be accepted. R
28 Total Charges R
29 Enter amount collected from patient, if any.
Note: Please review When not to show patient paid amounts on claims article before collecting payments from patients.
C
30 Leave blank — Medicare Part B Providers are not required to complete. NR
31 Provider signature and date
Note: “Signature on File” and/or a computer generated signature are acceptable. See section 10.4 Item 32 for details R
32-For services payable under the Medicare Physician Fee Schedule (MPFS) and anesthesia services:
Name, address and ZIP of location where services were rendered for all locations.
Note: As of January 1, 2011, all locations (including patient’s home) must be reported. R
32a-If reporting anti-markup services (formerly purchased diagnostic services), enter the NPI of the provider who performed the service.
Note: DO NOT report for providers outside of local jurisdiction. Instead, you are required to report the NPI of the provider who purchased the service. C
32b-DO NOT complete NR
33-Billing provider’s name, address, ZIP and telephone number R
33a-Enter the NPI of the billing provider or group. R
33b -DO NOT complete NR