CMS Billing Instruction

Here R and C indicates Required and conditional respectively.

14 DATE OF CURRENT: ILLNESS (First
symptom) OR INJURY (ACCIDENT)
OR PREGNANCY (LMP)

MMDDYY C

15 IF PATIENT HAS SAME OR SIMILAR
ILLNESS. GIVE FIRST DATE

MMDDYY

16 DATES PATIENT UNABLE TO
WORK IN CURRENT OCCUPATION

MMDDYY C

17 NAME OF REFERRING PHYSICIAN
OR OTHER SOURCE

REQUIRED if a physician other than the member’s primary care physician
rendered invoiced services
C

17a UNLABELED FIELD

17b

NPI

18 HOSPITALIZATION DATES RELATED
TO CURRENT SERVICES

REQUIRED when place of service is in-patient. MMDDYY C

19 RESERVED FOR LOCAL USE

Enter the Individual Provider’s Medical Assistance I.D. (MAID) number R

20 OUTSIDE LAB CHARGES

Not Required

21 DIAGNOSIS OR NATURE OF ILLNESS
OR INJURY. (RELATE ITEMS
1,2,3, OR 4 TO ITEM 24E BY LINE)

Diagnosis codes must be valid ICD-9 codes for the date of service. “E”
codes are NOT acceptable as a primary diagnosis. NOTE: Paper claims with
invalid diagnosis codes will be denied for payment.
R

22 MEDICAID RESUBMISSION CODE
ORIGINAL REF. NO.

For re-submissions or adjustments, enter the DCN (Document Control
Number) of the original claim. NOTE: Re-submissions may NOT currently
be submitted via EDI.
C

23 PRIOR AUTHORIZATION NUMBER

Enter the referral or authorization number. Refer to Section 3.1.6, Benefit
Matrix, to determine if services rendered require an authorization or referral.
C

Example CMS 1500
CMS 1500 claim form billing instruction – Part 1
CMS 1500 billing instruction – Part 2
Healthcare Billing instruction part 3