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Sample completed CMS1500 Claim Form

How to Complete the CMS1500 Form

Use these instructions to complete the CMS1500 form. Please note that you must submit the original "Red" CMS1500 form to Medicare Services. Photocopies or computer-generated forms will not be accepted.

As of Oct. 1, 2006 the CMS-1500 (12-90) is being revised to accommodate the reporting of the National Provider Identifier (NPI). The revised version is called CMS-1500 (08-05).

Claim Form (CMS1500) — Paper Billers
The CMS1500 claim form answers the needs of many health insurers. It is the basic form used in the Medicare program for claims from physicians, other providers and suppliers, except for ambulance services. It has also been adopted by the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) and has received the approval of the American Medical Association (AMA) Council on Medical Services.

Below are instructions to complete the CMS1500. The CMS1500 has space for providers and suppliers to provide information about other health insurance. Medicare uses this information to determine whether the patient has other coverage that is primary to Medicare, or if there is a Medigap policy under which payments are made to a participating physician or supplier.

CMS requires carriers to process "clean" claims within a designated time period. A "clean" claim is a claim that requires no outside request for additional information. Medicare must wait 13 days after receipt to process "clean" electronic claims and 27 days after receipt to process "clean" paper claims. If a "clean" claim is not processed within 30 days, Medicare will pay interest on the claim.

Note: You must submit original "Red" CMS1500 forms to Medicare Services. Photocopies or computer-generated forms will not be accepted.

Electronic Billers
Providers who bill electronically should consult the CMS Internet homepage for Electronic Data Interchange (EDI) information. The material includes facts about Medicare EDI, advantages to using Medicare EDI, news and updates in Medicare EDI, descriptions of Medicare EDI formats and EDI formats to download. To access this information on the Internet, enter the following address: www.cms.hhs.gov/providers/edi/edi3.asp. You may also access EDI information through CMS’s Homepage by entering the following address: www.cms.hhs.gov/providers/edi/

Ordering CMS1500 Claim Forms
The form specifications require red drop out ink in order to facilitate the use of image processing technology such as Image Character Recognition (ICR), facsimile transmission and image storage. It is available in various formats (e.g., single copy, duplicate, etc.). The CMS1500 claim form may be purchased from local printers or through the following organizations:

US Government Printing Office
Superintendent of Documents
Washington, DC 20402
202/512-1800 (Pricing Desk)
202/512-2250 (Fax)
or
Order Department
AMA
PO Box 109050
Chicago, IL 60610-9050
American Express, Visa and Master Card orders; call 800/621-8335

Completing the CMS1500 Claim Form
Note: If a provider of service or supplier chooses to enter 8-digit dates for items 11b, 14, 16, 18, 19 or 24a, he or she must enter 8-digit dates for all these fields. For instance, a provider of service or supplier will not be permitted to enter 8-digit dates for items 11b, 14, 16, 18, 19 and a 6-digit date for item 24a. The same applies to providers of service and suppliers who choose to submit 6-digit dates too. Items 12 and 31 are exempt from this requirement.

Item 1 (Type of Insurance): Show the type of health insurance coverage applicable to this claim by checking the appropriate box(es), e.g., if a Medicare claim is being filed, check the Medicare box. If the claim involves a Medicaid crossover, mark both the Medicare and Medicaid boxes.

Item 1 a (Insured's ID Number): Enter the patient's Medicare Health Insurance Claim Number (HICN) whether Medicare is the primary or secondary payer. Enter the number as shown on the patient's Medicare card. Be sure to include the alpha character(s).

Item 2 (Patient's Name): Enter the patient's last name, first name and middle initial, if any, as shown on the patient's Medicare card.

Item 3 (Patient's Birth date): Enter the patient's 8-digit date of birth and sex. Use the format MM/DD/CCYY.

Item 4 (Insured's Name): If there is insurance primary to Medicare, either through the patients or spouse's employment or any other source, list the name of the insured here. When the insured and the patient are the same, enter the word SAME. If Medicare is primary, leave blank.

Item 5 (Patient's Address): Enter the patient's mailing address and telephone number. On the first line, enter the street address; the second line, the city and state; the third line, the ZIP code and phone number.

