What you need to know about the new CMS-1500 claim form.
In case you missed it, the cms-1500 paper claim form has changed. The revision is the 02/12 version, which replaces the previous 08/05 version of the form. Medicare began to accept the new form on January 6, 2014, and, as of April 1, 2015, now accepts only the new 02/12 version.
Most commercial insurance companies are following Medicare’s lead and also require the new claim form. Some paper claims, such as for workers’ compensation, may continue to be filed on the previous 08/05 format, but policies vary from payer to payer and state to state.
Although the revision is for the paper claim form, many doctors who file claims electronically are also affected by this change. A common method of sending electronic claims is to create a print-image file. Essentially, the data that would normally print on the paper form is captured and saved as a digital text file, which is then sent to an electronic claims clearinghouse.
Most clearinghouses that accept print-image claims expect the format to be the now-required 02/12 version and may reject claim files in the older format. When receiving the new 02/12 formatted print-image claims, clearing- houses need to “re-map” the claim image to identify the location of each piece of data.
Providers who send the HIPAA- standard 837 (also referred to as the 5010) electronic claim format do not face remapping issues. They are largely unaffected by the claim form revision because the information in the 837 electronic claim has a different layout and does not resemble a printed claim form at all. But many doctors who file claims electronically continue to print some claims on paper, such as those for workers’ compensation or liability, and so the CMS-1500 revision may have some impact even on these doctors.
Rationale for the update
The modifications to the CMS-1500 claim form were mainly designed to support the planned transition to ICD-10 diagnosis codes. Although legislation that postpones ICD-10 until at least October 1, 2015 has recently been signed into law, the changes to the claim form are still needed to facilitate this now-delayed transition.
The 02/12 version of the CMS-1500 can be used for either ICD-9 or ICD-10 codes. The delay of the implementation of ICD-10 coding does not affect the rollout of the revised paper claim form. Other than the diagnosis changes to the form, other minor changes help to more closely align the paper claim to the 837 electronic versions.
The key changes
The biggest change to the form is in the diagnosis section, or box 21 (see example form). Because ICD-10 codes are more specific than ICD-9 codes, it is thought that when implemented, more codes will be needed to describe the patient’s condition. Therefore, the number of diagnosis code slots has been increased from four to 12.
The code positions are designated by letters A though L rather than numbers 1 through 4 in the previous version of CMS-1500. Previously, there was room for short diagnosis descriptions in box 21, but the 02/12 version allows for the ICD codes only. The final change to box 21 is the new “ICD Indicator” which specifies whether the codes listed are ICD-9 or ICD-10.
Although up to 12 diagnosis codes are allowed on a claim, be advised that for any one service line in box 24 (see example form), a maximum of four diagnosis pointers may be designated. So a given CPT code may point to up to four ICD codes only. The pointers are letters, rather than numbers as in the previous 08/05 version of the claim form.
Some date fields on the new claim form have qualifiers to indicate what type of date is being reported. Box 14, for the date of the current illness, injury, or pregnancy requires a qualifier of “431” to indicate the date of “Onset of Current Symptoms or Illness” or “484” for the date of the “Last Menstrual Period,” which is only needed when the condition is a pregnancy.
Box 15 now represents a field that can be used for some other required date. Previously, the generic “Reserved for Local Use” Box 19 was often used to report dates such as the last X-ray date or the date of initial treatment.
Now, those dates when needed should be placed in box 15. There is a qualifier to identify the date. For example, “454” would indicate the date of initial treatment or “455” would be the qualifier for the last X-ray date.
Several other less-significant modifications have been made to the form, such as the removal of the “Balance Due” and “Other insured’s date of birth, sex” fields. For a complete list of changes and instructions for filling out the form, visit the National Uniform Claim Committee website at nucc.org.
TONIO CUTRERA is the marketing director and sales manager for eZBIS and is a veteran of the healthcare software industry for over 20 years. He has been responsible for implementing numerous technology projects for eZBIS, particularly in the areas of electronic data exchange and clinical automation. He can be contacted at 800-445-7816 or email@example.com.