CMS 1500 Items 14-23: Physician or Supplier Information

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Introduction

From electronic options to paper forms, the CMS-1500 remains a common claims format. This guide clarifies the often-confusing 14 to 23 items: physician or supplier information. Whether submitting electronically or on paper, you’ll find precise instructions for accurate completion. Let’s understand how to fill CMS 1500 items 14-23.

Details of CMS 1500 Items 14-23: Physician or Supplier Information

Item 14: Date of Current Illness, Injury, or Pregnancy (LMP)

Enter the 6-digit (MM│DD│YY) or 8-digit (MM│DD│YYYY) date of the first date of the present illness, injury, or pregnancy. For pregnancy, use the date of the last menstrual period (LMP) as the first date. Enter the qualifier to the right of the vertical, dotted line.

431: Onset of Current Symptoms or Illness
484: Last Menstrual Period

Item 15: Other Date

Enter another date related to the patient’s condition or treatment. Enter the date in the 6-digit (MM│DD│YY) or 8-digit (MM│DD│YYYY) format. Enter the applicable qualifier to identify which date is being reported. Enter the qualifier between the left-hand set of vertical, dotted lines. The qualifiers are as follows:

454: Initial Treatment
471: Prescription
304: Latest Visit or Consultation
090: Report Start (Assumed Care Date)
453: Acute Manifestation of a Chronic Condition
091: Report End (Relinquished Care Date)
439: Accident
444: First Visit or Consultation
455: Last X-ray

Item 16: Dates Patient Unable to Work in Current Occupation

If the patient is employed and is unable to work in their current occupation, a 6-digit (MM│DD│YY) or 8-digit (MM│DD│YYYY) date must be shown for the “from–to” dates that the patient is unable to work. An entry in this field may indicate employment-related insurance coverage.

Item 17: Name of Referring Provider or Other Source

Enter the name (First Name, Middle Initial, Last Name) followed by the credentials of the professional who referred or ordered the service(s) or supply(ies) on the claim. If multiple providers are involved, enter one provider using the following priority order:

Referring Provider
Ordering Provider
Supervising Provider

Do not use periods or commas. A hyphen can be used for hyphenated names. Enter the applicable qualifier to identify which provider is being reported. Enter the qualifier to the left of the vertical, dotted line.

DN: Referring Provider
DK: Ordering Provider
DQ: Supervising Provider

Item 17A: Other ID#

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. The list of qualifiers is as follows:

0B: State License Number
1G: Provider UPIN Number
G2: Provider Commercial Number
LU: Location Number (This qualifier is used for Supervising Provider only.)

Item 17B: NPI#

Enter the NPI number of the referring, ordering, or supervising provider in Item Number 17b.

This item refers to an inpatient stay and indicates the admission and discharge dates associated with the service(s) on the claim. Enter the inpatient 6-digit (MM│DD│YY) or 8-digit (MM│DD│YYYY) hospital admission date followed by the discharge date (if the discharge has occurred). If not discharged, leave the discharge date blank. This date is when a medical service is furnished as a result of, or after, a related hospitalization.

Item 19: Additional Claim Information (Designated by NUCC)

Please refer to the most current instructions from the public or private payer regarding the use of this field. Report the appropriate qualifier, when available, for the information being entered. For the Claim Information (NTE), refer following list of qualifiers. Enter the qualifier ‘NTE’, followed by the appropriate qualifier, then the information. Do not enter spaces between the qualifier and the first word of the information. After the qualifier, use spaces to separate any words.

ADD: Additional Information
CER: Certification Narrative
DCP: Goals, Rehabilitation Potential, or Discharge Plans
DGN: Diagnosis Description
TPO: Third-Party Organization Notes

For additional identifiers (REFs), the following are the qualifiers in 5010A1. Enter the qualifier ‘REF’, followed by the qualifier, then the identifier.

0B: State License Number
1G: Provider UPIN Number
G2: Provider Commercial Number
LU: Location Number (This qualifier is used for Supervising Provider only.)
N5: Provider Plan Network Identification Number
SY: Social Security Number (The social security number may not be used for Medicare.)
X5: State Industrial Accident Provider Number
ZZ: Provider Taxonomy (The qualifier in the 5010A1 for Provider Taxonomy is PXC, but ZZ will remain the qualifier for the 1500 Claim Form.)

The above list contains both provider identifiers, as well as the provider taxonomy code. The provider identifiers are assigned to the provider either by a specific payer or by a third party to uniquely identify the provider. The taxonomy code is designated by the provider to identify his/her provider grouping, classification, or area of specialization. Both, provider identifiers and provider taxonomy may be used in this field. Taxonomy codes or other identifiers reported in this field must not be reportable in other fields, i.e., Item Numbers 17, 24J, 32, or 33.

For Supplemental Claim Information (PWK), the following are the qualifiers in the 5010A1. Enter the qualifier “PWK”, followed by the appropriate Report Type Code, the appropriate Transmission Type Code, and then the Attachment Control Number. Do not enter spaces between the qualifiers and data.

