Box 19 CMS-1500 Field Formats

by  Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
August 10th, 2015

FIELD 19 FORMATS

 X-Ray Date

 EXAMPLE:           “XRAY 01-30-2006” or “XRAY 01-30-06”      FORMAT: (XRAY MM-DD-CCYY or XRAY MM-DD-YY)

 II.         Initial Treatment Date

EXAMPLE:           “INIT 01-30-2006” or “INIT 01-30-06”       FORMAT: (INIT MM-DD-CCYY or INIT MM-DD-YY)

 

Date last seen by Referring Doctor

EXAMPLE:           “DATE LAST 01-30-2006” or “DATE LAST 01-30-06”

FORMAT:            (DATE LAST MM-DD-CCYY or DATE LAST MM-DD-YY)

 

  1. Nature of Condition Codes

A = Acute Condition        C = Chronic Condition       M = Acute Manifestation of Chronic Condition

            EXAMPLE:           “COND C”

 

When using Code A or M include the symptom date

EXAMPLE:           “COND A 01-30-2006” or ”COND A 01-30-06”                     

FORMAT:            (COND A MM-DD-CCYY or COND A MM-DD-YY)

 

  1. Supervising Provider

EXAMPLE:           “SUPER: ID, FIRST NAME, LAST NAME”   or

EXAMPLE:           “SUPER: SAME” (Same data in CMS-1500 fields 17/17a Supervising fields)

 

VI.        Remarks (Maximum 80 Characters)

EXAMPLE:           “REMARKS” OR “RMKS” then the text

 

  1. RX Date

            EXAMPLE:           “RX 01-30-2006” or “RX 01-30-06”       

            FORMAT: (RX MM-DD-CCYY or RX MM-DD-YY)

 

  1. Home Health Care Plan Information

            CR701 Discipline Type Code   (AI, MS, OT, PT, SN or ST)

            CR702 Total visits rendered, home health    (Number up to 9 characters long)

            CR703 Total visits projected, home health   (Number up to 9 characters long)

                    

             EXAMPLE:   “CR7:PT 102 999999999”

 

            Discipline Type Codes:

 

            AI = Home Health Aide

            MS = Medical Social Worker

            OT = Occupational Therapy

            PT = Physical Therapy

            SN = Skilled Nursing

            ST = Speech Therapy

 

 IX.        Service Authorization Exception Code

            EXAMPLE:  “EXC 7”

 

            1 - Immediate/Urgent Care                                  5 - Request from County for Second Opinion to

2 - Services Rendered in a Retroactive Period                    Determine if Recipient Can Work

3 - Emergency Care                                             6 - Request for Override Pending 

4 - Client as Temporary Medicaid                          7 - Special Handling

 

 

  1. Delay Reason Code

            Example:   “DRC 8”

           

            1 - Proof of Eligibility Unknown or Unavailable

            2 - Litigation

            3 - Authorization Delays

            4 - Delay in Certifying Provider

            5 - Delay in Supplying Billing Forms

            6 - Delay in Delivery of Custom-made Appliances

            7 - Third Party Processing Delay

            8 - Delay in Eligibility Determination

            9 - Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules

            10 - Administration Delay in the Prior Approval Process

            11 – Other

 

 

  1.         Demo 45

Example:   “RMKS DEMO 45”   or “RMKS DEMO45”

 

 

  1.        EPSDT Referral

Example: “EPSDT Y AV” or “EPSDT N”

 

Yes/No Condition or Response Code (Condition Indicator – enter Y if a referral was given, N if not.)

                        Y          Yes

                        N          No

 

AV = Available – Patient Refused Referral.

NU = Not Used   *NU must be used if EPSDT N is used.

