CMS 1500 – BLOCK 24A DATES OF SERVICE
Enter the six or eight – digit date (MMDDYY) (MMDDCCYY) for each procedure, service, or supply. When “from” and “to” dates are shown for a series of identical services, enter the number of days or units in column G; only report a range by month, do not combine months in a range date.
Completion of this field is required for all claims; all lines of service.
BLOCK 24B PLACE OF SERVICE
Enter the appropriate place of service code from the list provided below. Identify the location where the item is used or the service is performed.
BLOCK 24C TYPE OF SERVICE
Not required by Medicare. Leave blank.
BLOCK 24D PROCEDURES, SERVICES, OR SUPPLIES
Enter the procedures, services or supplies using the HCFA Common Procedure Coding System (HCPCS). When applicable, show the correct HCPCS modifiers with the HCPCS code.Enter the specific procedure code without a narrative description. However, when reporting an “unlisted procedure code” or a “not otherwise classified” (NOC) code, include a narrative.
BLOCK 24E DIAGNOSIS CODE
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. Enter only one reference number per line item. When multiple services are performed, enter the primary reference number for each service; either a 1, or a 2, or a 3, or a 4. If a situation arises where two or more diagnoses are required for a procedure code (e.g., pap smears), you must reference only one of the diagnoses in block 21.
BLOCK 24F ($) CHARGES
Enter the charge for each listed service.
Completion of this field is required for all claims (all lines of service).
BLOCK 24G DAYS OR UNITS
Enter the number of days or units. This field is most commonly used for multiple visits, units of supplies, anesthesia minutes or oxygen volume. If only one service is performed, the numeral 1 must be entered.
Completion of this field is required for all claims; (all lines of service).
BLOCK 24H EPSDT FAMILY PLANNING
Leave blank. Not required by Medicare.
BLOCK 24I EMG
Leave blank. Not required by Medicare.
BLOCK 24J COB
Leave blank. Not required by Medicare.
BLOCK 24K RESERVED FOR LOCAL USE
Enter the carrier assigned Provider Identification Number (PIN) and NPI number of the rendering physician.
BLOCK 25 FEDERAL TAX ID NUMBER
Enter your provider of service and (or) supplier Federal Tax Employer Identification Number (EIN) or Social Security Number. The participating provider of service and (or) supplier federal tax identification number is required for a mandated Medigap transfer.
Completion of this field is conditional for Medigap transfers.
BLOCK 26 PATIENT’S ACCOUNT NUMBER
Enter the patient’s account number assigned by the provider of service and (or) supplier’s accounting system. This is an optional field to enhance patient information.
BLOCK 27 ACCEPT ASSIGNMENT
Check the appropriate block to indicate whether the provider of service and (or) supplier accepts assignment of Medicare benefits. If MEDIGAP is indicated in block 9 and MEDIGAP payment authorization is given in block 13, the provider of service and (or) supplier must also be a Medicare participating provider of service and (or) supplier and must accept assignment of Medicare benefits for all covered charges for all patients.
BLOCK 28 TOTAL CHARGE
Enter the total charges of all services reported on the claim (i.e., total of all charges from block 24f).
Completion of this field is required for all claims.
BLOCK 29 AMOUNT PAID
Enter the total amount the patient paid on covered services only. The total amount should not exceed the total charges.
Completion of this field (i.e., amount paid or “$0.00”) is required for all claims.
BLOCK 30 BALANCE DUE
Leave blank. Not required by Medicare.
BLOCK 32 NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE RENDERED
Enter the name and address including the ZIP code of the facility where the services were furnished. When the name and address of the facility where the services were furnished is the same as the biller’s name and address shown in block 33, enter the word “SAME”. we Need to provide NPI number of the location.
BLOCK 33 PHYSICIAN’S, SUPPLIER’S BILLING NAME, ADDRESS, ZIP CODE AND TELEPHONE NUMBER
Enter the physician’s individual/group or or supplier’s billing name, address (physical location, NO P.O. Boxes), ZIP code, and telephone number.
Individual Provider
Enter the carrier assigned PIN# and NPI for the performing physician or supplier who is not a member of a group practice.
Group Practices
Enter the carrier assigned GRP# and NPI for the group.Complete either the PIN# or GRP# field, not both.
Completion of this field is required for all claims.
