CMS-1500 Manual Index
Item Locator Page
Payer Designation 1 3
Insured’s ID Number 1A 3
Patient’s Name 2 3
Patient’s Birthdate / Sex 3 3
Insured’s Name 4 4
Patient’s Address 5 4
Patient Relationship to Insured 6 6
Insured’s Address 7 6
Patient Status 8 6
Other Insured’s Name 9 6
Other Insured’s Policy or Group Number 9A 7
Other Insured’s Date of Birth / Sex 9B 7
Employer’s Name or School Name 9C 7
Insurance Plan Name or Program Name 9D 8
Is Patient’s Condition Related To:
   Employment?
10A 8
Is Patient’s Condition Related To:
   Auto Accident?
10B 8
Is Patient’s Condition Related To:
   Other Accident?
10C 8
Reserved for Local use 10D  
Insured’s Policy Group or FECA Number 11 8
Insured’s Date of Birth / Sex 11A 9
Employer’s Name or School Name 11B 9
Insurance Plan Name or Program Name 11C 9
Is There Another Health Benefit Plan? 11D 9
Patient’s or Authorized Person’s Signature / Date 12 9
Insured’s or Authorized Person’s Signature 13 9
Date of Current Illness, Injury or Pregnancy 14 10
If Patient Has Had Same or Similar Illness 15 10
Dates Patient Unable to Work in Current Occupation 16 10
Name of Referring Physician or Other Source 17 10
ID Number of Referring Physician 17A 11
Hospitalization Dates related to Current Services 18 11
Reserved for Local Use 19 11
Outside Lab / $ Charges 20 12
Diagnosis or Nature of Illness or Injury 21 12
Medicaid Resubmission 22 12
Prior Authorization Number 23 12
Dates of Service 24A 13
Place of Service 24B 13
Type of Service 24C 18
Procedures, Services, or Supplies 24D 19
Diagnosis Code 24E 19
$ Charges 24F 19
Days or Units 24G 19
EPSDT / Family Plan 24H 20
EMG 24I 20
COB 24J 20
Reserved for Local Use 24K 20
Federal Tax ID Number 25 20
Patient’s Account Number 26 21
Accept Assignment 27 21
Total Charge 28 21
Amount Paid 29 21
Balance Due 30 21
Signature of Physician or Supplier 31 22
Name and Address of Facility Where Services
   Were Rendered
32 22
Physician’s, Supplier’s Billing Name, Address,
   Zip Code & Phone Number
33 22




Item 1 - Payer designation  (back to index)
Definition: Payer identification
Procedures: Not required
Field Size: 7 fields: 1 alpha character
Instruction: Show the type of health insurance coverage by placing an ‘x’ in the “other” box.


Item 1A - Insured’s ID number  (back to index)
Definition: Insured’s unique benefit plan number assigned by BCBSND.
Procedures: Required. Enter the alpha prefix along with the benefit plan number as it appears on the identification card. No spaces between alpha-numeric characters.
Field Size: 1 field: 12 alpha-numeric characters


Item 2 - Patient’s name  (back to index)
Definition: Last name, first name and middle initial of the patient (the individual receiving care or services)
Procedures: Required - Enter last name(space)first name(space)middle initial.
Field Size: 1 field:
    18 alpha characters for last name,
    12 alpha characters for first name,
    1 alpha character for middle initial
Instruction: No nicknames or abbreviations. No space should be left between a prefix and a name as in MacBeth, VonSchmidt, McEnroe; or between such names as JoBeth or MaryAnn. Titles such as Sr., Jr., Rev., should be entered after last name with a space between last name and title.
Example: Patientlast Jr First M


Item 3 - Patient’s birth date / sex  (back to index)
Definition: The date of birth and sex of the patient.
Procedures: Required
Field Size: 2 fields:
    8 numeric characters for patient’s birth date
    1 alpha character for patient’s sex
Instruction: Enter month, day, century and year of birth. Recommended print format is “MMDDCCYY” Enter in the proper positions on the claim form. If full birth date is unknown, enter as much information as possible and zero fill the unknown.
Example: Example: Patient born in May 1924, but exact date is unknown. Enter 05001924 as the birth date. Enter an ‘x’ in the appropriate designating the sex of the patient.