S2 = Under Treatment

ST = New Services Requested

 

 

  1.       CLAIM SUPPLEMENTAL INFORMATION (Paperwork)

Example: “PWK 77 AA 12345678911” or “PWK DG EL 78945612378”

 

Report Type Code

77 = Support Data for Verification             AS = Admission Summary                                    B2 = Prescription

B3 = Physician Order                               B4 = Referral Form                                  CT = Certification

DA = Dental Models                                DG = Diagnostic Report                           DS = Discharge Summary

EB = Explanation of Benefits                    MT = Models                                          NN = Nursing Notes

OB = Operative Note                               OZ = Support data for claim                     PN = Physical Therapy Notes

PO = Prosthetics or Orthotic Certification   PZ = Physical Therapy Certification                       RB = Radiology Films

RR = Radiology Reports                           RT = Report of Tests and Analysis Report

 

Report Transmission Code

AA = Available on Request at Provider site BM = By Mail                                          EL = Electronically only

EM = Email                                            FX = By fax

 

Identification Code

Use attachment control number

 

NDC:     NDC Codes must be 11 digits (items XIV, XV & XVI listed below):

 A 10-digit NDC code is padded with a 'place-holder' (zero or *) by the drug supplier to make it a HIPAA compliant 11-digit NDC code.  If your code is 10 digits, please contact your supplier for the valid 11-digit code.  If your code contains an asterisk (*), please replace that with a zero (0).  Visit the FDA website for more information and a link to search the National Drug Code Directory: 

       NDC CODE & RX NUMBER (For Entire Claim)

Example: “NDC 12345678910 RXN Q103J0885A4730”

 

NOTE: Links only to charge line with procedure code that starts with J.

 

XV.       NDC CODE & RX NUMBER (Per Service Line)
           Example (Field 19):  “RXN Q103J0885A4730”
           Example (Field 24):  “NDC 12345678910”

 

NOTE:  This data will be linked to individual charge lines on the claim.

 

  1. NDC CODES & Drug Pricing Info (NDC code required with this)

            NDC CODE Must list Unit price, Quantity, Unit of measurement

 

            Units of Measurement may be:

            F2   International Unit

            GR   Gram

            ML   Milliliter

            UN   Unit

 

            Example (Field 19): “NDP 15.00 25 F2”

            Example (Field 24): “NDP 15.00 25 F2”

 

Data in Field 19: Links only to charge line with procedure code that starts with J.

Data in Field 24: Links to charge line the comment is linked to.

 

 

XVII.      DATE LAST WORKED

Example: “DLW 01-30-2006” or “DLW 01-30-06”                   FORMAT: (DLW MM-DD-CCYY or DLW MM-DD-YY)

 

 

XVIII.    AMBULANCE CERTIFICATION

Example: “AMB R C 12345 Y 05 RTR Brief reason for round trip (if needed) STR Brief reason for stretcher (if needed)"

 

Example:   AMB

 

Ambulance Transport Code (Indicates type of transport)

                        I           Initial Trip

                        R          Return Trip

                        T          Transfer Trip

                        X          Round Trip * Must include Round Trip Purpose Description if X *

 

Ambulance Transport Reason Code

                        A          Patient was transported to nearest facility for care of symptoms, complaints or                                                                                  both. Can be used to indicate that patient was transported to a residential facility.

                        B          Patient was transported for the benefit of a preferred physician

                        C          Patient was transported for the nearness of family members

                        D          Patient was transported for the care of a specialist or for availability of specialized                                                                 equipment.

                        E          Patient transferred to Rehabilitation Facility

 

Quantity (Transport Distance in Miles)

 

Yes/No Condition or Response Code (Condition Indicator – enter Y if the Condition Indicator applies, N if it does not apply)                        Y          Yes

            N          No

 

Condition Indicator(s) REQUIRED - if more than one, enter all with no spaces (ex: 010509)

                        01         Patient was admitted to hospital

                        02         Patient was bed confined before the ambulance service

                        03         Patient was bed confined after the ambulance service

                        04         Patient was moved by stretcher

                        05         Patient was unconscious or in shock

                        06         Patient was transported in an emergency situation

                        07         Patient had to be physically restrained

                        08         Patient has visible hemorrhaging

                        09         Ambulance service was medically necessary

                        60         Transportation was to nearest facility

 

            Round Trip Purpose Description (Free-form text – Required if Ambulance Transport Code = X)

 

            Stretcher Purpose Description (Free-form text – Required if Condition Indicator = 04)

