CMS Pub. 100-04, ch. 26, § 10.4

Reminder: For date fields other than date of birth, all fields shall 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 - Enter either an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date of

current illness, injury, or pregnancy. For chiropractic services, enter an 8-digit (MM |

DD | CCYY) or 6-digit (MM | DD | YY) 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.

Additional information for form version 02/12: Although this version of the form

includes space for a qualifier, Medicare does not use this information; do not enter a

qualifier in item 14.

Item 15 - Leave blank.

Item 16 - If the patient is employed and is unable to work in his/her current occupation,

enter an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date when patient is

unable to work. An entry in this field may indicate employment related insurance

coverage.

Item 17 - Enter the name of the referring or ordering physician if the service or item was

ordered or referred by a physician. All physicians who order services or refer Medicare

beneficiaries must report this data. Similarly, if Medicare policy requires you to report a

supervising physician, enter this information in item 17. When a claim involves multiple

referring, ordering, or supervising physicians, use a separate CMS-1500 claim form for

each ordering, referring, or supervising physician.

Additional instructions for form version 02/12: Enter one of the following qualifiers as

appropriate to identify the role that this physician (or non-physician practitioner) is

performing:

Qualifier Provider Role

DN Referring Provider

Qualifier Provider Role

DK Ordering Provider

DQ Supervising Provider

Enter the qualifier to the left of the dotted vertical line on item 17.

NOTE: Under certain circumstances, Medicare permits a non-physician practitioner to

perform these roles. Refer to Pub 100-02, Medicare Benefit Policy Manual, chapter 15

for non-physician practitioner rules. Enter non-physician practitioner information

according to the rules above for physicians.

The term "physician" when used within the meaning of §1861(r) of the Act and used in

connection with performing any function or action refers to:

1. 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;

2. 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;

3. 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;

4. 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

5. 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.

Referring physician - is a physician who requests an item or service for the beneficiary

for which payment may be made under the Medicare program.

Ordering physician - is a physician or, when appropriate, a non-physician practitioner

who orders non-physician services for the patient. See Pub. 100-02, Medicare Benefit

Policy Manual, chapter 15 for non-physician practitioner rules. Examples of services that

might be ordered include diagnostic laboratory tests, clinical laboratory tests,

pharmaceutical services, durable medical equipment, and services incident to that

physician’s or non-physician practitioner’s service.

The ordering/referring requirement became effective January 1, 1992, and is required by

§1833(q) of the Act. All claims for Medicare covered services and items that are the

result of a physician's order or referral shall include the ordering/referring physician's

name. The following services/situations require the submission of the referring/ordering

provider information:

• Medicare covered services and items that are the result of a physician's order

or referral;

• Parenteral and enteral nutrition;

• Immunosuppressive drug claims;

• Hepatitis B claims;

• Diagnostic laboratory services;

• Diagnostic radiology services;

• Portable x-ray services;

• Consultative services;

• Durable medical equipment;

• When the ordering physician is also the performing physician (as often is the

case with in-office clinical laboratory tests);

• When a service is incident to the service of a physician or non-physician

practitioner, the name of the physician or non-physician practitioner who

performs the initial service and orders the non-physician service must appear in

item 17;

• When a physician extender or other limited licensed practitioner refers a patient

for consultative service, submit the name of the physician who is supervising the

limited licensed practitioner;

• Effective for claims with dates of service on or after October 1, 2012, all claims

for physical therapy, occupational therapy, or speech-language pathology

services, including those furnished incident to a physician or nonphysician

practitioner, require that the name and NPI of the certifying physician or

nonphysician practitioner of the therapy plan of care be entered as the referring

physician in Items 17 and 17b.

Item 17a - Leave blank.

Item 17b - Enter the NPI of the referring, ordering, or supervising physician or non-physician practitioner listed in item 17. All physicians and non-physician practitioners

who order services or refer Medicare beneficiaries must report this data.

NOTE: Effective May 23, 2008, 17a is not to be reported but 17b MUST be reported

when a service was ordered or referred by a physician.

Item 18 - 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 either a 6-digit (MM | DD | YY) or an 8-digit (MM | DD | CCYY) date

patient was last seen and the NPI of his/her attending physician when a physician

providing routine foot care submits claims.

NOTE: Effective May 23, 2008, all provider identifiers submitted on the CMS-1500

claim form MUST be in the form of an NPI.

Enter either a 6-digit (MM | DD | YY) or an 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 chiropractor is certifying that all the

relevant information requirements (including level of subluxation) of Pub. 100-02,

Medicare Benefit Policy Manual, chapter 15, is on file, along with the appropriate x-ray

and all are available for A/B MAC (B) review.

