Understanding CMS 1500 Box 17-19: Ambulance Billing Guidelines


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

Billing instruction for Ambulance Billing - Box 17 to 19

BlockNo.Block NameBlock CodeNotes
17Name of Referring Physician or Other SourceMEnter the name and the degree of the attending practitioner.
17aI.D. Number of Referring PhysicianAIn 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
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.
17bNPI #AEnter the 10-digit National Provider Identifier number of the referring provider, ordering provider, or other source.
18Hospitalization Dates Related to Current ServicesLBDo not complete this block.
19Reserved For
Local Use
A/AThis 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 (,).