ANSI 837 v5010 to CMS-1500 Crosswalk
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- Arnold Phelps
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1 to CMS- 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- 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. CMS- Claim Form Crosswalk to CMS- 1a Medicare Number Loop 2010BA, NM1/IL, 09 2 Patient Last Name 2010BA, NM1/IL, 03 Patient First Name 2010BA, NM1/IL, 04 3 Patient Birth Date 2010BA, DMG, 02 Patient Sex 2010BA, DMG, 03 4 Insured Last Name 2330A, NM1/IL, 03 Insured First Name 2330A, NM1/IL, 04 5 Patient Street Address 2010BA, N3, 01 Patient City and State Patient ZIP Code and Phone Number 2010BA, N4, 01 (City) 2010BA, N4, 02 (State) 2010BA, N4, 03 (Zip Code) Phone Number not available in format 6 Patient Relationship to Insured 2000B, SBR, 02 7 Insured s Address and Phone Number Use only if Insured is Different than Patient 8 Patient Status 9 Medigap Patient Student Status Patient Employment Status Other Insured Last Name 2330A, NM1/IL, 03 Other Insured First Name 2330A, NM1/IL, 04 Other Insured Middle Initial 2330A, NM1/IL, 05 9a Other Insurance Policy or Group # (Enter the policy and/or group number of the Medigap insured preceded by MEDIGAP, MG, or MGAP.) 2330A, NM1/IL, 09 9b Other Insurance Date of Birth Not available in format 9c Employer Name or School Name 2330B, NM1/PR, 03
2 9d 10a,b,c 11 MSP Claims Insurance Plan Name or Program Name (Medigap 5-digit Insurer Code) Is Patient s Condition Related To: Employment, Auto Accident, Other Accident Insured Group or Policy Number (This item must be completed for paper claims.) 2330B, NM1/PR, , CLM, 11 Claim Filing Indicator See note in 11 Insurance Type Code See note in 11 11a Insured Date of Birth See note in 11 11b Employer Name or School Name See note in 11 11c Other Insured Group Name See note in 11 11d Is there another Health Benefit Plan? Note: There is no direct match for Blocks 11-11D of the CMS- Claim Form to the format. See note in Patient Signature 2300, CLM, 10 (Patient Signature Source Code) Release of Information Indicator 2300, CLM, Accident Date 2300, DTP/439, 03 Initial Treatment Date 2300 or 2400, DTP/454, Same/Similar Symptom Indicator Onset of Similar Symptoms or Illness 16 Dates patient was unable to work in current occupation 2300, DTP/360/361/or 314, Onset of current illness or injury 2300 or 2400, DTP/431, 03 17a Referring Provider Last Name 2310A or 2420F, NM1/DN, 03 Referring Provider First Name 2310A or 2420F, NM1/DN, 04 Ordering Provider Last Name 2420E, NM1/DK, 03 Ordering Provider First Name 2420E, NM1/DK, 04 Ordering Provider Secondary Identifier, no longer reported Referring Provider Secondary Identifier, no longer reported
3 17b Ordering Provider National Provider Identifier (NPI) (17B MUST be reported when a service was ordered or referred by a physician.) Referring Provider National Provider Identifier (NPI) (17B MUST be reported when a service was ordered or referred by a physician.) 2420E, NM1/DK, A or 2420F, NM1/DN, Ordering Provider Primary Identifier (SSN or EIN) Not Available in Format Referring Provider Primary Identifier (SSN or EIN) Referring Provider Secondary Identifier (NPI) Not Available in Format Narrative 2300, or 2400, NTE, 02 Date Last Seen and X-ray 2300 or 2400, DTP/304, 03 Supervising NPI 2310D or 2420D, NMI/DQ, 09 Anesthesia Minutes 2400, SV1, 04 (03=MJ) Homebound Indicator 2300, CRC/75, 03 Hospice Employed Provider Indicator 2400, CRC/70, 02 Assumed & Relinquished Care Dates 2300, DTP/90 or 91, Purchased Service Charges 2400, PS1, Diagnosis , HI, 01-2 Diagnosis , HI, 02-2 Diagnosis , HI, 03-2 Diagnosis , HI, 04-2 Diagnosis , HI, 05-2 Diagnosis , HI, 06-2 Diagnosis , HI, 07-2 Diagnosis , HI, 08-2 Diagnosis , HI, 09-2 Diagnosis , HI, 10-2 Diagnosis , HI, 11-2 Diagnosis , HI, 12-2
4 23 CLIA Number (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/X4, or 2400, REF/G1, , REF/LX, /REF/1J/02 24a Dates of Service (From Dates) 2400, DTP/472, 03 Dates of Service (To Dates) 2400, DTP/472, 03 24b Place of Service 2300, CLM, 05 or 2400, SV1, 05 24d Procedure Code 2400, SV1, e Diagnosis Pointer 2400, SV1, f Charges 2400, SV1, 02 24g Days or Units of Service 2400, SV1, 04 (03=UN) Anesthesia Minutes 2400, SV1, 04 (03=MJ) 24h Leave blank. Not required by Medicare. Leave blank. Not required by Medicare. 24i 24j Legacy Qualifier Rendering Provider: Rendering Provider Legacy Number (shaded area) NPI of rendering provider (unshaded area) 2310B or 2420A, NM1/82, 09 (08=XX) 25 Provider SSN# or EIN# 2010AA, REF, 02 (REF01=EI or SY) 26 Patient s Account Number 2300, CLM, Accept Assignment 2300, CLM, Total Charges 2300, CLM, Amount Paid 2300, AMT/F5, Balance Due
5 31 Provider Signature Indicator 2300, CLM, Facility Lab Name 2310C, NM1/77, 03 Facility Lab NPI 2310C, NMI/77, 09 Place of Service Address 2310C, N3, 01 Place of Service City 2310C, N4, 01 Place of Service State 2310C, N4, 02 Place of Service Zip Code 2310C, N4, 03 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.) 2400, PS1, 01 Mammography Certification Number 2300 or 2400, REF/EW, 02 32a Facility NPI Number 2310C, NM1/77, 09 32b Facility Qualifier and Legacy Number 33 Organization Name 2010AA, NM1/85, 03 Provider s Last Name 2010AA, NM1/85, 03 Provider s First Name 2010AA, NM1/85, 04 Address 2010AA, N3, 01 City 2010AA, N4, 01 State 2010AA, N4, 02 Zip Code 2010AA, N4, 03 33a Billing Provider NPI 2010AA/NM1/85/09 (08 = XX) 33b Billing Provider Legacy Number or PIN No longer used, effective 5/23/08
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