Medicare Billing: 837P and Form CMS-1500

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

FACT SHEET

Medicare FFS Contractors include

A/B Medicare Administrave

Contractors (MACs) and Durable

Medical Equipment (DME) MACs.

What are the 837P and Form CMS-1500?

The 837P (Professional) is the standard format used by health care

professionals and suppliers to transmit health c

are claims

electronically. The Form CMS-1500 is the standard paper claim form

to bill Medicare Fee-For-Service (FFS) Contractors when a paper

claim is allowed. In addion to billing Medicare, the 837P and Form CMS-1500 may be suitable for

billing various government and some private insurers.

Data elements in the Centers for Medicare & Medicaid Services (CMS) uniform electronic billing

specicaons are consist

ent with the hard copy data set to the extent that one processing system can

handle both. CMS designates the 1500 Health Insurance Claim Form as the CMS-1500 (08/05) and the form

is referred to throughout this fact sheet as the CMS-1500.

ANSI ASC X12N 837P

The American Naonal Standards Instute (ANSI) Accredited Standards Commiee (ASC) X12N 837P (Professional)

Version 5010A1 is the current electronic claim version. To learn more, visit the ASC X12 website on the Internet.

ANSI = American Naonal Standards Instute

ASC = Accredited Standards Commiee

X12N = Insurance secon of ASC X12 for the health insurance industry’s administrave transacons

837 = Standard format for transming health care claims electronically

P = Professional version of the 837 electronic format

Version 5010A1 = Current version of the Health Insurance Portability and Accountability Act (HIPAA)

electronic transacon standards for health care professionals and suppliers.

The Naonal Uniform Claim Commiee (NUCC) has developed a crosswalk between the ASC X12N 837P and the

hard copy claim form located on the Internet. Medicare FFS Contractors may also include a crosswalk on

their websites.

CPT Disclaimer-American Medical Associaon (AMA) Noce

CPT is a registered trademark of the American Medical Associaon.

Applicable FARS\DFARS Restricons Apply to Government Use.

Fee schedules, relave value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not

recommending their use. The AMA does not directly or indirectly pracce medicine or dispense medical services. The AMA assumes no liability for data

contained or not contained herein.

ICN 006976 March 2013

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Implementaon and Companion Guides for Electronic Transacons

ASC X12N Implementaon Guides are the specic technical instrucons for implemenng each of the adopted

HIPAA standards and provide instrucons on the content and format requirements for each of the standards’

requirements. Implementaon Guides are wrien for use by all health benet payers, not specically for

Medicare. Implementaon Guides, including Version 5010 Consolidated Guides, are found at

hp://www.wpc-edi.com on the Internet.

Companion Guides are issued by CMS and health plans in an eort to provide the most up-to-date informaon

related to how standard transacons must be submied to that specic plan. Medicare Companion Guides

provide further instrucons idened as situaonal in an Implementaon Guide and are accessed by vising the

Medicare Fee-for-Service Companion Guides web page.

Medicare Claims Submissions

The “Medicare Claims Processing Manual” (Internet-Only Manual Publicaon [IOM Pub.] 100-04) is found on the IOM

web page. This publicaon includes instrucons on claims submission. Chapter 1 includes general billing requirements

for various health care professionals and suppliers. Other chapters oer claims submission informaon specic to a

health care professional or supplier type. Once in IOM Pub. 100-04, look for a chapter(s) applicable to your health care

professional or supplier type and then search within the chapter for claims submission guidelines. For example, Chapter

20 is entled “Durable Medical Equipment, Prosthecs, Orthocs, and Supplies (DMEPOS).”

Visit Chapter 24 to learn more about electronic ling requirements, including the Electronic Data Interchange (EDI)

enrollment form that must be completed prior to subming Electronic Media Claims (EMCs) or other EDI transacons

to Medicare. Refer to Chapter 26 to learn what should be included in the 837P or in each item of the CMS-1500. The

“Medicare Benet Policy Manual” (IOM Pub. 100-02) and the “Medicare Naonal Coverage Determinaons (NCD)

Manual,” (IOM Pub. 100-03) both include coverage informaon that may be helpful in claims submission. Search for

coverage guidance once within a chapter.

Coding

Correct coding is key to subming valid claims. To ensure claims are as accurate as possible, use current valid diagnosis

and procedure codes and code them to the highest level of specicity (maximum number of digits) available. Chapter

23 of the “Medicare Claims Processing Manual” is entled “Fee Schedule Administraon and Coding Requirements” and

includes informaon on diagnosis coding and procedure coding, as well as instrucons for codes with modiers.

