The CMS-1500 Claim Form, Box by Box

0:00Intro: CMS-1500, 837P and the 7 practice claims

Alright guys, Assalamu alaikum wa rahmatullahi wa barakatuh. Let's start today's session. Today's session is about medical billing and coding. We'll try to understand the CMS-1500 form, known electronically as the 837P. First, I'd like to tell you that in this whole session we've prepared, we've included seven illustrations: seven CMS-1500 / 837P electronic transmissions, like the ones we do. I've prefilled the data in them so I can easily present and explain it to you, and after class, you can ask any questions, and InshaAllah my team will try to answer them.

0:53Case 01: New-patient office E/M (99203), box by box

First, let's talk about the case. It's a professional claim and a new patient. And all these claims, remember this: at the top of the form there's an option where we tell which payer the claim belongs to. Here you'll see the first claim is Medicare FFS, and all these claims are Medicare FFS. The illustrations I've made here are only of Medicare FFS claims. Not of Medicare Advantage, nor any commercial or private payer. Keep this in mind. But I've also included a DME claim in these illustrations. There's also a lab claim and a doctor's office claim, and apart from those, I've included a telehealth psychotherapy claim as well.

So, let's start. First, let's cover the information that stays the same across all the claims. First, in section number 1 of the claim form, we have to select what insurance the insured patient has. If it's Medicare, we mark Medicare; if it's another insurance, we mark that one. Next is section 2, i.e. box number 2, where we enter the patient's name. The last name comes first, then a comma like this, and then the patient's first name, and then the middle initial. You must not make any mistakes in this format.

In the third section comes the patient's date of birth, and whatever their gender is, we enter it by marking an X. Then, if you come to the fourth section, there's the insured name. Now, Medicare's rule is that if Medicare is primary, and I mean FFS, if it's primary, we leave this box blank, because we've already entered that information here. Okay? But if the claim is for another payer and its guideline says you also enter the insured name, and besides that all this information from boxes 4 and 7, and after that 11a, and then 11b.

So in box number 5, we enter the patient's address. And besides that, now we come to box number 6. In box number 6, we enter information on what the patient's relationship is to the insurance, I mean, to the insured person. For instance, in some cases, in fact most cases, it happens that one insured patient, I mean, one insured person has their spouse or children included under their coverage. So in that case, what we do is, the insured name, for instance in Medicare, well, this happens in Medicare too, but if we're talking about another insurance or payer, for instance, if the husband is the insured named on the card, So the husband's name comes here as insured, or else the patient's own.

Likewise, box 7 gets the insured's address, and likewise their information goes in this section, and the patient's info goes here. In 6, the patient's relationship to the insured person will be 'Spouse'. Now, we could click 'Self' in box number 6, but Medicare's guideline is that since Medicare is primary here, filling box 6 isn't required. Next, we come to box number 7. As I told you, we fill out box number 7 when we're filling a payer's claim where the insured person and the patient are different, but the patient falls under the insured person's coverage.

If we come to box number 11, at box 11d, remember one thing: if the patient has any secondary health insurance, so you mark 'Yes' in box 11d, and then enter its details in box 9, entering the insurance name and its policy and group ID. And the NUCC section, these boxes 9b and 9c, we leave blank. And the program or plan name goes in 9d. Okay? But if they don't have any secondary insurance, you mark 'No'. Remember this. Now let's come to boxes 12 and 13, where it says 'Signature on File'.

Here, the doctor's office or any facility provider already gets the patient to sign its forms and keeps that signature. Okay? The patient basically authorizes us to act on their behalf; their medical information, they've authorized it, and we submit it onward in the claim. Okay? And in 13, we need the signature of the authorized person, meaning the payment or reimbursement we collect from insurance on their behalf goes to the facility or provider, on the patient's behalf. That's basically the purpose of box 13. 'Signature on File' here means that in the doctor's office documentation, wherever the patient must sign, the signature has to be obtained.

