Medical Coding and Health Insurance Claims
The CMS 1500 health insurance claim form is the standard form used by a non-institutional
provider, or supplier to bill Medicare carriers, and durable medical equipment regional carriers (DMERCs) when a
provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for
electronic submission of claims. It is also used for billing of some Medicaid State Agencies.
Practical Medical Coding Process
Medical coders do not make up the codes as they go along, nor do they code from memory. The coder selects
appropriate codes from different existing coding systems for different purposes. For example, there are the
ICD-9-CM systems for international classification of diseases, and Level I HCPCS (CPT-4 codes) for current
procedural terminology used by hospital providers and certain Level II HCPCS codes for hospitals,
physicians and other health professionals. Then there are the DRG codes (diagnosis related groups), and RBRVS for
resource based values, and last but not least, the V codes used to indicate the reason for an encounter (NOT
The medical coding process involves 5 stages:
- quality assurance
- quality control
- submitting final output to clients, or the medical billing department
The combination of these codes tells the payer what was wrong with the patient, whether treatment was necessary,
and what services were performed. This makes it easier to handle these claims and lets heath care insurance
companies identify and reimburse the provider on a predetermined basis.
providers to be reimbursed for services.
Insurance Claim Form
|O.M.B. Expiration Date
National Uniform Claim
CMS 1500 health insurance claim form
(formerly known as HCFA-1500)
The revised Form CMS-1500 (08/05) became effective for optional use starting January 2, 2007 through March 30,
2007, and was then required as of April 2, 2007. This new form allows a qualifying health care provider to submit
reimbursement claims to Medicare by mail. Here is a sample
CMS-1500 health insurance claim form. You will notice that the standard health insurance CMS 1500 claim form
cannot be filled out on your computer. It must be printed, and then filled out by hand. If you want to keep a
copy as part of an electronic record you must scan it. Indeed, there are vendors that offer CMS-1500 form filler
software that fill out the forms on a PC, and save the claims to the hard drive. No doubt, the tricky part with
this is figuring out the printer margin settings.
One might wonder whether the restrictions of filling out and keeping the CMS 1500 health insurance claim form on
a computer is because of HIPAA rules. However, this is not so. A biller filling out a claim form on the computer is
not in HIPAA violation, because medical coding and billing professionals are part of the Treatment-Payment-Health
care operations of the HIPAA chain. It doesnt matter if the form is filled out by hand or through a software
program. As long as it meets NUCC, and the insurance company's requirements.
When Billing For a Group Practice
On November 17, 2008, 03:30:09 AM the following question was posted to our Medical Billing
Community forum » Question About
CMS 1500 Forms:
Can someone tell me when you are billing on a CMS 1500 form and you are a provider that is in a group, would you
use the group NPI number in Box 33a, or should we use the provider's NPI number. Also in box 33b should that be the
tax Id number? In box 24J (Rendering Provider ID) should the shaded portion be the group NPI, and the unshaded
portion be the provider NPI? I really need your help. Thanks!
The answer is rather simple:
- When billing for a group practice, the individual provider's NPI is placed in block 24J.
- Do not enter anything in block 32B and 33B.
- NPI's only now on the claim form, there is no need to cross-reference the old legacy numbers with the new
- Do not put the individual provider's NPI in 24J unless he is part of a GROUP! Medicare will reject claims
with an NPI in 24J if the provider is a sole practitioner!
(Answered by Michelle M. Rimmer, CHI, Textbook author "Medical Billing 101")
Insurance companies will no longer accept the old HCFA 1500 form, mainly because they have upgraded their software
to accept the new form. Please contact your Medicaid State Agency for more details.
Diagnosis and Service Codes...
Medical coders analyze medical source documents, assign universal alphanumeric codes, and verify
that the diagnosis matches the procedure codes. This is vital to medical quality control, medical billing, medical
research, health care statistics, and the reimbursement process for the provider. Furthermore, accurate coding
makes the medical record keeping and practice management processes more cost-effective and reliable.
Diagnosis Codes: In medicine, diagnostic codes are used to group and identify diseases, disorders,
symptoms, and medical signs, and are used to measure morbidity and mortality.