(Medicare Claims Processing Manual)

Item 21 -  Enter the patient's diagnosis/condition.  With the exception of claims submitted by ambulance suppliers (specialty type 59), all physician and nonphysician specialties (i.e., PA, NP, CNS, CRNA) use diagnosis codes to the highest level of specificity for the date of service.  Enter the diagnoses in priority order.  All narrative diagnoses for nonphysician specialties shall be submitted on an attachment.   Reminder:  Do not report ICD -10-CM codes for claims with dates of service prior to implementation of ICD -10-CM, on either the old or revised version of the CMS -1500 claim form.   For form version 08/05, report a valid ICD -9-CM code.  Enter up to four diagnosis codes.   For form version 02/12, it may be appropriate to report either ICD -9-CM or ICD -10-CM codes depending upon the dates of service (i.e., according to the effective dates of the given code set).    The ICD Indicator identifies the ICD code set being reported.  Enter the applicable ICD indicator according to the following:   Indicator  Code Set  9 ICD-9-CM diagnosis  0 ICD-10-CM diagnosis   Enter the indicator as a single digit between the vertical, dotted lines.   Do not report both ICD-9-CM and ICD -10-CM codes on the same claim form.  If there are services you wish to report that occurred on dates when ICD -9-CM codes were in effect, and others that occurred on dates when ICD -10-CM codes were in effect, then send separate claims such that you report only ICD -9-CM or only ICD -10-CM codes on the claim.  (See special considerations for spans of dates below.)    If you are submitting a claim with a span of dates for a service, use the from date to determine which ICD code set to use.    Enter up to 12 diagnosis codes.  Note that this information appears opposite lines with letters A -L.  Relate lines A - L to the lines of service in 24E by the letter of the line.  Use the highest level of specificity.  Do not provide narrative description in this field.    Do not insert a period in the ICD -9-CM or ICD -10-CM code.   Item 22 -  Leave blank.  Not required by Medicare.  Item 23 -  Enter the Quality Improvement Organization (QIO) prior authorization number for those procedures requiring QIO prior approval.   Enter the Investigational Device Exemption (IDE) number when an investigational device is used in an FDA -approved clinical trial.  Post Market Approval number should also be placed here when applicable.   For physicians performing care plan oversight services, enter the NPI of the home health agency (HHA) or hospice when CPT code G0181 (HH) or G0182 (Hospice) is billed.  Enter the 10- digit Clinical Laboratory Improvement Act (CLIA) certification number for laboratory services billed by an entity performing CLIA covered procedures.  For ambulance claims, enter the ZIP code of the loaded ambulance trips point -of-pickup.   NOTE:   Item 23 can contain only one condition.  Any additional conditions should be reported on a separate CMS -1500 claim form.  Item 24 -  The six service lines in section 24 have been divided horizontally to accommodate submission of supplemental information to support the billed service.  The top portion in each of the six service lines is shaded and is the location for reporting supplemental information.  It is not intended to allow the billing of 12 service lines.  When required to submit NDC drug and quantity information for Medicaid rebates, submit the NDC code in the red shaded portion of the detail line item in positions 01 through position 13.  The NDC is to be preceded with the qualifier N4 and followed immedia tely by the 11 digit NDC code (e.g. N499999999999).  Report the NDC quantity in positions 17 through 24 of the same red shaded portion.  The quantity is to be preceded by the appropriate qualifier: UN (units), F2 (international units), GR (gram) or ML (milliliter).  There are six bytes available for quantity.  If the quantity is less than six bytes, left justify and space -fill the remaining positions (e.g., UN2 or F2999999).  Item 24A -  Enter a 6 -digit or 8 -digit (MMDDCCYY) date for each procedure, service, or supply.  When "from" and "to" dates are shown for a series of identical services, enter the number of days or units in column G.  This is a required field.  Return as unprocessable if a date of service extends more than 1 day, and a valid "to" date is not present.  Item 24B -  Enter the appropriate place of service code(s) from the list provided in section 10.5.  Identify the setting, using a place of service code, for each item used or service performed.  This is a required field.   NOTE:   When a service is rendered to a patient who is a registered inpatient or an outpatient (off campus or on campus) of a hospital, use the inpatient hospital POS code 21, Off Campus -Outpatient Hospital POS code 19, or On Campus -Outpatient Hospital POS code 22, respectively, as discussed in section 10.5 of this chapter.   Item 24C -  Medicare providers are not required to complete this item.   Item 24D -  Enter the procedures, services, or supplies using the CMS Healthcare Common Procedure Coding System (HCPCS) code.  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.  However, when reporting an "unlisted procedure code" or a "not otherwise classified" (NOC) code, include a narrative description in item 19 if a coherent description can be given within the confines of that box.  Otherwise, an attachment shall be submitted with the claim.  This is a required field.   Return as unprocessable  if an "unlisted procedure code" or a NOC code is indicated in item 24d, but an accompanying narrative is not present in item 19 or on an attachment.   Item 24E -  This is a required field.  Enter the diagnosis code reference number or letter (as appropriate, per form version) as shown in item 21 to relate the date of service and the procedures performed to the primary diagnosis.  Enter only one reference number/lett er per line item.  When multiple services are performed, enter the primary reference number/letter for each service.   When using form version 08/05, this reference will be either a 1, or a 2, or a 3, or a 4.   