Item 6 (Patient’s Relationship to Insured): Check the appropriate box for the patient's relationship to the insured when item 4 is completed.

Item 7 (Insured's Address): Enter the insured's address and telephone number. When the address is the same as the patient's, enter the word SAME. Complete this item only when items 4 and 11 are completed.

Item 8 (Patient Status): Check the appropriate box for the patient's marital status and whether employed or a student.

Item 9 (Other Insured's Name): Enter the last name, first name and middle initial of the enrollee in a Medigap policy, if it is different from that shown in item 2. Otherwise, enter the word SAME. If no Medigap benefits are assigned, leave blank. Note on ltem 9 P-- Only participating physician and suppliers are to complete item 9 and its subdivision, and only when the beneficiary wishes to assign his/her benefits under a Medigap policy to the participating physician or supplier. Participating physicians and suppliers must enter information required in item 9 and its subdivisions, if requested by the beneficiary. Participating physicians/suppliers sign an agreement with Medicare to accept assignment of Medicare benefits for all Medicare patients. A claim for which a beneficiary elects to assign his/her benefits under a Medigap policy to a participating physician/supplier is called a mandated Medigap transfer. Medigap. A Medigap policy meets the statutory definition of a "Medicare supplemental policy" contained in §1882(g)(1) of title XVIII of the Social Security Act (the Act) and the definition contained in the NAIC Model Regulation that is incorporated by reference to the statute. It is a health insurance policy or other health benefit plan offered by a private entity to those persons entitled to Medicare benefits and is specifically designed to supplement Medicare benefits. It fills in some of the "gaps" in Medicare coverage by providing payment for some of the charges for which Medicare does not have responsibility due to the applicability of deductibles, coinsurance amounts, or other limitations imposed by Medicare. It does not include limited benefit coverage available to Medicare beneficiaries such as "specified disease" or "hospital indemnity" coverage. Also, it explicitly excludes a policy or plan offered by an employer to employees or former employees, as well as that offered by a labor organization to members or former members. Do not list other supplemental coverage in item 9 and its subdivisions at the time a Medicare claim is filed. Other supplemental claims are forwarded automatically to the private insurer, if the private insurer contracts with Medicare Services to send Medicare claim information electronically. If there is no such contract, the beneficiary must file his/her own supplemental claim.

Item 9 a: Enter the policy and/or group number of the Medigap enrollee preceded by the word "MEDIGAP", "MG" or "MGAP". If you bill electronically, enter the policy and or group number in NSF fields DA0.18 (Insured ID) and/or DA0.10 (Group #) followed by MG in the DA0.06 field (Ins Type Code). Note: Item 9d must be completed if a policy and/or group number is in item 9a.

Item 9 b: Enter the Medigap insured’s 8-digit date of birth and sex. Use the format MM/DD/CC/YY.

Item 9 c: Disregard "employer's name or school name" which is printed on the form. Enter the claims processing address for the Medigap insurer. Use an abbreviated street address, two letter State postal code, and zip code copied from the Medigap enrollee's Medigap identification card: For example:1257 Anywhere Street; Baltimore, Maryland 21204 is shown as "1257 Anywhere St. MD 21204." Note: If a carrier assigned unique identifier of a Medigap insurer appears in item 9d, item 9c may be left blank.

Item 9 d: The 9-digit PAYERID number of the Medigap insurer. If no PAYERID number exists, then the Medigap insurance program or plan name is shown. If a participating provider of service or supplier and the patient wants Medicare payment data forwarded to a Medigap insurer under a mandated Medigap transfer, all of the information in items 9, 9a, 9b, and 9d must be complete and accurate. Otherwise, you cannot forward the claim information to the Medigap insurer.

Items 10 a -10 c (Patient's Condition Related to): Check "YES" or "NO" to indicate whether employment, auto liability or other accident involvement applies to one or more of the services described in item 24. The state postal code, (i.e. MO) must be shown. Any item checked "YES" indicates there may be other insurance primary to Medicare. Primary insurance information must then be shown in item 11.

Item 10 d: Use this item exclusively for Medicaid (MCD) information. If the patient is entitled to Medicaid, this item must show the patient's Medicaid number, preceded by MCD.