Item 4 - Insured’s name  (back to index)
Definition: Last name, first name, and middle initial of the individual in whose name the insurance is carried, as qualified below by the payer organization.
Procedures: Required
Enter last name(space)first name(space)middle initial of the insurer.
Field Size: 1 field:
    18 alpha characters for last name
    12 alpha characters for first name
    1 alpha character for middle initial
Instruction: No nicknames or abbreviations. No space should be left between a prefix and a name as in MacBeth, VonSchmidt, McEnroe; or between such names as JoBeth or MaryAnn. Titles such as Sr., Jr., Rev., should be entered after last name with a space between last name and title.
Example: Patientlast Jr First M


Item 5 - Patient’s address  (back to index)
Definition: The address of the patient.
Procedures: Required
Field Size: 5 fields:
    24 alpha-numeric characters for street
    15 alpha characters for city
    2 alpha characters for state
    9 alpha-numeric characters for zip code
    10 numeric characters for phone number
Instruction: Enter the following information: full mailing address including street number and name or post office box number or RR; city; state; zip code; and phone number. Cities such as St. Thomas or St. Louis should be entered as ‘St Thomas’ or ‘St Louis’ without the period. Use the Standard Post Office State Abbreviations that appear on page 5. If a nine-digit zip code is used, it should be printed in the form XXXXX-YYYY where X’s are five digit zip code and Y’s are the zip code extension.
Example: Patientlast Jr First M

Standard Post Office State Abbreviations
AlabamaALNew JerseyNJ
AlaskaAKNew MexicoNM
ArizonaAZNew YorkNY
ArkansasARNorth CarolinaNC
CaliforniaCANorth DakotaND
ColoradoCOOhioOH
ConnecticutCTOklahomaOK
DelawareDEOregonOR
District Of ColumbiaDCPennsylvaniaPA
FloridaFLRhode IslandRI
GeorgiaGASouth CarolinaSC
HawaiiHISouth DakotaSD
IdahoIDTennesseeTN
IllinoisILTexasTX
IndianaINUtahUT
IowaIAVermontVT
KansasKSVirginiaVA
KentuckyKYWashingtonWA
LouisianaLAWest VirginiaWV
MaineMEWisconsinWI
MarylandMDWyomingWY
MassachusettsMA  
MichiganMIAmerican Territories 
MinnesotaMNAmerican SamoaAS
MississippiMSCanal ZoneCZ
MissouriMOGuamGU
MontanaMTPuerto RicoPR
NebraskaNETrust TerritoriesTT
NevadaNVVirgin IslandsVI
New HampshireNH  

Canadian Provinces
AlbertaABNova ScotiaNS
British ColumbiaBCOntarioON
LabradorLBPr. Edward IslandPE
ManitobaMBQuebecQB
New BrunswickNBSaskatchewanSK
NewfoundlandNFYukonYK
Northwest TerritoryNT  


Item 6 - Patient relationship to insured  (back to index)
Definition: Indicates the relationship of the patient to the insured.
Procedures: Required
Field Size: 1 field: 1 alpha character
Instruction: Enter an “x” in the appropriate box designating the patient’s relationship to the insured.


Item 7 - Insured’s address  (back to index)
Definition: The address of the insured.
Procedures: Required
Field Size: 5 fields:
    24 alpha-numeric characters for street
    15 alpha characters for city
    2 alpha characters for state
    9 alpha-numeric characters for zip code
    10 numeric characters for phone number
Instruction: Enter the following information: full mailing address including street number and name or post office box number or RR; city; state; zip code; and phone number. Cities such as St. Thomas or St. Louis should be entered as ‘St Thomas’ or ‘St Louis’ without the period. Use the Standard Post Office State Abbreviations that appear on page 5. If a nine-digit zip code is used, it should be printed in the form XXXXX-YYYY where X’s are five digit zip code and Y’s are the zip code extension.


Item 8 - Patient status  (back to index)
Definition: The status of the patient at the time the services were rendered.
Procedures: Not required
Field Size: 6 fields: 1 alpha character
Instruction: Check the appropriate box for the patient’s marital status and whether employed or a student.


