Knowledge Base  -  Article 0056  
Print Image Format (Form CMS-1500 version 02-12)


The "Print Image" mode in UniCharts electronic medical record software generates files that are text equivalent of CMS-1500 forms. Note that generated output is not for printing CMS-1500 on paper nor is it for direct submission to insurance companies as the data would need to be completed and scrubbed before submitting. Instead, the generated output facilitates transfer of billing data to a billing company or a clearing house for further processing in an easy and automated way. You just need to generate a daily batch of CMS-1500 text data at the end of each day and then send/upload the generated file to the billing company/clearing house's website for further processing.


Export File Specifications:   These specs are according to the Grid Template of CMS-1500 (02-12) defined by the National Uniform Claim Committee (NUCC)

 LINE  BOX  DESCRIPTION  TYPE  MAX COLUMNS
 4    [SEND TO] Primary Insurance Name  A/N  35  47-82 
 5    [SEND TO] Primary Insurance Street Address  A/N  35  47-82 
 6    [SEND TO] Primary Insurance City, State and ZIP Code  A/N  35  47-82 
 10  1a  Insured's ID Number  A/N  29  53-82 
 12  2  Patient's Name (Last, First, MI)  A  28  04-31 
 12  3  Patient's Birth Date (Month)  N  2  34-35 
 12  3  Patient's Birth Date (Day)  N  2  37-38 
 12  3  Patient's Birth (Year)  N  4  40-43 
 12  3  Sex-Male  M  1  45 
 12  3  Sex-Female  M  1  50 
 12  4  Insured Name (Last, First, MI)  A  29  53-82 
 14  5  Patient's Address  A/N  28  04-31 
 14  6  Patient Relationship to Insured (Self)  M  1  36 
 14  6  Patient Relationship to Insured (Spouse)  M  1  41 
 14  6  Patient Relationship to Insured (Child)  M  1  45 
 14  6  Patient Relationship to Insured (Other)  M  1  50 
 16  5  Patient's City  A  24  04-27 
 16  5  Patient's State  A  3  29-31 
 18  5  Patient's ZIP Code  N  12  04-15 
 18  5  Patient's Area Code  N  3  18-20 
 18  5  Patient's Phone Number  N  10  22-31 
 18  7  Insured's Area Code  N  3  68-70 
 18  7  Insured's Phone Number  N  10  72-82 
 20  9  Other Insured's Name (Last, First, MI)  A  28  04-31 
 20  11  Insured's Policy, Group or FECA Number  A/N  29  53-82 
 22  9a  Other Insured's Policy or Group Number  A/N  28  04-31 
 22  11a  Insured's Date of Birth (Month)  N  2  56-57 
 22  11a  Insured's Date of Birth (Day)  N  2  59-60 
 22  11a  Insured's Date of Birth (Year)  N  4  62-65 
 22  11a  Sex-Male  M  1  71 
 22  11a  Sex-Female  M  1  78 
 26  11c  Insured's Insurance Plan or PayerID  A/N  29  53-82 
 28  9d  Other Insured's Insurance Plan Name or PayerID  A/N  28  04-31 
 28  11d  Another Benefit Health Plan (Yes)  M  1  55 
 28  11d  Another Benefit Health Plan (No)  M  1  60 
 32  12  Patient's Signature [SIGNATURE ON FILE or BLANK]  A  17  09-25 
 32  12  Patient's Signature Date (Month)  N  2  39-40 
 32  12  Patient's Signature Date (Day)  N  2  42-43 
 32  12  Patient's Signature Date (Year)  N  2  45-48 
 32  13  Insured's Signature [SIGNATURE ON FILE or BLANK]  A  17  59-75 
 36  17  Referring Physician Qualifier ("DN" or BLANK]  A  2  05-06 
 36  17  Name of Referring Physician or Other Source  A  23  07-30 
