Other CMS-1500 Codes

Box 11b - Other Claim ID

The following qualifier and accompanying identifier has been designated for use:

Y4	Property Casualty Claim Number

Enter the applicable qualifier to identify which date is being reported.

431	Onset of Current Symptoms or Illness
484	Last Menstrual Period

Enter the applicable qualifier to identify which date is being reported.

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

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

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.)

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

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

AV	Available – Not Used (Patient refused referral.)
S2	Under Treatment (Patient is currently under treatment for referred diagnostic or corrective health problem.)
ST	New 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.)
NU	Not Used (Used when no EPSDT patient referral was given.)

ZZ	Narrative description of unspecified code
N4	National Drug Codes (NDC)
CTR	Contract rate
JP	Universal/National Tooth Designation System
JO	ANSI/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 – 32	Permanent dentition
51 – 82	Permanent supernumerary dentition
A – T	Primary dentition
AS – TS	Primary supernumerary dentition

The following are the codes for areas of the oral cavity, reported with the JO qualifier:

Thank you for choosing Find-A-Code, please Sign In to remove ads.