Diagnosis Coding

The Internaonal Classicaon of Diseases, Ninth Revision, Clinical Modicaon (ICD-9-CM), is currently used to code

diagnosc informaon on claims. The United States Government publishes the ICD-9-CM. Mulple enes publish ICD-

9-CM manuals and the full ICD-9-CM is available for purchase on CD-ROM through a link on the CMS website. From the

ICD-9-CM web page, select the CD-ROM Version of ICD-9-CM.

ICD-10-CM (tenth revision) will replace the ICD-9-CM to report diagnoses on October 1, 2014. An ICD-10 web page

explains the recommended steps to plan and prepare for this new system.

Procedure Coding

Use Healthcare Common Procedure Coding System (HCPCS) Level I and II codes to code procedures on all claims. Level I

Current Procedural Terminology (CPT-4) codes describe medical procedures and professional services. CPT is a numeric

coding system maintained by the AMA. The “CPT” code book is available from the AMA Bookstore on the Internet.

The Medicare Learning Network® (MLN) oers a downloadable guide about Evaluaon and Management (E/M) codes,

which are a subset of HCPCS Level I codes. The “Evaluaon and Management Services Guide” is available on the

CMS website.

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Level II of the HCPCS is a standardized coding system that is used primarily to idenfy products, supplies,

and services not included in the CPT codes, such as ambulance services and DMEPOS when used outside a

physician’s oce or injecons administered within a physician’s oce or clinic. Because Medicare and other

insurers cover a variety of services, supplies, and equipment that are not idened by CPT codes, the Level II HCPCS

codes, or alpha-numeric codes as they may be referred to, were established for subming claims for these items. These

codes are found in the “Health Care Procedure Coding System (HCPCS)” code book or by vising the Alpha-Numeric

HCPCS web page.

Modiers

Proper use of modiers with procedure codes is essenal to subming correct claims. The AMA’s “CPT” code book

includes HCPCS Level I codes and modiers, while the “HCPCS” code book includes HCPCS Level II codes and related

modiers. Resources about modiers on the CMS website include:

• The “Modier -59” arcle explains the correct use of -59 as a disnct procedural service;

• The Physician Quality Reporng System (PQRS) web page explains the incenve payment to pracces with

eligible professionals who sasfactorily report data on their claims;

• The Physician Bonuses web page outlines whether or not a modier is required to receive the Health

Professional Shortage Area (HPSA) bonus payment; and

• Chapters of the “Medicare Claims Processing Manual” (IOM Pub. 100-04) also oer modier informaon.

For example, Chapter 30 includes informaon related to modiers for Advance Beneciary Noces (ABNs).

Subming Accurate Claims

Health care professionals and suppliers play a vital role in protecng the integrity of the Medicare Program by

subming accurate claims, maintaining current knowledge of Medicare billing policies, and ensuring all

documentaon required to support the medical need for the service rendered is submied.

In addion to correct claims compleon, Medicare payment requires that an item or service:

• Meets a benet category;

• Is not specically excluded from coverage; and

• Is reasonable and necessary.

In general, fraud is dened as making false statements or representaons of material facts to obtain some benet or

payment for which no entlement would otherwise exist.

Abuse describes pracces that, either directly or indirectly, result in unnecessary costs to the Medicare Program.

It is a crime to defraud the Federal government and its programs. Punishment may involve imprisonment, signicant

nes, or both under a number of laws including the False Claims Act, the An-Kickback Statute, the Physician Self-

Referral Law (Stark Law), and the Criminal Health Care Fraud Statute.

For more informaon about Medicare Program integrity funcons and how health care professionals and suppliers can

help to protect Medicare from fraud and abuse, reference the “Medicare Program Integrity Manual” (IOM Pub. 100-

08, Chapter 4) on the CMS website. The MLN also provides a fact sheet tled “Medicare Fraud & Abuse: Prevenon,

Detecon, and Reporng.” This fact sheet is designed to provide educaon on prevenng, detecng, and reporng

Medicare fraud and abuse. It includes denions as well as informaon on laws, partnerships with other organizaons,

and resources for addional informaon.

The MLN also provides a number of compliance educaon products designed to help health care professionals and

suppliers submit accurate claims.

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When Does Medicare Accept a Hard Copy Claim Form?

Inial claims for payment under Medicare must be submied electronically unless a health care

professional or supplier qualies for a waiver or excepon from the Administrave

Simplicaon Compliance Act (ASCA) requirement for electronic submission of claims.

