DrChrono will pull data from a patient’s chart and your office settings to populate the CMS HCFA-1500 form. The following is a guide to identify which fields the data will be pulled from so updates can be made if necessary.
Essential Background Information
For an individual appointment, you can generate a CMS HCFA-1500 form by clicking on the appointment and going to the Billing tab at the top. In the top right corner of this window, we can click Other Forms and select the first option, HCFA-1500 if you are printing on regular plain, white paper. Select the HCFA-1500 (text) option if you are using the red, preprinted HCFA paper.
Figure 0
The CMS 1500 will update dynamically based on the Payment Profile field.
Figure 1
This will direct the system to pull data from the corresponding Insurance item under the Insurances tab under the Demographics section in the patient chart:
Figure 2
(Please note that alongside Insurances there are various blue “tabs,” one of which is labeled Demographics. I will refer to this item as the Demographics tab, which exists within the Demographics section.)
HCFA 1500 items:
Carrier Block - Under Account > Account Settings > Billing > HCFA/CMS-1500, the first checkbox says Payer Address. If this box is checked, the Carrier Block will pull address data from the insurance information in the patient chart.
Box 1 - The checkbox will update based on which payer is selected in “Insurance Company” in the patient chart. Box 1a will pull data from the “Insurance ID Number.”
Figure 3
Box 2 - Data pulls from First Name and Last Name fields, found under Important tab in the patient chart.
Box 3 - Data pulls from Patient Date of birth and Patient Sex fields, found under the Demographics tab in the patient chart.
Box 4 - In Figure 3, there is a checkbox called Subscriber is the Patient. If this is selected, nothing will appear in Box 4. If it is de-selected, Subscriber fields will appear below Primary Insurance Notes on the page, allowing you to enter subscriber information when the patient is covered under someone else's insurance policy.
Figure 4
Box 5 - Address information is found in the Demographics tab. Relevant fields are Street Address, Zip Code, City, State
Phone number pulls from the Important tab. (The system will prioritize the Cell Phone field, then the Home Phone field, then the Office Phone field.)
Box 6 - Pulls from Patient relationship to the Subscriber in the Insurances tab (Figure 4)
Box 7 - Subscriber address information, as shown in Figure 4, comes from the Insurances tab. Relevant fields are Subscriber Address, Subscriber Zip Code, Subscriber City, Subscriber State
Box 8 - This box is reserved for NUCC use
Box 9 - If there is information under Secondary Insurance for the patient, this box will display the Subscriber’s name.
9a - displays whatever information is entered under Insurance Group # in the Secondary Insurance under the Insurances tab.
9b - this box is reserved for NUCC use
9c - this box is reserved for NUCC use
9d - Insurance Plan Name or Program Name - displays whatever information is entered under Insurance Company in the Secondary Insurance under the Insurance tab.
Box 10 - Items A, B, C in this Box will update automatically based on the Payment Profile of the appointment (figure 1) but can be manually edited using the Yes/No fields dedicated for this item:
Figure 5 - Click on the Appointment, then go to the Billing tab
Auto Accident - Go to the Insurances section (Figure 3), click Auto Accident, and look for Auto accident state of occurrence. The state of occurrence is required when billing for services related to an accident, auto, or work comp.
10d - This box is reserved for Claim Codes. Valid NUCC Claim Codes can be found here.
Box 11 - The information here pulls from the Insurance group number field in the Primary Insurance under the Insurances tab.
11a - Pulls from Patient Date of Birth in Demographics if the patient is the subscriber. If not, Subscriber DOB is used
11b - Other claim id- for use with Property & Casualty Claims - list P & C claim number with qualifier Y4 (Agency Claim Number/Property Casualty Claim Number)
11c - Depending on the relevant insurance information for the appointment, this box will display what is in Insurance Company for Primary or Secondary Insurance, Auto Accident Company for Auto Accident, or Insurance Provider for Worker’s Comp
11d - This box will be marked as Yes if the Primary Insurance is being used and there is data under Secondary Insurance
Box 12 - Under the Demographics tab, the second to last item is Signature On File. If Consent on File is selected in this field, the box will display Signature on File. The date will auto-populate when the HFCA 1500 form is generated.
Please note that this field will automatically update to Consent On File if the patient has signed the HIPAA Data Use Agreement when checking in on the Check In-app or OnPatient.com
Box 13 - For Auto Accident, if you de-select the checkbox Claim representative is the insurer in the Insurances tab and enter data for the Claim Representative in the subsequent fields, this Box will display Signature on File.
Box 14 - This box pulls from the Onset Date fields shown in Figure 5. (431- Onset of Current Symptoms or Illness; 484- Last Menstrual Period)
(431- Onset of Symptoms can also be edited in the Insurances tab, under Primary Insurance, below the HCFA Options header)
Box 15 - This box pulls from the Other Date fields shown in Figure 5.
