The place of service or diagnosis may be considered when determining the appropriate TOS. The descriptors for each of the TOS codes listed in the following table are:
Type of Service Indicators
0 Whole Blood
1 Medical Care
4 Diagnostic Radiology
5 Diagnostic Laboratory
6 Therapeutic Radiology
8 Assistant at Surgery
9 Other Medical Items or Services
A Used DME
B High Risk Screening Mammography
C Low Risk Screening Mammography
E Enteral/Parenteral Nutrients/Supplies
F Ambulatory Surgical Center (Facility Usage for Surgical Services)
G Immunosuppressive Drugs
J Diabetic Shoes
K Hearing Items and Services
L ESRD Supplies
M Monthly Capitation Payment for Dialysis
N Kidney Donor
P Lump Sum Purchase of DME, Prosthetics, Orthotics
Q Vision Items or Services
R Rental of DME
S Surgical Dressings or Other Medical Supplies
T Outpatient Mental Health Treatment Limitation
U Occupational Therapy
V Pneumococcal/Flu Vaccine
W Physical Therapy
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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...
Click the image for see full size sample CMS 1500 claim form. Claim Form Sample
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...