CMS 1500 Boxes Flashcards
1
Q
21
A
Diagnosis Code
2
Q
22
A
Resubmission Code
3
Q
23
A
Prior Authorization/
CLIA No.
4
Q
24( J )
A
Rendering Provider NPI
5
Q
24(D)
A
Procedure Code & Modifier
6
Q
25
A
Federal Tax ID
7
Q
31
A
Provider Name & Signature
8
Q
32
A
Service Address
9
Q
33
A
Facility Address/
Billing Provider NPI/
Group NPI
10
Q
14
A
Date of Injury/
WCR
11
Q
26
A
Patient’s A/C no.
12
Q
12
A
ROI
13
Q
13
A
AOB
14
Q
24(B)
A
Place of Service
15
Q
19
A
Additional Information
