11 NCAC 12 .1503             REQUIREMENTS FOR USE OF CMS FORM 1500

(a)  The CMS Form 1500 shall be the standard claim form for all manual individual health care provider billing, and the CMS Form 1500 shall be accepted by all payors conducting business in this State.

(b)  Payors may require individual health care providers to use only the following coding system for the filing of claims for health care services:

(1)           ICD‑9‑CM Codes to report all diagnoses, reasons for encounters, and procedures based upon code level changes made effective October 1 of each year or other effective date designated by the CMS.

(2)           HCPCS Level I and Level II Codes based upon code level changes made effective October 1 of each year or other effective date designated by the CMS.

(3)           CPT‑4 Codes based upon code level changes made effective January 1 of each year or other effective date designated by the CMS.

(c)  When there is no applicable HCPCS Level I or Level II Code or modifier, the payor shall establish its own code or modifier. A complete list of all codes and modifiers established by payors shall be published by and available upon request from payors.

(d)  Type of service codes may not be used.

(e)  Place of service codes and descriptions shall be recognized by all payors processing claims for services rendered in North Carolina.

(f)  CMS physician and specialty codes shall be recognized by payors processing claims for services rendered in North Carolina.

History Note:        Authority G.S. 58‑2‑40; 58‑3‑171;

Eff. October 1, 1994;

Amended Eff. February 1, 1995;

Readopted Eff. May 1, 2020.