See, that's how the claim form works: whatever info you enter must match all the records and documentation. After that, we come to box number 14. In box 14, we've entered the date of current illness here, that is, the patient's date, the date of current illness; we've entered it here. As I told you, this is a professional claim, and it's a new patient claim. Okay, it's not an established patient claim. Here, the date... okay, yes. Now let's do one thing: move ahead step by step. The next section, box 19, is 'Designated by NUCC'.

We'll leave it blank. In box 17, 'Name of Referring Provider or Other Source' is written. The doctor's name goes here. I'll show you later, in upcoming claims where we prefilled it. It's not needed here, so we didn't fill it. There's a reason for that. The reason is, box 17 always has the doctor who has either ordered, ordered the test or DME supply, or referred the patient or the procedure. So basically their name goes here, and then their NPI goes in 17b. And if it's a supervising doctor or supervising provider, their name and NPI go here.

The CPT code here, as you can see, is 99203. It's basically the new patient office evaluation and management service; this is its code. Of the diagnoses found, we enter only those relevant to the service we billed. Basically, basically, the service that we have billed, the service we billed, we enter the related diagnosis codes present in the chart notes. Medicare's guideline is that in its claims, in box 24E, where we put the diagnosis pointer, meaning this CPT code must be linked to that diagnosis code. And this diagnosis code section, 21A, must be reflected in the diagnosis pointer, to tell the insurance that this CPT code we're about to bill is basically being billed on the basis of this diagnosis.

Then we enter its charges, based on its fee schedule, and also its units, which is the most important thing. You must know, for whatever service, test or DME supply you're billing, how many units you're billing and how many units are allowed, and how many units a supply equals. Medicare and insurers have their own guidelines; you enter the units after checking those. And here, it's always the rendering provider's number. Rendering provider basically means the one who provided this service to the patient. So here, the patient has received a procedure.

So this rendering provider, this rendering provider here, this NPI belongs to the rendering provider. Okay, keep this in mind. And of course, this is the doctor; this here is the doctor's NPI. Now, don't get confused by this, because there's information in box number 32 and box number 33, and you'll see the NPI in 33 is different. The NPI in 33 belongs to the billing provider who is billing this claim. That's the physician group, and its NPI number is entered here. But since the rendering provider is the doctor, that's why their NPI is entered here.

And if you come to box 17 here, the doctor's name isn't entered here because the doctor isn't an ordering or referring provider. The doctor is the rendering provider. That's why their NPI number is entered here. Now, the date of service, which is the most important thing: the date on which the patient sat in front of the doctor, or had a telehealth session over a call. That date goes in as month, day, year, from and to, as month, day, year. Okay? And 11 is the place of service, meaning the patient came to the doctor's office.

The place of service for a doctor's office is 11. So we've entered the place of service here. Then this is the CPT code, and after it, the diagnosis pointer, the pointer to the diagnosis on whose basis we are billing this service. And here is the unit, here is the NPI, and below, the total is written. Okay, and box 26 here holds the patient's account number, from the provider's EMR or practice management software, Whatever the patient's ID is goes here, so that when its EOB comes, it automatically merges with the patient's account number.

Okay? This is very important. And here goes the Tax ID; the facility's Tax ID will go here. Okay? And that's why on the EIN number... Also, Box 31 again has Signature on File. This is the physician's, not the patient's. Here, the document for the physician's or supplier's signature has the physician's or supplier's signature on it. So whenever you write Signature on File here... So basically, three sections are for Signature on File. We need two patient signatures on the documents. One, the patient has authorized the release of medical records. Second, for the payment insurance sends to the provider, the patient has also already signed that the patient's provider can collect payment from insurance on the patient's behalf. Okay?

14:32Case 02: Established-patient E/M (99214) and diagnosis pointers

So we've covered the first claim, a new patient claim. Now let's look at the second. All the information in it is the same. Let's come to the diagnoses. Okay, this patient has a BP follow-up. It's an established patient, an existing one. The patient is already being treated at the practice. The doctor reviewed the diabetes and blood pressure and gave a management plan. And the 35 qualifying minutes are documented. This CPT, 99214, is for an established patient: the office E/M service that has been billed. Okay. Diagnosis A, E11.9, is for type 2 diabetes, which is documented in the medical notes and chart notes.

