Medicare Part B. CMS-1500 Paper Claim Form Crosswalk to EMC Loops and Segments

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1 CMS-1500 Paper Claim Form Crosswalk to EMC Loops and Segments Claims submitted to NAS for payment are submitted in two different formats: paper (CMS-1500 Claim Form) and electronic: (ANSI 410A1) electronic media claim (EMC). Many articles published by CMS and NAS contain references to paper claim fields by noting an Item number, such as Item 19 or Item 24e. These specific item numbers can be referenced in the crosswalk below for the correct placement on EMC claims using the corresponding loop and segment identifier on the electronic claim submission. For example, if an NAS article states that the information in Item One must be provided, the health care provider would know from the crosswalk chart below that the EMC claim would be referencing the 2000B Loop and the SBR09 Segment. Please note the item numbers with asterisks (*). There are several variations of the loops and segments depending upon the type of claim being submitted. CMS-1500 Claim Crosswalk (Medicare Part B) For Version 4010A1 Effective January Form Locator (Item) 1500 Description EMC ANSI 837 Loop EMC ANSI Segments 1 Type of health insurance 2000B SBR09 1A Insured s ID number 2010BA 2 Patient s name - Last name, First Name, Middle Initial 2010BA 3 Patient s birth date Patient s sex 2010BA DMG02 DMG03 4* Insured name - Last name, First Name, Middle Initial

2 5 Patient s address (No., Street) City State Zip Code Telephone 6* Patient relationship to insured 2010BA 2000B N302 N402 N403 SBR02 SBR02 7* Insured s address (No., Street) City State Zip Code Telephone number N302 N402 N403 8 Patient marital status, student status and employment status 9* Other insured s name - Last name, First name, Middle Initial 9A* Other insured s policy or group number SBR03 9B* Other insured s date of birth Other insured s sex DMG02 DMG03 9C Employer s name or school name (Medigap Address) 9D* Insurance plan name or program name 2330B SBR04 10 A, B, Is patient s condition related to: Employment? (current or previous) Auto accident? Other accident? CLM11-1 CLM11-2 CLM11-3

3 10C Place (STATE) CLM D Reserved for local use Blank for Medicare Blank for Medicare 11* Insured s policy group or FECA number 2000B SBR03 SBR03 11A* Insured s date of birth and sex DMG02 DMG03 11B* Employer s name or school name 11C* Insurance plan name or program name SBR04 11D Is there another health benefit plan? Leave blank by Medicare. 12 Patient s or authorized person s signature Date 13 Insured s or authorized person s signature CLM09 CLM10 OI04 OI06 14 Date of current: illness, injury, pregnancy ** DTP03 (439) DTP03 (454) DTP03 (484) 15 If patient has had same or similar illness. Give first date ** DTP03 (438) DTP03 (431) 16 Dates patient unable to work in current occupation (From and To) DTP03 (360) DTP03 (361)

4 17 Name of referring provider or other source 2420F** 2420F 2420F (DN) (referring) (DN) (referring) (DK) (ordering) 17A First Block Second Block 2420F** 2420F** REF01 REF01 REF01 REF02 REF02 REF02 17B NPI 2420F** 18 Hospitalization dates related to current services (From and To) DTP03 (435) DTP03 (096) 19 Reserved for local use Last seen date Supervising provider ID ** 2310E 2420D** DTP03 (304) DTP03 (304) (DQ) (DQ) Test Results MEA02 (TR) Homebound indicator CRC03 (IH) Extra narrative data Electronic Equivalent Data Element

5 Demonstration Project Identifier * REF02 (P4) Date-assumed care date Date-relinquished care date Purchased Service Provider Identifier Last X-Ray date 20 Purchased service charge amount 2310C 2420B DTP03 (090) DTP03 (091) (QB) (QB) DTP03 (455) DTP03 (455) AMT02 (NE) PS Diagnosis or nature of illness or injury HI01-02 (BK) HI02-02 (BF) HI03-02 (BF) HI04-02 (BF) HI05-02 (BF) HI06-02 (BF) HI07-02 (BF) HI08-02 (BF) 22 Medicaid resubmission code Original ref. No. Leave blank by Medicare 23 Prior authorization number REF02 (G1) IDE number REF02 (LX) HHA/Hospice provider number for CPO services 2310D 2420C** (FA) REF02 (LU)

6 CLIA number Ambulance Point of Pickup (zip code) ** 2310D REF02 (X4) REF02 (X4) REF02 (F4) NM101 (77) NM102 (2) N302 24A Dates of service(s) DTP03 (472) 24B Place of service ** CLM05-1 SV10 24C EMG Leave blank by Medicare 24D Procedures, services or supplies CPT/HCPCS Modifier SV101-2 SV101-3 SV101-4 SV101-5 SV E Diagnosis pointer SV107-1 SV107-2 SV107-3 SV107-4 SV107-5 SV107-6 SV107-7 SV F Charges SV102

7 24G Days or units 24H EPSDT Family Plan Leave blank SV104 (UN) SV104 (MJ) by Medicare 24I ID Qual. 24J Rendering Provider ID. # 25 NPI 2310B 2420A** 2010AA or 2010AB** 26 Patient s account No. CLM01 27 Accept assignment? CLM07 28 Total charge CLM02 29 Amount paid AMT02 (F5) 30 Balance due Leave blank by Medicare 31 Signature of physician or supplier including degrees or credentials Date signed CLM06 32 Service facility location information 2310D 2420C*, 02, 03, 02, 03

8 32A 2310D 2420C** 2310C 2420B PS101 32B Leave blank Leave blank 33 Billing Provider Info & PH # 2010AA or 2010AB**, 04, 05 (85, 87) N402 N403 PER04 33A NPI 2010AA or 2010AB** 33B Leave blank Leave blank * If Medicare Secondary Payer or Medigap is involved, refer to ANSI 4010A1 Implementation Guide. ** = Use if different than information given at the claim level. Additional Information The crosswalk chart above is located on the NAS Web site. To locate: Navigate to Select the Claims link from the Part B Quick Links under your state Locate the file Electronic Claim Crosswalk January 2009 beneath the Electronic Claims Submission heading and double click to open the file