 36  17b  NPI Number of Referring Physician  N  17  35-51 
 39  21  ICD Code Version Indicator  N  1  45 
 40  21.A  Diagnosis or Nature of Illness or Injury (Code)  A/N  7  06-12 
 40  21.B  Diagnosis or Nature of Illness or Injury (Code)  A/N  7  19-25 
 40  21.C  Diagnosis or Nature of Illness or Injury (Code)  A/N  7  32-38 
 40  21.D  Diagnosis or Nature of Illness or Injury (Code)  A/N  7  45-51 
 41  21.E  Diagnosis or Nature of Illness or Injury (Code)  A/N  7  06-12 
 41  21.F  Diagnosis or Nature of Illness or Injury (Code)  A/N  7  19-25 
 41  21.G  Diagnosis or Nature of Illness or Injury (Code)  A/N  7  32-38 
 41  21.H  Diagnosis or Nature of Illness or Injury (Code)  A/N  7  45-51 
 42  21.I  Diagnosis or Nature of Illness or Injury (Code)  A/N  7  06-12 
 42  21.J  Diagnosis or Nature of Illness or Injury (Code)  A/N  7  19-25 
 42  21.K  Diagnosis or Nature of Illness or Injury (Code)  A/N  7  32-38 
 42  21.L  Diagnosis or Nature of Illness or Injury (Code)  A/N  7  45-51 
 45  24  Line Detail Narrative  A/N  63  04-66 
 46  24.1a  Date(s) of Service - (From Month)  N  2  04-05 
 46  24.1a  Date(s) of Service - (From Day)  N  2  07-08 
 46  24.1a  Date(s) of Service - (From Year)  N  2  10-11 
 46  24.1a  Date(s) of Service - (To Month)  N  2  13-14 
 46  24.1a  Date(s) of Service - (To Day)  N  2  16-17 
 46  24.1a  Date(s) of Service - (To Year)  N  2  19-20 
 46  24.1b  Place of Service  A/N  2  22-23 
 46  24.1d  Procedures, Services or Supplies (CPT/HCPCS)  A/N  6  28-33 
 46  24.1d  Procedures, Services or Supplies (Modifier 1)  A/N  2  36-37 
 46  24.1d  Procedures, Services or Supplies (Modifier 2)  A/N  2  39-40 
 46  24.1e  Diagnosis Pointer  N  4  48-51 
 46  24.1f  $ Charges  N  8  53-60 
 46  24.1g  Days or Units  N  3  62-64 
 46  24.1j  NPI Number of Rendering Provider  N  11  71-82 
 47  24  Line Detail Narrative  A/N  63  04-66 
 48  24.2a  Date(s) of Service - (From Month)  N  2  04-05 
 48  24.2a  Date(s) of Service - (From Day)  N  2  07-08 
 48  24.2a  Date(s) of Service - (From Year)  N  2  10-11 
 48  24.2a  Date(s) of Service - (To Month)  N  2  13-14 
 48  24.2a  Date(s) of Service - (To Day)  N  2  16-17 
 48  24.2a  Date(s) of Service - (To Year)  N  2  19-20 
 48  24.2b  Place of Service  A/N  2  22-23 
 48  24.2d  Procedures, Services or Supplies (CPT/HCPCS)  A/N  6  28-33 
 48  24.2d  Procedures, Services or Supplies (Modifier 1)  A/N  2  36-37 
 48  24.2d  Procedures, Services or Supplies (Modifier 2)  A/N  2  39-40 
 48  24.2e  Diagnosis Pointer  N  4  48-51 
 48  24.2f  $ Charges  N  8  53-60 
 48  24.2g  Days or Units  N  3  62-64 
 48  24.2j  NPI Number of Rendering Provider  N  11  71-82 
 49  24  Line Detail Narrative  A/N  63  04-66 
 50  24.3a  Date(s) of Service - (From Month)  N  2  04-05 
 50  24.3a  Date(s) of Service - (From Day)  N  2  07-08 
 50  24.3a  Date(s) of Service - (From Year)  N  2  10-11 
 50  24.3a  Date(s) of Service - (To Month)  N  2  13-14 
 50  24.3a  Date(s) of Service - (To Day)  N  2  16-17 
 50  24.3a  Date(s) of Service - (To Year)  N  2  19-20 
 50  24.3b  Place of Service  A/N  2  22-23 
 50  24.3d  Procedures, Services or Supplies (CPT/HCPCS)  A/N  6  28-33 
