Other CMS-1500 Codes

Box 11b - Other Claim ID

The following qualifier and accompanying identifier has been designated for use:
Y4Property Casualty Claim Number

Box 14 - Date of Current Illness, Injury, or Pregnancy (LMP)

Enter the applicable qualifier to identify which date is being reported.
431Onset of Current Symptoms or Illness
484Last Menstrual Period

Box 15 - Other Date

Enter the applicable qualifier to identify which date is being reported.
454Initial Treatment
304Latest Visit or Consultation
453Acute Manifestation of a Chronic Condition
455Last X-ray
090Report Start (Assumed Care Date)
091Report End (Relinquished Care Date)
444First Visit or Consultation

Box 17 - Name of Referring Provider or Other Source

Enter the applicable qualifier to identify which provider is being reported. Enter the qualifier to the left of the vertical, dotted line.
DNReferring Provider
DKOrdering Provider
DQSupervising Provider

Box 17a, 19, 24i, 32b, 33b - Identifier Qualifiers

0BState License Number
1GProvider UPIN Number
G2Provider Commercial Number
LULocation Number (This qualifier is used for Supervising Provider only.)
N5Provider Plan Network Identification Number
SYSocial Security Number (The social security number may not be used for Medicare.)
X5State Industrial Accident Provider Number
ZZProvider Taxonomy (The qualifier in the 5010A1 for Provider Taxonomy is PXC, but ZZ will remain the qualifier for the 1500 Claim Form.)

Box 21 - ICD indicator


Box 22 - Bill Frequency Code

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

Box 24h - EPSDT Reason Codes

AVAvailable – Not Used (Patient refused referral.)
S2Under Treatment (Patient is currently under treatment for referred diagnostic or corrective health problem.)
STNew Service Requested (Referral to another provider for diagnostic or corrective treatment/scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service, not including dental referrals.)
NUNot Used (Used when no EPSDT patient referral was given.)

Box 24 (grey area) - Supplemental Information Qualifiers

ZZNarrative description of unspecified code
N4National Drug Codes (NDC)
CTRContract rate
JPUniversal/National Tooth Designation System
JOANSI/ADA/ISO Specification No. 3950-1984 Dentistry Designation System for Tooth and Areas of the Oral Cavity
The following are the codes for tooth numbers, reported with the JP qualifier:
1 – 32Permanent dentition
51 – 82Permanent supernumerary dentition
A – TPrimary dentition
AS – TSPrimary supernumerary dentition
The following are the codes for areas of the oral cavity, reported with the JO qualifier:
00Entire oral cavity
01Maxillary arch
02Mandibular arch
10Upper right quadrant
20Upper left quadrant
30Lower left quadrant
40Lower right quadrant

Source:  CMS-1500 02/12 Instructions

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