Item 11: (Insured's Policy Number): This item must be completed. By completing this item, the physician/supplier acknowledges having made a good faith effort to determine whether Medicare is the primary or secondary payer. If there is insurance primary to Medicare, enter the insured's policy or group number and proceed to items 11a -11c. Items 4, 6 and 7 must also be completed. Note: The appropriate information in item 11c is shown if insurance primary to Medicare is indicated in item 11. If there is no insurance primary to Medicare, enter the word "NONE" and proceed to item 12. If the insured reports a terminating event with regard to insurance which had been primary to Medicare (e.g., insured retired), enter the word "NONE" and proceed to item 11b. Insurance primary to Medicare: Circumstances under which Medicare payment may be secondary to other insurance include: Group Health Plan Coverage: Working Aged; Disability — (Large Group Health Plan); and End Stage Renal Disease, No Fault and/or Other Liability, Work-Related Illness/Injury: Workers' Compensation; Black Lung; and Veterans Benefits Note: For a paper claim to be considered for Medicare Secondary Payer benefits, a copy of the primary payer's explanation of benefits (EOB) must be forwarded along with the claim form.

Item 11 a: The insured’s 8-digit birth-date (MM/DD/CCYY) and sex if different from item 3.

Item 11 b: Enter employer's name, if applicable. If there is a change in the insured's insurance status, (e.g., retired), enter either a 6-digit (MM/DD/YY) or 8-digit (MM/DD/CCYY) retirement date preceded by the word "RETIRED." If you bill electronically, enter the information in NSF field DA2.10 (retire date) and DA2.12 (insured’s employer name).

Item 11 c: The 9-digit PAYERID number of the primary insurer. If no PAYERID number exists, then enter the complete primary payer’s program or plan name. If the primary payer’s EOB does not contain the claims processing address, record the primary payer’s claims processing address directly on the EOB. This is required if there is insurance primary to Medicare that is indicated in Field 11.

Item 11 d: Leave blank. Not required by Medicare.

Item 12 (Signature): The patient or authorized representative must sign and date and enter either a 6-digit date (MM/DD/YY), 8-digit date (MM/DD/CCYY), or an alphanumeric date (e.g., January 1, 1998) unless the signature is on file. In lieu of signing the claim, the patient must sign a statement to be retained in the provider, physician, or supplier’s file in accordance with Chapter 1 "General Billing Requirements". If the patient is physically or mentally unable to sign, a representative specified in Chapter 1 "General Billing Requirements" may sign on the patient’s behalf. In this event, the statement’s signature line must indicate the patient’s name followed by "by" the representative’s name, address, relationship to the patient, and the reason the patient cannot sign. The authorization is effective indefinitely unless the patient or the patient’s representative revokes this arrangement. Note: This can be "Signature on File" and/or a computer generated signature. The patient’s signature authorizes release of medical information necessary to process the claim. It also authorizes payment of benefits to the provider of service or supplier when the provider of service or supplier accepts assignment on the claim. Signature by Mark (X): Where an illiterate or physically handicapped enrollee signs by mark (X), a witness must enter his or her name and address next to the mark.

Item 13 (Signature): The signature in this item authorizes payment of mandated Medigap benefits to the participating physician or supplier if the required Medigap information is included in ltem 9 and its subdivisions. The patient or his or her authorized representative signs this item, or the signature must be on file as a separate Medigap authorization (See Signature on File beginning on p. 3.S.1.) The Medigap assignment on file in the participating physician/supplier's office must be insurer specific. It may state that the authorization applies to all occasions of service until it is revoked. Note: This can be "Signature on File" and/or a computer generated signature. Reminder: For date fields other than date of birth, all fields must be one or the other format, 6-digit: (MM/DD/YY) or 8-digit: (MM/DD/CCYY). Intermixing the two formats on the claim is not allowed.

Item 14 (Date of Illness): The patient’s 6-digit (MM/DD/YY) or 8-digit (MM/DD/CCYY) date of current illness, injury, or pregnancy. For chiropractic services, enter either a 6-digit (MM/DD/YY) or 8-digit (MM/DD/CCYY) date of the initiation of the course of treatment and enter an 8-digit (MM/DD/CCYY) or 6-digit (MM/DD/YY) date in item 19.

Item 15: Leave blank. Not required by Medicare.

