|BlockNo.||Block Name||Block Code||Notes|
|24a||Dates of Service||M/M||Enter the applicable date(s) of service. |
If billing for a service that was provided on one day only, complete either the From or the To column (but not both.).
If the same service was provided on consecutive days, enter the first day of the service in the From column and the last day of service in the To column. Use an eight-digit (MMDDCCYY) format to record the From and To dates, (e.g. 03012004).
If the dates are not consecutive, separate claim lines must be used.
|24b||Place of Service||M||Enter the 2-digit place of service code that indicates where the recipient was transported (i.e., destination). |
12 – Patient’s Home
21 – Inpatient Hospital
22 – Outpatient Hospital
23 – Emergency Room
24 – Ambulatory Surgical Center (ASC)/ Hospital
Short Procedure Unit (SPU)
32 – Nursing Facility
49 – Independent Clinic
50 – Federally Qualified Health Center
54 – Intermediate Care Facility/Mentally Retarded
55 – Residential Substance Abuse Treatment
65 – End Stage Renal Disease Treatment Facility
72 – Rural Health Clinic
99 – Other Unlisted Facility
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Sunday, December 26, 2010
Billing instruction for Ambulance Billing - Box 24a to 24b
The other ID number of the referring provider, ordering provider, or other source should be reported in 17a in the shaded area. The qualifie...
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...
For Adjustments: When requesting an adjustment to a paid claim, enter an “A” followed by the 13-character internal control number (ICN) as...
Item 21 - Enter the patient's diagnosis/condition. With the exception of claims submitted by ambulance suppliers (specialty type 59), al...
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
TWO-DIGIT QUALIFIERS The shaded fields in boxes 17a, 24I, 24J, 32b and 33b should be used to report provider numbers other than the NPI as...