CMS 1500 FORM Field 19 - Additional Claim Information (Designated by NUCC)

Field 19 - Additional Claim Information (Designated by NUCC)


“Additional Claim Information” identifies additional information about the patient’s condition or the claim.

NUCC INSTRUCTIONS: Please refer to the most current instructions from the public or private payer regarding the use of this field. Report the appropriate qualifier, when available, for the information being entered. Do not enter a space, hyphen, or other separator between the qualifier and the information.
For the Claim Information (NTE), the following are the qualifiers in 5010A1. Enter the qualifier “NTE”, followed by the appropriate qualifier, then the information. Do not enter spaces between the qualifier and the first word of the information. After the qualifier, use spaces to separate any words.
  1. ADD Additional Information
  2. CER Certification Narrative
  3. DCP Goals, Rehabilitation Potential, or Discharge Plans
  4. DGN Diagnosis Description
  5. TPO Third Party Organization Notes
EXAMPLE:


For additional identifiers (REFs), the following are the qualifiers in 5010A1. Enter the qualifier “REF”, followed by the qualifier, then the identifier. Do not enter spaces between the qualifier and identifier.
  1. 0B State License Number
  2. 1G Provider UPIN Number
  3. G2 Provider Commercial Number
  4. LU Location Number (This qualifier is used for Supervising Provider only.)
  5. N5 Provider Plan Network Identification Number
  6. SY Social Security Number (The social security number may not be used for Medicare.)
  7. X5 State Industrial Accident Provider Number
  8. ZZ Provider Taxonomy (The qualifier in the 5010A1 for Provider Taxonomy is PXC, but ZZ will remain the qualifier for the 1500 Claim Form.)

The above list contains both provider identifiers, as well as the provider taxonomy code. The provider identifiers are assigned to the provider either by a specific payer or by a third party in order to uniquely identify the provider. The taxonomy code is designated by the provider in order to identify his/her provider grouping, classification, or area of specialization. Both, provider identifiers and provider taxonomy may be used in this field.
Taxonomy codes or other identifiers reported in this field must not be reportable in other fields, i.e., Item Numbers 17, 24J, 32, or 33.
EXAMPLE:


For Supplemental Claim Information (PWK), the following are the qualifiers in the 5010A1. Enter the qualifier “PWK”, followed by the appropriate Report Type Code, the appropriate Transmission Type Code, then the Attachment Control Number. Do not enter spaces between the qualifiers and data.

REPORT TYPE CODES
  1. 03 Report Justifying Treatment Beyond Utilization
  2. 04 Drugs Administered
  3. 05 Treatment Diagnosis
  4. 06 Initial Assessment
  5. 07 Functional Goals
  6. 08 Plan of Treatment
  7. 09 Progress Report
  8. 10 Continued Treatment
  9. BS Baseline
  10. BT Blanket Test Results
  11. CB Chiropractic Justification
  12. CK Consent Form(s)
  13. CT Certification
  14. D2 Drug Profile Document
  15. DA Dental Models
  16. DB Durable Medical Equipment Prescription
  17. DG Diagnostic Report
  18. DJ Discharge Monitoring Report
  19. DS Discharge Summary
  20. EB Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)
  21. HC Health Certificate
  22. HR Health Clinic Records
  23. I5 Immunization Record
  24. IR State School Immunization Records
  25. LA Laboratory Results
  26. M1 Medical Record Attachment
  27. MT Models
  28. NN Nursing Notes
  29. OB Operative Note
  30. OC Oxygen Content Averaging Report
  31. OD Orders and Treatments Document
  32. OE Objective Physical Examination (including vital signs) Document
  33. OX Oxygen Therapy Certification
  34. OZ Support Data for Claim
  35. P4 Pathology Report
  36. P5 Patient Medical History Document
  37. PE Parenteral or Enteral Certification
  38. PN Physical Therapy Notes
  39. PO Prosthetics or Orthotic Certification
  40. PQ Paramedical Results
  41. PY Physician’s Report
  42. PZ Physical Therapy Certification
  43. RB Radiology Films
  44. RR Radiology Reports
  45. RT Report of Tests and Analysis Report
  46. RX Renewable Oxygen Content Averaging Report
  47. SG Symptoms Document
  48. V5 Death Notification
  49. XP Photographs
TRANSMISSION TYPE CODES
  1. AA Available on Request at Provider Site
  2. BM By Mail
EXAMPLE:

When reporting multiple separate items, enter three blank spaces and then the next qualifier and followed by the information

EXAMPLE:



MEDICARE INSTRUCTIONS - Enter either a 6-digit (MM | DD | YY) or an 8-digit (MM | DD | CCYY) date patient was last seen and the NPI of his/her attending physician when a physician providing routine foot care submits claims.
NOTE: Effective May 23, 2008, all provider identifiers submitted on the CMS-1500 claim form MUST be in the form of an NPI.

