Bottom section of the CMS 1500 form
�� In the shaded area across Fields 24A through 24H, enter supplemental information about the service rendered.
�� If entering more than one item of information on a line, make sure each item begins with a qualifier and is separated by at least 1 blank space.
Box 24A - Required
Date of Service
�� This box must list numeric dates of service.
�� If billing for one day, complete only the “from” column.
�� If the “from and to” dates are used, a service must be on consecutive days and provided no more than once per day.
Box 24B - Required
Place of Service
�� Enter the two-digit place of service code of where the service was provided.
�� Place of service codes can be found in CPT/HCPCS codebooks or on the Web site at:
Box 24C - Optional
�� If the service you provided was a result of an emergency, enter a “Y” for “yes” in this box for each line item.
�� If this was not an emergent service, leave blank or enter a “N” for “nonemergent”.
Box 24D - Required
�� Enter the five-digit/character CPT or HCPCS code(s) for the specific service provided.
�� Optional - Enter up to four two-digit national modifiers that relate to this service.
�� For procedure codes that indicate “unlisted,” you must attach an operative/medical report.
Box 24E - Required
�� Enter the one-digit diagnosis code reference number (pointer) as shown in box 21 to relate
the date of service and the procedure performed to the primary diagnosis.
�� Do not enter the actual ICD-9-CM code here.
Box 24F - Required
�� Enter the total usual and customary charge for each line.
�� Do not list credits.
�� Do not use dashes.
Box 24G - Required
Service Days or Units
�� Enter the number of days or units for each number of consecutive days or services as
indicated in box 24A.
�� Some services are billed by units depending on the service provided.
Box 24J - Optional
Rendering Provider ID
�� This box is only required when clinics or group practices use a specific billing provider number in box 33. This identifies who rendered the service.
�� Shaded - Enter the six (6)-or nine (9)- digit DHS provider number of the individual rendering the service.
�� Non-shaded - Enter the ten-digit NPI of the rendering provider that was identified in the shaded area.
Box 26 - Optional
Patient Account Number
�� Enter your patient account number here.
�� This box allows up to twelve characters.
�� This number will appear on your Remittance Advice (RA).
Box 28 - Required
�� Enter the total charge amount for all services listed in column 24F.
�� Each claim form is a separate document, and is to be totaled as such.
Box 29 - Optional
�� Enter the total amount paid by any prior resource(s).
�� Do not include write-offs.
�� Do not include copayments.
Box 30 - Required
�� Enter the balance due.
�� Box 28 minus box 29 must equal box 30.
Box 33 - Required
Billing Provider Information
�� Box 33 - (Billing provider info & phone number) Enter the name and address of the provider that is requesting to be paid for the services rendered.
�� 33a - (NPI) Enter the ten-digit NPI of the billing provider.
�� 33b - (Other ID) Enter the six (6)-or nine (9)-digit provider number of the billing provider.
Note: Non-medical services do not require NPI (e.g., taxis).
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Item 21 - Enter the patient's diagnosis/condition. With the exception of claims submitted by ambulance suppliers (specialty type 59), al...
The other ID number of the referring provider, ordering provider, or other source should be reported in 17a in the shaded area. The qualifie...
For Adjustments: When requesting an adjustment to a paid claim, enter an “A” followed by the 13-character internal control number (ICN) as...
Item 17 Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician. All physicia...
Bottom section of the CMS 1500 form Supplemental information Shaded line �� In the shaded area across Fields 24A through 24H, enter s...
Billing instruction for Ambulance Billing - Box 20 to 23 BlockNo. Block Name Block Code Notes ...
When submitting attachments with the CMS-1500 claim form, please follow these guidelines: Any attachment should be marked with the benef...
The fields on the UB claim form are called Field Locators (FL). Shaded boxes are fields DMAP uses to process your claim; your claim may susp...
Click the image for see full size sample CMS 1500 claim form. Claim Form Sample