Instructions on how to fill out the
CMS 1500 Form
policies continue to apply. For example, for identification of the
ordering physician who provided the initial service, see item 17 and
17a and/or 17b, and for the identification of the supervisor, see item
24J of this section.
• Enter either a 6-digit (MM | DD | YY) or an 8-digit
(MM | DD | CCYY) x-ray date for chiropractor services (if an x-ray,
rather than a physical examination was the method used to demonstrate
the sublaxation). By entering an x-ray date and the initiation date for
course of chiropractic treatment in item 14, the chiropractor is
certifying that all the relevant information requirements (including
level of sublaxation) of Pub. 100-02, Medicare Benefits Policy Manual,
Chapter 15, are on file, along with the appropriate x-ray and all are
available for carrier review.
• Enter the drug’s name, strength, and dosage when submitting a claim
for Not Otherwise Classified (NOC) drugs.
• Enter a concise description of an “unlisted procedure code” or a “not
otherwise classified” (NOC) code within the confines of this box. An
attachment may also need to be submitted to help expedite claim
rocessing. If more than one unlisted procedure code is reported on the
claim, precede each description in item 19 with the line item number
that corresponds to the line that contains the NOC code. This will
enable claims processing staff to determine the correct description for
each unlisted procedure code. If billing the same unlisted procedure
code more than once on the claim, you may need to indicate the
charges of the procedure codes to indicate which description belongs
to each line.
• Enter all applicable modifiers when modifier 99 (multiple modifiers) is
entered in item 24D. If modifier 99 is entered on multiple line items of
a single claim form, all applicable modifiers for each line item
containing a 99 modifier should be listed as follows: 1=(mod), where
the number 1 represents the line item and “mod” represents all
modifiers applicable to the referenced line item. Modifier 99 is only
appropriate when more than four modifiers are necessary per claim
line. When four or less modifiers apply, each modifier can be entered
in the existing space in item 24D on the CMS-1500 Form.
• Enter the statement “Homebound” when an independent laboratory
renders an EKG tracing or obtains a specimen from a homebound or
institutionalized patient. (See Pub. 100-02, Medicare Benefit Policy
Manual, Chapter 15, “Covered Medical and Other Health Services,”
and Pub. 100-04, Medicare Claims Processing Manual, Chapter 16,
“Laboratory Services from Independent Labs, Physicians, and
Providers,” and Pub. 100-01, Medicare General Information,
Eligibility, and Entitlement Manual, Chapter 5, “Definitions,”
respectively for the definition of “homebound” and a more complete
definition of a medically necessary laboratory service to a homebound