Item 16 (Dates Patient Unable to Work): The patient is employed and is unable to work in current occupation, a 6-digit (MM/DD/YY) or 8-digit (MM/DD/CCYY) date must be shown when patient is unable to work. An entry in this field may indicate employment related insurance coverage.

Item 17 (Name of Referring Physician): Enter the name of the referring and/or ordering physician if the service or item was ordered or referred by a physician. Referring Physician: A physician who requests an item or service for the beneficiary for which payment may be made under the Medicare program. Ordering Physician: A physician who orders non-physician services for the patient, such as diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, or durable medical equipment. The ordering/referring requirement became effective January 1, 1992, and is required by §1833(q) of the Act. AlI claims for Medicare covered services and items that are the result of a physician's order or referral must include the ordering/referring physician’s name and Unique Physician Identification Number (UPIN). This includes parenteral and enteral nutrition, immunosuppressive drug claims, and the following: Diagnostic laboratory services; Diagnostic radiology services; Portable x-ray services; Consultative services; and Durable medical equipment Claims for other ordered/referred services not included in the preceding list must also show the ordering/referring physician's name and UPIN. For example, a surgeon must complete items 17 and 17a when a physician refers the patient. When the ordering physician is also the performing physician (as often is the case with in-office clinical laboratory tests), the performing physician's name and assigned UPIN must appear in items 17 and 17a. All physicians who order or refer Medicare beneficiaries or services must obtain an UPIN, even though they may never bill Medicare directly. A physician who has not been assigned a UPIN must contact Medicare Services. When a physician extender or other limited licensed practitioner refers a patient for consultative service, the name and UPIN of the physician supervising the limited licensed practitioner must appear in items 17 and 17a of the first claim form. When a patient is referred to a physician who also orders and performs a diagnostic service, a separate claim form is required for the diagnostic service. Enter the original ordering/referring physician's name and UPIN in items 17 and 17a of the first claim form. Enter the ordering (performing) physician's name and UPIN in items 17 and 17a of the second claim form (the claim for reimbursement for the diagnostic service). Surrogate UPINs: If the ordering/referring physician has not been assigned a UPIN, one of the surrogate UPINs listed below must be used in item 17a. The surrogate UPIN used depends on the circumstance and is used only until the physician is assigned a UPIN. Enter the physician's name in item 17 and the surrogate UPIN in item 17a. All surrogate UPINs, with the exception of retired physicians (RET000) are temporary and may be used only until a UPIN is assigned. Medicare Services will monitor claims with surrogate UPINs. The term "physician," when used within the meaning of §1861(r) the Social Security Act, and used in connection with performing any function or action, refers to: A doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he/she performs such function or action; A doctor of dental surgery or dental medicine who is legally authorized to practice dentistry by the State in which he/she performs such functions, and who is acting within the scope of his/her license when performing such functions; A doctor of podiatric medicine for purposes of §(k), (m), (p)(1) and (s) and §1814(a), 1832(a)(2)(F)(ii) and 1835 of the Act, but only with respect to functions which he/she is legally authorized to perform as such by the State in which he/she performs them; A doctor of optometry, but only with respect to the provision of items or services described in §1861(s) of the Act, which he/she is legally authorized to perform as a doctor of optometry by the State in which he/she performs them; or A chiropractor who is licensed as such by a State (or in a State which does not license chiropractors as such) and is legally authorized to perform the services of a chiropractor in the jurisdiction in which he/she performs such services, and who meets uniform minimum standards specified by the Secretary, but only for purposes of §1861(s)(1) and 1861(s)(2)(A) of the Act, and only with respect to treatment by means of manual manipulation of the spine (to correct a subluxation). For the purposes of §1862(a)(4) of the Act and subject to the limitations and conditions provided above, chiropractor includes a doctor of one of the arts specified in the statute and legally authorized to practice such art in the country in which the inpatient hospital services (referred to in §1862(a)(4) of the Act) are furnished.

