CMS-1500 (02/12) Claim Form: A Comprehensive Medicare Billing Guide & Field Requirements
Key Takeaways for Accurate CMS-1500 Submission
- The CMS-1500 (02/12) form is crucial for billing Medicare Part B services by physicians, non-physician practitioners, and suppliers.
- Accurate, field-by-field completion is vital to avoid claim denials and ensure timely reimbursement.
- Strict adherence to current ICD-10-CM coding standards is mandatory for all dates of service.
- Incorrect NPIs, missing qualifiers, and incomplete patient information are common errors that lead to unprocessable claims.
- While electronic submissions (837-P) are prevalent, understanding paper form requirements remains essential for specific scenarios.
The CMS-1500 (02/12) paper claim form serves as the universal claim form for submitting professional health care services to Medicare Part B and other payers. This comprehensive guide provides a detailed, field-by-field breakdown of the requirements for completing the CMS-1500 (02/12) form, highlighting key Medicare billing instructions, common pitfalls, and essential tips for accurate submission. Mastering this form is critical for physicians, non-physician practitioners, and various suppliers to ensure proper reimbursement and minimize claim rejections. Understanding how to fill out CMS-1500 form for Medicare is fundamental for efficient practice management.
While many claims are now submitted electronically via the 837-P transaction standard, the paper CMS-1500 (02/12) form remains indispensable for certain situations, such as claims requiring attachments, or for providers with low claim volumes. Tools like the First Coast Service Options Inc. (First Coast) PC-ACE Pro32™ software assist providers in generating electronic claims with built-in edits, but the underlying data element requirements mirror those of the paper form. The National Uniform Claim Committee (NUCC) offers valuable resources, including presentations, that review the changes to the revised form in detail. You can view the NUCC presentation on the CMS-1500 (02/12) paper claim form for a deeper dive.
Understanding CMS-1500 Form Sections and Requirement Status
Claims missing, containing incomplete, or invalid information for any required or conditionally required item will be returned as unprocessable. To guide you, we use the following 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 Part B providers
Below is a detailed, item-by-item guide to completing the CMS-1500 (02/12) claim form, incorporating essential Medicare Part B claim form instructions and clarifications.
| Item Number | Item Description and Guidance | Requirement Status |
|---|---|---|
| 1 | Type of Insurance: Indicate the type of insurance coverage relevant to the claim. | R |
| 1a | Patient’s Medicare Health Insurance Claim (HIC) number: Enter the patient’s Medicare HIC number. | R |
| 2 | Patient’s Name: Enter the patient’s last name, first name, and middle initial (if any), exactly as shown on the patient’s Medicare card. | R |
| 3 | Patient’s Birth Date and Sex: Enter the patient’s eight-digit birth date (MM/DD/CCYY) and check the appropriate box for sex. | R |
| 4 | Insured’s Name: Complete this item only if there is insurance primary to Medicare. This field should be completed when items 6, 7, and 11a-c are also completed. | C |
| 5 | Patient’s Mailing Address, City, State, and Phone Number: Provide the patient’s complete contact information. | R |
| 6 | Patient’s Relationship to Insured: Check the appropriate box for the patient’s relationship to the insured. Complete this item only if there is insurance primary to Medicare, and when items 4, 7, and 11a-c are completed. | C |
| 7 | Insured’s Address and Telephone Number: Enter the insured’s address and telephone number. If the address is the same as the patient’s, enter “SAME.” Complete this item only if there is insurance primary to Medicare, and when items 4, 6, and 11a-c are completed. | C |
| 8 | Leave Blank: Medicare Part B Providers are not required to complete this item. | NR |
| 9-9d | Medigap Information: Provide Medigap policy details if applicable. Leave Items 9b and 9c blank. | C |
| 10a-c | Employment/Accident Indicators: Indicate if the patient’s condition is related to employment, an auto accident, or another type of accident. | R |