Item 9 - Other insured’s name  (back to index)
Definition: Last name, first name, and middle initial of the individual in whose name the insurance is carried.
Procedures: Required, if 11D is marked “yes.”
Field Size: 1 field:
    18 alpha characters for last name
    12 alpha characters for first name
    1 alpha character for middle initial
Instruction: Enter last name(space)first name(space)middle initial. No nicknames or abbreviations. No space should be left between a prefix and a name as in MacBeth, VonSchmidt, McEnroe; or between such names as JoBeth or MaryAnn. Titles such as Sr., Jr., Rev., should be entered after last name with a space between last name and title.
Example:: Patientlast Jr First M


Item 9A - Other insured’s policy or group number  (back to index)
Definition: Insured’s unique identification number assigned by the other insurance.
Procedures: Required, if 11D is marked “yes.”
Field Size: 1 field: 14 alpha-numeric characters
Instruction: Enter the unique identification number of the other insurance policy. No spaces between alpha-numeric characters.


Item 9B - Other insured’s date of birth / sex  (back to index)
Definition: Date of birth and sex of the insured.
Procedures: Required, if 11D is marked “yes.”
Field Size: 2 fields:
    6 numeric characters for patient’s birth date
    1 alpha character for patient’s sex
Instruction: Enter month, day, century, and year of birth. Recommended print format is “MMDDCCYY”. Enter in the proper positions on the claim form. If full birth date is unknown, enter as much information as possible and zero fill the unknown. Example: Patient born in May 1924, but exact date is unknown. Enter 05001924 as the birthdate. Enter an “x” in the appropriate box designating the sex of the insured.


Item 9C - Employer’s name or school name  (back to index)
Definition: Name of the employer or school that provides health care coverage for the individual identified in Item 9.
Procedures: Required, if 11D is marked “yes.”
Field Size: 1 field: 20 alpha characters


Item 9D - Insurance plan name or program name  (back to index)
Definition: Name of other insurance organization
Procedures: Required, if 11D is marked “yes.”
Field Size: 1 field: 20 alpha characters


Item 10A - Is patient’s condition related to employment? (current or previous)  (back to index)
Definition: Designates if the patient’s condition is related to an injury, accident, or illness resulting from current or previous employment.
Procedures: Required, if applicable
Field Size: 1 field: 1 alpha character
Instruction: Enter an “x” in the appropriate box for either “yes” or “no”.


Item 10B - Is patient’s condition related to: auto accident? Place (state)  (back to index)
Definition: Designates if the patient’s condition is related to an injury, accident, or illness resulting from an automobile accident.
Procedures: Required, if applicable
Field Size: 2 fields:
    1 alpha character for “yes” or “no”
    2 alpha characters to indicate state code
Instruction: Enter an “x” in the appropriate box for either “yes” or “no”. If “yes” is indicated, use the Standard Post Office State Abbreviations as shown on page 5.


Item 10C - Is patient’s condition related to: other accident?  (back to index)
Definition: Designates if the patient’s condition is related to an injury, accident, or illness resulting from another accident.
Procedures: Required, if applicable
Field Size: 1 field: 1 alpha character
Instruction: Enter an “x” in the appropriate box for either “yes” or “no”.


Item 10D - Reserved for local use  (back to index)
Definition: This item is for internal use only, leave blank.
Procedures: Not required
Field Size: 1 field, XX characters


Item 11 - Insured’s policy group or FECA number  (back to index)
Definition: The identification number, control number, or code assigned by the carrier or administrator to identify the group or Federal Employees Compensation Act (FECA) under which the individual is covered.
Procedures: Not required, if applicable
Field Size: 1 field: 14 alpha-numeric characters


Item 11A - Insured’s date of birth / sex  (back to index)
Definition: The date of birth and sex of the insured in whose name the insurance is carried.
Procedures: Required
Field Size: 2 fields:
    6 numeric characters for patient’s birth date
    1 alpha character for patient’s sex
Instruction: Enter month, day, century, and year of birth. Recommended print format is “MMDDCCYY.” Enter in the proper positions on the claim form. If full birth date is unknown, enter as much information as possible and zero fill the unknown. Example: Patient born in May 1924, but exact date is unknown. Enter 05001924 as the birthdate.