 

XIX.   NPI: BILLING, RENDERING, REFERRING & FACILITY

Example: “NRF 1234567890 NFC 0987654321”

 

NBL ##########          (Billing NPI)

NRD ##########          (Rendering NPI)

NRF ##########           (Referring NPI)

NFC ##########          (Facility NPI)

 

  1. CORRECTED/VOID CLAIM SUBMITTAL *** do not use for Medicare – claims will be rejected ***

             Example Corrected: “CRTD 123456789”

            Example Void: “VOID 123456789”

 

In examples above, 123456789 is the original claim number as assigned by the carrier (not the MD On-Line claim ID                            number).

 

  1. CARE PLAN OVERSIGHT SERVICES

            Example: “HHA 19-7260”

 

            In field 23 on the CMS-1500 form, input “HHA” followed by the Care Plan Oversight Authorization Number.    If also entering a CLIA number in field 23, place the CLIA information first, followed by the Care Plan Oversight  information.

 

  1.      MEASUREMENT/TEST RESULT

            Example: “TR R2 33.8”

            Example (multiple measurements): “TR R1 9.1 TR R2 27.4”

 

            Format:

            NOTE: This data will attach to all ‘J’ codes on the claim. See below for valid Identifiers & Qualifiers.

           

            Measurement Identifier

                        OG        Original; Starting dosage

                        TR        Test Results

            Measurement Qualifier

                        GRA      Gas Test Rate

                        HT        Height

                        R1        Hemoglobin

                        R2        Hematocrit

                        R3        Epoetin Starting Dosage

                        R4        Creatin

                        ZO        Oxygen

           

            Measurement Value (the value of the measurement)

 

  1.    P A R T – for Chiropractors billing Medicare - Incomplete Physical Exam Information

            Example: “RMKS PART” * At least 2 letters required – one must be A or R *

 

            Incomplete Physical Exam Information 

For Chiropractic services ONLY:

Report the physical exam requirements in block 19

 

Use P, A, R, and T

(P) Pain/tenderness evaluated in terms of location, quality, and intensity;

(A) Asymmetry/misalignment identified on a sectional or segmental level;

(R) Range of motion abnormality (changes in active, passive, and accessory joint movements resulting in an increase or decrease of sectional or segmental mobility); and

(T) Tissue, tone changes in the characteristics of contiguous, or associated soft tissues, including skin, fascia, muscle, and ligament;

 

At least TWO are required

One must be A or R

            You must enter RMKS (and one space) before the applicable letters (PAR and/or T)

 REFERRAL NUMBER

            Example: “REFERRAL: 123456”

 

Note: Referral Number in field 19 requires that you also enter the name and NPI of the Referring Provider in fields 17 and 17b. If you wish to report a ‘Prior Authorization Number’ – enter that number in field 23.

 

  1. Mammography FDA Certification Number

            Example: “FDA 123456”

 

            Required when mammography services are rendered by a certified mammography provider.                                                                                                                                                                

 

  1. Anesthesia Time

            Example: “TIME 40 BEG 1100 END 1140”

 

            Data in Field 19: Links to first charge line

Data in Field 24: Links to charge line the comment is linked to

 

  1. Billing Provider Taxonomy (Specialty) Code

            Example: “BTX 261QM0801X”

 

            NOTE: Rendering Provider Taxonomy Code (Loop 2310B PRV01 = PE) is based on specialty code on file:

WebLink - My Account>Manage Providers

Link1500 - Maintenance>Physician/Organization

 

837 Mapping: Loop 2000A PRV03 (PRV01 = BI, PRV02 = ZZ)

 

  1. Assumed and Relinquished Care Dates (Medicare global surgery/shared post-op care)

            Example/Format: “D090 MMDDYY D091 MMDDYY”

 

            D090 = Start/Assumed Care Date

            D091 = End/Relinquished Care Date

 

            837 Mapping: Loop 2300 DTP03 (DTP01 = 090 for Start, 091 for End, DTP02 = D8)

Box 19 CMS-1500 Field Formats. (2015, August 10). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/box-19-needs-work-2105.html

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