Wednesday, May 26, 2010

Box 24 - 33 - How to billing - CMS 1500

Bottom section of the CMS 1500 form

Supplemental information

Shaded line

�� 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

Emergency Indicator

�� 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

Procedure Code
�� 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

Diagnosis Pointer
�� 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
Total Charges
�� 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
Total Charge
�� 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
Amount Paid

�� Enter the total amount paid by any prior resource(s).
�� Do not include write-offs.

�� Do not include copayments.

Box 30 - Required

Balance Due
�� 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).

CMS 1500 BOX 33 filing example

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