Item 11B - Employer’s name or school name  (back to index)
Definition: The name of the employer that provides health care coverage for the individual identified in Item 2.
Procedures: Required, if applicable
Field Size: 1 field: 20 alpha characters
Instruction: Enter the city and state of the primary payer.


Item 11C - Insurance plan name or program name  (back to index)
Definition: Name identifying the insurance plan from which the provider might expect some payment for the bill.
Procedures: Required, if applicable
Field Size: 1 field: 20 alpha characters


Item 11D - Is there another health benefit plan?  (back to index)
Definition: Identifies if there is another health benefit plan for this patient.
Procedures: Required
Field Size: 1 field: 1 alpha character
Instruction: Enter an “x” in the appropriate box for either “yes” or “no.”


Item 12 - Patient’s or authorized person’s signature / date  (back to index)
Definition: The patient or his/her authorized representative signs and dates this block unless the signature is on file.
Procedures: Not required
Field Size: 2 fields: XX characters


Item 13 - Insured’s or authorized person’s signature  (back to index)
Definition: The patient or his/her authorized representative signs this block unless the signature is on file authorizing the third party payer to make payment on the billing to the facility.
Procedures: Not required
Field Size: 1 field: XX characters


Item 14 - Date of current illness, injury or pregnancy  (back to index)
Definition: The date of the current injury or pregnancy is entered, as applicable.
Procedures: Required, if applicable, date of injury for which patient is receiving services and LMP for pregnancy.
Field Size: 1 field: 6 numeric characters
Instruction: Required print format is “MMDDYY.” Enter in the proper positions on the claim form.


Item 15 - If patient has had same or similar illness, give first date  (back to index)
Definition: The first occurrence date of a similar illness reported by the patient.
Procedures: Not required
Field Size: 1 field: 6 numeric characters
Instruction: Required print format is “MMDDYY.”


Item 16 - Dates patient unable to work in current occupation  (back to index)
Definition: The from and through dates of the patient’s period of not being able to work.
Procedures: Not required
Field Size: 2 fields:
    6 numeric characters for from date
    6 numeric characters for through date
Instruction: Enter the “from” and “to” (through) dates. Recommended print format is “MMDDYY.”


Item 17 - Name of referring/ordering physician  (back to index)
Definition: The name of the physician that has referred/ordered the patient to the performing provider for treatment of the condition.
Procedures: Required, if applicable for a referral
Field Size: 1 field: 20 alpha-numeric characters
Instruction: Enter the name of the referring/ordering physician if the patient was referred to the performing physician for diagnostic laboratory services, diagnostic radiology services, consultative services and/or specific durable medical equipment.


Item 17A - ID number of referring/ordering physician  (back to index)
Definition: The provider or UPIN (Unique Provider Identification Number) associated with the physician name that has referred/ordered the patient to the performing provider for treatment.
Procedures: Required, if Item 17 is completed
Field Size: 1 field: 12 alpha-numeric characters
Instruction: Enter the UPIN of the referring or ordering physician. The format is 1 alpha and 5 numeric or one of the surrogate codes listed below:

RES000 – Residents
INT000 – Interns
VAD000 – Veterans Administration
PHS000 – Public Health Service/Indian Health Service
RET000 – Retired
OTH000 – Other
NPP000 – Nurse Practitioners/Certified Nurse Specialist

OTH000 is to be used when the ordering or referring physician has not been assigned a UPIN and the ordering and performing physician are one in the same and does not qualify for any of the other surrogates.

If the service is not ordered/referred by another physician, the performing physician is to provide his/her name and UPIN. Also, if the service is initiated by the beneficiary and is not a physician service, no ordering/referring UPIN is required.


Item 18 - Hospitalization dates related to current services  (back to index)
Definition: The from and through dates of a prior hospitalization for which the services currently rendered by the provider to the patient are related.
Procedures: Required, if applicable
Field Size: 2 fields:
    6 numeric characters for "from" date
    6 numeric characters for "to" (through) date
Instruction: Enter the “from” and “to” (through) dates. Recommended print format is “MMDDYY.” If the patient has not been discharged, use the last date of service provided.