List of Report Types Codes

03: Report Justifying Treatment Beyond Utilization: BS: Baseline; OB: Operative Note; 04: Drugs Administered; BT: Blanket Test Results; OC: Oxygen Content Averaging Report; 05: Treatment Diagnosis; CB: Chiropractic Justification; OD: Orders and Treatments Document; 06: Initial Assessment; CK: Consent Form(s); OE: Objective Physical Examination Document; 07: Functional Goals; CT: Certification; OX: Oxygen Therapy Certification; 08: Plan of Treatment; D2: Drug Profile Document; OZ: Support Data for Claim; 09: Progress Report; DA: Dental Models; P4: Pathology Report; 10: Continued Treatment; DB: Durable Medical Equipment Prescription; P5: Patient Medical History Document; 11: Chemical Analysis; DG: Diagnostic Report; PE: Parenteral or Enteral Certification; 13 Certified Test Report; DJ: Discharge Monitoring Report; PN: Physical Therapy Notes; 15: Justification for Admission; DS: Discharge Summary; PO: Prosthetics or Orthotic Certification; 21: Recovery Plan; EB: Explanation of Benefits; PQ: Paramedical Results; A3: Allergies/Sensitivities Document; HC: Health Certificate; PY: Physician’s Report; A4: Autopsy Report; HR: Health Clinic Records; PZ: Physical Therapy Certification; AM: Ambulance Certification’ I5: Immunization Record; RB: Radiology Films; AS: Admission Summary; IR: State School Immunization Records’ RR: Radiology Reports; B2: Prescription; LA: Laboratory Results; RT: Report of Tests and Analysis Report; B3: Physician Order; M1: Medical Record Attachment; RX: Renewable Oxygen Content Averaging Report; B4: Referral Form; MT: Models; SG: Symptoms Document; BR: Benchmark Testing Results; NN: Nursing Notes; XP: Photographs.

Transmission Type Codes

AA: Available on Request at the Provider Site
BM: By Mail

‘Additional Claim Information’ identifies additional information about the patient’s condition or the claim. When reporting multiple separate items, enter three blank spaces and then the next qualifier and followed by the information.

Item 20: Outside Lab and Charges

This item indicates that services have been rendered by an independent provider as indicated in Item Number 32 and the related costs. Complete this field when billing for purchased services by entering an X in ‘YES.’ A ‘YES’ mark indicates that the reported service was provided by an entity other than the billing provider (for example, services subject to Medicare’s anti-markup rule). A ‘NO’ mark or blank indicates that no purchased services are included on the claim.

If ‘YES’ is marked, enter the purchase price under ‘Charges’ and complete Item Number 32. Each purchased service must be reported on a separate claim form as only one charge can be entered. When entering the charge amount, enter the amount in the field to the left of the vertical line. Enter the number right justified to the left of the vertical line. Enter 00 for cents if the amount is a whole number. Do not use dollar signs, commas, or decimal point when reporting amounts. Negative dollar amounts are not allowed. Leave the right-hand field blank.

Item 21: Diagnosis or Nature of Illness or Injury

Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Enter the indicator between the vertical, dotted lines in the upper right-hand area of the field.

9: ICD-9-CM
0: ICD-10-CM

Enter the codes left justified on each line to identify the patient’s diagnosis or condition. Do not include the decimal point in the diagnosis code, because it is implied. List no more than 12 ICD-10-CM or ICD-9-CM diagnosis codes. Relate lines A – L to the lines of service in 24E by the letter of the line. Use the greatest level of specificity. Do not provide a narrative description in this field.

Item 22: Resubmission and/or Original Reference Number

‘Resubmission’ means the code and original reference number assigned by the destination payer or receiver to indicate a previously submitted claim or encounter. List the original reference number for resubmitted claims. Please refer to the most current instructions from the public or private payer regarding the use of this field. When resubmitting a claim, enter the appropriate bill frequency code left justified in the left-hand side of the field. Note that this Item Number is not intended for use for original claim submissions.

7: Replacement of prior claim
8: Void/cancel of prior claim

Item 23: Prior Authorization Number

The ‘Prior Authorization Number’ is the payer-assigned number authorizing the service(s). Enter any of the following: prior authorization number, referral number, mammography pre-certification number, or Clinical Laboratory Improvement Amendments (CLIA) number, as assigned by the payer for the current service. Do not enter hyphens or spaces within the number.

We hope that this article has given you a clear idea of how to fill CMS 1500 items 14-23. CMS 1500 items 14-23 contain physician or supplier information. The CMS-1500 form is definitely tough to master and it’s just one piece of a big thousand-piece billing puzzle! Don’t worry, contact PrimeCare and forget about your billing worries. We are a trusted medical billing service provider for solo practitioners and small group practices. With our assistance, you can simply focus on your patients and you don’t have to worry about insurance reimbursements. We will handle it for you, ’cause that’s what we are good at. See you soon.

Reference:

Medicare Claims Processing Manual

CMS-1500 Claim Form Reference Instruction Manual

Additional CMS 1500 Resources

CMS 1500 Items 14-23: Physician or Supplier Information