Instructions for Not Otherwise Classified (NOC) Codes – Any unlisted services or

procedure code. Note: When reporting NOC codes, this field must be populated as

specified below.

Enter the drug's name and dosage when submitting a claim for NOC drugs.

Enter 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 shall be submitted with

the claim.

When billing for unlisted laboratory tests using a NOC code, this field MUST include the

specific name of the laboratory test(s) and/or a short descriptor of the test(s). Claims for

unlisted laboratory tests that are received without this information shall be treated

according to the requirements found in Pub. 100-04, Medicare Claims Processing

Manual, Chapter 1, Section 80.3.2 and “returned as unprocessable.” Section 216(a) of the

Protecting Access to Medicare Act of 2014 (PAMA) requires reporting entities to report

private payor payment rates for laboratory tests and the corresponding volumes of

tests. In compliance with PAMA, CMS must collect private payor data on unique tests

currently being paid as a NOC code, Not Otherwise Specified (NOS) code, or unlisted

service or procedure code.

Enter 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.

Enter the statement "Homebound" when an independent laboratory obtains a specimen

from a homebound or institutionalized patient. (See Pub. 100-02, Medicare Benefit

Policy Manual, Chapter 15, "Covered Medical and Other Health Services," and Pub. 100-

04, Medicare Claims Processing Manual, Chapter 16, "Laboratory Services,” and Pub.

100-01, 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 non-participating physician/supplier who accepts

assignment on a claim. In this case, payment can only be made directly to the

beneficiary.

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, enter 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 a 6-digit (MM | DD | YY) or an 8-digit (MM | DD | CCYY) assumed and/or

relinquished date for a global surgery claim when providers share post-operative care.

Enter demonstration ID number "30" for all national emphysema treatment trial claims.

Enter demonstration ID number “56” for all national Laboratory Affordable Care Act

Section 113 Demonstration Claims.

Enter the NPI of the physician who is performing the technical or professional

component of a diagnostic test that is subject to the anti-markup payment limitation. (See

Pub. 100-04, chapter 1, section 30.2.9 for additional information.)

NOTE: Effective May 23, 2008, all provider identifiers submitted on the CMS-1500

claim form MUST be in the form of an NPI.

Method II suppliers shall enter the most current HCT value for the injection of Aranesp

for ESRD beneficiaries on dialysis. (See Pub. 100-04, chapter 8, section 60.7.2.)

Individuals and entities who bill A/B MACs (B) for administrations of ESAs or Part B

anti-anemia drugs not self-administered (other than ESAs) in the treatment of cancer

must enter the most current hemoglobin or hematocrit test results. The test results shall

be entered as follows: TR= test results (backslash), R1=hemoglobin, or R2=hematocrit

(backslash), and the most current numeric test result figure up to 3 numerics and a

decimal point [xx.x]). Example for hemoglobin tests: TR/R1/9.0, Example for

Hematocrit tests: TR/R2/27.0.

Item 20 - Complete this item when billing for diagnostic tests subject to the anti-markup

payment limitation. Enter the acquisition price under charges 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 "no anti-markup tests are

included on the claim." When "yes" is annotated, item 32 shall be completed. When

billing for multiple anti-markup tests, each test shall be submitted on a separate claim

form CMS-1500. Multiple anti-markup 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 service facility locations. See chapter 1.

NOTE: This is a required field when billing for diagnostic tests subject to the anti-markup payment limitation.

Item 21 - Enter the patient's diagnosis/condition. With the exception of claims submitted

by ambulance suppliers (specialty type 59), all physician and nonphysician specialties

(i.e., PA, NP, CNS, CRNA) use diagnosis codes to the highest level of specificity for the

date of service. Enter the diagnoses in priority order. All narrative diagnoses for

nonphysician specialties shall be submitted on an attachment.

Reminder: Do not report ICD-10-CM codes for claims with dates of service prior to

implementation of ICD-10-CM, on either the old or revised version of the CMS-1500

claim form.

For form version 08/05, report a valid ICD-9-CM code. Enter up to four diagnosis codes.

For form version 02/12, it may be appropriate to report either ICD-9-CM or ICD-10-CM

codes depending upon the dates of service (i.e., according to the effective dates of the

given code set).

• The “ICD Indicator” identifies the ICD code set being reported. Enter the

applicable ICD indicator according to the following:

Indicator Code Set

9 ICD-9-CM diagnosis

0 ICD-10-CM diagnosis

Enter the indicator as a single digit between the vertical, dotted lines.

