Tuesday, November 30, 2010

Box 17 - 19 - Reserved for local use - cms 1500

Billing instruction for Ambulance Billing - Box 17 to 19



BlockNo. Block Name Block Code Notes
17 Name of Referring Physician or Other Source M Enter the name and the degree of the attending practitioner.
17a I.D. Number of Referring Physician A In the first portion of this block, enter a two-digit qualifier that indicates the type of ID:
0B = License Number
1D = 13-digit Provider ID number (Legacy
Number)
In the second portion, enter the
license number of the referring or prescribing practitioner named in Block 17 (e.g., MD123456X). If the practitioner's license number was issued after June 29, 2001, enter the number in the new format (e.g., MD123456).
If an out-of-state provider orders the service, enter the two-letter State abbreviation, followed by six
9’s, and an X. For example, a prescribing practitioner from New Jersey would be entered as NJ999999X.
17b NPI # A Enter the 10-digit National Provider Identifier number of the referring provider, ordering provider, or other source.
18 Hospitalization Dates Related to Current Services LB Do not complete this block.
19 Reserved For
Local Use
A/A This field must be completed with attachment type codes, when applicable. Attachment type codes begin with the letters “AT”, followed by a two- digit number (i.e., AT05).
Enter up to four, 4-character alphanumeric attachment type codes. When entering more than one attachment type code, separate the codes with a comma (,).

1 comment:

  1. Find blank and fillable W-9 and 1500 Claim forms at PDFfiller.
    http://goo.gl/3Kbg3B
    You can fill the text fields, add a variety of checkmarks, digitally sign the form and even add pictures. After your pdf form is completed, it can be printed, emailed, faxed or saved on your computer. You can even send fillable pdf forms to your customers, employees, vendors and partners.

    ReplyDelete

Popular Posts