CMS 1500 Instructions (12-1990)

1: TYPE OF HEALTH INSURANCE - Show the type of health insurance coverage applicable to this claim by checking the appropriate box.
1A: Required INSURED'S IDENTIFICATION NUMBER - Enter the three-digit alpha prefix and identification number of the insured exactly as shown on the identification card.
2: Required PATIENT'S NAME - Enter the last name, first name, and middle initial (if known) of the patient exactly as shown on the identification card. Do not use nicknames.
3: Required PATIENT'S BIRTH DATE AND SEX - Enter the eight-digit month, day, century, and year of the patient's birth (MMDDCCYY). Check the appropriate box to identify patient's sex.
4: Required INSURED'S NAME - Enter the last name, first name, and middle initial of the insured as shown on the identification card. If the patient is the insured, enter the word "same".
5: Required PATIENT'S ADDRESS - Enter the patient's complete address.
6: Required PATIENT'S RELATIONSHIP TO INSURED - Check self, spouse, child, other.
7: INSURED'S ADDRESS - Complete if the patient is not the insured.
8: PATIENT STATUS - Check the appropriate box.
9: Recommended OTHER INSURED'S NAME - Enter the name of the insured with other insurance company.
9A: Recommended OTHER INSURED'S POLICY OR GROUP NUMBER - Enter the policy and/or group number of the other insurance coverage.
9B: Recommended OTHER INSURED'S DATE OF BIRTH - Enter the information available to you in eight-digit format (MMDDCCYY).
9C: EMPLOYER'S NAME OR SCHOOL NAME -  Enter the complete name.
9D: INSURANCE PLAN NAME OR PROGRAM NAME - Enter the name of the insurance plan.
10: Required IS PATIENT'S CONDITION RELATED TO - Check the correct boxes in a., b., and c.
10D: RESERVED FOR LOCAL USE - Leave blank.
11: Required INSURED'S POLICY GROUP OR FECA NUMBER - Enter the group number of the insured as shown on the identification card.
11A: INSURED’S DATE OF BIRTH - Use eight-digit date format if submitting.
11B: EMPLOYERS NAME OR SCHOOL NAME
11C: INSURANCE PLAN NAME OR PROGRAM NAME
11D: ADDITIONAL BENEFIT PLANS?
12: PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE - Have patient sign if your office requires it.
13: INSURED'S OR AUTHORIZED PERSON'S SIGNATURE - May be left blank.
14: Required for accidents or injury, recommended for all others DATE OF CURRENT ILLNESS, INJURY, PREGNANCY - Enter the date of the current illness, injury or pregnancy.
15: IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS - Enter the date the patient first consulted you for this condition.
16: DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION - Leave blank.
17: Required
(if applicable)
NAME OF REFERRING PHYSICIAN OR OTHER SOURCE - List the name of the referring or ordering physician.
17A: ID NUMBER OF REFERRING PHYSICIAN - Enter the assigned identification number of the physician whose name is listed in Block 17.
18: Recommended HOSPITALIZATION DATES RELATED TO CURRENT SERVICES -    Leave blank.
19: RESERVED FOR LOCAL USE - Leave blank.
20: OUTSIDE LAB? - If your patient had lab work done, check the correct box even if you are not billing for the lab work. Do not list charges in this block.
21: Required DIAGNOSIS OR NATURE OF ILLNESS OR INJURY - Identify the patient’s condition(s) by entering up to four ICD-9-CM codes in order of relevance. Codes must be carried out to the highest possible (4th or 5th) digit. Non-specific diagnoses, such as 780, may result in denials.
22: MEDICAID RESUBMISSION - Leave blank.
23 PRIOR AUTHORIZATION NUMBER - Leave blank.
24A: Required DATE(S) OF SERVICE - Enter the date(s) of service. If only one    service is provided, the date can be entered as a "from date" or a "to date".
24B: Required PLACE OF SERVICE - Indicate where services were provided by entering the appropriate two-digit place of service code. Valid codes are as follows:
 
11 Office 34 Hospice
12 Home 41 Ambulance (land)
21 Inpatient Hospital 42 Ambulance (air or water)
22 Outpatient Hospital 51 Inpatient Psychiatric Facility
23 Emergency Room 52 Psychiatric Facility Partial Hospitalization
24 Ambulatory Surgical Center 53 Community Mental Health Facility
25 Birthing Center 54 Intermediate Care Facility/Mentally Retarded
26 Military Treatment Center 55 Residential Substance Abuse Treatment Facility
31 Skilled Nursing Facility 56 Psychiatric Residential Treatment Center
32 Nursing Facility 61 Comprehensive Inpatient Rehabilitation Facility
33 Custodial Care Facility 62 Comprehensive Outpatient Rehabilitation Facility
24C: Required TYPE OF SERVICE - Enter the "Type of Service Code" for each service.
24D: Required PROCEDURES, SERVICES, OR SUPPLIES: CPT/HCPCS, MODIFIER - Enter a valid procedure code best describing each service or supply. Explain unusual services or situations with procedure code modifiers. If a CPT and a HCPCS code describe the same service, use the CPT code. Claims with an invalid or missing procedure code may be denied or returned for correction and resubmission.
24E: Required DIAGNOSIS CODE - Enter the diagnosis code reference number (i.e. up to four ICD-9-CM codes) as shown in item 21, to relate the date of service and the procedures performed to the appropriate diagnosis.
24F: Required CHARGES - Enter your charge for each listed service.
24G: Required DAYS OR UNITS - Enter the number of services billed on the line. For anesthesia services, report time and modifier units on separate lines.
24H: EPSDT FAMILY PLAN - Leave blank.
24I: EMG - Leave blank.
24J: COB - Leave blank.
24K: RESERVED FOR LOCAL USE - Leave blank
25: Required FEDERAL TAX ID NUMBER - Enter the provider's tax identification number as given by the Internal Revenue Service.
26: Recommended PATIENT'S ACCOUNT NO. - If you use patient account numbers,  enter the number for this patient.
27: Required for Medicare only ACCEPT ASSIGNMENT- please check applicable box.
28: TOTAL CHARGE - Enter the total of all charges submitted on this claim.
29: AMOUNT PAID - Enter the exact amount the patient and/or other insurance carrier has paid to you for these services. Entering the words ‘patient paid’ without indicating the exact amount may cause claims delays and inaccurate processing.
30: BALANCE DUE - Enter the difference between Field 28 and Field 29.
31: Required SIGNATURE OF PHYSICIAN OR SUPPLIER - Sign and date the form. Stamped and printed signatures are acceptable.
32: Required NAME/ADDRESS OF FACILITY WHERE SERVICES WERE RENDERED - Enter name and address of facility if other than home or office.
33: Required PHYSICIAN'S, SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE, AND PHONE NUMBER - Enter the provider's name, address, zip code, and telephone number. The provider identification number must be displayed in this field after the “PIN” reference.