(444- First Visit or Consultation can also be edited in the Insurances tab, under Primary Insurance, below the HCFA Options header)
Box 16 - Currently DrChrono does not support filling out Box 16, as it is not required for claims.
Box 17 - This box pulls from information found in the Demographics tab, under Referring Doctor. The fields Referring Dr. First Name and Referring Dr. Last Name will be used, and the identifier DN will be applied. If no information is available under Referring Doctor, information found under Ordering Doctor will be used instead, and the identifier DK will be applied.
17a - This item pulls from the fields Referring Dr. Qualifier and Referring Dr. Number under Referring Doctor. The identifiers for this item are as follows, and come from the selection in Referring Dr. Qualifier:
0B State License Number
1G Provider UPIN Number
G2 Provider Commercial Number
17b - This item pulls from Referring Dr. NPI Number, or if no Referring Dr. data is present, Ordering Dr. NPI Number.
Supervising provider information can be shown by marking off Display the claim's supervising provider in box 17. (Figure 6) This option can be found in Account Settings > Billing. Selecting this option will cause box 17 to pull data from the supervising provider’s information, once a supervisor is selected in the Appointment details. Relevant information for that supervising provider is First Name, Last Name, and Rendering Provider NPI - this information will be pulled from that provider’s DrChrono Account Settings.
Figure 6 - Go to Account > Account Settings > Medical Billing
***Please note that Box 17 will not update if the demographics of the patient chart are updated AFTER the appointment is scheduled.***
If you need to update this box after the appointment is scheduled, the information will need to be added to the Billing Details of an appointment. Access this screen by clicking Billing Details next to the Other Forms button we use to generate HCFA 1500s (see Figure 0) For the items in Box 17, click on the pencil icon next to Providers (Figure 7, Red Box)
Figure 7 - Billing Details
Box 18 - Data should only be entered in this box if the patient's hospitalization is related to the current services. (See Box 24b / Figure 9 for information on how to edit Place of Service.) If the appointment is scheduled in an office using Place of Service 21 (inpatient hospital) or 22 (outpatient hospital), “Hospitalization Info” will appear in Billing Details (Figure 7, Orange Box)
Box 19 - This box pulls from Billing Details, on the EDI Billing Note This text box is fully customizable and allows for manual entry of additional information that needs to be transmitted to the payer. (Figure 7, Yellow Box)
Box 20 - Box 20 will be updated to Yes if the outside lab information is entered into the Purchased Serv Provider field (Figure 7, Green Box), which can be edited by clicking the corresponding pencil icon.
The last item in the box which comes up is Charge Amount, where a charge from using outside labs can be added.
Box 21 - Any ICD-10 codes applied to the appointment will display here in the order they are entered. A "0”, to represent ICD-10 is being used will automatically populate. Up to 12 ICD10 codes can be entered.
Box 22 - This box pulls from the Claim Type and ID of original claim fields found in Billing Details. (Figure 7, Light Blue Box). If Re-submission is selected, bill frequency code 7 will be used, whereas if Void claim is selected, code 8 will be used. The billing frequency codes will be added automatically, based on whether re-submission/void claim is selected.
Box 23 - In Billing Details, the field Payer pre-auth # (Figure 7, Blue Box) can be edited to fill in this box. Other numbers such as a referral number, mammography certification number, or CLIA number can also be entered to print in this box.
(This item will also be shown under Appointment > Billing as Pre Authorization Approval #. Note that Box 18 and 19 can also be edited here.)
Box 24 - This Box will display procedure codes associated with the appointment
24a - The dates of service for each individual code. By default, the From and To date will display the date of the appointment. If further specification is needed for each code, you can go to Billing Details and modify the Service Date field.
Figure 8 - Billing Details, Coding section
24b - Place of Service will pull from the Office Details of the office in which the appointment was scheduled. This item can be specified on a per-office basis by going to Account > Offices, and clicking Edit on the office you wish to specify.
On the resulting Edit Office page, click on the blue Billing tab (See Figure 9). The second item on this screen is Facility Code. By default, it will be 11 - Office, but it can be changed to anything you need.
Figure 9 - Go to Account > Offices > Edit > Billing tab
Box 24c - In the appointment’s Billing Details, the item immediately below the ID of Original Claim is labeled Emergency Service (Figure 7, Purple Box). If Yes is selected, a Y will display in Box 24c.
Shaded Areas of Box 24 - NDC codes attached to the appointment and corresponding data will display in the shaded area above each line item.
Box 24d - This box will display the code identifier for any CPT or HCPCS codes attached to the appointment, and corresponding modifiers for these codes.
