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CMS-1500 Form

Blocks (14-24) Physician Demographics Diagnosis Procedures

QuestionAnswer
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