Required Fields – Professional Claims - CMS1500 (08-05)

Medical billing CMS 1500 - hint & tips to complete claim

CMS1500 FL #            Description of Information Required

1a Patient’s ID Number
2 Patient’s Name, as it appears on identification card
3 Patient’s Date of Birth (mm/dd/ccyy) and Sex
4 Subscriber’s Name—if same as patient, enter SAME.
5 Patient’s address—if different from subscriber’s, complete item 7
9-9d Other insurance information—if applicable. DOB must be in mm/dd/ccyy format.
10a-c If services are related to patient’s employment, auto accident or other accident, please complete. Otherwise leave blank.
11a-c Subscriber’s Insurance Group Number, Subscriber’s DOB (mm/dd/ccyy), Subscriber’s Sex
11d “Yes/No”—If “yes”, complete Item 9.
14 Date of onset of current illness or injury. (Use LMP for pregnancy)
17 Name of referring physician—required for lab and radiology claims only
17a Shaded area—Legacy qualifier / legacy number of referring physician (legacy qualifiers—1G for UPIN; G2 for MHP ID; 1C for PIN)
17b NPI of referring physician
18 Admission and discharge

date if services were rendered in a hospital
19 Use to communicate information for which there is no other field designated; e.g., name of
provider for whom this provider is covering; multiple modifier information, etc., when applicable.
21 Diagnosis, ICD-9-CM to the highest level of specificity
23 Prior Authorization and/or Referral codes if applicable
24a Date of service—if only one day, please enter same date in each field
24b Place of service (as established by Medicare)
24d Procedure code using CPT4 or HCPCS codes with modifiers if applicable

Please Note: Shaded areas above Boxes 24a-d are for additional information related to the CPT/HCPC (e.g., NDC #, DME description when an unspecified HCPCS code is submitted.

24e Enter 1, 2, 3, or 4 to indicate specific ICD-9-CM code treated as indicated in Box 21. Use only
one reference number for each line item.
24f Enter the charge for each listed service, as normally billed by your office. Do not enter $0.00 for
capitated claims.
24g Number of days or units (unless included in the procedure description); report units of supplies, anesthesia minutes, oxygen volume, or multiple visits.
24i shaded Legacy ID qualifier (legacy qualifiers—1G for UPIN; G2 for MHP ID; 1C for PIN)
24j shaded Legacy ID number
24j NPI number
25 Federal Tax ID Number—Please indicate either SSN or EIN
26 Patient Account Number—For reference, if needed.
28 Enter the sum of the line item charges.
31 Name/legible signature of the provider of service, with degree or credentials
32 Name and address of facility where services were rendered
33 Pay to information
33a NPI of provider of services
33b Legacy qualifier and identifier (legacy qualifiers—G for UPIN; G2 for InsuranceProvider ID; 1C for PIN)