And diagnosis B, I10, is basically hypertension, a hypertension diagnosis. This is also listed in the diagnoses. But you may have noticed here that for the CPT service that's been billed, the diagnosis pointer is only A, not B, because the diagnosis, primarily, only the primary diagnosis. It's the Medicare guideline that you create only one pointer here. That's why we've made E11.9 the pointer here. Okay? Alright. Then one unit is billed for $210, and the total is below. The NPI number here, remember, is the doctor's. And here in Box 17, no one referred, no one ordered, no one supervised.

That's why there's no doctor's name. And for the date of current illness, the patient's date is written here: the date of the patient's illness. Okay? This is also in the documents, in the patient's notes, or the encounter face-to-face sheet, where it's always present.

16:55Case 03: Modifier 25, RT and JZ (knee injection and drug units)

Okay, now let's move ahead to the third form. Everything in it will automatically stay the same. And in Box 14, you'll see that here, the date of current illness has been entered. Besides that, this claim is a blood pressure follow-up, and in the right knee the doctor gave an injection. The doctor gave an injection in the right knee. The doctor evaluated blood pressure separately, and also gave an injection in the knee. Okay, diagnosis A is I10, for high blood pressure, and diagnosis B is M17.11. Whenever we enter a diagnosis here, we remove the decimal points.

Remember this. But when you look in the International Classification of coding, the codes have points, but when we put them on the CMS-1500 form, we remove the points, so don't get confused. Second, a 0 has been entered in this ICD indicator. It's the indicator for ICD-10, which is what's used now. So here we have to enter 0, which shows that the diagnoses we're entering are ICD-10 indicators... ICD-10 codes, diagnosis codes. Okay, now let's move ahead. Okay, now you may have noticed that we've billed three codes here.

99213, and after it, its modifier is 25, for the separately documented blood pressure evaluation and management of 22 minutes. And the pointer we've attached to it is I10. The pointer we attached, which is its primary pointer, is I10. We attached that. One unit is billed, one unit is entered, and the NPI here will, of course, be the doctor's. Next, we come to 20610. This is the right knee; RT is for right knee: a joint injection procedure without ultrasound. This CPT, I'm giving you its details. And the pointer here that's primarily important for it is diagnosis B, M17.11, so we've pointed to it.

And now you'll come to number 3. This is the drug given in the injection. Okay? So this is a HCPCS code, this is a HCPCS code, not a CPT code. And here we've also added the JZ modifier, and I'll explain the JZ modifier in detail later too. Okay, remember this: here the total charges will go, since 4 units have been billed. So whatever the 4 units come to, that's the total amount. Okay? And then the total of all three services goes at the bottom. Okay? Remember this; this mistake shouldn't happen. Likewise, the billing provider is the doctor's office, so of course its NPI is here, and its details are here. So this was a follow-up patient, case number 3.

20:26Case 04: Radiology professional component (71046-26)

Now let's go to case number 4. You'll see a doctor is listed here in Box 17. Okay, why is a doctor listed here? The doctor is listed because the patient had a cough, and because of that this doctor gave the patient a chest X-ray; they ordered it. DK, the modifier, I mean the qualifier, is for the ordering physician. So that's mentioned here. Okay? Their NPI is written here. Okay, but here this NPI is different and that NPI is different. Why? Let me explain. Okay, why is the NPI in 24J different?

The NPI in 24J is different because here we've billed a CPT code, and its modifier is 26. So basically, this is for the examination. Meaning, what came before the radiologist: the X-ray came before the radiologist, and he made the report. That service has been billed separately. The hospital's infrastructure was used in it; the technical support and the machine were the hospital's, but that will be billed separately, not on this. Only the examination and report are billed: the radiologist's exam from looking at the X-ray. That service is billed here, and its unit is one, and its $45 charges are billed below.

And the radiologist's number is here. Here's its billing provider, and its NPI is here. And the service facility, where this service was done, is inside the hospital. Meaning, the radiology department where the X-ray was done is inside the hospital. The hospital's address is here, and of course its NPI. So remember this. And the diagnosis code we've entered, R05.9, is for cough, okay, unspecified. Then we put the pointer here to point to it. Okay? So that's what there was to understand in this one.

