Skip Navigation

CMS 1500 Claim Form

Switch to CMS 1500 form by April 1

CMS has updated its 1500 claim form to accept the new ICD-10 code set. All practices must begin using the new form (version 02/12) April 1.

Changes to Box 21

You can enter either ICD-9 or ICD-10 codes in the new form, but must indicate the code set used in the new "ICD Ind." field added to box 21. View a completed CMS-1500 version 02/12 form [PDF 638K].

Box 21 on the old form:

Box 21 on the old version of the CMS 1500 form.

Box 21 on the new form:

Box 21 on the new version of the CMS 1500 form.

Note the new lettered sequence of diagnosis codes, and the horizontal sequence. The revised box also has room for more codes.

Provider information added to Box 17

The ordering physician’s NPI must be listed in box 17 when any tests are billed. Although there is space to identify up to three providers (DN – referring, DK – ordering, DQ –supervising provider), the only one required for payment is the ordering provider. If more than one physician of the practice orders tests on the same day, it will be necessary to report them on separate claim forms. If only an exam is billed, you can enter the referring provider in this space.

CMS1500 Claim Form, Sample Box 17

View sample completed form

CMS has been accepting the new 1500 form since January, so your practice could start using it now. View a completed CMS-1500 version 02/12 form [PDF 638K].

Tip: Does your office use other forms designed for ICD-9 codes? Make sure your ICD-10 plan includes replacing or updating those forms by Oct. 1.

Only providers who qualify for exemptions from electronic submission may submit the CMS-1500 Claim Form to Medicare. CMS encourages providers who use service vendors to check with them to find out when vendors will switch to the new form. Starting April 1, Medicare will accept only the revised version of the form.

Learn more about the new 1500 form in this YO Info article.