Revised CMS 1500 Paper Claim Form: Version 02/12

The National Uniform Claim Committee (NUCC), an industry organization in which CMS participates, maintains the CMS 1500 claim form and periodically revises it according to industry needs. The NUCC recently revised this form (version 02/12). The NUCC changed the form to adequately accommodate and implement ICD-10-CM diagnosis codes, although the form does include other changes as well. More information is available on the NUCC website.

On June 10, 2013, the White House Office of Management and Budget (OMB) approved the revised CMS 1500 claim form, version 02/12, OMB control number, 0938-1197. The CMS 1500 claim form is the required format for submitting claims to Medicare on paper.

Features of the Revised Form

The revised form, among other changes, notably adds the following functionality:
Indicators for differentiating between ICD-9-CM and ICD-10-CM diagnosis codes.
Expansion of the number of possible diagnosis codes to 12. (now only 4 codes are available)
Qualifiers to identify the following provider roles (on item 17):
        o Ordering
        o Referring
        o Supervising

Instructions for Completing the Revised Form
CMS is updating the Medicare Claims Processing Internet Only Manual (IOM, Pub. 100-04) Chapter 26 to instruct contractors and providers regarding how to complete the revised form. CMS will post this information on the CMS website when it is available.
Tentative Timeline for Implementing the Revised Form for Medicare Claims

Medicare anticipates implementing the revised CMS 1500 claim form (version 02/12) as follows:
January 6, 2014: Medicare begins receiving and processing paper claims submitted on the revised CMS 1500 claim form (version 02/12).
January 6 through March 31, 2014: Dual use period during which Medicare continues to receive and process paper claims submitted on the old CMS 1500 claim form (version 08/05).
April 1, 2014: Medicare receives and processes paper claims submitted only on the revised CMS 1500 claim form (version 02/12).
These dates are tentative and subject to change. CMS will provide more information as it is available.

Note: The Administrative Simplification Compliance Act (ASCA) requires that Medicare claims be sent electronically unless certain exceptions are met. Some Medicare providers qualify for these exceptions and send their claims to Medicare on paper. For more information about ASCA exceptions, please contact the Medicare contractor who processes your claims. Claims sent electronically must abide by the standards adopted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The current standard adopted under HIPAA for electronically submitting professional health care claims is the 5010 version of the ASC X12 837 Professional Health Care Claim standard and its implementation specification, Technical Report 3 (TR3). More information about the ASC X12 and TR3 is available on the ASC X12 website.