CMS1500 Billing Tips
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1 CMS1500 Billing Tips INSTRUCTION ADVICE FOR COMPLETING THE CMS1500 FORM FOR OREGON WORKERS COMPENSATION CLAIMS Page 1 of 30
2 Field 1: Page 2 of 30
3 Field 1: 1: Always mark the OTHER box. This informs the insurer that this is a workers compensation claim. x Page 3 of 30
4 Field 1a: INSURED S ID NUMBER: Page 4 of 30
5 Field 1a: INSURED S I.D. NUMBER: Put the worker s SSN here (if known) 1a: Put the worker s social security number here (if it is known). If worker does not have a SSN put five 9 s (99999) in this box so the insurer knows you didn t just forget to put it in. Note: this is different information than what is usually put in this box for a general health/medicare claim. Page 5 of 30
6 Field 4: INSURED S NAME: Page 6 of 30
7 Field 4: INSURED S NAME: Put the employer s name here 4: Put the employer s name here. For workers compensation claims, the insured is the employer. Page 7 of 30
8 Field 7: INSURED S ADDRESS: Field 7: INSURED S ADDRESS Page 8 of 30
9 Field 7: INSURED S ADDRESS: Put the employer s address here (include City, State, and Field Zip 7: INSURED S Code). ADDRESS 7. Put the employer s address here; telephone number is also useful but not required. Page 9 of 30
10 Field 10: IS PATIENT S CONDITION RELATED TO: Page 10 of 30
11 Field 10: IS PATIENT S CONDITION RELATED TO: 10: Always check the YES box under a. EMPLOYMENT? (Current or Previous). If the injury was due to an automobile accident, check the YES box in b. AUTO ACCIDENT? If the injury was due to an automobile accident, put the state where the automobile accident occurred under PLACE in b. x x MD Page 11 of 30
12 Field 11: INSURED S POLICY GROUP OR FECA NUMBER: Field 11: Insured s Policy Group or FECA Number Page 12 of 30
13 11: INSURED S POLICY GROUP OR FECA NUMBER: Put the worker s compensation claim number here (if known). 11: Put the workers compensation claim number here (if known). Page 13 of 30
14 Field 11c: INSURANCE PLAN NAME OR PROGRAM NAME: Page 14 of 30
15 Field 11c: INSURANCE PLAN NAME OR PROGRAM NAME: Put the employer s department or division (if different from box 4) 11c: Put the Workers Compensation employer department or division here (if different from box 4). Page 15 of 30
16 Field 17: NAME OF REFERRING PROVIDER: Page 16 of 30
17 Field 17: NAME OF REFERRING PROVIDER: Put the name of the Referring Provider here 17: Put the name of the referring provider here. Page 17 of 30
18 Fields 17a & 17b: REFERRING PROVIDER S NPI and TAXONOMY CODE: Page 18 of 30
19 Fields 17a & 17b: REFERRING PROVIDER S NPI and TAXONOMY CODE: When using the taxonomy code, put the required ZZ qualifier here. Put the referring provider taxonomy number here. Put the referring provider NPI number here. 17a: Put the referring provider s taxonomy number here. Put ZZ as the qualifier when using the referring provider s taxonomy number. 17b: Put the referring provider s NPI number here. Note: If you do not have the referring provider s NPI number, do not report the provider s taxonomy number. If the referring provider doesn t have an NPI, put the referring provider s state license number in box 17a. Put 0B as the qualifier in this field when using the provider s state license number. Page 19 of 30
20 Field 21: DIAGNOSIS OR NATURE OF ILLNESS OR INJURY: Page 20 of 30
21 Field 21: DIAGNOSIS OR NATURE OF ILLNESS OR INJURY: : Each space must be completed with a correct ICD-9-CM code. Use the ICD-9-CM, 9 th Revision book for codes and all applicable digits. Note: If the 5 th digit applies, you must use it here. Examples from the ICD-9-CM book: contusion of the trunk.3 - contusion of the back (more specific) intervertebral disc disorders.5 - degeneration of thoracic or lumbar intervertebral disc.51 - thoracic or thoracolumbar intervertebral disc Page 21 of 30
22 Field 24: specifically 24J: RENDERING PROVIDER I.D. NUMBER: Page 22 of 30
23 Field 24: specifically 24J: RENDERING PROVIDER I.D. NUMBER: Put rendering taxonomy code here Put the corresponding ZZ qualifier here Put the rendering NPI number here 24J: In the upper shaded box put the rendering taxonomy number. Use ZZ as the qualifier in box 24I. Put the NPI number in the NPI box. Note: If no NPI number is available for rendering provider, do not use the taxonomy number. Put the rendering provider s state license number in the upper shaded box of 24J and use 0B in box 24I for the qualifier. Page 23 of 30
24 Field 25: FEDERAL TAX I.D. NUMBER: (Billing provider s SSN or FEIN.) Page 24 of 30
25 Field 25: FEDERAL TAX I.D. NUMBER: Billing provider Fed. Tax ID no. here X 25: Put the Federal Tax I.D. number of the billing provider (the one being paid) here. Page 25 of 30
26 Field 32: (specifically 32a and 32b) SERVICE FACILITY LOCATION INFORMATION: Page 26 of 30
27 Field 32: (specifically 32a and 32b) SERVICE FACILITY LOCATION INFORMATION: NPI # here ZZ Taxonomy Code here 32a. Put the service facility s NPI number. 32b. Put the service facility s taxonomy code. Use ZZ as the qualifier ahead of the taxonomy code. Note: If you do not use the service facility s NPI number, do not use the taxonomy code. Put the state license number in box 32b. Use 0B as the qualifier ahead of the state license number. Page 27 of 30
28 Field 33: (specifically 33a & 33b) BILLING PROVIDER INFO & PH#: Page 28 of 30
29 Field 33: (specifically 33a & 33b) BILLING PROVIDER INFO & PH#: NPI # here ZZ Taxonomy Code here 33a. Put the billing provider s NPI number. 33b. Put the billing provider s taxonomy code. Use ZZ as the qualifier ahead of the taxonomy code. Note: If you do not use the billing provider s NPI number, do not use the taxonomy code. Put their state license number in box 33b. Use 0B as the qualifier ahead of the state license number. Page 29 of 30
30 CMS1500 Billing Tips RESOURCES CMS1500 form information: 1) For information on the CMS 1500 form, go to the Centers for Medicare & Medicaid Services (CMS) Web Click on CMS Forms in the Overview Box, and go to CMS1500 form 2) For instructions on the CMS 1500, go to the National Uniform Claim Committee s Web The NUCC regularly updates this site for revisions to the CMS 1500 instructions. Workers Compensation Division: 1) Medical Section, Resolution Team: Or toll , ask for the Medical Section, Resolution Team 2) Employer Compliance Unit: in Salem Or toll Workers Compensation Division s Web Find WCD s laws and rules on this same site. For a direct link to the Health Care Provider s page, go to To find the employer s workers compensation insurance carrier, go to and click on the Employer Coverage link under Business Tools Page 30 of 30
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