| 10d | Medicaid ID: If the patient has Medicaid coverage in addition to Medicare, enter the Medicaid ID. | C |
| 11 | Primary Insurance Policy Number: Enter the policy number for the primary insurance. If Medicare is primary, enter “NONE.” This field is crucial for proper coordination of benefits. | R |
| 11a-c | Insured’s Birth Date, Employer, Plan Name: Provide the insured’s birth date, employer’s name, and health plan name. For 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: This signifies authorization for the release of medical information and payment directly to the provider. | R |
| 13 | Patient Signature — Medigap Authorization: This must be completed if information is contained in items 9-9d, authorizing payment of Medigap benefits to the provider. | C |
| 14 | Date of Current Illness, Injury, or Pregnancy: Enter the onset date. Although space for a qualifier is included, Medicare does not use this information; do not enter a qualifier. | C |
| 15 | Leave Blank: Medicare Part B Providers are not required to complete. | NR |
| 16 | Patient Unable to Work Dates: If the patient is employed and unable to work in their current occupation due to the illness or injury, enter the start and end dates. | C |
| 17 | Referring, Ordering, or Supervising Physician Name and Qualifier: Enter the name and appropriate qualifier of the referring, ordering, or supervising physician if the item or service was ordered, supervised, or referred by a physician.
Enter the qualifier to the left of the dotted vertical line on item 17. Claims submitted with an NPI but without one of the notated qualifiers or with an invalid qualifier will be returned as an unprocessable claim (RUC). Incorrect use of these qualifiers is a common CMS-1500 billing error. |
C (Required if services are ordered, referred or supervised) |
| 17a | DO NOT complete. | NR |
| 17b | Referring/Ordering Individual Provider NPI: If the service is referred or ordered, enter the National Provider Identifier (NPI) of the referring/ordering individual provider only. This field is essential for verifying the eligibility of the referring/ordering provider. This also relates to CMS-1500 box 17 NPI requirements. You can verify a provider’s NPI using the official NPI Registry. Ensure the NPI is valid and active to prevent claim denials. | C (Required if services are ordered, referred or supervised) |
| 18 | Hospitalization Dates: Enter the dates related to patient hospitalization if applicable to the service. | C |
| 19 | Additional Claim Information: This field is used for supplemental information that may be required for specific services or circumstances, such as documentation for unlisted procedures, emergency services, or consent forms. Always refer to CMS IOM Pub 100-04, Chapter 26, Section 10.4 for specific guidance on when and how to complete Item 19 to prevent common CMS-1500 billing errors. Providing clear, concise, and necessary details here can prevent delays. | C |
| 20 | Outside Lab: If services were performed by an outside laboratory, indicate this here. Refer to CMS guidance on purchased services for additional details on reporting. | C |
| 21 | Diagnosis Codes (ICD-10-CM): Report up to twelve primary diagnosis codes. For all current dates of service, only ICD-10-CM codes are applicable. ICD-9-CM is now largely obsolete for U.S. medical billing. Enter the ICD indicator ‘0’ as a single digit between the vertical, dotted lines to denote ICD-10-CM. If submitting a claim with a span of dates for a service, use the “from” date to determine which ICD code set to use, but for current billing, this will always be ICD-10-CM. This field is critical for demonstrating medical necessity. | R |
| 22 | Resubmission/Original Reference Number: Leave blank — Medicare Part B Providers are not required to complete. | NR |
| 23 | Prior Authorization Number: Enter any prior authorization number assigned by the payer. | C |
| 24A | Date(s) of Service (DOS): Enter the “from” and “to” dates for each service line. | R |
| 24B | Place of Service (POS): Enter the appropriate place of service code for each service line. Refer to CMS IOM Pub 100-04, Chapter 26, Section 10.5 for official codes and definitions. | R |
| 24C | Leave Blank: Medicare Part B Providers are not required to complete. | NR |
| 24D | Procedure Code/Applicable Modifiers: Enter the CPT/HCPCS procedure code and any applicable modifiers for each service line. | R |
