ANSI 837 v5010 to CMS-1500 Crosswalk

The implementation of ANSI ASC X12N electronic transactions to version 5010 presents substantial changes in the content of the data you will submit with your claims. In order to help you prepare for these changes, we have created a CMS-1500 Claim Form Crosswalk to ANSI 837 Electronic Claim v5010 for professional claims. This crosswalk will help you with correct claims submission during and after your transition to ANSI 837 v5010. CMS-1500 Claim Form Crosswalk to ANSI 837 v5010
CMS1500 Item # 1a 2 Medicare Number Patient Last Name Patient First Name 3 Patient Birth Date Patient Sex 4 Insured Last Name Insured First Name 5 Patient Street Address Patient City and State Patient ZIP Code and Phone Number ANSI 837 v5010 Loop, Segment, Element Loop 2010BA, NM1/IL, 09 2010BA, NM1/IL, 03 2010BA, NM1/IL, 04 2010BA, DMG, 02 2010BA, DMG, 03 2330A, NM1/IL, 03 2330A, NM1/IL, 04 2010BA, N3, 01 2010BA, N4, 01 (City) 2010BA, N4, 02 (State) 2010BA, N4, 03 (Zip Code) Phone Number not available in format 2000B, SBR, 02 Not Used Use only if Insured is Different than Patient Not Used Not Used Not Used 2330A, NM1/IL, 03 2330A, NM1/IL, 04 2330A, NM1/IL, 05 2330A, NM1/IL, 09

Description

6 7 8

Patient Relationship to Insured Insureds Address and Phone Number Patient Status Patient Student Status Patient Employment Status

9 Other Insured Last Name Medigap Other Insured First Name Other Insured Middle Initial 9a Other Insurance Policy or Group # (Enter the policy and/or group number of the Medigap insured preceded by MEDIGAP, MG, or MGAP.) Other Insurance Date of Birth Employer Name or School Name

9b 9c

Not available in format 2330B, NM1/PR, 03

CMS1500 Item # 9d 10a,b,c 11 MSP Claims

Description Insurance Plan Name or Program Name (Medigap 5-digit Insurer Code) Is Patients Condition Related To: Employment, Auto Accident, Other Accident Insured Group or Policy Number (This item must be completed for paper claims.)

ANSI 837 v5010 Loop, Segment, Element 2330B, NM1/PR, 09 2300, CLM, 11 Note: There is no direct match for Blocks 11 - 11D of the CMS-1500 Claim Form to the ANSI 837 v5010 format. See note in 11 See note in 11 See note in 11 See note in 11 See note in 11 See note in 11 2300, CLM, 10 (Patient Signature Source Code) 2300, CLM, 09 2300, DTP/439, 03 2300 or 2400, DTP/454, 03 Not used Not used 2300, DTP/360/361/or 314, 03 2300 or 2400, DTP/431, 03 2310A or 2420F, NM1/DN, 03 2310A or 2420F, NM1/DN, 04 2420E, NM1/DK, 03 2420E, NM1/DK, 04 Not Used Not Used

Claim Filing Indicator Insurance Type Code 11a 11b 11c 11d 12 Insured Date of Birth Employer Name or School Name Other Insured Group Name Is there another Health Benefit Plan? (Leave blank. Not required by Medicare.) Patient Signature Release of Information Indicator 14 Accident Date Initial Treatment Date 15 Same/Similar Symptom Indicator (Leave blank. Not required by Medicare.) Onset of Similar Symptoms or Illness (Leave blank. Not required by Medicare.) 16 17 Dates patient was unable to work in current occupation Onset of current illness or injury Referring Provider Last Name Referring Provider First Name Ordering Provider Last Name Ordering Provider First Name 17a Ordering Provider Secondary Identifier, no longer reported Referring Provider Secondary Identifier, no longer reported

CMS1500 Item # 17b

Description

ANSI 837 v5010 Loop, Segment, Element

Ordering Provider National Provider Identifier (NPI) 2420E, NM1/DK, 09 (17B MUST be reported when a service was ordered or referred by a physician.) Referring Provider National Provider Identifier (NPI) 2310A or 2420F, NM1/DN, 09 (17B MUST be reported when a service was ordered or referred by a physician.)

