Medicare Billing: CMS-1500 & 837P Code Sources
| Hardcopy Item | Electronic Loop | Medicare Requirement | Code Source and Location |
|---|---|---|---|
| Item 17 fields – Name of Referring Provider or Other Source | 2310A NM1 Name of Referring Provider or Other Source 2310D NM1 – Supervising Provider 2420E NM1 – Ordering Provider | Required if applicable Refer to the Medicare Claims Processing Manual, Chapter 26, to decide when the claim requires this item. | National Plan and Provider Enumeration System (NPPES) nppes.cms.hhs.gov/# Medicare Claims Processing Manual, Chapter 26 CMS.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c26pdf.pdf |
| Item 21 fields – Diagnosis or Nature of Illness or Injury ICD Ind. | 2300 HI01-HI12 – Claim Information | Required *Exception includes hardcopy claims submitted by ambulance suppliers. | ICD-10-CM cdc.gov/nchs/icd/icd-10-cm/files.html |
| Item 23 – Prior Authorization Number | 2300 REF– 1. Quality Improvement Organization (QIO) prior authorization number (2300) | Required if Applicable 1. Enter the QIO prior authorization number for those procedures requiring QIO prior approval. | 1. Contact the QIO who gave the authorization to get the prior authorization number. |
| Item 23 – Prior Authorization Number (continued) | 2. Investigational Device Exemption (IDE) number (2300) | 2. Enter the IDE number when you use an investigational device in an FDA-approved clinical trial. You should also place the Post Market Approval number here when applicable. | 2. Contact the health care professional or supplier participating in the clinical trial for a copy of the FDA approval or clearance letter. |
| Item 23 – Prior Authorization Number (continued) | 3. NPI of the Home Health Agency (HHA) or hospice (2300) | 3. For physicians performing care plan oversight services, enter the NPI of the HHA or hospice when you bill CPT code G0181 (HH) or G0182 (Hospice). | 3. NPPES nppes.cms.hhs.gov/# |
| Item 23 – Prior Authorization Number (continued) | 4. Clinical Laboratory Improvement Amendments (CLIA) certification number (2300 or 2400) | 4. Enter the 10-digit CLIA certification number for laboratory services when an entity performing CLIA covered procedures bills. | 4. State Agency CMS.gov/medicare/quality/clinical-laboratory-improvement-amendments/apply |
| Item 23 – Prior Authorization Number (continued) | 5. ZIP Code | 5. For ambulance claims, enter the ZIP Code of the loaded ambulance trip’s point-of-pickup. | 5. U. S. Postal Service (USPS) tools.usps.com/go/ZipLookupAction!input.action |
| Item 24B – Place of Service | 2300 CLM05 -01 or 2400 SV105 – Facility Code Value | Required | Medicare Claims Processing Manual, Chapter 26 CMS.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c26pdf.pdf |
| Item 24D – Procedures, Services, or Supplies - CPT/ HCPCS | 2400 SV101-2– Product/Service ID | Required | Level I: CPT codes maintained by the American Medical Association (AMA) ama-assn.org Level II: HCPCS codes maintained by CMS CMS.gov/medicare/coding-billing/healthcare-common-procedure-system |
| Item 24D – Procedures, Services, or Supplies - Modifier | 2400 SV101-2 – SV101-6 – Procedure Modifier | Required if applicable Refer to the CPT Manual or the HCPCS Book to decide when you need a modifier. | Level I: CPT codes maintained by the AMA ama-assn.org Level II: HCPCS codes maintained by CMS CMS.gov/medicare/coding-billing/healthcare-common-procedure-system |
| Item 24J – Rendering Provider ID Number | 2310B NM109 or 2420A NM109 – Rendering Provider Identifier | Required | NPPES nppes.cms.hhs.gov/# |
| Item 26 – Patient Account Number | Loop 2300 CLM01 – Patient Control Number | Situational | Provider or supplier’s records |
| Item 32a – Service Facility NPI | 2310C NM109 – Laboratory or Facility Primary Identifier | Required | NPPES nppes.cms.hhs.gov/# |
| Item 33a – Billing Provider NPI | 2010AA NM109 – Billing Provider Identifier | Required | NPPES nppes.cms.hhs.gov/# |
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