| 24E | Diagnosis Pointer: Reference a letter (A-L) from the diagnosis codes in Item 21 to indicate the primary diagnosis for each service line. | R |
| 24F | Charge (in dollars) for Service: Enter the billed amount for each service line. | R |
| 24G | Days/Units: Enter the number of days or units for each service line. | 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 | Rendering Provider NPI: Enter the NPI of the rendering provider in the lower non-shaded portion. Do not report anything in the upper shaded portion. | C |
| 25 | Federal Tax Identification Number (TIN): Enter the federal tax ID number or EIN of the billing entity. | C |
| 26 | Patient’s Account Number: Enter the patient’s account number assigned by your practice. | C |
| 27 | Assignment: Indicate whether the provider accepts assignment. Refer to CMS IOM Pub 100-04, Chapter 1, Section 30.3.1 for a list of provider and claim types for which assignment must always be accepted. | R |
| 28 | Total Charges: Enter the total billed charges for all services on the claim. | R |
| 29 | Amount Collected from Patient: Enter any amount collected from the patient at the time of service. Review Medicare guidelines on patient paid amounts before collecting payments. | C |
| 30 | Leave Blank: Medicare Part B Providers are not required to complete. | NR |
| 31 | Provider Signature and Date: The billing provider’s signature (or “Signature on File”) and date. Computer-generated signatures are acceptable. Refer to CMS guidelines on signature requirements for details. | R |
| 32 | Service Location Information: For services payable under the Medicare Physician Fee Schedule (MPFS) and anesthesia services, enter the name, address, and ZIP of the location where services were rendered. As of January 1, 2011, all locations (including a patient’s home) must be reported. | R |
| 32a | Anti-Markup Services NPI: If reporting anti-markup services (formerly purchased diagnostic services), enter the NPI of the provider who performed the service. DO NOT report for providers outside of local jurisdiction; instead, report the NPI of the provider who purchased the service. | C |
| 32b | DO NOT complete. | NR |
| 33 | Billing Provider Information: Enter the billing provider’s name, address, ZIP, and telephone number. This is often the group practice or institutional billing entity. | R |
| 33a | Billing Provider/Group NPI: Enter the NPI of the billing provider or group. | R |
| 33b | DO NOT complete. | NR |
Common CMS-1500 Form Errors and How to Avoid Them
Submitting accurate claims is paramount for timely reimbursement. Here are some of the most common CMS-1500 billing errors and strategies to avoid them when dealing with Medicare Part B claim form instructions:
- Incorrect or Missing NPIs: Ensure all NPIs (rendering, referring/ordering, billing) are correct, active, and properly entered in the designated fields (e.g., Item 17b, 24J, 33a). Always verify NPIs using the official NPI Registry.
- Outdated or Incorrect Diagnosis Codes: For all current dates of service, only ICD-10-CM codes are valid. Submitting ICD-9-CM codes will result in a denial. Double-check that the diagnosis pointers (Item 24E) correctly link to the diagnoses in Item 21.
- Missing or Invalid Qualifiers: When reporting referring, ordering, or supervising physicians (Item 17), ensure the correct qualifier (DN, DK, DQ) is used. Missing or invalid qualifiers will lead to unprocessable claims.
- Improper Handling of Primary/Secondary Insurance: When Medicare is not the primary payer, ensure complete and accurate primary insurance information is provided (Items 4, 6, 7, 11-11c). Failure to coordinate benefits correctly can cause significant delays.
- Incomplete or Illegible Information: Even on paper claims, ensure all required fields are filled out completely and legibly. Incomplete forms are a frequent cause of claim rejections.
- Missing Patient Signatures: Items 12 and 13 require patient signatures or “Signature on File.” Ensure these are present when necessary for authorization and assignment.
By diligently reviewing these common errors and implementing these preventative measures, providers can significantly improve the accuracy of their CMS-1500 submissions and streamline the Medicare billing and reimbursement process.