Item 17 a (UPIN or NPI of Referring Physician): Enter the CMS assigned UPIN of the referring/ordering physician listed in item 17. The UPIN may be reported on the Form CMS-1500 until May 22, 2007, and MUST be reported if an NPI is not available. NOTE: Field17a and/or 17b is required when a service was ordered or referred by a physician. Effective May 23, 2007, and later, 17a is not to be reported but 17b MUST be reported when a service was ordered or referred by a physician.When a claim involves multiple referring and/or ordering physicians, a separate Form CMS-1500 shall be used for each ordering/referring physician. All physicians who order or refer Medicare beneficiaries or services must report either an NPI or UPIN or both prior to May 23, 2007. After that date, an NPI (but not a UPIN) must be reported even though they may never bill Medicare directly. A physician who has not been assigned a UPIN shall contact the Medicare carrier.

Item 17b Form CMS-1500 (08-05) — Enter the NPI of the referring/ordering physician listed in item 17 as soon as it is available. The NPI may be reported on the Form CMS-1500 (08-05) as early as October 1, 2006. NOTE: Field17a and/or 17b is required when a service was ordered or referred by a physician. Effective May 23, 2007, and later, 17a is not to be reported but 17b MUST be reported when a service was ordered or referred by a physician.

Item 18 (Hospitalization Dates): Enter either an 8-digit (MM/DD/CCYY) or a 6-digit (MM/DD/YY) date when a medical service is furnished as a result of, or subsequent to a related hospitalization.

Item 19 Enter the 6-digit (MM/DD/YY) or 8-digit (MM/DD/CCYY) date patient was last seen and theUPIN(NPI when it becomes effective) of his/her attending physician when an independent physical or occupational therapist or physician providing routine foot care submits claims. For physical and occupational therapists, entering this information certifies that the required physician certification (or recertification) is being kept on file. (See Medicare Benefits Policy Manual, Chapter 15) Enter the 6-digit (MM/DD/YY) or 8-digit (MM/DD/CCYY) x-ray date for chiropractor services (if an x-ray, rather than a physical examination was the method used to demonstrate the subluxation). By entering an x-ray date and the initiation date for course of chiropractic treatment in item 14, the contractor is certifying that all the relevant information requirements (including level of subluxation) of the Medicare Benefits Policy Manual, Chapter 15, are on file, along with the appropriate x-ray and all are available for carrier review. The drug's name and dosage when submitting a claim for Not Otherwise Classified (NOC) drugs. A concise description of an "unlisted procedure code" or a NOC code if one can be given within the confines of this box. Otherwise an attachment must be submitted with the claim. All applicable modifiers when modifier -99 (multiple modifiers) is entered in item 24d. If modifier -99 is entered on multiple line items of a single claim form, all applicable modifiers for each line item containing a -99 modifier should be listed as follows: 1=(mod), where the number 1 represents the line item and "mod" represents all modifiers applicable to the referenced line item. The statement "Homebound" when an independent laboratory renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient. (See the Medicare Benefit Policy Manual, Chapter 15, "Covered Medical and Other Services," and the Claims Processing Manual, Chapter 16, "Laboratory Services," and the Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, "Definitions," respectively for the definition of "homebound" and a more complete definition of a medically necessary laboratory service to a homebound or an institutional patient.) Enter the statement, "Patient refuses to assign benefits" when the beneficiary absolutely refuses to assign benefits to a participating provider. In this case, no payment may be made on the claim. Enter the statement, "Testing for hearing aid" when billing services involving the testing of a hearing aid(s) is used to obtain intentional denials when other payers are involved. When dental examinations are billed, the specific surgery for which the exam is being performed. Enter the specific name and dosage amount when low osmolar contrast material is billed, but only if HCPCS codes do not cover them. Enter the 6-digit (MM/DD/YY) or 8-digit (MM/DD/CCYY) assumed and/or relinquished date for a global surgery claim when providers share post-operative care. Enter the demonstration ID number "30" for all national emphysema treatment trial claims. Enter the PIN (or NPI when effective) of the physician who is performing a purchased interpretation of a diagnostic test (see the Medicare Claims Processing Manual, Chapter 1, "General Billing Requirements," for additional information). Report the interpreting physician’s PIN proceeded by a "PI" indicator (i.e., PI999999).