Item 19 - Reserved for local use  (back to index)
Definition: Descriptions required for unlisted service, CPT, or HCPC codes.
Procedures: Required, if applicable
Field Size:  
Instruction: Enter descriptions of unlisted service, CPT, or HCPC codes. If there is more than one unlisted procedure code, specify which line item it is referring to.
Example: L1 99070 – back brace


Item 20 - Outside lab / $ charges  (back to index)
Definition: Identifies whether laboratory services were provided outside the provider’s office for the patient. If yes, the total charge of outside laboratory work provided for the patient outside the provider’s office is entered. Also, if outside diagnostic tests were purchased by the billing provider from an outside source, the amount billed to the billing provider by the outside source is entered.
Procedures: Not required
Field Size: 2 fields:
    1 alpha character for “yes” or “no”
    5 numeric characters to indicate dollars
    2 numeric characters to indicate cents
Instruction: Enter the “from” and “to” (through) dates. Recommended print format is “MMDDYY.” If the patient has not been discharged, use the last date of service provided.


Item 21 - Diagnosis or nature of illness or injury (relate items 1, 2, 3, or 4 to item 24e by line)  (back to index)
Definition: The ICD-9-CM code(s) describing the diagnosis present at the time of treatment, which relate specifically to the procedure(s) performed.
Procedures: Required
Field Size: 4 fields: 5 alpha-numeric characters for each field
Instruction: List no more than four ICD-9-CM diagnosis codes. Enter up to four diagnosis codes in order of priority (1,2,3,4) using the degree of specificity. When submitting only two diagnosis codes, the second diagnosis code must be shown in item 21 diagnosis code position #2. If you need to submit more than four diagnosis codes, you must submit another CMS-1500 claim form with the additional data. “E” codes are not allowed as the primary diagnosis. Descriptions of the ICD-9-CM codes should not be included.


Item 22 - Medicaid resubmission code / original ref. no.  (back to index)
Definition: The codes required by some Medicaid agencies for claim resubmission. Currently not used by North Dakota Medicaid.
Procedures: Not required
Field Size: 2 fields:
    20 alpha-numeric characters for resubmission code
    12 alpha-numeric characters for original reference number


Item 23 - Prior authorization number  (back to index)
Definition: The prior authorization number, which has been assigned by the carrier to the billing.
Procedures: Required, if applicable
Field Size: 1 field: 15 alpha-numeric characters
Instruction: Enter the 10 digit preauthorization number assigned by BCBSND.


Item 24A - Date (s) of service  (back to index)
Definition: The from and through date of the service provided by the provider for the patient.
Procedures: Required
Field Size: 2 fields:
    6 numeric characters for “from” date
    6 numeric characters for “to” (through) date
Instruction: Enter month, day, and year for each procedure, service, or supply. Enter the “from” and “to” (through) dates. Recommended print format is “MMDDYY.” Both the “from” and “to” dates are required unless the “from” date is equal to the “to” date. Then the “to” date does not need to be entered.


Item 24B - Place of service  (back to index)
Definition: A code identifying the specific location of the service provided by the provider for the patient.
Procedures: Required
Field Size: 2 numeric characters per field
Instruction: Enter the appropriate two-digit place of service code(s) as shown on pages 14-17.


Place of Service Codes:

00 – 10 (Unassigned)

11 = Office
Location, other than a hospital, Skilled Nursing Facility (SNF), Military Treatment Facility, Community Health Center, State or Local Public Health Clinic or Intermediate Care Facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment or illness or injury on an ambulatory basis.

12 = Home
Location, other than a hospital or other facility, where the patient receives care in a private residence.

13 – 20 (Unassigned)

21 = Inpatient Hospital
A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical) and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.

22 = Outpatient Hospital
A portion of a hospital which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

23 = Emergency Room – Hospital
A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided.

24 = Ambulatory Surgical Center
A freestanding facility, other than a physician’s office, where surgical and diagnostic services are provided on an ambulatory basis.