23:01Case 05: CLIA-waived lab test (87880-QW and Box 23)

Now let's move on to case 5. Okay, this is the rapid strep test for throat inflammation. Okay? So this is a lab test. What's new here is the prior authorization box, which is Box 23. The number written here, remember, this is where the CLIA number goes when we bill lab tests. So here we enter the CLIA number. Okay? So this isn't a prior authorization number. And if any service requires prior authorization in advance, you have to get prior authorization. After approval, the affirmation comes and a UTN number comes; we enter that here.

But what's entered here now is the lab's CLIA number. The CLIA license number is entered here. Okay, now let's come here. This is the ordering physician who ordered this test; their NPI is here. Basically, here it is. Okay? Now let's come to the date of service. So here is the date of service. Here's the CPT code for the lab test being billed. Here's its modifier, the one used for a CLIA-waived test. Okay? And after that, the rendering provider: the rendering provider's NPI is here, and the billing provider's NPI is different because the billing provider is the physician group.

And the service facility is within the physician group itself. So these sections are the same. So this is basically a lab claim. The one thing different in it, as I told you, was the prior authorization box.

24:51Case 06: Home telehealth psychotherapy (90834, POS 10)

Now let's go to case number 6, telehealth. This is a patient's telehealth claim. And in it, one CPT code, 90834, has been billed. And of course, here we enter only one diagnosis pointer, and that's F41.1. And here are its charges and units, and then the telehealth doctor. This is their NPI, as the rendering provider. Then the behavioral group they belong to, since this is a psychotherapy code. So this is the NPI of the behavioral group they belong to. And boxes 32 and 33 are the same, because the service facility and the billing provider are the same. So these sections are the same. Okay, and now this Now let's try to understand this last case.

25:44Case 07: DME walker purchase (E0143-NU, POS 12)

This is a durable medical equipment claim. And in Box 1a, you saw the insured ID number. In every claim, you'll see the insurance number entered here. Okay, here too, as you saw, since this doctor ordered the DME supply, we wrote the doctor's name here and their NPI. And of course, the ordering doctor must not be a chiropractor. They must be a PECOS-approved doctor. If the doctor here is a chiropractor, or some other doctor who can't order a prescription, who isn't able to prescribe, then the claim will be denied automatically.

So their PECOS must be verified and approved. Remember this: if a chiropractor orders anything, then their name can't be entered here. Keep this in mind, okay? Now let's move ahead. Here, of course, the diagnosis is listed, on the basis of which this E0143, the wheeled walker, a folding wheeled walker, has been billed. And this is the DME supply modifier, NU, which means it's billed as new, with one-time charges. RR is for rental. So this isn't a rental claim; it's a claim for new equipment. Meaning it's paid one time, and the equipment is new.

So its modifier is here, and the pointer has been entered here. And this number here is the DME's. Remember this. It's the NPI, because the rendering provider here is the DME. Here, for the service facility, the DME's address has been entered. And the billing provider is the DME, so these sections are the same. And the difference is 24B, place of service. The place of service here is 12 because place of service 12 is the patient's home. This wheeled walker went to their home, so we enter that as the place of service.

And the same Tax ID has been entered here. And the patient's account number from the EMR has been entered. Assignment always has to be accepted, and these are the total charges. And that's all the information. Okay, now the things you need to remember. I want to tell you the key points about billing. The first one is this: whatever diagnosis is in the chart notes, the medical notes or the face-to-face encounter, you must always enter that same one on the CMS-1500. You can't pull out some other pointer and put it in, one that gets medical necessity approved.

The second thing to remember is the prescription: the diagnosis codes on it, even with the doctor's signature, have no value. The value is always in the diagnosis in progress notes, chart notes and face-to-face.

29:08Bonus: NotebookLM for billing teams (with human review)

Okay? Now let me explain the third thing: the billing you'll be doing now. Obviously, a new era of AI has begun. So whatever facility you're billing for, related to it, for all the insurance orders coming in, whatever their coverage criteria are, and whatever products you bill repeatedly, put all of those documents into NotebookLM. Put all the guides into NotebookLM. Then, when you chat with it and have it fill in the claim form information, it won't go beyond those documents. Okay? Of course, you'll still need an expert, meaning you'll need a human signatory, but it will stay within the books, okay?

