New CMS-1500 Claim Form is Here: What You Need to Know
By Barbara Griswold, LMFT
(Updated March 26, 2014)
The past few years have brought a lot of changes, including the CPT service code overhaul last year, the release of the DSM-5, and the new Affordable Care Act plans that began this year. While all this has been going on, the folks that oversee the CMS-1500 claim form – the claim form required by most insurance plans – came up with an updated version of the form.
When do we start using the new form? Plans are accepting the new forms already, but as of April 1, 2014, plans will accept claims only on the new 2/12 version of the CMS 1500 claim form. It doesn’t matter what dates of service you are billing for.
Why the change? The new 2/12 version of the CMS-1500 form (often incorrectly still called the HCFA-1500) accommodates upcoming diagnosis code changes (more on this below).
What’s gone: Several questions have been deleted, including the client’s marital and employment status (Box 8), the insured’s employer or school name (Box 11b), and “Other Insured’s Date of Birth, Sex, and Employer” (Box 9b and 9c). Even the “Balance Due” box (Box 30) has been deleted.
What’s new: Don’t panic – the form is mostly unchanged. It may be hard to notice the changes at first. But in the upper left hand corner the “1500” in a circle has been replaced with a black square symbol, known as a QR code. And 12 diagnoses can now be reported on the form instead of four. Since the DSM-5 ditched multi-axial diagnosis, this allows health professionals to record more codes to describe the client’s presenting issues. You may notice the diagnosis code spaces are no longer numbered, but use letters A through L. These letters will have to be used again in Box 24E (Diagnosis Pointer) to list which diagnoses were focused on in the session. Also in Box 21, you’ll see “ICD Ind.” to identify whether your diagnosis is from the current International Classification of Diseases Manual, the ICD-9 or the ICD-10, coming October 1, 2014. Write a “9” if you are using the ICD-9, and a “0” if using the ICD-10. The ICD Indicator will be important as we transition to the ICD-10 (read on…)
What’s this ICD you are referring to? Think of the ICD as a book that simply lists all the medical and psychiatric diagnosis codes that exist. Then think of the DSM as a chapter of this book, listing all the psychiatric codes from that ICD list, with each diagnosis described in great detail as to symptoms, prevalence, differential diagnoses, etc. So when you use a DSM code, you are usually using an ICD code. However, a new set of ICD codes (the ICD-10) is on the horizon. Originally scheduled to go into effect in 2013, it has now been pushed back to October, 2015. The good news is that the DSM-5 lists both the ICD-9 and ICD-10 code for each diagnosis. For now it looks like we can use ICD-9 codes (listed in both the DSM-4 and 5) until October 1, 2015, and after that switch over to the ICD-10 codes.
What you need to do: Purchase some of the new forms so you have them on hand when needed – just visit the “Order ” page of this website. Even if you file electronically, it’s a good idea to have a stack of paper claims in case you need to file a corrected claim, for appeals, or if you need to fax a claim to expedite processing when there is a problem with electronic submission. Then make sure your claims software, clearinghouse, or billing service is ready for the transition. Also, purchase a DSM-5 and get trained on the coming diagnosis changes.
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Barbara Griswold, LMFT, is the author of Navigating the Insurance Maze: The Therapist’s Complete Guide to Working with Insurance – And Whether You Should. To purchase the book or other resources for therapists, click here. Contact Barbara at email@example.com to get answers to your insurance questions.
Copyright 2008-, Barbara Griswold, LMFT. No part may be reproduced without written permission of the author.