Enter either a 6-digit (MM | DD | YY) or an 8-digit (MM | DD | CCYY) x-ray date for chiropractor services (if an x-ray, rather than a physical examination was the method used to demonstrate the subluxation). By entering an x-ray date and the initiation date for course of chiropractic treatment in item 14, the chiropractor is certifying that all the relevant information requirements (including level of subluxation) of Pub. 100-02, Medicare Benefit Policy Manual, chapter 15, is on file, along with the appropriate x-ray and all are available for A/B MAC (B) review.

Instructions for Not Otherwise Classified (NOC) Codes – Any unlisted services or procedure code. Note: When reporting NOC codes, this field must be populated as specified below.

Enter the drug's name and dosage when submitting a claim for NOC drugs.

Enter a concise description of an "unlisted procedure code" or a NOC code if one can be given within the confines of this box. Otherwise an attachment shall be submitted with the claim.

When billing for unlisted laboratory tests using a NOC code, this field MUST include the specific name of the laboratory test(s) and/or a short descriptor of the test(s). Claims for unlisted laboratory tests that are received without this information shall be treated according to the requirements found in Pub. 100-04, Medicare Claims Processing Manual, Chapter 1, Section 80.3.2 and “returned as unprocessable.” Section 216(a) of the Protecting Access to Medicare Act of 2014 (PAMA) requires reporting entities to report private payor payment rates for laboratory tests and the corresponding volumes of tests. In compliance with PAMA, CMS must collect private payor data on unique tests currently being paid as a NOC code, Not Otherwise Specified (NOS) code, or unlisted service or procedure code.

Enter all applicable modifiers when modifier -99 (multiple modifiers) is entered in item 24d. If modifier -99 is entered on multiple line items of a single claim form, all applicable modifiers for each line item containing a -99 modifier should be listed as follows: 1=(mod), where the number 1 represents the line item and "mod" represents all modifiers applicable to the referenced line item.

Enter the statement "Homebound" when an independent laboratory obtains a specimen from a homebound or institutionalized patient. (See Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, "Covered Medical and Other Health Services," and Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, "Laboratory Services,” and Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, "Definitions," respectively, for the definition of "homebound" and a more complete definition of a medically necessary laboratory service to a homebound or an institutional patient.)

Enter the statement, "Patient refuses to assign benefits," when the beneficiary absolutely refuses to assign benefits to a non-participating physician/supplier who accepts assignment on a claim. In this case, payment can only be made directly to the beneficiary.

Enter the statement, "Testing for hearing aid" when billing services involving the testing of a hearing aid(s) is used to obtain intentional denials when other payers are involved.
When dental examinations are billed, enter the specific surgery for which the exam is being performed.
Enter the specific name and dosage amount when low osmolar contrast material is billed, but only if HCPCS codes do not cover them.

Enter a 6-digit (MM | DD | YY) or an 8-digit (MM | DD | CCYY) assumed and/or relinquished date for a global surgery claim when providers share post-operative care.

Enter demonstration ID number "30" for all national emphysema treatment trial claims.

Enter demonstration ID number “56” for all national Laboratory Affordable Care Act Section 113 Demonstration Claims.

Enter the NPI of the physician who is performing the technical or professional component of a diagnostic test that is subject to the anti-markup payment limitation. (See Pub. 100-04, chapter 1, section 30.2.9 for additional information.)

NOTE: Effective May 23, 2008, all provider identifiers submitted on the CMS-1500 claim form MUST be in the form of an NPI.

Method II suppliers shall enter the most current HCT value for the injection of Aranesp for ESRD beneficiaries on dialysis. (See Pub. 100-04, chapter 8, section 60.7.2.)

Individuals and entities who bill A/B MACs (B) for administrations of ESAs or Part B anti-anemia drugs not self-administered (other than ESAs) in the treatment of cancer must enter the most current hemoglobin or hematocrit test results. The test results shall be entered as follows: TR= test results (backslash), R1=hemoglobin, or R2=hematocrit (backslash), and the most current numeric test result figure up to 3 numerics and a decimal point [xx.x]). Example for hemoglobin tests: TR/R1/9.0, Example for Hematocrit tests: TR/R2/27.0.

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