What information should appear in Items 17, 17a & 17b of the CMS-1500 (08/05)?

Can more than four diagnosis codes be submitted in Item 21 of the CMS-1500 (08/05) claim form?

We have been told to enter information regarding the National Drug Codes (NDC) for our Medicare-Medicaid patients. Can you clarify this information? Where should the National Drug Codes be indicated on the paper claim?

Item 24E has been changed to read “Diagnosis Pointer.” What is this item used for?

What information should appear in Items 24J and 24K of the CMS-1500 (08/05)?

What information is needed in Item 31 on the CMS 1500 claim form?

What information should appear in Item 32, 32a & 32b of the CMS-1500 (08/05)?

What information should be included in Item 33, 33a & 33b on the CMS-1500 (08/05)?

A: Item 17 is used to report the name of the referring or ordering provider. Item 17a is used to report the referring or ordering practitioner’s Unique Physician Identification Number (UPIN). Item 17b was added to accommodate the National Provider Identifier (NPI) of the referring or ordering practitioner. Completion of these items is required when a service has been ordered or referred by a physician. The timeline below reflects how to complete this item based on the Medicare Fee-For-Service’s NPI Contingency Plan, which was announced in Change Request (CR) 5595.

A: No.

Although Change Request (CR) 5441 requires Part B shared system maintainers to accept claims containing up to eight diagnosis codes, the CMS-1500 (08/05) claim form only supports up to four diagnosis codes in Item 21. Since CMS did not provide instructions for paper submitters using the CMS-1500 (08/05) to bill up to eight diagnosis codes, only four diagnosis codes are allowed. Until the CMS-1500 paper claim form is modified to accommodate more than four diagnosis codes, providers shall file these Medicare claims electronically.

A: Physicians’ offices, hospital outpatient departments and outpatient clinics that submit paper claims and serve patients dually eligible for Medicaid and Medicare must now include National Drug Codes (NDC) and corresponding quantity amounts on claims for all physician-administered drugs. This requirement was implemented with Change Request (CR) 5835.

Medicare providers billing paper claims for dually eligible patients are required to submit the NDCs for physician-administered drugs in the red shaded area of item 24 of the CMS-1500 paper claim form in order for this data to be crossed over to Medicaid. Note: Prior to these requirements, the red shaded area of the CMS-1500 paper claim form has not been used by Medicare for any purpose.

A: This is a 1-character field used to relate the diagnosis shown in Item 21 to the specific code billed in Item 24D. Claims will be returned as unprocessable if the word “ALL” or anything other than 1, 2, 3 or 4 is used in Item 24E.

A: If the practitioner rendering a service is associated with a billing group, report the individual’s information in Item 24J. The individual’s Medicare Provider Identification Number (PIN) is reported in the upper, shaded portion of Item 24J. Report the individual practitioner’s National Provider Identifier (NPI) in the lower, non-shaded portion of Item 24J. Item 24K has been removed from the CMS-1500 (08/05). The table below outlines key information on these items based on direction provided in Change Request (CR) 5858.

Reminder: If services being billed were rendered by an individual associated with an incorporated entity or a group, the individual practitioner’s NPI and/or PIN depending on date, must be reported as indicated above and the billing entity or group identifier must be reported in Item 33a. If the billing provider is an Independent Lab, Ambulatory Surgical Center (ASC), Independent Diagnostic Testing Facility (IDTF), Ambulance Supplier, or solo practitioner not associated with a group, a rendering provider identifier is not required in Item 24J.

A. The signature of the provider of service or supplier, or his/her representative, and either the 6-digit date (MM/DD/YY), 8-digit date (MM/DD/CCYY), or alphanumeric date (e.g., January 1, 2007) the form was signed.

In the case of a service that is provided incident to the service of a physician or non-physician practitioner, when the ordering physician or non-physician practitioner is directly supervising the service as in 42 CFR 410.32, the signature of the ordering physician or non-physician practitioner shall be entered in item 31.

When the ordering physician or non-physician practitioner is not supervising the service, then enter the signature of the physician or non-physician practitioner providing the direct supervision in item 31.

Note: This is a required field, however, the claim can be processed if the following is true. If a physician, supplier, or authorized person’s signature is missing, but the signature is on file; or if any authorization is attached to the claim or if the signature field has "Signature on file" and/or a computer generated signature.

A: The name and complete address (including the ZIP code) of the physical location where services were rendered is reported in Item 32. Complete Item 32 for all claims submitted to Medicare, unless services are rendered in the patient’s home (POS 12). Providers in affected localities should report a nine-digit ZIP code, instead of five-digits. (Refer to Change Request (CR) 5208 – Use of Nine-digit ZIP Codes for Determining Correct Payment Locality for Services and CR 5730 – Update to the Nine-Digit ZIP Code List for Establishing Payment Based on Locality for guidance.)

Providers purchasing the technical component or interpretation of certain diagnostic tests from a separate entity would submit a separate claim for the purchased service, identifying the actual rendering location in Item 32. For Medicare’s purposes, Items 32a and 32b are only used when reporting Purchased Diagnostic Tests (PDT) or interpretations. Item 32a is for the rendering provider’s NPI. Item 32b is used for the Medicare Provider Identification Number (PIN) of the rendering provider. The table below outlines key information on these items based on direction provided in Change Request (CR) 5858.

Note: Effective October 1, 2007, Items 32a (NPI) and 32b (PIN) should not be reported for providers outside of the carrier’s jurisdiction. Instead, the purchasing provider would report their own NPI or PIN. Items 32a and/or 32b are still reported (subject to the information in the table) for providers rendering PDT services within the state.

Reminder: Since only one address can be billed in Item 32, do not include the professional component on the same claim as the purchased technical component or vice versa. Failure to submit a separate claim for each component of a PDT will result in the claim being returned unprocessable.

A: Item 33 is used to report the billing provider’s name and address. Item 33a is for the National Provider Identifier (NPI) of the billing provider. The billing group’s or the billing individual’s Medicare Provider Identification Number (PIN) is reported in Item 33b (the shaded item). The table below outlines key information on these items, based on direction provided in Change Request (CR) 5858.

Reminder: If billing services rendered by an individual associated with an incorporated entity or a group, the individual practitioner’s NPI and/or PIN must be appropriately reported in Item 24J and the billing entity or group identifier must be reported as indicated above. If the billing provider is an Independent Lab, Ambulatory Surgical Center (ASC), Independent Diagnostic Testing Facility (IDTF), Ambulance Supplier, or solo practitioner not associated with a group, a rendering provider identifier is not required in Item 24J.

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