When using form version 02/12, the reference to supply in 24E will be a letter from A -L.  Otherwise, the instructions above apply.   If a situation arises where two or more diagnoses are required for a procedure code (e.g., pap smears), the provider shall reference only one of the diagnoses in item 21.  Item 24F - Enter the charge for each listed service.   Item 24G -  Enter the number of days or units.  This field is most commonly used for multiple visits, units of supplies, anesthesia minutes, or oxygen volume.  If only one service is performed, the numeral 1 must be entered.  Some services require that the actual number or quantity billed be clearly indicated on the claim form (e.g., multiple ostomy or urinary supplies, medication dosages, or allergy testing procedures).  When multiple services are provided, enter the actual nu mber provided.  For anesthesia, show the elapsed time (minutes) in item 24g.  Convert hours into minutes and enter the total minutes required for this procedure.   For instructions on submitting units for oxygen claims, see chapter 20, section 130.6 of this manual.   Beginning with dates of service on and after January 1, 2011, for ambulance mileage, enter the number of loaded miles traveled rounded up to the nearest tenth of a mile up to 100 miles.  For mileage totaling 100 miles and greater, enter the number of cover ed miles rounded up to the nearest whole number miles.  If the total mileage is less than 1 whole mile, enter a 0 before the decimal (e.g. 0.9).  See Pub. 100- 04, chapter 15, 20.2 for more information on loaded mileage and 30.1.2 for more information on reporting fractional mileage.   NOTE:  This field should contain an appropriate numerical value.  The A/B MAC (B) should program their system to automatically default "1" unit when the information in this field is missing to avoid returning as unprocessable, except on claims for ambulance milea ge.  For ambulance mileage claims, contractors shall automatically default 0.1 unit when total mileage units are missing in this field.   Item 24H  - Leave blank.  Not required by Medicare.   Item 24I -  Leave Blank. Not required by Medicare.   Item 24J -  Enter the rendering providers NPI number in the lower unshaded portion.  In the case of a service provided incident to the service of a physician or non- physician practitioner, when the person who ordered the service is not supervising, enter the NPI of the supervisor in the lower unshaded portion.  This unprocessable instruction does not apply to influenza virus and pneumococcal vaccine claims submitted on roster bills as they do not require a rendering provider NPI.   NOTE:   Effective May 23, 2008, the shaded portion of 24J is not to be reported.  Item 25 -  Enter the provider of service or supplier Federal Tax ID (Employer Identification Number or Social Security Number) and check the appropriate check box. Medicare providers are not required to complete this item for crossover purposes since the Medicare con tractor will retrieve the tax identification information from their internal provider file for inclusion on the COB outbound claim.  However, tax identification information is used in the determination of accurate National Provider Identifier reimbursement.  Reimbursement of claims submitted without tax identification information will/may be delayed.   Item 26 -  Enter the patient's account number assigned by the provider's of service or supplier's accounting system.  This field is optional to assist the provider in patient identification.  As a service, any account numbers entered here will be returned to the provider.   Item 27 -  Check the appropriate block to indicate whether the provider of service or supplier accepts assignment of Medicare benefits.  If Medigap is indicated in item 9 and Medigap payment authorization is given in item 13, the provider of service or supplier shall  also be a Medicare participating provider of service or supplier and accept assignment of Medicare benefits for all covered charges for all patients.   The following providers of service/suppliers and claims can only be paid on an assignment basis:    Clinical diagnostic laboratory services;    Physician services to individuals dually entitled to Medicare and Medicaid;    Participating physician/supplier services;    Services of physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives, certified registered nurse anesthetists, clinical psychologists, and clinical social workers;    Ambulatory surgical center services for covered ASC procedures;    Home dialysis supplies and equipment paid under Method II;    Ambulance services;    Drugs and biologicals; and   Simplified Billing Roster for influenza virus vaccine and pneumococcal vaccine.   Item 28 -  Enter total charges for the services (i.e., total of all charges in item 24f).  Item 29 -  Enter the total amount the patient paid on the covered services only.  Item 30 -  Leave blank.  Not required by Medicare.  Item 31 -  Enter the signature of provider of service or supplier, or his/her representative, and either the 6 -digit date (MM | DD | YY), 8- digit date (MM | DD | CCYY), or alpha -numeric date (e.g., January 1, 1998) the form was signed.  In the case of a service that is provided incident to the service of a physician or non-physician practitioner, when the ordering physician or non- physician practitioner is directly supervising the service as in 42 CFR 410.32, the signature of the ordering physician or non- physician practitioner shall be entered in item 31.  When the ordering physician or non- physician practitioner is not supervising the service, then enter the signature of the physician or non- physician practitioner providing the direct supervision in item 31.   NOTE:  This is a required field; however, the claim can be processed if the following is true:  if a physician, supplier, or authorized person's signature is missing, but the signature is on file; or if any authorization is attached to the claim or if the signatu re field has "Signature on File" and/or a computer generated signature.