19

Ordering Provider Primary Identifier (SSN or EIN) Referring Provider Primary Identifier (SSN or EIN) Referring Provider Secondary Identifier (NPI) Narrative Date Last Seen and X-ray Supervising NPI Anesthesia Minutes Homebound Indicator Hospice Employed Provider Indicator Assumed & Relinquished Care Dates

Not Available in Format Not Available in Format Not Used 2300, or 2400, NTE, 02 2300 or 2400, DTP/304, 03 2310D or 2420D, NMI/DQ, 09 2400, SV1, 04 (03=MJ) 2300, CRC/75, 03 2400, CRC/70, 02 2300, DTP/90 or 91, 03 2400, PS1, 02 2300, HI, 01-2 2300, HI, 02-2 2300, HI, 03-2 2300, HI, 04-2 2300, HI, 05-2 2300, HI, 06-2 2300, HI, 07-2 2300, HI, 08-2 2300, HI, 09-2 2300, HI, 10-2 2300, HI, 11-2 2300, HI, 12-2

20 21

Purchased Service Charges Diagnosis 1 Diagnosis 2 Diagnosis 3 Diagnosis 4 Diagnosis 5 Diagnosis 6 Diagnosis 7 Diagnosis 8 Diagnosis 9 Diagnosis 10 Diagnosis 11 Diagnosis 12

CMS1500 Item # 23

Description

ANSI 837 v5010 Loop, Segment, Element

CLIA Number 2300 or 2400, REF/X4, 02 (Enter the 10-digit Clinical Laboratory Improvement Act (CLIA) certification number for laboratory services billed by an entity performing CLIA covered procedures.) Prior Authorization Number (Enter the Quality Improvement Organization (QIO) prior authorization number for those procedures requiring QIO prior approval.) Investigational Device Exemption (IDE) number (Enter the Investigational Device Exemption (IDE) number when in investigational device is used in an FDA-approved clinical trial. Post Market Approval number should also be placed here when applicable. Care Plan Oversight Services: HHA or Hospice NPI (Enter the NPI of the home health agency (HHA) or hospice when HCPCS code G0181 (HH) or G0182 (Hospice) is submitted.) 2300 or 2400, REF/G1, 02

2300, REF/LX, 02

2300/REF/1J/02

24a

Dates of Service (From Dates) Dates of Service (To Dates)

2400, DTP/472, 03 2400, DTP/472, 03 2300, CLM, 05 or 2400, SV1, 05 2400, SV1, 01-2 2400, SV1, 07-1 2400, SV1, 02 2400, SV1, 04 (03=UN) 2400, SV1, 04 (03=MJ) Leave blank. Not required by Medicare. Not used Not used 2310B or 2420A, NM1/82, 09 (08=XX) 2010AA , REF, 02 (REF01=EI or SY) 2300, CLM, 01 2300, CLM, 07 2300, CLM, 02 2300, AMT/F5, 02 Not Used

24b 24d 24e 24f 24g

Place of Service Procedure Code Diagnosis Pointer Charges Days or Units of Service Anesthesia Minutes

24h 24i 24j

Leave blank. Not required by Medicare. Legacy Qualifier Rendering Provider: (No longer reported.) Rendering Provider Legacy Number (shaded area) (No longer reported.) NPI of rendering provider (unshaded area)

25 26 27 28 29 30

Provider SSN# or EIN# Patients Account Number Accept Assignment Total Charges Amount Paid Balance Due

CMS1500 Item # 31 32

Description Provider Signature Indicator Facility Lab Name Facility Lab NPI Place of Service Address Place of Service City Place of Service State Place of Service Zip Code Lab ID (Complete this item for all laboratory work performed outside a physician's office. If an independent laboratory is billing, enter the place where the test was performed.) Mammography Certification Number

ANSI 837 v5010 Loop, Segment, Element 2300, CLM, 06 2310C, NM1/77, 03 2310C, NMI/77, 09 2310C, N3, 01 2310C, N4, 01 2310C, N4, 02 2310C, N4, 03 2400, PS1, 01

2300 or 2400, REF/EW, 02 2310C, NM1/77, 09 Not used 2010AA, NM1/85, 03 2010AA, NM1/85, 03 2010AA, NM1/85, 04 2010AA, N3, 01 2010AA, N4, 01 2010AA, N4, 02 2010AA, N4, 03 2010AA/NM1/85/09 (08 = XX) No longer used, effective 5/23/08

32a 32b 33

Facility NPI Number Facility Qualifier and Legacy Number (No longer reported.) Organization Name Providers Last Name Providers First Name Address City State Zip Code

33a 33b

Billing Provider NPI Billing Provider Legacy Number or PIN (No longer reported.)