Before subming a hard copy claim, health care professionals and suppliers should self-assess

to determine if they meet one or more of the ASCA excepons. For example, health care

professionals and suppliers that have fewer than 10 Full-Time Equivalent (FTE) employees and

bill a Medicare FFS Contractor are considered to be small and might therefore qualify to be

exempt from Medicare electronic billing requirements. If a health care professional or supplier meets an excepon, there

is no need to submit a waiver request.

There are other situaons when the ASCA electronic billing requirement could be waived for some or all claims, such

as if disability of all members of a health care professional’s or supplier’s sta prevents use of a computer for electronic

submission of claims. Health care professionals and suppliers must obtain Medicare pre-approval to submit paper claims

in these situaons by subming a waiver request to their Medicare FFS Contractor.

To learn more about the ASCA waivers and excepons, visit the Electronic Billing & EDI Transacons web page and select

one of the ASCA opons in the le menu. Refer to Chapter 24, Secons 90-90.6, of the “Medicare Claims Processing

Manual” (IOM Pub. 100-04) for further informaon on ASCA electronic billing requirements and enforcement reviews of

health care professionals and suppliers.

Download a sample of the form by vising the CMS Forms List web page. In the Filter On box, enter 1500. Copies of the

CMS-1500 should not be downloaded for submission of claims, since they may not accurately replicate colors included in

the form. These colors are needed to enable automated reading of informaon on the form. Visit the U.S. Government

Bookstore to order the form. The CMS-1500 is also available from prinng companies and oce supply stores, as long as

it follows the CMS approved specicaons found in the “Medicare Claims Processing Manual” (IOM Pub. 100-04, Chapter

26, Secon 30).

Timely Filing

The mely ling period for both paper and electronic Medicare claims is 12 months, or one calendar year, aer the date

of service.

Claims are denied if they arrive aer the deadline date. When a claim is denied for having been led aer the mely

ling period, such a denial does not constute an inial determinaon. As such, the determinaon that a claim was not

led mely is not subject to appeal.

Medicare uses the line item ‘From’ date to determine the date of service for claims ling meliness for claims submied

by health care professionals and suppliers that include span dates of service. (This includes DME supplies and rental

items.) If a line item ‘From’ date is not mely but the ‘To’ date is mely, contractors must split the line item and deny the

unmely services as not mely led.

Medicare regulaons allow excepons to the 12-month me limit for ling claims. To review these excepons, refer to

the “Medicare Claims Processing Manual” (IOM Pub. 100-04, Chapter 1) on the CMS website.

Where to Submit FFS Claims

Claims for services must be submied to the appropriate Medicare FFS Contractor. Contact the Medicare FFS Contractor

by referencing the Provider Compliance Group Interacve Map on the CMS website. Medicare beneciaries cannot be

charged for compleng or ling a claim. Health care professionals and suppliers may be subject to penalty for violaons.

If a beneciary is enrolled in a Medicare Advantage (MA) Plan, claims should not be submied to the Medicare

FFS Contractor; the beneciary’s MA Plan is responsible for claims processing. CMS provides a list of

MA claims processing contacts on the CMS website.

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Medicare Secondary Payer (MSP)

MSP provisions apply to situaons when Medicare is not the beneciary’s primary health insurance coverage

and ensure that Medicare does not pay for services and items that certain other health insurance or coverage is

primarily responsible for paying. For more informaon, reference the “Medicare Secondary Payer for Provider,

Physician, and Other Supplier Billing Sta” fact sheet available through the MLN “Catalog of Products” on the CMS

website. The Medicare Secondary Payer & You web page oers informaon on MSP laws and the various methods

employed by CMS to gather data on other insurance that may be primary to Medicare.

Where to Learn More

WEB PAGES

Electronic Billing & EDI Transacons

hp://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/index.html

To read more about submission of electronic claims, visit the CMS Electronic Billing & EDI Transacons web page.

Health Care Payment and Remiance Advice

hp://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/Remiance.html

Medicare FFS Contractors use a noce called a Remiance Advice (RA) as a means to communicate to health care

professionals and suppliers claim processing decisions such as payments, adjustments, and denials. The Health Care

Payment and Remiance Advice web page oers informaon on the 835 standard transacon for the Electronic Remit

Advice (ERA) and the Standard Paper Remit (SPR).

HIPAA Versions 5010 and D.0 & 3.0

hp://www.cms.gov/Regulaons-and-Guidance/HIPAA-Administrave-Simplicaon/Versions5010andD0/index.html

This secon of the CMS website contains informaon and educaonal resources pertaining to Version 5010, which is the

version of the X12 standards for HIPAA transacons.

