HDG #016: The Guru’s Guide to CMS-1500 Professional Claim Fields
Read time: 3 minutes
Greetings, Gurus! This edition we’ll will dive deep into a CMS-1500 professional claim’s fields and descriptions.
I highly recommend you bookmark this for future reference. In a later article, we’ll also do a UB-04 (institutional) claim form.
The CMS-1500 isn’t just any form.
It’s arguably the backbone of medical billing in the US, where every box is a trove of valuable information for analytics.
The CMS-1500 form was born out of the necessity to streamline multiple claim forms and coding systems used by third-party payers in the 1960s. Thus, the American Medical Association (AMA) in collaboration with the Centers for Medicare & Medicaid Services (CMS), birthed a universal health claim form.
Today, it’s recognized nationwide and is maintained by the National Uniform Claim Committee (NUCC). All credit for the resources below go to the NUCC.
If you ever see a red version, it is because the CMS-1500 form was printed in a particular shade of red (Flint OCR Red J6983). This allows the form to be scanned using Optical Character Recognition (OCR) technology, which then allows the data contents on the form to be read-in while the form fields remain invisible.
This is what a CMS-1500 form looks like.
Notice it only has up to 6 lines to report separate services/CPTs?
Now, let’s dive into the major sections.
Carrier Information (Carrier Block): This is where providers list the name and address of the patient’s insurance carrier, the name of the primary policy holder, their group and member ID, etc. This ensures claims get directed to the right place.
Patient Information: Your patient’s name, address, and date of birth go here. It ensures the claim is linked to the right individual.
Claim Details: This section captures what happened. You’ll be noting down the date of the incident, type of service, charges, and the provider’s details.
Diagnosis Information: This is where providers enter the patient’s diagnosis using the appropriate code. It explains why the service was necessary, what the condition was, etc. Now, here’s an important note when dealing with multiple-page claims: The diagnosis code(s) mentioned on the first page should be repeated on subsequent pages. If more than 12 diagnoses are necessary, you’ll need to split the claim and bill the services related to additional diagnoses separately. The same applies if you have more than 50 service lines.
Provider (Physician & Supplier) Information: This is where the attending provider’s details, such as NPI number and taxonomy code, are recorded.
And now to dissect the individual fields (!!)
I wouldn’t be a health data guru without having some thoughts/opinions on these fields after using them for more than a decade in many, many different types of analysis.
Since my goal is to help you all become health data gurus too, soon I will also be posting my own “plain-language” interpretation of each of the 1500 form’s fields, other names/terms they’re commonly referred to as or are known by, and how/if they’re commonly used for healthcare analytics.
Important notes:
Is the 1500 for professional services only?
Technically, the formal name is the CMS-1500 and I added “Professional” into the title so more people could find this article — this is because the 1500 is often referred to as a “Professional” claim, even though technically many types of providers and suppliers use this claim to render services beyond what you might consider traditional “Professional” such as office visits and physician services. This can include things like durable medical equipment (DME), pharmacy claims, telehealth services, digital health application/disease management services, and more.“Patient” = “Member”
Remember, this claim is submitted to a health plan/insurance carrier/payer so labels on the form such as “Patient Name” make sense. However, if you’re in health plan land, you will very rarely ever refer to them as “Patients” but rather “Members.”Similarly, “Insured” = “Subscriber”
. . .
I created a downloadable Cheat Sheet for you:
I’ve also created a downloadable reference table for you that formally lists all the fields on a 1500 and their descriptions (according to NUCC):
. . .
As I mentioned above, a great source for more information is the NUCC Reference Instruction Manual available online at www.nucc.org, which provides a more in-depth explanation of each field on the CMS-1500 form. The link is embedded below for quick reference.
So, next time you work with a 1500 claim form (or more likely, its data), remember, it’s not just boxes and lines.
It’s a conversation, where every field is integral to telling a story.
. . .
Actionable Idea of the Week:
Bookmark this Guide and reference it often. This is one of the most common concepts you’ll want to master in health data analytics whether you are a provider, payer, vendor, or agency. Almost all population health data comes back to a claim in some way, and Professional claims outnumber Institutional by at least 2-to-1 if not upwards of 4 or 5-to-1 in my experience. In a future edition, we’ll also deep dive into a UB-04 Institutional Claim.
Happy analyzing, my gurus!!
-Stefany
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