CMS-1500 field matrix and examples
Field Matrix
As set forth in 12 NYCRR 325-1.25(b), medical providers must submit medical bills in the format prescribed by the Chair. The format for electronic medical bills is below:
- CMS-1500 Field Table Matrix for Electronic Submission (MS Excel) (Updated 03/04/2024)
Additionally, HP-1.0s (Request for Decision on Unpaid Medical Bills) will be denied if the bill sent to the payer does not match the bill in the Board file.
CMS-1500 examples
- Services provided by authorized physician
- Services provided by self-employed, authorized physical therapist (referred by authorized physician).
- Services provided by authorized physical therapist in physician’s office (referred by authorized physician).
- Services provided by authorized physician assistant (under the supervision of an authorized physician).
- Services provided by authorized nurse practitioner
- DME product ordered by authorized physician
- Services provided by psychologist (referred by authorized physician)
- Services provided by radiologist (referred by authorized physician)
- Surgery bill with surgeon and assistant procedure codes
- Services provided by behavior health provider eligible for enhanced reimbursement (modifier 1B, 20% reimbursement increase)
- Services provided by physician assistant supervised by designated provider eligible for enhanced reimbursement (modifier 1D, 20% reimbursement increase)
Medical billing forms crosswalk
- C-4.0 to CMS-1500
- C-4.2 to CMS-1500
- C-4AMR to CMS-1500
- C-5 to CMS-1500
- EC-4NARR to CMS-1500
- PS-4 to CMS-1500
- PT-4/OT-4 to CMS-1500
Medical narrative requirements
All CMS-1500 submissions require a medical narrative and/or attachment.
The Board has developed a medical narrative report template that can be used to create the medical narrative report that accompanies provider submissions of the Form CMS-1500.
The template includes at the top of the page the three elements to include with most narratives: the patient’s work status, causal relationship of the injury to the patient's work activities, and temporary impairment percentage. A medical narrative report may be found legally defective if these elements are missing.
| Provider Type | Causal Relationship | Temporary Impairment Percentage | Work Status |
|---|---|---|---|
| Acupuncturists | NO* | NO | YES |
| Chiropractors | YES | YES | YES |
| Nurse Practitioners | YES | YES | YES |
| Occupational Therapists | NO* | NO | YES |
| Physical Therapists | NO* | NO | YES |
| Physicians | YES | YES | YES |
| Physician Assistants | NO* | YES** | YES |
| Podiatrists | YES | YES | YES |
| Psychologists | YES | YES | YES |
| Social Workers | YES | YES | YES |
* A record, report or opinion of a physical therapist, occupational therapist, acupuncturist or physician assistant shall not be considered as evidence of the causal relationship of any condition to a work-related accident or occupational disease. Nor may a record, report or opinion of a physician assistant be considered evidence of the presence of a permanent or initial disability or the degree thereof.
** PA services may only be provided under the direct supervision of a physician.
Providers must attach a narrative report with examination findings to the template. The additional narrative should include the history of the injury/illness, any objective findings based on the clinical evaluation, plan of care and your diagnosis(es)/assessment of the patient. In lieu of using the template, the provider’s own medical narrative report is acceptable, if it includes work status, causal relationship and temporary impairment percentage. Examples of narrative reports are shown below.
- Initial Narrative Report
- Subsequent Narrative Report
- Psychology Narrative Report
- Subsequent Psychology Narrative Report
- PT/OT Narrative Report
- Ophthalmology Narrative Report
Attachment requirements
| Type of CMS-1500 Medical Bill | Required Attachment |
|---|---|
| DME | A copy of the physician's prescription (order) for the item(s) and proof of certification of enrollment in the NYS Medicaid program including the Medicaid Management Information System (MMIS) number of the DME supplier. |
| Pharmacy-Drugs | Bill or invoice for the medication(s) dispensed and a copy of the physician's prescription (order) for the medication(s) |
| Radiology | Bill or invoice for service and copy of radiologic report |
| Laboratory | Bill or invoice for services and lab report (with the exception of UDS lab results, which by regulation can't be released to the Board, payer or employer) |
| Audiology | Documentation of audiologic test battery results. (based on Record of Percentage Hearing Loss (Form C-72.1)) |
| Dental | Detailed SOAP note reflecting history, exam, assessment and plan of care consistent with accepted dental documentation standards. |
| Optometry | Detailed SOAP note reflecting history, exam, assessment and plan of care consistent with accepted optometry documentation standards. |
| Anesthesia | Anesthesia record indicating the exact time the anesthesia services were started, ended, all of the anesthesia team members who participated in the care, surgeon, procedure, patient vital signs, etc. |
CMS-1500 electronic forms submissions
Providers and electronic submission partners will be required to follow specific technical processes and XML submission formats. Review the CMS-1500 Electronic Forms Submission section of this website to obtain the detailed submission requirements. The Board followed the National Uniform Claim Committee's (NUCC) July 2018 Instruction Manual for the CMS-1500 form.