Item 20 Complete this item when billing for diagnostic tests subject to purchase price limitations. The purchase price under charges must be shown if the "yes" block is checked. A "yes" check indicates that an entity other than the entity billing for the service performed the diagnostic test. A "no" check indicates that "no purchased tests are included on the claim." When "yes" is annotated, item 32 must be completed. When billing for purchased diagnostic tests, each test must be submitted on a separate claim form. Multiple purchased tests may be submitted on the ASC X12 837 electronic format as long as appropriate line level information is submitted when services are rendered at different facility service locations. See Chapter 1. Note: This is a required field when billing for diagnostic tests subject to purchase price limitations.

Item 21 Enter the patient's diagnosis/condition. With the exception of claims submitted by ambulance suppliers (specialty type 59), all physician and non-physician specialties (i.e., PA, NP, CNS, CRNA) must use an ICD-9-CM code number and code to the highest level of specificity. Enter up to four codes in priority order (primary, secondary condition). An independent laboratory must enter a diagnosis only for limited coverage procedures. All narrative diagnoses for non-physician specialties must be submitted on an attachment.

Item 22 Leave blank. Not required by Medicare.

Item 23 Enter the Quality Improvement Organization (QIO) prior authorization number for those procedures requiring PRO prior approval. Enter the Investigational Device Exemption (IDE) number when an investigational device is used in an FDA-approved clinical trial. For physicians performing care plan oversight services, enter the 6-digit Medicare provider number (or NPI when effective) of the home health agency (HHA) or hospice when CPT code G0181 (HH) or G0182 (Hospice) is billed. The 10-digit Clinical Laboratory Improvement Act (CLIA) certification number for laboratory services billed by an entity performing CLIA covered procedures. When a physician provides services to a beneficiary residing in a SNF and the services were rendered to a SNF beneficiary outside of the SNF, the physician should enter the Medicare facility provider number of the SNF in item 23. A substituting physician under a reciprocal billing or locum tenens arrangement (mandated by statute §1842(b)(6)(D) of the Act) may be accommodated using item 23. The billing "absentee" physician’s Provider Identification Number (PIN) must continue to be reported in item 33 under solo practice arrangements and in item 24k under group practice arrangements. Note: Item 23 can contain only one condition. Any additional conditions must be reported on a separate CMS1500 form.

Item 24a Enter a 6-digit or 8-digit (MM/DD/CCYY) date for each procedure, service, or supply. When "from" and "to" dates are shown for a series of identical services, enter the number of days or units in column G. This is a required field. Note: Claim is unprocessable if a date of service extends more than one day and a valid "to" date is not present.

Item 24b Enter the appropriate place of service code(s) from the list provided in §50.5. Identify the location, using a place of service code, for each item used or service performed. This is a required field.

Item 24c Medicare providers are not required to complete this item.

Item 24d Enter the procedures, services, or supplies using the CMS Common Procedure Coding System (HCPCS). When applicable, show HCPCS modifiers with the HCPCS code. The Form CMS-1500 (08-05) has the ability to capture up to four modifiers. Enter the specific procedure code must be shown without a narrative description. However, when reporting an "unlisted procedure code" or a NOC code, include a narrative description in item 19 if a coherent description can be given within the confines of that box. Otherwise, an attachment must be submitted with the claim. This is a required field. Note: Claim is unprocessable if an "unlisted procedure code" or a "not otherwise classified" (NOC) code is indicated in item 24d, but an accompanying narrative is not present in Item 19 or on an attachment.

Item 24e Enter the diagnosis code reference number as shown in item 21 to relate the date of service and the procedures performed to the primary diagnosis. Enter only one reference number per line item. When multiple services are performed, the primary reference number for each service; either a 1, or a 2, or a 3, or a 4. This is a required field. If a situation arises where two or more diagnoses are required for a procedure code (e.g., pap smears), the provider must reference only one of the diagnoses in item 21.

Item 24f Enter the charge for each listed service.

