Understanding the New CMS-1500 Form
By Sean Peterson, AOPA Government Affairs Department

"If it ain’t broke, don’t fix it.”

This is wise advice—and the reason why some Medicare forms remain the same over many years. For example, the CMS-1500 form, used for health insurance claims submission, was last updated in 1990. Those who submit claims for health care providers have become very familiar with this form over the past 17 years. However, earlier this year the CMS-1500 form was finally replaced with a new version.

With this new form come questions about how to accurately fill it out. Here are answers to some of the most frequently asked questions AOPA experts have received.

Q: Why was there a need for a new claim form?

A: The main reason for the new form was to allow space for the now-required National Provider Identifier (NPI) number. The new CMS-1500 form has several boxes for the NPI (17b, 24j, 32a, and 33a).

Q: Do I need to fill out every single box on the form for Medicare claims submission?

A: The CMS-1500 form is a universal form used not only for Medicare, but also for other government and private health programs. As such, not everything on the form is applicable to O&P providers. Some boxes should simply be left blank.

Q: Box 11 is used to indicate an insurance primary to Medicare. If the patient has no insurance primary to Medicare, can this box be left blank?

A: Medicare specifically states that box 11 must be filled in. If the patient has no insurance primary to Medicare, put the word “none” in this box. This indicates to Medicare that a good faith effort has been made to verify that no other insurance is liable for the services being billed.

Q: Does the patient have to sign the claim form each time, or is a signature on file acceptable?

A: You may obtain the beneficiary’s one-time authorization for filing claims on his behalf. Future claims can be filed without obtaining an additional signature by simply filling in the words “signature on file” in box 12 of the claim form.

Computer-generated signatures are also acceptable with the patient’s approval on file. This authorization should be kept in the patient’s file and made available upon request (see sample One-Time Authorization form in sidebar).

The exception is DME rentals. You may obtain a one-time authorization for DME rental claims only if you accept assignment. If you do not accept assignment, and are providing an item or service that is classified by Medicare as a rental item, you will need to obtain the beneficiary’s authorization every month.

Q: If a one-time signature authorization was obtained for box 12 on the claim form, can this same authorization be used for box 13 (Insured or Authorized Person’s Signature)?

A: No. This box requires a separate signature authorization. Box 13 is signed to authorize payment to the provider of Medigap benefits. This authorization should have specific verbiage related to the applicable Medigap plan the patient is using. As with the one-time authorization for box 12, this authorization should be kept in the patient’s file and made available upon request (see sample Medigap Authorization form above).

Q: What information should go into box 17, “Name of Referring Provider or Other Source”?

A: Box 17 should contain the same name and information as is on the prescription. This may be a physician, or possibly a nurse practitioner or physician assistant (if they are legally authorized to prescribe). A prescription may also come from podiatrists, provided they are prescribing an item for an area of the body within their scope of practice.

Along with the name of the referring provider, you will see a box new to the claim form: 17b. This is where you will enter the National Provider Identifier (NPI) of the referring provider. This will eventually replace box 17a, currently used for the UPIN or legacy number of the referring provider.

Q: Box 19 is labeled “Reserved for Local Use.” What is that box used for?

A: Box 19 should be used to provide any additional information that may assist Medicare in making a coverage determination for a particular item or service. The most common usage of the box in the O&P field is to provide a concise description of an unlisted (or “miscellaneous procedure”) code.

Q: I thought Medicare didn’t cover miscellaneous codes.

A: Contrary to popular belief, Medicare does cover many claims submitted with miscellaneous codes.

What Medicare does not cover are claims submitted with miscellaneous codes that have no further description in box 19. Unlisted codes, commonly referred to as “99 codes,” will almost always be denied if no additional information is provided in this box. However, a brief description of what is being provided may be all a Medicare claims processor needs to approve a claim for a miscellaneous code.

Use a miscellaneous code when there is no other HCPCS code available that would accurately describe the item or service being provided. Fill out box 19 carefully. Be short and to the point, but provide as much description and detail as you can fit in this box.

Medicare dislikes miscellaneous codes just as much as practitioners do. Every time a claim with a “99 code” comes through, it must be processed manually, delaying Medicare’s claims processing. As more and more miscellaneous codes are submitted for the same item, Medicare can justify assigning a new HCPCS code to describe that item. In the end, you could possibly contribute to getting an L code assigned to a 99-coded item.

Q: I have a patient with multiple diagnoses, which will be listed in box 21. In box 24e, do I reference all diagnoses that apply?

A: No. Medicare has stated that even if a patient has multiple diagnoses, only one diagnosis should be referenced in box 24e. Use either the primary diagnosis, or review your applicable Local Coverage Determination (LCD) and Policy Article to determine if one of the other diagnoses would be more appropriate to reference for a particular HCPCS code.

Q: Box 24j calls for the “Rendering Provider ID #.” Whose NPI number should go in this box?

A: Since O&P providers are not required to obtain individual NPI numbers, but numbers for a physical location, the NPI number entered in this box should correspond with the NPI number assigned to the practitioner’s office.

Q: What if an item is delivered to a facility other than the practitioner’s office? Do I have to obtain that facility’s NPI to fill in box 32a?

A: No. Box 32a is not a required field. If you happen to have the NPI number for the facility where the item or services were delivered, you may fill in this box. If you do not have this number, simply fill in the address in box 32 where the item was delivered. To clarify, if the information in box 33 (billing) is different than box 32 (service facility), you should fill in box 32 with the address information.

If an item was delivered at the same location as the billing office, leave box 32 completely blank. Do not put the word “same” in this box—simply leave it blank.

Q: We have multiple offices, with one central billing office. What information goes in box 33 if an item is delivered to a patient at a satellite office?

A: Some providers prefer all payments and inquiries to come to one central location. If that is how your practice is set up, enter the central billing office address and corresponding NPI number in box 33. If the central billing office does not have an NPI, because no patients are seen at that location, enter the address and NPI number of the satellite office where the item was delivered.

These are just some of the many questions prompted by the new CMS-1500 form. CMS is updating instructions for filling out this new claim form in an effort to further clarify how it should properly be filled out. AOPA will continue to provide updated information regarding claims submission as changes take place.  

Sean Peterson was reimbursement services coordinator at AOPA. Questions? Please contact Joe McTernan at (571) 431-0876, ext. 211.