MLN Guided Pathways (GP) to Medicare Resources

hp://www.cms.gov/Outreach-and-Educaon/Medicare-Learning-Network-MLN/MLNEdWebGuide/Guided_Pathways.

html

The MLN Guided Pathways (GP) to Medicare Resources web page helps health care professionals, providers, suppliers,

and contractors gain knowledge on resources and products related to Medicare and the CMS website.

Naonal Correct Coding Iniave Edits

hp://www.cms.gov/Medicare/Coding/NaonalCorrectCodInitEd/index.html

In the le column of this web page are NCCI edits for physician and hospital outpaent claims and Medically Unlikely

Edits (MUEs).

Professional Paper Claim Form (CMS-1500)

hp://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/16_1500.html

This web page contains informaon about subming paper claims. Click on Administrave Simplicaon Compliance Act

Self Assessment in the le column to read about the limited circumstances when an inial claim may be a paper claim.

WEB-BASED TRAINING (WBT) COURSES

“CMS Form 1500”

hp://www.cms.gov/Outreach-and-Educaon/Medicare-Learning-Network-MLN/MLNProducts/WebBasedTraining.html

This web-based training course is designed to provide educaon on how to accurately le Medicare Part B claims.

It includes informaon and direcons for billing that will help to reduce or eliminate the chances of receiving

unprocessable rejecons. To locate this course, scroll down the page and select Web-Based Training (WBT) Courses.

Page 5

“Health Insurance Portability and Accountability Act (HIPAA) EDI Standards”

hp://www.cms.gov/Outreach-and-Educaon/Medicare-Learning-Network-MLN/MLNProducts/WebBasedTraining.html

This web-based training course is designed to provide educaon on electronic billing, transacon standards, and code

sets. It includes an overview of the steps involved in the Medicare electronic data interchange process. To locate this

course, scroll down the page and select Web-Based Training (WBT) Courses.

“Medicare Billing Cercate Program for Part B Providers”

hp://www.cms.gov/Outreach-and-Educaon/Medicare-Learning-Network-MLN/MLNProducts/WebBasedTraining.html

This program is designed to provide educaon on Part B of the Medicare Program. It includes required web-based

training courses, readings, and a list of helpful resources. Upon successful compleon of this program, you will receive a

cercate in Medicare billing for Part B providers from CMS. To locate this course, scroll down the page and select Web-

Based Training (WBT) Courses.

“Medicare Secondary Payer Provisions”

hp://www.cms.gov/Outreach-and-Educaon/Medicare-Learning-Network-MLN/MLNProducts/WebBasedTraining.html

This web-based training course is designed to provide educaon on the MSP provisions. Understanding and correctly

applying these provisions when subming claims to Medicare can reduce claim submission errors. To locate this course,

scroll down the page and select Web-Based Training (WBT) Courses.

INTERNET-ONLY MANUAL

“Medicare Claims Processing Manual,” IOM Pub. 100-04, Chapter 26, “Compleng and Processing the Form CMS-1500

Data Set”

hp://www.cms.gov/Regulaons-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf

Chapter 26 outlines billing requirements for health care professionals and suppliers using the 837P or Form CMS-1500.

GUIDES

“Evaluaon and Management Services Guide”

hp://www.cms.gov/Outreach-and-Educaon/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_

serv_guide-ICN006764.pdf

This guide is designed to provide educaon on evaluaon and management services. It includes the following

informaon: medical record documentaon, evaluaon and management billing and coding consideraons, and the

“1995 Documentaon Guidelines for Evaluaon and Management Services” and the “1997 Documentaon Guidelines

for Evaluaon and Management Services.”

“MLN Guided Pathways to Medicare Resources: Basic Curriculum for Health Care Professionals, Suppliers,

and Providers”

hp://www.cms.gov/Outreach-and-Educaon/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/Guided_

Pathways_Basic_Booklet.pdf

This basic curriculum includes informaon about Medicare resources applicable to all health care professionals,

suppliers, and providers.

“MLN Guided Pathways to Medicare Resources: Intermediate Curriculum for Health Care Professionals and Suppliers”

hp://www.cms.gov/Outreach-and-Educaon/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/Guided_

Pathways_Intermediate_PartB_Booklet.pdf

This intermediate curriculum provides detailed resources for informaon on Medicare policies and requirements

applicable to physicians, non-physician praconers, and suppliers who enroll using the CMS-855B, CMS-855I, CMS-

855O, or CMS-855S enrollment applicaons.

