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Form CMS-1500 Instructions and Sample Form


Information and Instructions for Form CMS-1500 (02/12) for all insurance companies:

  1. CMS-1500: Until March 31, 2014, one can use either the old CMS-1500 claim form (version 08/05, as marked in the lower right hand corner) or the new CMS-1500 (version 02/12), for paper claims submitted to Medicare, BCBS and BHS. Tufts does not want the new form until April 1, 2014. As of April 1, 2014, one must use the new claim form for all insurance companies. The new forms can be ordered online from,, and others.

  2. ICD-10-CM: As of October 1, 2014, every insurance company will require that ICD-10 codes be used to report diagnoses, instead of ICD-9 and DSM diagnostic codes. DSM codes and ICD-10 codes are very different; for example, the DSM-5 code for the diagnosis Major Depressive Disorder, Recurrent, Moderate is 296.32; the ICD-10 code for this disorder is F33.1. The ICD-10 codes are included in the new DSM-5 manual, in an easy-to-use format (each DSM code lists the equivalent ICD code right next to it). Do NOT submit ICD-10 codes for claims with dates of service prior to October 1, 2014. The change to ICD-10 does not affect CPT coding.

  3. For Medicare only: Electronic filing of Medicare claims is NOT mandatory for social workers in individual private practices. There have been confusing notices sent out, but electronic filing is only needed for practices with over 25 full time equivalent employees. One can continue to submit paper claims to Medicare, and they can be handwritten.

  4. There Are Only Three Changes When Using The New CMS-1500 (02/12) Form!

    • Item 21 – Do not insert a period in the ICD-9 or ICD-10 code.

    • There is a new area “ICD Ind.” Use “9” between the vertical, dotted lines when reporting ICD-9 codes (which you must do for dates of service before October 1, 2014); use “0” when using ICD-10 codes, which you must do for dates of service after (but not before) October 1, 2014.

    • Item 24 E – Be sure to use a letter as the diagnostic pointer, not a number as was used on the old form. Use only one diagnostic pointer, even if several diagnoses are listed in item 21.

For further information, you can access the CMS manual at:

Additional information from National NASW for members:

The information above was originally published in the March 2014 FOCUS newsletter.
Author: Erica Kirsners, LICSW; Private Practice; Chair, SWTRS Commission; Member, HMO-MCO Commission.

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