CMS-1500 blocks 24–33

Section 3b: Physician or supplier Information - Blocks 24 through 33

Procedure codes, such as the Current Procedural Terminology (CPT) or the Healthcare Common Procedure Coding System (HCPCS) codes, are listed in Block 24. Each procedure code is considered a line item; the line numbers are found to the left of Block 24. All data in one line belongs to the coordinated CPT/HCPCS code. For claims that require more than six line items, a second CMS-1500 form should be generated. Check with the insurance company to confirm how to indicate that the claim has multiple pages; some insurance companies require the statement “Continued” or “Page 1 of 2” in Block 28, Total Charges.

Block 24: Procedures and charges

Block 24A: Date(s) of service

Note that there is space for both “From” and “To” dates. If the service was provided on just one day, you would only enter a From date in a MM/DD/YY format. If the service was provided on multiple days, such as an inpatient hospital stay, the first day the service was provided would be put in the From field, and the last day the service was provided would be entered in the To field. The number of times that service was provided would be indicated in Block 24G.

Block 24B: Place of service

The Place of Service (POS) codes indicate where the services were provided.

Common place of service codes

Code	Description
11	Doctor’s office
12	Patient’s home
21	Inpatient hospital
22	Outpatient hospital
23	Emergency department - hospital
24	Ambulatory surgical center
31	Skilled nursing facility (swing bed visits)
81	Independent laboratory

Block 24C: EMG (emergency) A Y in this field indicates that the service was an emergency.

Block 24D: Procedures, service or supplies

There are two sections in this block: CPT/HCPCS and Modifier. There is space for a single 5-digit code and up to four separate two-digit modifiers. No space is provided for a written description of the code; only the code is required.

Block 24E: Diagnosis pointer

This block indicates which diagnosis is used for each line item. The letter from diagnosis listed in Block 21 should be used here to link the diagnosis to the service. Do not enter the ICD-10-CM codes in this block.

Block 24F: $ Charges

The dollar amount of the provider’s fee for the service is entered here. This fee is calculated in the office based on work, expertise, and time. If a series of services was performed on any one line, multiply the number of days or units (Block 24G) by the charge for one procedure or service and enter the total amount for all days or units. This field is most commonly used for multiple visits, units of supplies, or anesthesia units.

Block 24G: Days or units

The number of days or units is entered here. This block is used for multiple visits and units of supplies. If only one service is performed, 1 would be entered.

Block 24H: EPSDT/Family plan

The acronym EPSDT stands for early and periodic screening, diagnosis, and treatment, the child health program under Medicaid. This block identifies specific services covered under state health insurance plans. Refer to the appropriate insurance payer’s guidelines (typically Medicaid or the Medicaid intermediary) for instructions on completing this block. Leave the block blank for Medicare, TRICARE, and the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) (military insurance plans), group health plans, Federal Employees Compensation Act (FECA)/Black Lung, and most other types of insurance.

Block 25: Federal tax ID number

The federal tax ID number of the provider filing the claim can be listed as a Social Security number (SSN) or an employer identification number (EIN); mark the appropriate box with an X.

Block 26: Patient’s account number

Enter the account number or medical record number assigned to the patient by the provider of the service. This information will be included on the EOB from the insurance company to help with posting the payment.

Block 27: Accept assignment?

Put an X in the YES box if the provider will accept assignment; this means that the provider is a participating provider (PAR) and agrees to accept the terms of the agreement with the insurance company and also to accept what the plan states as an allowed amount for the services provided.

Block 28: Total charge

This block shows the amount billed on the claim form for all services rendered. To arrive at this amount, add up the charges reported in Block 24F for all the lines of service on the claim form. For example, if the 24F charges on a claim are $75, $120, $45, and $60, Block 28 shows their sum: $300.

Block 29: Amount paid The amount received from the patient or other payers.

Block 30: Reserved for NUCC use Some secondary insurance claims use this box to claim the amount due after the primary insurance has paid.

Block 31: Signature of physician or supplier

This block is for the signature of the authorized or accountable person for the services on the claim; it verifies that the individual has provided the services listed and that those services have been checked for accuracy.

Block 32: Service facility location information

Enter the name, address, city, state, and zip code for the site where the services listed in the claim were provided. Enter the facility’s NPI in Block 32a only if it is different from the Billing Provider NPI (Block 33a).

Block 33: Billing provider info and phone number Enter the address and phone number of the provider asking to be paid on this claim.