Monday, October 5, 2015

Modified Form CMS-1500 for Cover Document for roster billing

Entities submitting roster claims to A/B MACs (B) must complete the following blocks on a single modified Form CMS-1500, which serves as the cover document for the roster for each facility where services are furnished. In order for A/B MACs (B) to reimburse by correct payment locality, a separate Form CMS-1500 must be used for each different facility or physical location where services are furnished.

Item # Instruction

Item # Instruction Item 1: An X in the Medicare block

Item 2: (Patient's Name): "SEE ATTACHED ROSTER"

Item 11: (Insured's Policy Group or FECA Number): "NONE"

Item 20: (Outside Lab?): An "X" in the NO block

Item 21: (Diagnosis or Nature of Illness): Line A: Choose appropriate diagnosis code from §10.2.1 ICD Ind. Block: Enter 9 if ICD-9-CM or 0 if ICD-10-CM is applicable. Enter the indicator as a single digit between the vertical dotted lines.

Item 24B: (Place of Service (POS)): Line 1: "60" Line 2: "60" NOTE: POS Code “60" must be used for roster billing.

Item 24D: (Procedures, Services or Supplies): Line 1: Pneumococcal vaccine: "90732" or Influenza Virus vaccine: “Select appropriate influenza virus vaccine code” Line 2: Pneumococcal vaccine Administration: "G0009" or Influenza Virus Vaccine Administration: "G0008"

Item 24E: (Diagnosis Pointer): Lines 1 and 2: "A"

Item 24F: ($ Charges): The entity must enter the charge for each listed service. If the entity is not charging for the vaccine or its administration, it should enter 0.00 or "NC" (no charge) on the appropriate line for that item. If your system is unable to accept a line item charge of 0.00 for an immunization service, do not key the line item. Likewise, electronic media claim (EMC) billers should submit line items for free immunization services on EMC pneumococcal or influenza virus vaccine claims only if your system is able to accept them.

Item 27: (Accept Assignment): An "X" in the YES block.

Item 29: (Amount Paid): "$0.00" Item 31: (Signature of Physician or Supplier): The entity's representative must sign the modified Form CMS-1500.

Item 32: Enter the name, address, and ZIP code of the location where the service was provided (including centralized billers).

Item32a: Enter the NPI of the service facility.

Item 33: (Physician's, Supplier's Billing Name): The entity must complete this item to include the Provider Identification Number (not the Unique Physician Identification Number) or NPI when required.

Item 33a: Effective May 23, 2007, and later, enter the NPI of the billing provider or group.

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