Properly Completing Items Number 21 and 24E on the CMS-1500 is Critical for Ensuring Payment

December 21, 2012

We are seeing a number of situations where adjustments are needed when routine exams, such as annual physicals, are billed.

It is important to remember that the primary reason for the patient’s visit indicates the primary diagnosis code pointer that should be used on the claim. Diagnosis code pointers are used to indicate the appropriate order of importance in relation to the service being performed. The first pointer designates the primary diagnosis for the service line. Remaining diagnosis pointers indicate declining level of importance to service line.

For additional information about properly completing the form, view the CMS-1500 Instructions on the National Uniform Claim Committee (NUCC) website. The information below is excerpted from the NUCC site for your convenience.

Item Number 21

Title: Diagnosis or Nature of Illness or Injury (relate items 1, 2, 3, or 4 to 24E by line)

Instructions: Enter the patient’s diagnosis/condition. List no more than four ICD-9-CM diagnosis codes. Relate lines 1, 2, 3, 4 to the lines of service in 24E by line number. Use the highest level of specificity. Do not provide narrative description in this field.

When entering the number, include a space (accommodated by the period) between the two sets of numbers. If entering a code with more than 3 beginning digits (e.g., E codes), enter the fourth digit above the period.

Description: The "Diagnosis or Nature of Illness or Injury" refers to the sign, symptom, complaint, or condition of the patient relating to the service(s) on the claim.

Field Specification: This field allows for the entry of 3 characters prior to the period, 1 character above the period, and 4 characters after the period in each of the four line areas.


21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line)

  1. 998 . 59
  2. 780 . 6
  3. V18 . 0
  4. E878 . 8

Item Number 24E

Title: Diagnosis Pointer [lines 1–6]

Instructions: Enter numbers left justified in the field. Do not use commas between the numbers.

Description: The "Diagnosis Pointer" refers to the line number from Item Number 21 that relates to the reason the service(s) was performed.

Field Specification: This field allows for the entry of 4 characters in the unshaded area.