Billing, Coding, Healthcare Provider, Medicare, Practice Management, Reimbursement



  1. McNicholas, Faith C. M.


ABSTRACT: Beginning April 1, 2014, the only acceptable format for paper claim submission will be on the revised CMS 1500 Form, version 02/12. Paper claim submissions using any previous format will be returned to providers as unprocessable. Learn the changes so that you can accurately complete the claim form to avoid claim submission denials.


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NOTE: Regardless of the revised paper claim form version 02/12 becoming mandatory, you cannot submit ICD-10 codes for claims with dates of service before the ICD-10 implementation date. For healthcare providers who submit electronic claims, please review instructions on how to complete the CMS-1500 02/12 at for corresponding electronic loop numbers.



There are some notable changes to the CMS-1500 form, 02/12 that healthcare providers need to be aware of. These include the following:


a. Item 17 requires qualifiers to identify whether providers are being identified as having performed an ordering, referring, or supervising role in the furnishing of the service. Enter one of the following qualifiers as appropriate to identify the role that this physician (or nonphysician practitioner) is performing:


Qualifier provider role


[check mark]PDN - referring provider


[check mark]PDK - ordering provider


[check mark]PDQ - supervising provider



Item 17 (Electronic Loop 2310A OR 2420F OR 2420E): Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician. All physicians who order services or refer Medicare beneficiaries must report these data. Similarly, if Medicare policy requires you to report a supervising physician, enter this information here. When a claim involves multiple referring, ordering, or supervising physicians, use a separate CMS-1500 claim form for each ordering, referring, or supervising physician.

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Most of the services rendered in a dermatology practice are rarely referred, ordered, or supervised; in which case, enter qualifier DK-Ordering provider (electronic loop 2420E) as the identity for the role of the dermatologist or nonphysician practitioner rendering the service.


b. Item 21 includes use of letters, instead of numbers, as diagnosis code pointers. Report to their highest level of specificity as well as



c. Expansion to the number of possible diagnosis codes on a claim from 4 to 12. Do not insert a period in the ICD-9-CM or ICD-10-CM code.

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d. New "ICD indicators" to differentiate between ICD-9 and ICD-10 codes reported on a claim. Enter the applicable ICD indicator as follows:


"9" for ICD-9-CM diagnosis


"0" for ICD-10-CM diagnosis



Note: Do not report both ICD-9-CM and ICD-10-CM codes on the same claim form. If there are services you wish to report that occurred on dates before October 1, 2014, and those that occur after ICD-10-CM codes go into effect, send separate claims so that you report ICD-9-CM on a single claim form and ICD-10-CM codes on another claim form.

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For more information on these changes and detailed instructions on how to complete the revised CMS 1500 form, please visit