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Where do you place modifiers in the CMS 1500 claim form?

Modifiers, when applicable, are listed to the right of the primary code under the column marked modifier. If the item is a medical supply, enter the two-digit manufacturer code in the modifier area after the five-digit medical supply code.

Are modifiers allowed on a 1500 claim form?

When applicable, show HCPCS code modifiers with the HCPCS code. The CMS-1500 claim form has the capacity to capture up to four modifiers. Enter the specific procedure code without a narrative description.

What goes in box 17a on CMS 1500?

Box 17a. The Other ID number of the referring, ordering, or supervising provider is reported in 17a in the shaded area. The qualifier indicating what the number represents is reported in the qualifier field to the immediate right of 17a.

What goes in box 22 on a CMS 1500?

If you are submitting a void/replacement paper CMS 1500 claim, please complete box 22. For replacement or corrected claim enter resubmission code 7 in the left side of item 22 and enter the original claim number of the claim you are replacing in the right side of item 22.

What goes in box 17a on CMS 1500?

Box 17a. The Other ID number of the referring, ordering, or supervising provider is reported in 17a in the shaded area. The qualifier indicating what the number represents is reported in the qualifier field to the immediate right of 17a.

What goes in box 19 on a CMS 1500?

Box 19 is used to identify additional information about the patients condition or the claim.

What goes in box 21A on CMS 1500?

21A Diagnosis or Nature of Illness or Injury Enter all letters and/or numbers of the ICD-10-CM code for the primary diagnosis, including fourth through seventh characters, if present. (Do not enter decimal point).

How do I fill out a 1500 claim form?

How to fill out a CMS-1500 form The type of insurance and the insureds ID number. The patients full name. The patients date of birth. The insureds full name, if applicable. The patients address. The patients relationship to the insured, if applicable. The insureds address, if applicable. Field reserved for NUCC use.

What goes in box 15 on HCFA 1500?

Information about Item 15 (Other Date) The National Uniform Claim Committee (NUCC) claim form specification state to use Item 15 to identify additional date information about the patients condition. Report the information that is required by the payer receiving claims.

What goes in box 23 on CMS 1500?

Box 23 - TITLE: Prior Authorization Number (this field is also used for CLIA numbers) INSTRUCTIONS: Enter any of the following: prior authorization number, referral number, or Clinical Laboratory Improvement Amendments (CLIA) number, as assigned by the payer for the current service.

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