Item 24g Enter the number of days or units. This field is most commonly used for multiple visits, units of supplies, anesthesia minutes, or oxygen volume. If only one service is performed, the numeral 1 must be entered. Some services require that the actual number or quantity billed be clearly indicated on the claim form (e.g., multiple ostomy or urinary supplies, medication dosages, or allergy testing procedures). When multiple services are provided, the actual number provided must be indicated. For anesthesia, the provider must indicate the elapsed time (minutes) in item 24g. Convert hours into minutes and enter the total minutes required for this procedure. Suppliers must furnish the units of oxygen contents except for concentrators and initial rental claims for gas and liquid oxygen systems. Rounding of oxygen contents is as follows: For stationary gas system rentals, suppliers must indicate oxygen contents in unit multiples of 50 cubic feet in item 24g, rounded to the nearest increment of 50. For example, if 73 cubic feet of oxygen were delivered during the rental month, the unit entry "01" indicating the nearest 50 cubic foot increment is entered in item 24g. · For stationary liquid systems, units of contents must be specified in multiples of 10 pounds of liquid contents delivered, rounded to the nearest 10 pound increment. For example, if 63 pounds of liquid oxygen were delivered during the applicable rental month billed, the unit entry "06" is entered in item 24g. · For units of portable contents only (i.e., no stationary gas or liquid system used), round to the nearest five feet or one liquid pound, respectively. Note: This field should contain at least one day or unit.

Item 24h Leave blank. Not required by Medicare.

Item 24i Enter the ID qualifier 1C in the shaded portion.

Item 24j Prior to May 23, 2007, enter the rendering provider’s PIN in the shaded portion. In the case of a service provided incident to the service of a physician or non-physician practitioner, when the person who ordered the service is not supervising, enter the PIN of the supervisor in the shaded portion. Effective May 23, 2007 and later, do not use the shaded portion. Beginning no earlier than October 1, 2006, enter the rendering provider’s NPI number in the lower portion. In the case of a service provided incident to the service of a physician or non-physician practitioner, when the person who ordered the service is not supervising, enter the NPI of the supervisor in the lower portion.

Item 24k There is no Item 24K on version (08-05).

Item 25 Enter the provider of service or supplier Federal Tax I.D. (Employer Identification Number) or Social Security Number. The participating provider of service or supplier Federal Tax I.D. number is required for a mandated Medigap transfer.

Item 26 Enter the patient's account number assigned by the provider of service's or supplier's accounting system. This field is optional to assist the provider in patient identification. As a service, any account numbers entered here will be returned to the provider.

Item 27 Check the appropriate block must be checked to indicate whether the provider of service or supplier accepts assignment of Medicare benefits. If MEDIGAP is indicated in block 9 and MEDIGAP payment authorization is given in item 13, the provider of service or supplier must also be a Medicare participating provider of service or supplier and must accept assignment of Medicare benefits for all covered charges for all patients. The following providers of service/suppliers and claims can only be paid on an assignment basis: Clinical diagnostic laboratory services; Physician services to individuals dually entitled to Medicare and Medicaid; Participating physician/supplier services, Services of physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives, certified registered nurse anesthetists, clinical psychologists, and clinical social workers; Ambulatory surgical center services for covered ASC procedures; Home dialysis supplies and equipment paid under Method II; Ambulance services; and Drugs and biologicals.

Item 28 Enter the total charges for the services (i.e., total of all charges in item 24f).

Item 29 Enter the total amount the patient paid on the covered services only.

Item 30 Leave blank. Not required by Medicare.

Item 31 Enter the signature of the practitioner or supplier, or his/her representative, and either the 6-digit date (MM/DD/YY), 8-digit date (MM/DD/CCYY), or alphanumeric date (e.g., January 1, 1998) the form was signed. Note: This is a required field, however, the claim can be processed if the following is true. If a physician, supplier, or authorized person’s signature is missing, but the signature is on file; or if any authorization is attached to the claim or if the signature field has "Signature on file" and/or a computer generated signature.

