Get Icd Diagnosis Code Requirements Part I - Cms.gov

This guide provides you with detailed, step-by-step instructions for completing the ICD Diagnosis Code Requirements Part I form available on CMS.gov. Whether you are familiar with the process or new to it, this guide aims to assist you in accurately filling out the form online.

Follow the steps to successfully complete the form online.

1. Click the ‘Get Form’ button to obtain the form and open it in your browser.
2. Enter the claimant name. Provide the last name, first name, and middle initial of the claimant as it appears on their compensability approval letter or social security card.
3. Fill in the claimant address. Ensure you include the complete mailing address, including street number, post office box, city, state, and zip code.
4. Input the claimant's social security number. This is crucial for identification.
5. Record the date of injury or date of last exposure. This should reflect the pertinent date relevant to the claimant's situation.
6. Enter the diagnosis code (ICD-9-CM). Use the appropriate numeric code followed by a description of the primary diagnosis. Ensure to only use accepted codes as specified.
7. List the authorization number if applicable. This applies to services that required prior authorization.
8. Indicate if the services were rendered on an emergency basis by checking the designated block.
9. Provide the provider account number. This is necessary for internal tracking.
10. Enter the provider's FEIN. Include any additional codes if prompted.
11. Check the block if payment is to be made to the claimant.
12. If necessary, list the payee name and address.
13. Input the date of service. Use the MM/DD/YY format.
14. Enter the specific procedure code relevant to the billed services.
15. If required, provide the modifier code.
16. Give a description of the procedure. Brief descriptions or abbreviations are acceptable.
17. List the total charge for each procedure code entered.
18. Specify the number of units for the service provided.
19. Select the place of service code from the provided list.
20. If applicable, enter the dental tooth number for dental claims.
21. Ensure the invoice is signed by the provider or a legally responsible designee.
22. Document the date when the invoice is signed.
23. Total the charges for all services billed.
24. Include the amount that has already been paid.
25. Calculate and enter the balance due.
26. Add the provider name and address corresponding to the provider number.
27. Use the remarks section to explain any unusual services or fees briefly.
28. List a contact phone number for the provider.
29. Document the National Provider Identifier (NPI) number.
30. Finally, review all entries for accuracy, save the changes, and then proceed to download, print, or share the form as required.

Complete your documents online today to ensure accuracy and compliance.