CMS-1500 FORM

Question 1

Field 4

Answer 1

Name of Insured (leave blank if Medicare is Primary

Question 2

Field 9

Answer 2

Medigap

Question 3

How many diagnoses can you report in Field 21

Answer 3

Can report up to 9 diagnoses

Question 4

What field would you indicate ICD 9 or 10 spot?

Answer 4

Field 21

Question 5

When did ICD 10 codes come into effect?

Answer 5

10/01/2015

Question 6

Field 23

Answer 6

Prior auth or CLIA#

Question 7

Field 24B

Answer 7

Place of Service

Question 8

How would you indicate place of service being Office?

Answer 8

Put 11 in field 24B

Question 9

How you you indicate place of service being ER

Answer 9

Put 23 in Field 24B

Question 10

How would you indicate place of service being Birthing center?

Answer 10

Put a 25 in Field 24B

Question 11

Field 25

Answer 11

Federal Tax ID

Question 12

Field 26

Answer 12

Patient’s Account number

Question 13

Field 27

Answer 13

Accept Assignment

Question 14

Field 28

Answer 14

Total Charge

Question 15

Field 29

Answer 15

Amount Paid

Question 16

Field 31

Answer 16

Signature of physician or supplier

Question 17

Field 32

Answer 17

Facility where services were performed

Question 18

Field 32A

Answer 18

NPI of facility

Question 19

Field 33

Answer 19

Billing address (provider is requesting to be paid

Question 20

Field 33A

Answer 20

Billing NPI

Question 21

How many lines of service can you report on a claim?

Answer 21

6 lines of service per claim, use a new form for additional services

Question 22

Billing form used to submit physician and professional service claims?

Answer 22

CMS 1500/837P

Question 23

Field 24C

Answer 23

EMG-Emergency

Question 24

Field 24D

Answer 24

Procedure,services or supplies: CPT/HCPCs & modifiers

Question 25

Field 24E

Answer 25

Diagnosis Pointer

Question 26

Field 24F

Answer 26

Charge for each listed service

Question 27

Field 24J

Answer 27

Rendering provider

Question 28

Who uses the top right margin of the form?

Answer 28

It is used by the carrier (we do not use)

Question 29

True or False? 6/1/17 is an acceptable way to put in DOB

Answer 29

False- you must use 8 digits for DOB . All other dates can be 6 or 8 digits, which ever you choose it must be the same format for entire form.

Question 30

Sheet used to record certain data related to patient encounter.

Answer 30

Super bill

Question 31

True or False” 837P a uniquely-numbered form with a provider’s most common E&M codes, procedures and diagnosis codes preprinted on it

Answer 31

False: The description was of a superbill

Question 32

True or False: For professional claims submitted by physicians or suppliers, the “from” date will determine the date of service for timely filing

Answer 32

True