25 = Birthing Center
A facility, other than a hospital’s maternity facilities or a physician’s office, which provides a setting for labor, delivery, and immediate postpartum care as well as immediate care of new born infants.

26 = Military Treatment Facility (MTF)
A medical facility operated by one or more of the Uniformed Services. MTF also refers to certain former US Public Health Services (USPHS) facilities now designated as Uniformed Services Treatment Facilities (USTF).

27 – 30 (Unassigned)

31 = Skilled Nursing Facility
A facility which primarily provides inpatient skilled nursing care and related services to patients who required medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.

32 = Nursing Facility
A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals.

33 = Custodial Care Facility
A facility which provides room, board, and other personal assistance services, generally on a long-term basis, and which does not include a medical component.

34 = Hospice
A facility, other than a patient’s home, in which palliative and supportive care for terminally ill patients and their families are provided.

35 – 40 (Unassigned)

41 = Ambulance – Land
A land vehicle specifically designed, equipped, and staffed for lifesaving and transporting the sick or injured.

42 = Ambulance – Air or Water
An air or water vehicle specifically designed, equipped, and staff for lifesaving and transporting the sick or injured.

43 – 49 (Unassigned)

50 = Federally Qualified Health Center

51 = Inpatient Psychiatric Facility
A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician.

52 = Psychiatric Facility Partial Hospitalization
A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not require full-time hospitalization, but who need broader programs than are possible from outpatient visits in a hospital-based or hospital-affiliated facility.

53 = Community Mental Health Center
A facility that provides comprehensive mental health services on an ambulatory basis primarily to individuals residing or employed in a defined area.

54 = Intermediate Care Facility/Mentally Retarded
A facility which primarily provides health-related care and services above the level of custodial care to mentally retarded individuals but does not provide the level of care or treatment available in a hospital or SNF.

55 = Residential Substance Abuse Treatment Facility
A facility, which provides treatment for substance (alcohol and drug) abuse to live-in residents who, do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing, and room and board.

56 = Psychiatric Residential Treatment Center
A facility or distinct part of a facility for psychiatric care, which provides a total 24-hour therapeutically, planned and professionally staffed group living and learning environment.

57 – 59 (Unassigned)

60 = Immunization Center
A location where providers administer pneumococcal pneumonia and influenza virus vaccinations and submit these services as electronic media claims, paper claims or using the roster billing method. This generally takes place in a mass immunization setting, such as a public health center, pharmacy, or mall but may include a physician office setting.

61 = Comprehensive Inpatient Rehabilitation Facility
A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities. Services include physical therapy, occupational therapy, speech pathology, social or psychological services, and orthotics and prosthetics services.

62 = Comprehensive Outpatient Rehabilitation Facility
A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities. Services include physical therapy, occupational therapy, and speech pathology services.

63 – 64 (Unassigned)

65 = End Stage Renal Disease Treatment Facility
A facility other than a hospital, which provides dialysis treatment, maintenance, and/or training to patients or care givers on an ambulatory or home-care basis.

66 – 70 (Unassigned)

71 = State or Local Public Health Clinic
A facility maintained by either State or local health departments that provides ambulatory primary medical care under the general direction of a physician.

72 = Rural Health Clinic
A certified facility, which is located in a rural medically, underserved area that provides ambulatory primary medical care under the general direction of a physician.

73 – 80 (Unassigned)

81 – Independent Laboratory
A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician’s office.

82 – 98 (Unassigned)

99 = Other Unlisted Facility
Other service facilities not identified above.