• Do not report both ICD-9-CM and ICD-10-CM codes on the same claim form. If

there are services you wish to report that occurred on dates when ICD-9-CM

codes were in effect, and others that occurred on dates when ICD-10-CM codes

were in effect, then send separate claims such that you report only ICD-9-CM or

only ICD-10-CM codes on the claim. (See special considerations for spans of

dates below.)

• If you are submitting a claim with a span of dates for a service, use the “from”

date to determine which ICD code set to use.

• Enter up to 12 diagnosis codes. Note that this information appears opposite lines

with letters A-L. Relate lines A- L to the lines of service in 24E by the letter of

the line. Use the highest level of specificity. Do not provide narrative description

in this field.

• Do not insert a period in the ICD-9-CM or ICD-10-CM code.

Item 22 - Leave blank. Not required by Medicare.

Item 23 - Enter the Quality Improvement Organization (QIO) prior authorization number

for those procedures requiring QIO prior approval.

Enter the Investigational Device Exemption (IDE) number when an investigational

device is used in an FDA-approved clinical trial. Post Market Approval number should

also be placed here when applicable.

For physicians performing care plan oversight services, enter the NPI of the home health

agency (HHA) or hospice when CPT code G0181 (HH) or G0182 (Hospice) is billed.

Enter the 10-digit Clinical Laboratory Improvement Act (CLIA) certification number for

laboratory services billed by an entity performing CLIA covered procedures.

For ambulance claims, enter the ZIP code of the loaded ambulance trip’s point-of-pickup.

NOTE: Item 23 can contain only one condition. Any additional conditions should be

reported on a separate CMS-1500 claim form.

Item 24 - The six service lines in section 24 have been divided horizontally to

accommodate submission of supplemental information to support the billed service. The

top portion in each of the six service lines is shaded and is the location for reporting

supplemental information. It is not intended to allow the billing of 12 service lines.

When required to submit NDC drug and quantity information for Medicaid rebates,

submit the NDC code in the red shaded portion of the detail line item in positions 01

through position 13. The NDC is to be preceded with the qualifier N4 and followed

immediately by the 11 digit NDC code (e.g. N499999999999). Report the NDC quantity

in positions 17 through 24 of the same red shaded portion. The quantity is to be preceded

by the appropriate qualifier: UN (units), F2 (international units), GR (gram) or ML

(milliliter). There are six bytes available for quantity. If the quantity is less than six

bytes, left justify and space-fill the remaining positions (e.g., UN2 or F2999999).

Item 24A - Enter a 6-digit or 8-digit (MMDDCCYY) 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. Return as unprocessable if

a date of service extends more than 1 day, and a valid "to" date is not present.

Item 24B - Enter the appropriate place of service code(s) from the list provided in section

10.5. Identify the setting, using a place of service code, for each item used or service

performed. This is a required field.

NOTE: When a service is rendered to a patient who is a registered inpatient or an

outpatient (off campus or on campus) of a hospital, use the inpatient hospital POS code

21, Off Campus-Outpatient Hospital POS code 19, or On Campus-Outpatient Hospital

POS code 22, respectively, as discussed in section 10.5 of this chapter.

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

Item 24D - Enter the procedures, services, or supplies using the CMS Healthcare

Common Procedure Coding System (HCPCS) code. When applicable, show HCPCS

code modifiers with the HCPCS code. The CMS-1500 claim form has the capacity to

capture up to four modifiers.

Enter the specific procedure code without a narrative description. However, when

reporting an "unlisted procedure code" or a "not otherwise classified" (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 shall be submitted with the claim. This is

a required field.

Return as unprocessable if an "unlisted procedure code" or a NOC code is indicated in

item 24d, but an accompanying narrative is not present in item 19 or on an attachment.

Item 24E - This is a required field. Enter the diagnosis code reference number or letter

(as appropriate, per form version) as shown in item 21 to relate the date of service and the

procedures performed to the primary diagnosis. Enter only one reference number/letter

per line item. When multiple services are performed, enter the primary reference

number/letter for each service.

When using form version 08/05, this reference will be either a 1, or a 2, or a 3, or a 4.

When using form version 02/12, the reference to supply in 24E will be a letter from A-L.

Otherwise, the instructions above apply.

If a situation arises where two or more diagnoses are required for a procedure code (e.g.,

pap smears), the provider shall 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, enter the actual number

provided.

For anesthesia, show the elapsed time (minutes) in item 24g. Convert hours into minutes

and enter the total minutes required for this procedure.

For instructions on submitting units for oxygen claims, see chapter 20, section 130.6 of

this manual.