“MLN Guided Pathways to Medicare Resources: MLN Guided Pathways Provider Specic”

hp://www.cms.gov/Outreach-and-Educaon/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/Guided_

Pathways_Provider_Specic_Booklet.pdf

This advanced curriculum includes specialty and facility specic informaon for Medicare instuonal providers,

physicians, health care professionals, and suppliers.

Page 6

BOOKLETS

“How to Use The Naonal Correct Coding Iniave (NCCI) Tools”

hp://www.cms.gov/Outreach-and-Educaon/Medicare-Learning-Network-MLN/MLNProducts/Downloads/How-

To-Use-NCCI-Tools.pdf

This booklet is designed to provide educaon on how to navigate the CMS NCCI web pages. It includes informaon

on how to look up Medicare code pair edits and MUEs, as well as an explanaon of how the NCCI tools can help

providers avoid coding and billing errors and subsequent payment denials.

“Medicare Claim Review Programs: MR, NCCI Edits, MUEs, CERT, and RAC”

hp://www.cms.gov/Outreach-and-Educaon/Medicare-Learning-Network-MLN/MLNProducts/downloads/

MCRP_Booklet.pdf

This booklet is designed to provide educaon on the dierent CMS claim review programs and assist providers

in reducing payment errors; in parcular, coverage and coding errors. It includes frequently asked quesons,

resources, and an overview of the various programs, including Medical Review, Recovery Audit Contractor (RAC),

and the Comprehensive Error Rate Tesng (CERT) Program.

“The Naonal Provider Idener (NPI): What You Need to Know”

hp://www.cms.gov/Outreach-and-Educaon/Medicare-Learning-Network-MLN/MLNProducts/downloads/

NPIBooklet.pdf

This booklet is designed to provide educaon on the NPI. It includes informaon on NPI basics, the Naonal Plan

and Provider Enumeraon System (NPPES), health care provider categories, and how to apply for an NPI.

FACT SHEET

“Medicare Claim Submission Guidelines”

hp://www.cms.gov/Outreach-and-Educaon/Medicare-Learning-Network-MLN/MLNProducts/downloads/Medic

areClaimSubmissionGuidelines-ICN906764.pdf

This fact sheet is designed to provide educaon on Medicare claim submissions. It includes informaon about

enrolling in the Medicare Program; private contracts with Medicare beneciaries; ling Medicare claims;

deducbles, coinsurance, and copayments; and coordinaon of benets.

OTHER MLN PRODUCTS

“MLN Suite of Products and Resources for Billing and Coding Professionals”

hp://www.cms.gov/Outreach-and-Educaon/Medicare-Learning-Network-MLN/MLNProducts/downloads/

Billers_and_Coders_Suite_of_Products_Lisngs.pdf

This suite of products provides business oce management professionals with a list of accurate, mely, and

easy-to understand billing and coding products as well as informaon to assist in understanding and streamlining

claims submissions.

New Maximum Period for the Submission of Medicare Claims Podcast

hp://www.cms.gov/Outreach-and-Educaon/Medicare-Learning-Network-MLN/MLNProducts/MLN-Mulmedia.

html

This podcast is designed to provide educaon on the new maximum period that health care professionals and

suppliers have for the submission of Medicare claims. It includes informaon to determine the date of service on

the claim statement. In the Filter On box, enter the name of the podcast.

Page 7

Disclaimers

This fact sheet was current at the me it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been

provided within the document for your reference.

This fact sheet was prepared as a service to the public and is not intended to grant rights or impose obligaons. This fact sheet may contain references or links to

statutes, regulaons, or other policy materials. The informaon provided is only intended to be a general summary. It is not intended to take the place of either the

wrien law or regulaons. We encourage readers to review the specic statutes, regulaons, and other interpreve materials for a full and accurate statement of

their contents.

The Medicare Learning Network® (MLN), a registered trademark of the Centers for Medicare & Medicaid Services (CMS), is the brand name for ocial CMS educaon

and informaon for Medicare Fee-For-Service Providers. For addional informaon, visit the MLN’s web page at hp://go.cms.gov/MLNGenInfo on the CMS website.

Your feedback is important to us and we use your suggesons to help us improve our educaonal products, services and acvies and to develop products, services

and acvies that beer meet your educaonal needs. To evaluate Medicare Learning Network® (MLN) products, services and acvies you have parcipated in,

received, or downloaded, please go to hp://go.cms.gov/MLNProducts and click on the link called ‘MLN Opinion Page’ in the le-hand menu and follow

the instrucons.

Please send your suggesons related to MLN product topics or formats to [email protected].

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