Get Ready for the Revised CMS-1500 Claim Form
Cindy Hughes, CPC
Fam Pract Manag. 2006;13(9) ©2006 American Academy of Family Physicians
The first step, which some physicians have already completed, is to obtain your NPI number. If you still need to do this, see "All about the NPI number" below. Your Medicare carrier and other payers will continue to accept your current payer-assigned provider numbers until May 23, 2007, but it may be most efficient to implement the revised form and your NPI at the same time. By submitting claims using the NPI number as soon as the payers in your area are ready to receive it, you can detect any system errors before the NPI is required for all submissions to large payers.
This article offers answers to common questions about the revised CMS-1500 form and its implementation.
How is the revised form different from the form currently in use?
Field 17a was split to provide space for the NPI number or other types of identifiers that payers may require (e.g., your current payer-assigned provider number or your Unique Physician Identifier Number). Similar changes were made to fields 24I, 32 and 33. Other changes are minor. If you would like to review all of the changes, a PDF file detailing the changes is available online at http://www.nucc.org/images/stories/PDF/final_1500_change_log.pdf.
When must I begin using the revised 1500 form?
Here's the time line for implementing the revised form:
- Jan. 2, 2007 - Health plans, clearinghouses and other information-support vendors should be ready to accept the revised form.
- Jan. 2, 2007, through March 30, 2007 - Providers can use either the current form (CMS-1500 [12-90]) or the revised form.
- April 2, 2007 - Only the revised form can be used. Rebilled claims should also use the revised form, even if earlier submissions were on the previous form.
Have instructions for use of the revised form been published?
Yes. The National Uniform Claims Committee (NUCC) instruction manual, available online at http://www.nucc.org/images/stories/PDF/claim_form_manual_v1-3_7-06.pdf, provides general guidance on the use of the revised form. It includes the following pointers:
- The shaded fields in boxes 17a, 24I, 24J, 32b and 33b should be used to report provider numbers other than the NPI as needed. Fields 17a and 24I include a separate space for a two-digit qualifier that describes the type of identifier entered. (See "Two-digit qualifiers" for a list.) Fields 32b and 33b do not have a separate area for the qualifiers, but the qualifier should still be the first two digits entered.
- The six service lines in section 24 are now divided horizontally with the upper half shaded. The shaded areas in fields 24A-24G let you report supplemental information, such as the National Drug Code or a description of an unspecified procedure code. When entering a number such as the National Drug Code, start with the two-digit identifier. Do not enter a space, hyphen or other separator between the identifier and the code number. When entering supplemental information for which no identifier exists, leave the first two spaces blank. Not including these first two spaces, 61 characters can be entered into fields 24A-24G.
- There are still only six service lines. Do not attempt to report more than six services per claim using the shaded areas.
- Field 24C is now labeled "EMG," which on the previous form was located in 24I. This replaces the type of service code field, which is no longer used by payers. "EMG" stands for emergency and should be completed only to indicate an emergency service. Enter a "Y" to indicate an emergency service. Leave it blank if services were non-emergent.
- Field 24E is now labeled "Diagnosis Pointer." However, this field should still be used to link the diagnoses listed in field 21 to the lines of service.
Will my billing system need an upgrade to work with the revised form?
Yes. Your software vendor will need to update the form fields, which is most likely a minor revision. However, even minor changes take time, and it would be best to contact your vendor now to ensure that the changes will be made and that you'll have ample time for testing. You will want to know whether the qualifier fields can be set to automatically populate based on the type of identification number being reported and whether the software is set up to accept the correct number of spaces per field.
Can I get an electronic file of the revised form for use in testing?
Yes. A PDF version of the revised form is available online at http://www.nucc.org/images/stories/PDF/final_1500_claim_form.pdf. The file contains three different versions of the same 1500 form: one in a standard format, one in a grid format and one in a template format. The PDF file might not print to exact specifications. Print specifications are available in Appendix A of the NUCC instruction manual referenced earlier.
Prepare now, avoid delays
If your practice is among the majority that submit claims electronically, preparing your billing system to print paper claims correctly may be of relatively little concern. However, submitting secondary claims, those that require attachments and others that are typically paper-based will require that you make some changes to your billing system. Like applying now for your NPI number, preparing for the use of this revised claim form may help you avoid potential delays in payment later.
Sidebar: Two-digit Qualifiers
These two-digit qualifiers should be used as appropriate in fields 17a, 24I, 32b and 33b of the revised 1500 claim form.
0B State license number
1B Blue Shield provider number
1C Medicare provider number
1D Medicaid provider number
1G Provider UPIN
1H CHAMPUS identification number
EI Employer's identification number
G2 Provider commercial number
LU Location number
N5 Provider plan network identification number
SY Social Security number (This may not be used for Medicare.)
X5 State industrial accident provider number
ZZ Provider taxonomy
The following identifiers are to be used when reporting services related to them.
ZZ Narrative description of unspecified code
N4 National Drug Codes (NDC)
VP Vendor product number Health Industry Business Communications Council (HIBCC) labeling standard
OZ Product number Health Care Uniform Code Council - Global Trade Item Number (GTIN)
CTR Contract rate
Cindy Hughes is the coding and compliance specialist for the AAFP and is a contributing editor to Family Practice Management.