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CMS-1500 Form
Blocks (14-24) Physician Demographics Diagnosis Procedures
| Question | Answer |
|---|---|
| Block 14 | Date of current illness, injury, or pregnancy ( LMP ) |
| Block 15 | Other Date ( identifies additional date information about the patients condition or treatment ) |
| Block 16 | Dates patient is unable to work in current occupation |
| Block 17 | Name of referring provider or other source. ( Enter a qualifier to the left of the vertical, dotted line to identify which provider is being reported |
| Block 17 a | Leave Blank |
| Block 17 b | NPI ( National Provider Number ) |
| Block 18 | Hospitalization Dates Related to Current Services |
| Block 19 | Additional Claim Information ( NUCC ) |
| Block 20 | Outside Lab $ Charges ( Yes or No question ) |
| Block 21 | Diagnosis or Nature of illness or injury |
| Block 22 | Resubmission and/ or Original Reference Number |
| Block 23 | Prior authorization number |
| Block 24 a | Dates of service [ Line 1-6 ] |
| Block 24 b | Place of Service [ Line 1-6 ] |
| Block 24 c | EMG identifies if the service was an emergency |
| Block 24 d | Procedures, Services or supplies ( CPT/HCPCS ) ( Modifiers) |
| Block 24 e | Diagnosis Pointer |
| Block 24 f | $ Charges |
| Block 24 g | Days of units ( 1-6) it allows for up to 3 characters |
| Block 24 h | EPSDT Family Plan [Lines 1-6 ] |
| Block 24 i | ID Qualifier [ Lines 1-6 ] |
| Block 24 j | Rendering Provider ID # |
Created by:
Leiannlg
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