Box 24e - This box will display any Diagnosis Pointers entered for any codes in lowercase letters. The letters correspond to diagnosis codes entered in box 21.
Box 24f - Any charges entered in the Price box will display in Box 24f. Base prices will be multiplied by values entered in the “Quantity/Minutes” field for each code.
Box 24g - This box will display the value entered in Quantity/Minutes for each code. This field is most commonly used for multiple visits, units of supplies, anesthesia units or minutes, or oxygen volume.
Box 24h - This box pulls from the EPSDT Services (Early & Periodic Screening, Diagnosis, and Treatment) field in the patient chart, in the Demographics tab. This field is applied on a per-patient basis.
Box 24i - This box will remain static with the NPI identifier.
Box 24j - This box will display the NPI of whichever provider is listed as the rendering provider of this appointment. The provider can specify their NPI number by going to Account > Account Settings > Billing (Figure 6), and entering data into the Rendering Provider NPI field.
Box 25 - By default, this box will display data that is entered in the Practice Tax ID field found in Account > Account Settings > Billing. However, as shown in Figure 6, there is a checkbox that reads Mark the SSN checkbox instead of the EIN checkbox in Box 25. If there is an SSN on file for your DrChrono account, you will see that displayed in Box 25 when that checkbox is checked.
- If you check off the checkbox and Box 25 does not update accordingly, this means that we at DrChrono do not have your SSN on file. To resolve this, please contact support by submitting a ticket at drchrono.com/help
Box 26 - The Patient Account number in this box is automatically generated from the DrChrono system.
Box 27 - This box can be updated on a per-payer basis by going to Billing > Insurance set up, and deselecting the Accept Assignment box.
Figure 10 - Billing > Insurance Set Up > “Edit” Icon
Please note that in Figure 10, many of the items previously discussed can be overwritten on a per-payer basis.
Box 28 - This box will calculate the sum total of charges in box 24f.
Box 29 - This box will update as patient payments are logged into the system, only if Box 27 is marked as No. Patient payments can be logged in Appointment Details > Billing.
Box 30 - This field is reserved for NUCC use and will not populate data in DrChrono.
Box 31 - This box will pull data from fields under Account Settings > Profile for your DrChrono account. Make sure that the account has the correct First Name and Last Name fields entered here.
- Under Account Settings > Billing (Figure 6) there is a checkbox that allows a user to toggle between writing out the full first name, or only using the first initial.
- The date in Box 31 will display whatever date the HCFA 1500 form was generated.
Box 32 - All of the information entered in this Box can be edited by going to Account > Offices, and clicking the Edit pencil icon for the office in which the appointment was scheduled.
The relevant fields are Office Name, Address, City, State, Zip Code, and Facility NPI Number.
Box 32a - By default, this box will display whatever data is on file for Rendering Provider NPI, found in Account Settings > Billing (Figure 6).
By going to Account > Offices, clicking Edit, and then going to the blue Billing tab (Figure 9). The checkbox Use facility NPI number in box 32a of the CMS 1500 form will allow data from the Facility NPI number field to display in box 32a.
Box 32b - By default, this box will not populate with data. If you need to have the facility information populate this field. See our article here.
Box 33 - By default, this box will populate based on what is entered in the Practice Official Name field, found in Account Settings > Billing (Figure 6). Further down on that page, however, there is a checkbox for Box 33 which would allow you to use the doctor’s name instead.
*** Important note *** - if you are rendering services at a location other than your office (example: outpatient OR, assisted living facility, skilled nursing facility, etc.) please make sure you update the 3rd line titled Billing Provider Office to show what office location you would like correspondence and/or payments to be sent. If this section is blank, the system will automatically use the information in box 32, which is the service location, and correspondence and/or payments could be sent to the service facility instead of your office location.
You can access this by navigating to Account > Offices > Billing Tab in the alternate service location
- The Address and Phone number items will pull from Account > Offices, under the Basic tab on the Edit Office screen. If you click on the Billing tab (Figure 9), you will find a checkbox that states Use alternate pay to address for HCFA. Checking this box allows you to enter alternate data, which will then be displayed in Box 33.
Box 33a - By default this box will pull from the Billing NPI number in Account Settings > Billing (Figure 6), but this item can be overwritten in Account > Offices > Edit > Billing by entering data in the Billing NPI number (Figure 9)
Box 33b - By default, this box will not populate with data, but in the Edit Payer (Billing > Insurance setup) screen (Figure 10), the Group Provider # and Group Provider # Qualifier fields can be used to populate data into this box as required by a payer.
For an in-depth explanation of the content of each box as it exists outside of DrChrono, please use the attached guide as a reference. It is active as of July 2021; updates should be retrieved from NUCC https://www.nucc.org/.