Revised paper claim form CMS-1500 (version 02/12)


Revised paper claim form CMS-1500 (version 0212)

All paper claims are required to be submitted using the new CMS-1500 (02/12) form.

The National Uniform Claim Committee (NUCC) recently revised the CMS-1500 claim form to align the paper claim form with changes in the 5010 837P and accommodate ICD-10 reporting needs. On June 10, 2013, the White House Office of Management and Budget (OMB) approved the revised paper claim form, CMS-1500 (version 02/12). The Centers for Medicare & Medicaid Services (CMS) adopted form CMS-1500 (02/12), which replaced the older CMS-1500 claim form (08/05), effective with claims received on and after April 1, 2014.

• Medicare began accepting claims on the revised form, (02/12), on January 6, 2014;
• As of April 1, 2014, Medicare only accepts paper claims on the revised CMS-1500 claim form, (02/12); and
When completing the claim form, ensure to use all capital typeface.
The revised form has a number of changes. The two most prevalent changes are new indicators to differentiate between ICD-9 and ICD-10 codes and new qualifiers to identify the role of the provider entered in item 17.
• The NUCC created a presentation that reviews the changes in detail. Click here external pdf file to view the NUCC presentation on the CMS-1500 (02/12) paper claim form.

Item 17 qualifiers
The qualifiers appropriate for identifying an ordering, referring, or supervising role are as follows:
• DN -- referring provider
• DK -- ordering provider
• DQ -- supervising provider
Providers should enter the qualifier to the left of the dotted vertical line on item 17.
• Note: Claims submitted with a national provider identifier (NPI) and without one of the qualifiers notated above or an invalid qualifier will be returned as an unprocessable claim (RUC).

Item 21 and 24E diagnosis changes
The revised form uses letters, instead of numbers, as diagnosis code pointers, and expands the number of possible diagnosis codes on a claim to 12.

Item 21
• For version 02/12, it may be appropriate to report either ICD-9-CM or ICD-10-CM codes depending upon the dates of service (i.e., according to the effective dates of the given code set), up to 12 diagnosis codes.
• Enter up to 12 diagnosis codes. Note: this information appears opposite lines with letters A-L. Relate lines A- L to lines of service in 24E by the letter of the line. Use the highest level of specificity.
• Do not provide narrative description in this field.
• Do not insert a period in the ICD-9-CM or ICD-10-CM code.
• The "ICD Indicator" identifies the ICD code set being reported. Enter the applicable ICD indicator as a single digit between the vertical, dotted lines.
• Indicator code set
• 0 -- ICD-10-CM diagnosis
• 9 -- ICD-9-CM diagnosis
Reminder: Providers cannot submit ICD-9 codes for claims with dates of service on and after October 1, 2015.

Item 24E
• For version 02/12, the reference will be a letter from A-L.
• When completing the claim form, ensure to use all capital typeface. This is especially important when indicating letter "I" and "L".
Additional changes
The following additional changes are also included in the revised form:

Item 8
• Form version 02/12: Leave blank.

Item 9b
• Form version 02/12: Leave blank.

Item 11b
• Form version 02/12: Enter employer's name, if applicable. If there is a change in the insured's insurance status, e.g., retired, enter either a 6-digit (MM | DD | YY) or 8-digit (MM | DD | CCYY) retirement date preceded by the word, "RETIRED." Provide this information to the right of the vertical dotted line.

Item 14
• Form version 02/12: Although this version of the form includes space for a qualifier, Medicare does not use this information; do not enter a qualifier in item 14.
ASCA reminder