New York Billing: CMS-1500 Field 19 (Additional Claim Information)

New York State workers’ comp billing is in transition. Ultimately, the state will make a full, mandatory switch to e-billing. But before that, starting on January 1, 2019, providers may begin using the universal CMS-1500 billing form.

Like any transition, the switch to the CMS-1500 has its challenges. One portion of the form, in particular, has raised concerns among New York providers: Field 19 for Additional Claim Information.

Here, we explain exactly how to complete this section.

As we explained in our last installment, New York’s Workers’ Compensation Board (WCB) will require providers to fill out the CMS-1500 in accordance with the board’s Field Table Matrix, available on the CMS-1500 Initiative webpage. For accurate reimbursement, it will be crucial to follow the Matrix guidelines.

Pictured below are the instructions from the Field Table Matrix for completing Field 19:

CMS 1500 Item#

CMS 1500 (02-12) Item Description

Workers Compensation Code (Required/ Situational/ Optional / Not Applicable)

NYS Workers' Compensation Requirements

Character Length

Comments

19

ADDITIONAL CLAIM INFORMATION (Designated by NUCC)

R

Enter rendering provider information and/or referring, ordering or supervising provider (see item 17). Enter additional identifier (REF) followed by X5 qualifier and WCB Auth# (no spaces). The next data sequence should be separated by 3 spaces followed by the G2 qualifier and the WCB rating code. The next data sequence should be separated by 3 spaces followed by the claim information NTE and the ADD qualifier followed by the name of the rendering provider.

71

Example: REFX5123456-7B[space][space][space]G2COS[space][space][space]NTEADDName of rendering provider,

where "123456-7B" is the WCB Auth# and "COS" is the WCB rating code of the rendering or the ordering, supervising or referring provider. Only the name of the rendering provider is entered after the NTEADD qualifier sequence.

The information required in Field 19 is unique to New York State workers’ comp and somewhat complicated. Refer to our step-by-step guide below to ensure compliance.

For each step, we’ve bolded the specific portion of the Field Table Matrix instructions the step is referring to.

Step 1:  REFX5

NYS Workers’ Comp Requirement

Enter rendering provider information and/or referring, ordering or supervising provider (see item 17).  Enter additional identifier (REF) followed by X5 qualifier and WCB Auth# (no spaces).”

Comment Example

REFX5123456-7B[space][space][space]G2COS[space][space][space]NTEADDName of rendering provider

REFX5 always populates this field. The qualifier X5 indicates a “State industrial accident provider number.”

Step 2:  WCB Auth# (no spaces)

NYS Workers’ Comp Requirement

“Enter rendering provider information and/or referring, ordering or supervising provider (see item 17). Enter additional identifier (REF) followed by X5 qualifier and WCB Auth# (no spaces).”

Comment Example

REFX5123456-7B[space][space][space]G2COS[space][space][space]NTEADDName of rendering provider

The “WCB Auth# “ is the WCB Authorization Number assigned by the New York WCB to all workers’ comp Authorized Providers. The WCB Health Care Provider Search portal lists this WCB Authorization Number for all authorized providers, as shown in the example below:

If Field #17 is blank, enter the rendering provider’s assigned WCB Authorization Number.

If Fields #17, #17a and #17b are not blank, enter the WCB Authorization Number assigned to the referring, ordering, or supervising provider listed in Field #17.

For NY workers’ comp, Fields #17, #17a and #17b are completed when “other provider is associated with the bill” as follows:

  • Referring Provider: There was a medical provider who referred the injured worker for the provided treatment. Use Qualifier ‘DN’ in Field #17.
  • Supervising Provider: There was a physician who supervised a Nurse Practitioner (NP), Physician’s Assistant (PA), Certified Registered Nurse Anesthetist (CRNA) or other non-physician Practitioner. Use Qualifier ‘DK’ in Field #17
  • Ordering Provider: There was a physician who ordered durable medical equipment, clinical lab tests, or imaging services for the injured worker from a separate provider. Use Qualifier ‘DQ’ in Field #17.

Pictured below are the detailed instructions from the Field Table Matrix that describe the proper way to complete CMS-1500 Fields #17, #17a and #17b:

CMS 1500 Item#

CMS 1500 (02-12) Item Description

Workers Compensation Code (Required/ Situational/ Optional / Not Applicable)

NYS Workers' Compensation Requirements

Character Length

Comments

17

NAME OF REFERRING PROVIDER OR OTHER SOURCE [Qualifier]

S

Required when Referring Provider [DN], Ordering Provider [DK] or Supervising Provider [DQ] is associated with the bill. Enter applicable qualifier, [DN,DK,DQ], respectively and provider name.

2

17

NAME OF REFERRING PROVIDER OR OTHER SOURCE [Name]

24

17a

OTHER ID # [Qualifier]

S

Enter '0B' qualifier followed by the State License Number of the provider. Required when other provider is associated with the bill.

2

17a

OTHER ID #

S

Required when other provider is associated with the bill. Enter State License Number.

17

17b

NPI #

S

Enter NPI of provider in Field 17. Required when other provider is associated with the bill.

10

Step 3: [3 Spaces] + G2 Qualifier

NYS Workers’ Comp Requirement

“The next data sequence should be separated by 3 spaces followed by the G2 qualifier and the WCB rating code.”  

Comment Example

REFX5123456-7B[space][space][space]G2COS[space][space][space]NTEADDName of rendering provider

The G2 qualifier is always used. For group health and Medicare, the G2 qualifier indicates a “Provider commercial number.” For NYS workers’ comp, the G2 qualifier indicates the WCB rating code of the provider.

Step 4:  WCB Rating Code

NYS Workers’ Comp Requirement

“The next data sequence should be separated by 3 spaces followed by the G2 qualifier and the WCB rating code.”  

Comment Example

REFX5123456-7B[space][space][space]G2COS[space][space][space]NTEADDName of rendering provider

The WCB assigns the Rating Code based on the Physician Specialty Classification Codes. To properly determine the WCB Rating Code, you will need to know the specialty assigned to the provider whose WCB Auth# is reported in after REFX5 (Step 2).

Step 5: [3 Spaces] + NTEADD + Rendering Provider Name

NYS Workers’ Comp Requirement

“The next data sequence should be separated by 3 spaces followed by the claim information NTE and the ADD qualifier followed by the name of the rendering provider.”

Only the name of the rendering provider is entered after the NTEADD qualifier sequence.”

Comment Example

REFX5123456-7B[space][space][space]G2COS[space][space][space]NTEADDName of rendering provider

This sequence is populated with the name of the rendering provider listed in Field 24J on the CMS 1500.

CMS 1500 Item#

CMS 1500 (02-12) Item Description

Workers Compensation Code (Required/ Situational/ Optional / Not Applicable)

NYS Workers' Compensation Requirements

Character Length

Comments

24J

RENDERING PROVIDER ID. # [Shaded] - line 1

R

Report State License Number.

11

24J

RENDERING PROVIDER ID. # [Unshaded] - line 1

R

NPI# required, if available.

10

As you can see, New York’s journey to more efficient workers’ comp billing won’t be easy or simple. Fortunately, we’re here to help. Feel free to contact DaisyBill with any further questions or concerns your office might have.


Workers’ comp e-billing is coming to New York State. Get ahead of the curve with DaisyBIll’s Billing Software. Schedule a free demonstration today.

SCHEDULE DEMO

intercom_chat_bubble_icon