It won't recommend putting anything on the claim form that it guessed on its own. Whatever documentation you put in it, the Pro version of Google's NotebookLM, I can even show you, but I'll have to share this screen. Okay. So this is NotebookLM. You go here and add sources. There's a limit of 300 sources. You can also create separate notebooks, I mean, as many notebooks as you want. You can go here and create new notebooks. Like here, I just made one for the billing video I'm making.

I organized it so I wouldn't make any mistake while explaining in a hurry, in the basics. So it stays within the books and documents when it suggests things to you. So this way, all your documentation, and even YouTube videos can be added here. If there's a YouTube channel, like the CMS one, you can attach that too. After that, you have it fill in the claim form. Here you have lots of options in the right-side sections, and you can create an audio Deep Dive to understand forms, or anything you want to understand but can't manage to read.

You also have a language option, and Urdu is included. So set it to Urdu, and whatever you want to understand, you can understand in English too; there's an English option. Up here are the format options for how you want to listen. I mostly listen to Deep Dive whenever I'm trying to grasp a concept. There's also Slide Deck, Video, Mind Map, Flashcards, Reports, Quiz, Infographics and Data Table; these sections are here too. So I made this notebook for you all, to show you and explain that by staying inside the notebook, work can be done this way; both coding and billing can be done.

And its accuracy will be really, really good. There'll be minimal room for error. Okay, so now, I was telling you all that you Okay, there's one more thing you must not do.

32:06Wrap-up: clean billing, documentation and proof of delivery

What you must not do is... If you're a biller, you must always keep your practice transparent, clean and transparent. And in the chase to make money, never bill anything that isn't good practice, or a service that never happened, and you bill it just for the money. Beyond that, it can also harm the doctor's office. And if the doctor or any of the doctor's staff ever asks you to bill this, tell them right back: Look, this service was never even rendered, right? It was never rendered, so why should we bill it?

You must always keep your practices legitimate and clean. And the thing is, billing schemes happen in back offices in Pakistan. Stay away from that, because when you do complex billing for hospitals and clinics, if you don't have experience there, and you haven't done legitimate, good billing, then you can never get on that track. Remember this. So avoid all these things, and do clean, transparent billing, so that neither the provider nor the beneficiary is harmed, nor the insurance, nor the doctor, nor the DME, nor the lab, nor Medicare or Medicaid.

Don't cause harm to anyone. Okay? And each of you, on your own, as much as you can, should spread this awareness. For DME, remember one thing: we need three kinds of documentation. One is the SWO, the standard written order, which we get from the patient, and some products now also require a face-to-face encounter, and chart notes, from which you put the diagnosis code in the diagnosis section, Box 21. Besides that, proof of delivery. Before you bill, the date of service, in a way, becomes the date you delivered to the patient, and that becomes your date of service, so you need its proof of delivery.

When an audit comes to you someday, you have to provide all the documentation, and if it doesn't match your claim, the insurance company will ask you for the money back. So at first, the insurance company, when you submit the claim form, trusts you, and it trusts that whatever information you've filled in is true. But later it comes after you, to audit, and checks whether, for the claim form you filled, your documentation matches, or if there's a mistake. Okay? So remember this: when submitting a claim, no documentation is needed beyond what we put on the claim form, though some claims do need it, like for prior authorization, you have to submit all the documentation.

Now, with the new Medicare rules that came in 2026, it's gotten much stricter for new providers. So new providers, even for items that don't require prior authorization, they... If you want me to make any other video, InshaAllah, let me know. I'll surely make it. And for now, on the claim form, I've made a basic video, though I'm very tired right now. It's time for the Fajr adhan, and the Fajr adhans have been called. So I'm going to pray as well. I hope you liked it. InshaAllah, see you in the next video. All of you, take care of yourselves. JazakAllah khair. Assalamu alaikum wa rahmatullah.