Beginning with dates of service on and after January 1, 2011, for ambulance mileage,

enter the number of loaded miles traveled rounded up to the nearest tenth of a mile up to

100 miles. For mileage totaling 100 miles and greater, enter the number of covered miles

rounded up to the nearest whole number miles. If the total mileage is less than 1 whole

mile, enter a “0” before the decimal (e.g. 0.9). See Pub. 100-04, chapter 15, §20.2 for

more information on loaded mileage and §30.1.2 for more information on reporting

fractional mileage.

NOTE: This field should contain an appropriate numerical value. The A/B MAC (B)

should program their system to automatically default "1" unit when the information in

this field is missing to avoid returning as unprocessable, except on claims for ambulance

mileage. For ambulance mileage claims, contractors shall automatically default “0.1”

unit when total mileage units are missing in this field.

Item 24H - Leave blank. Not required by Medicare.

Item 24I - Leave Blank. Not required by Medicare.

Item 24J - Enter the rendering provider’s NPI number in the lower unshaded 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 unshaded portion.

This unprocessable instruction does not apply to influenza virus and pneumococcal

vaccine claims submitted on roster bills as they do not require a rendering provider NPI.

NOTE: Effective May 23, 2008, the shaded portion of 24J is not to be reported.

Item 25 - Enter the provider of service or supplier Federal Tax ID (Employer

Identification Number or Social Security Number) and check the appropriate check box.

Medicare providers are not required to complete this item for crossover purposes since

the Medicare contractor will retrieve the tax identification information from their internal

provider file for inclusion on the COB outbound claim. However, tax identification

information is used in the determination of accurate National Provider Identifier

reimbursement. Reimbursement of claims submitted without tax identification

information will/may be delayed.

Item 26 - Enter the patient's account number assigned by the provider's of service 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 to indicate whether the provider of service or

supplier accepts assignment of Medicare benefits. If Medigap is indicated in item 9 and

Medigap payment authorization is given in item 13, the provider of service or supplier

shall also be a Medicare participating provider of service or supplier and 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;

• Drugs and biologicals; and

• Simplified Billing Roster for influenza virus vaccine and pneumococcal vaccine.

Item 28 - Enter 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 provider of service or supplier, or his/her representative,

and either the 6-digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY), or alpha-numeric date (e.g., January 1, 1998) the form was signed.

In the case of a service that is provided incident to the service of a physician or non-physician practitioner, when the ordering physician or non-physician practitioner is

directly supervising the service as in 42 CFR 410.32, the signature of the ordering

physician or non-physician practitioner shall be entered in item 31. When the ordering

physician or non-physician practitioner is not supervising the service, then enter the

signature of the physician or non-physician practitioner providing the direct supervision

in item 31.

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 - For services payable under the physician fee schedule and anesthesia services,

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, enter 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, only one name,

address and ZIP code may be entered in the block. If additional entries are needed,

separate claim forms shall be submitted. Effective January 1, 2011, for claims processed

on or after January 1, 2011, submission of the location where the service was rendered

will be required for all POS codes.

Providers of service (namely physicians) shall identify the supplier's name, address, and

ZIP code when billing for anti-markup tests. When more than one supplier is used, a

separate CMS-1500 claim form shall be used to bill for each supplier. (See Pub. 100-04,

chapter 1, §10.1.1.2 for more information on payment jurisdiction for claims subject to

the anti-markup limitation.)

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 A/B MAC (B)

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 (DME MAC only). This field is required.

When more than one supplier is used, a separate CMS-1500 claim form shall 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 the supplier is a certified mammography screening center, enter the 6-digit FDA

approved certification number.

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 - If required by Medicare claims processing policy, enter the NPI of the service

facility.

Effective for claims submitted with a receipt date on and after October 1, 2015, the

billing physician or supplier must report the name, address, and NPI of the performing

physician or supplier on the claim on reference laboratory claims, even if the performing

physician or supplier is enrolled in a different A/B MAC (B) jurisdiction. See Pub. 100-

04, Chapter 1, §10.1.1 for more information regarding claims filing jurisdiction.

Item 32b - Effective May 23, 2008, Item 32b is not to be reported.

Item 33 - Enter the provider of service/supplier's billing name, address, ZIP code, and

telephone number. This is a required field.

Item 33a - Enter the NPI of the billing provider or group. This is a required field.

Item 33b - Item 33b is not generally reported. However, for some Medicare policies you

may be instructed to use this item; direction as to how to use this item will be in the

instructions you received regarding the specific policy, if applicable.