Item 24C - Type of service  (back to index)
Definition: A code indicating the type of service provided by the provider for the patient which relates specifically to the procedure and diagnosis.
Procedures: Not required
Field Size: 2 numeric characters per field
Type of Service Indicators:
0-Whole Blood
1-Medical Care
2-Surgery
3-Consultation
4-Diagnostic Radiology
5-Diagnostic Laboratory
6-Therapeutic Radiology
7-Anesthesia
8-Assistant at Surgery
9-Other Medical Items or Services
A-Used DME
B-High Risk Screening Mammography
C-Low Risk Screening Mammography
D-Ambulance
E-Enteral/Parenteral Nutrients/Supplies
F-Ambulatory Surgical Center (Facility Usage for Surgical Services)
G-Immunosuppresive Drugs
H-Hospice
J-Diabetic Shoes
K-Hearing Items and Services
L-ESRD Supplies
M-Monthly Capitation Payment for Dialysis
N-Kidney Donor
P-Lump Sum Purchase of DME, Prosthetics, Orthotics
Q-Vision items or Services
R-Rental of DME
S-Surgical Dressings or Other Medical Supplies
T-Outpatient Mental Health Treatment Limitation
U-Occupational Therapy
V-Pneumococcal/Flu Vaccine
W-Physical Therapy


Item 24D - Procedures, services, or supplies  (back to index)
Definition: The CPT-4 code or HCPC code, which identifies the specific procedure(s), performed for the patient along with any appropriate modifier(s).
Procedures: Required
Field Size: 5 alpha-numeric characters per field for the CPT/HCPC code and, if applicable,
    2 alpha-numeric characters per modifier with a maximum of 3 modifiers per CPT/HCPC code
Instruction: Up to three (3) modifiers per CPT/HCPC code is allowed. Descriptions can be submitted in item 19. For anesthesia, show the time in minutes in Item 24g.


Item 24E - Diagnosis code  (back to index)
Definition: The diagnosis pointer(s) referencing the appropriate ICD-9 code as shown in Item 21 which relates to the procedures performed and the date of service.
Procedures: Required
Field Size: Maximum 4 characters per field
Instruction: Show a maximum of 4 diagnosis pointers in priority order. Include only the diagnosis pointers referencing the appropriate ICD-9-CM code in item 21. ICD 9 CM codes should not be included in item 24e. E codes cannot be listed as the primary diagnosis.


Item 24F - $ Charges  (back to index)
Definition: The charge pertaining to the corresponding procedure.
Procedures: Required
Field Size: 5 numeric for dollars; 2 numeric for cents entered per field.
Instruction: Enter the charge for each listed service. Do not include dollar signs ($) or decimals (.). Example: $101.50 should be entered as 10150.


Item 24G - Days or units  (back to index)
Definition: Value indicating the frequency with which the services are provided to the patient (e.g., days, units, minutes, mgs, etc.).
Procedures: Required if greater than 1
Field Size: 4 numeric characters per field
Instruction: Include days (if greater than 1), units or minutes for that line item. When multiple services are provided on the same day, enter the actual number provided. For anesthesia, show the time in minutes. For example, 2 hours and 30 minutes should be billed as 150 in item 24g. Specific psychiatric and substance abuse procedure codes require the time in hours and minutes. For example, to record 1 hour and 10 minutes for procedure code 90801, the time would be reported at 110. Please reference HealthCare News #175 for specific information on submitting units for psychiatric and substance abuse procedure codes.


Item 24H - EPSDT / family plan  (back to index)
Definition: Indicates whether the patient has been involved in an early periodic screening, diagnosis and treatment program or whether the services provided relate to a family planning program.
Procedures: Not required
Field Size: 1 alpha character per field


Item 24I - EMG  (back to index)
Definition: A code indicated whether the treatment provided to the patient was necessitated by an emergency.
Procedures: Not required
Field Size: 1 alpha character per field


Item 24J - COB  (back to index)
Definition: The coordination of benefits indicator.
Procedures: Required, if applicable
Field Size: 1 alpha character per field
Instruction: Enter “x” in this field when appropriate.


Item 24K - Reserved for local use  (back to index)
Definition: Identifies the performing providers abbreviated last name and provider identification number (PIN).
Procedures: Required, if applicable
Field Size: 1 field: 9 alpha-numeric characters
Instruction: Enter the first 3 initials of the performing providers last name and PIN on each detail line. Example: Dr. Johnson with a PIN as 123456 should be billed as “JOH123456” in item 24k


Item 25 - Federal tax ID number  (back to index)
Definition: The employer identification number assigned by the federal government for tax report purposes. A code indicating that the number entered in the tax ID field is either an EIN or SSN.
Procedures: Required, if applicable.
Field Size: 2 fields:
    10 alpha-numeric characters for the tax ID
    1 alpha character to signify if tax ID is an EIN or SSN
Instruction: Enter an “x” in the appropriate box to signify if the tax ID number is an EIN or SSN. This is not required for ND providers, but is required for out-of-state or non-participating providers.