Item 32 Enter the name and address, and ZIP code of the facility if the services were furnished in a hospital, clinic, laboratory, or facility other than the patient's home or physician's office. Effective for claims received on or after April 1, 2004, the name, address, and zip code of the service location for all services other than those furnished in place of service home — 12. Effective for claims received on or after April 1, 2004, on the Form CMS-1500, only one name, address and zip code may be entered in the block. If additional entries are needed, separate claim forms shall be submitted. Providers of service (namely physicians) shall identify the supplier's name, address, and ZIP code when billing for purchased diagnostic tests. When more than one supplier is used, a separate Form CMS-1500 should be used to bill for each supplier. For foreign claims, only the enrollee can file for Part B benefits rendered outside of the United States. These claims will not include a valid ZIP code. When a claim is received for these services on a beneficiary submitted Form CMS-1490S, before the claim is entered in the system, it should be determined if it is a foreign claim. If it is a foreign claim, follow instructions in chapter 1 for disposition of the claim. The carrier processing the foreign claim will have to make necessary accommodations to verify that the claim is not returned as unprocessable due to the lack of a ZIP code. For durable medical, orthotic, and prosthetic claims, the name and address of the location where the order was accepted must be entered (DMERC only). This field is required. When more than one supplier is used, a separate Form CMS-1500 should be used to bill for each supplier. This item is completed whether the supplier's personnel performs the work at the physician's office or at another location. If a modifier is billed, indicating the service was rendered in a Health Professional Shortage Area (HPSA) or Physician Scarcity Area (PSA), the physical location where the service was rendered shall be entered if other than home. Complete this item for all laboratory work performed outside a physician's office. If an independent laboratory is billing, enter the place where the test was performed.

Item 32a Enter the NPI of the service facility as soon as it is available. The NPI may be reported on the CMS-1500 (08-05) as early as October 1, 2006.

Item 32b Enter the ID qualifier 1C followed by one blank space and then the PIN of the service facility. Effective May 23, 2007, and later, 32b is not to be reported. Providers of service (namely physicians) shall identify the supplier's PIN when billing for purchased diagnostic tests. If the supplier is a certified mammography screening center, enter the 6-digit FDA approved certification number. For durable medical, orthotic, and prosthetic claims, enter the PIN (of the location where the order was accepted) if the name and address was not provided in item 32 (DMERC only).

Item 33 Enter the practitioner's/supplier's billing name, address, zip code, and telephone number. Enter the UPINfor the performing provider of service/supplier who is not a member of a group practice. This includes the PIN of a billing "absentee" physician in a solo practice. Suppliers billing the DMERC will use the National Supplier Clearinghouse (NSC) number in this field. Enter the group PIN for the performing practitioner/supplier who is a member of a group practice.

Item 33a Effective May 23, 2007, and later, you MUST enter the NPI of the billing provider or group. The NPI may be reported on the CMS-1500 (08-05) as early as October 1, 2006. This is a required field.

Item 33b Enter the ID qualifier 1C followed by one blank space and then the PIN of the billing provider or group. Effective May 23, 2007, and later, 33b is not to be reported. Suppliers billing the DMERC will use the National Supplier Clearinghouse (NSC) number in this item. Enter the PIN for the performing provider of service/supplier who is not a member of a group practice. Enter the group PIN for the performing provider of service/supplier who is a member of a group practice. Enter the group UPIN, including the 2-digit location identifier, for the performing practitioner/supplier who is a member of a group practice.

Source: CMS, www.cms.hhs.gov/transmittals/downloads/R899CP.pdf.

Helpful Hints for Filing Claims

To expedite the handling of paper claims, consider these few suggestions:

• Some claim forms come with an attachment piece on the bottom of the form. If the form is perforated on the bottom, please remove the attachment in your office before mailing.
• Many providers use CMS1500 forms that are attached as they run through a printer. To speed the handling of these claims, please burst them before mailing.
• If you have an attachment to a claim, please staple the attachment behind the claim. This will ensure the right attachment is kept with the right claim.
• One vs. multiple-paged claims: If you have a multiple-paged claim, do not put the total on each page. You must place the total on the last or final page of the multiple-paged claim. If you put a total on each page, Medicare will consider the page a stand-alone claim. Also, if you have attachments (e.g., operative notes) for a multiple-page claim, it is especially important not to total each page of the claim and then attach the operative notes. The claim will be separated in our office, and most likely, your operative notes may get attached to the wrong part of the claim. Remember, on multiple page claims, place the total on only the last page of the claim and then the attachments and staple together.
• If you file both non-assigned and assigned claims, please send your non-assigned claims in a separate envelope than your assigned claims.
• Do not print any information on the top portion of the CMS1500. This space is needed for Medicare to place the Internal Control Number (ICN).

By following these few helpful hints, you will ensure that your paper claims will be handled properly. However, if you don’t want to have to deal with these minor details, you might want to consider filing electronically.

Source: Louisiana Medicare Services; http://www.lamedicare.com/

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