Note: Physicians and suppliers who qualify for an exemption from the mandatory electronic claims submission requirements and who submit claims using the paper claim Form CMS-1500, must use Form CMS-1500 (08-05) beginning July 2, 2007.

Items 17 and 17a/17b
Enter the name and National Provider Identifier (NPI) of the ordering physician here. This is a required field for all diagnostic radiology claim submissions. If the name and NPI of the ordering physician is not entered, the claim will be rejected as unprocessable.

Item 19
Enter the NPI of the physician or supplier who is performing the technical or professional component of a diagnostic test that is subject to the anti-markup payment limitation.

Item 20
If any portion of the test was acquired and the anti-markup limitation applies, check the “Yes” box and enter the acquired price under Charges.

Item 32
Enter the complete name and physical address of the facility where the services are provided. This is a required field for all services provided in any place of service other than the patient’s home.
If billing for acquired services, also report the NPI of the entity that performed the test in Item 32.