Item 26 - Patient’s account no.  (back to index)
Definition: The patient’s account number assigned by the provider to facilitate retrieval of individual medical records.
Procedures: Not required
Field Size: 1 field: 12 alpha-numeric characters
Instruction: Enter patient account number. This information is not required for claims processing but, if entered, the patient’s account number is printed on the provider payment listing. Blue Shield will key numeric, alpha, and a space to separate the number into parts.


Item 27 - Accept assignment?  (back to index)
Definition: Indicates whether the provider accepts assignment for the benefit payments made by the payer organization.
Procedures: Required, if applicable
Field Size: 1 field: 1 alpha character
Instruction: Enter “x” in the appropriate box for either “yes” or “no.” Complete this field for FEP to indicate if the physician/supplier accepts assignment of Medicare benefits.


Item 28 - Total charge  (back to index)
Definition: The total charge of the services provided to the patient, which are included on this billing.
Procedures: Required
Field Size: 1 field: 6 numeric for dollars; 2 numeric for cents
Instruction: Enter the total of all charges listed in Item 24F. The amount $101.50 should be entered as 10150. Each claim form must have total charges up to six detail lines. A separate claim form should be sent for anything beyond the six detail lines. No “continuation” should be listed in Item 28.


Item 29 - Amount paid  (back to index)
Definition: The amount, which has been received toward payment of this bill prior to submission of the billing to the indicated payer.
Procedures: Required, if applicable.
Field Size: 1 field: 6 numeric for dollars; 2 numeric for cents
Instruction: The amount $101.50 should be entered as 10150.


Item 30 - Balance due  (back to index)
Definition: The balance estimated to be due from the indicated payer
Procedures: Required
Field Size: 1 field: 6 numeric for dollars; 2 numeric for cents
Instruction: The amount $101.50 should be entered as 10150.


Item 31 - Signature of physician or supplier  (back to index)
Definition: Show the signature of the physician/supplier, or his representative, and the date the form was signed.
Procedures: Required
Instruction: The signature of the physician/supplier providing the service must be here along with the date of the signature. A person legally representing the physician/supplier may also sign.


Item 32 - Name and address of facility where services were rendered  (back to index)
Definition: The name and address of another facility, which rendered services to the patient.
Procedures: Required, if different from Item 33
Field Size: 1 field:
    20 alpha-numeric characters for name
    20 alpha-numeric characters for address
    15 alpha characters for city
    2 alpha characters for state
    9 alpha-numeric characters for zip code
Instruction: Enter the facility name, full mailing address including street number and name or post office box number or RR, city, state, and zip code. Do not use punctuation. Cities such as St. Thomas or St. Louis should be entered as ‘St Thomas’ or ‘St Louis’ without the period. Use the Standard Post Office State Abbreviations as shown on page 5. If a nine-digit zip code is used, it should be printed in the format XXXXX-YYYY where X’s are five digit zip code and Y’s are the zip code extension.


Item 33 - Physician’s, supplier’s billing name, address, zip code & phone #  (back to index)
Definition: Show the name, address, telephone number of the physician or supplier who furnished services.
Procedures: Required
Field Size: 1 field:
    20 alpha-numeric characters for name
    20 alpha-numeric characters for address
    15 alpha characters for city
    2 alpha characters for state
    9 alpha-numeric characters for zip code
Instruction: Enter the facility name, full mailing address including street number and name or post office box number or RR, city, state, and zip code. Do not use punctuation. Cities such as St. Thomas or St. Louis should be entered as ‘St Thomas’ or ‘St Louis’ without the period. Use the Standard Post Office State Abbreviations as shown on page 5. If a nine-digit zip code is used, it should be printed in the format XXXXX-YYYY where X’s are five digit zip code and Y’s are the zip code extension.