Block 12. The patient or authorized representative must sign and date this Block unless the signature is on file. In lieu of signing the claim, the patient may sign a statement to be retained in the provider, physician, or supplier file in accordance with §§3047.7-3047.3. If the patient is physically or mentally unable to sign, a representative specified in §3008 may sign on the patient’s behalf.
Block 13. The signature in this Block authorizes payment of mandated Medigap benefits to the participating physician or supplier if required Medigap information is included in Block 9 and its subdivisions. The patient or his/her authorized representative signs this Block, or the signature must be on file as a separate Medigap authorization. The Medigap assignment on file in the participating provider of service/supplier’s office must be insurer specific. It may state that the authorization applies to all occasions of service until it is revoked.
Blocks 14-33 – Provider of Service or Supplier Information
Block 14. Enter the date of current illness, injury, or pregnancy. For chiropractic services, enter the date of the initiation of the course of treatment and enter the X-ray date in Block 19.
Block 15. Leave it blank. Not required by Medicare.
Block 16. Enter dates if patient is employed and unable to work in current occupation. An entry in this field may indicate employment related insurance coverage.
Block 17. Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician.
Block17a – Enter the CMS assigned UPIN of the referring/ordering physician listed in item 17. The UPIN may be reported on the Form CMS-1500 until May 22, 2007, and MUST be reported if an NPI is not available.
Block 17b Form CMS-1500 (08-05) – Enter the NPI of the referring/ordering physician listed in item 17 as soon as it is available.
Block 18. Complete this Block when a medical service is furnished as a result of, or subsequent to, a related hospitalization.
Block 19. Enter the date, the patient was last seen and the NPI of his/her attending physician when an independent physical or occupational therapist or physician providing routine foot care submits claims.
Block 20. Complete this Block when billing for diagnostic tests subject to purchase price limitations. Enter the purchase price under charges if the “yes” block is checked.
Block 21. Enter the patient’s diagnosis/condition. All physician specialties must use an ICD-9-CM code number and code to the highest level of specificity.
Block 22. Leave it blank. Not required by Medicare.
Block 23. Enter the Professional Review Organization (PRO) prior authorization number for those procedures requiring PRO prior approval.
Block 24a. Enter the month, day and year for each procedure, service, or supply.
Block 24b. Enter the appropriate place of service code from the list provided in §2010.3. Identify the location where the Block is used or the service is performed. NOTE: When a service is rendered to a hospital inpatient, use the “inpatient hospital” code.
Block 24c. Medicare providers are not required to complete this Block.
Block 24d. Enter the procedures, services or supplies using the CMS Common Procedure Coding System (HCPCS).
Block 24e. Enter the diagnosis code reference number as shown in Block 21, to relate the date of service and the procedures performed to the primary diagnosis.
Block 24f. Enter the charge for each listed service.
Block 24g. Enter the number of days or units. This field is most commonly used for multiple visits, units of supplies, or anesthesia minutes. If only one service is performed, the numeral “1” must be entered.
Block 24h. Leave it blank. Not required by Medicare.
Block 24i. Leave it blank. Not required by Medicare.
Block 24j. Enter the NPI of the performing provider of service/supplier if they are a and member of a group practice.
Block 24k. Enter the first two digits of the NPI in Block 24j. Enter the remaining six digits of the NPI in Block 24k, including the two-digit location identifier.
When several different providers of service or suppliers within a group are billing on the same CMS-1500, show the individual NPI in the corresponding line Block.
Block 25. Enter your provider of service or supplier Federal Tax I.D. (Employer Identification Number) or Social Security Number.
Block 26. Enter the patient’s account number assigned by the provider of service’s or suppliers accounting system. This field is optional to assist you in patient identification. As a service, any account numbers entered here will be returned to you.
Block 27. Check the appropriate block to indicate whether the provider of service or supplier accepts assignment of Medicare benefits.
Block 33. Enter the provider of service/supplier’s billing name, address, zip code, and telephone number.
Enter the NPI, including the 2-digit location identifier, for the performing provider of service/supplier who is not a member of a group practice.