 50  24.3d  Procedures, Services or Supplies (Modifier 1)  A/N  2  36-37 
 50  24.3d  Procedures, Services or Supplies (Modifier 2)  A/N  2  39-40 
 50  24.3e  Diagnosis Pointer  N  4  48-51 
 50  24.3f  $ Charges  N  8  53-60 
 50  24.3g  Days or Units  N  3  62-64 
 50  24.3j  NPI Number of Rendering Provider  N  11  71-82 
 51  24  Line Detail Narrative  A/N  63  04-66 
 52  24.4a  Date(s) of Service - (From Month)  N  2  04-05 
 52  24.4a  Date(s) of Service - (From Day)  N  2  07-08 
 52  24.4a  Date(s) of Service - (From Year)  N  2  10-11 
 52  24.4a  Date(s) of Service - (To Month)  N  2  13-14 
 52  24.4a  Date(s) of Service - (To Day)  N  2  16-17 
 52  24.4a  Date(s) of Service - (To Year)  N  2  19-20 
 52  24.4b  Place of Service  A/N  2  22-23 
 52  24.4d  Procedures, Services or Supplies (CPT/HCPCS)  A/N  6  28-33 
 52  24.4d  Procedures, Services or Supplies (Modifier 1)  A/N  2  36-37 
 52  24.4d  Procedures, Services or Supplies (Modifier 2)  A/N  2  39-40 
 52  24.4e  Diagnosis Pointer  N  4  48-51 
 52  24.4f  $ Charges  N  8  53-60 
 52  24.4g  Days or Units  N  3  62-64 
 52  24.4j  NPI Number of Rendering Provider  N  11  71-82 
 53  24  Line Detail Narrative  A/N  63  04-66 
 54  24.5a  Date(s) of Service - (From Month)  N  2  04-05 
 54  24.5a  Date(s) of Service - (From Day)  N  2  07-08 
 54  24.5a  Date(s) of Service - (From Year)  N  2  10-11 
 54  24.5a  Date(s) of Service - (To Month)  N  2  13-14 
 54  24.5a  Date(s) of Service - (To Day)  N  2  16-17 
 54  24.5a  Date(s) of Service - (To Year)  N  2  19-20 
 54  24.5b  Place of Service  A/N  2  22-23 
 54  24.5d  Procedures, Services or Supplies (CPT/HCPCS)  A/N  6  28-33 
 54  24.5d  Procedures, Services or Supplies (Modifier 1)  A/N  2  36-37 
 54  24.5d  Procedures, Services or Supplies (Modifier 2)  A/N  2  39-40 
 54  24.5e  Diagnosis Pointer  N  4  48-51 
 54  24.5f  $ Charges  N  8  53-60 
 54  24.5g  Days or Units  N  3  62-64 
 54  24.5j  NPI Number of Rendering Provider  N  11  71-82 
 55  24  Line Detail Narrative  A/N  63  04-66 
 56  24.6a  Date(s) of Service - (From Month)  N  2  04-05 
 56  24.6a  Date(s) of Service - (From Day)  N  2  07-08 
 56  24.6a  Date(s) of Service - (From Year)  N  2  10-11 
 56  24.6a  Date(s) of Service - (To Month)  N  2  13-14 
 56  24.6a  Date(s) of Service - (To Day)  N  2  16-17 
 56  24.6a  Date(s) of Service - (To Year)  N  2  19-20 
 56  24.6b  Place of Service  A/N  2  22-23 
 56  24.6d  Procedures, Services or Supplies (CPT/HCPCS)  A/N  6  28-33 
 56  24.6d  Procedures, Services or Supplies (Modifier 1)  A/N  2  36-37 
 56  24.6d  Procedures, Services or Supplies (Modifier 2)  A/N  2  39-40 
 56  24.6e  Diagnosis Pointer  N  4  48-51 
 56  24.6f  $ Charges  N  8  53-60 
 56  24.6g  Days or Units  N  3  62-64 
 56  24.6j  NPI Number of Rendering Provider  N  11  71-82 
 58  25  Federal Tax ID Number  N  15  04-19 
 58  25  Federal Tax ID Number (SSN)  M  1  20 
 58  25  Federal Tax ID Number (EIN)  M  1  22 
 58  26  Patient's Account Number [Charge Ticket number within EMR]  A/N  14  26-39 
 58  27  Accept Assignment (Yes)  M  1  41 
 58  27  Accept Assignment (No)  M  1  46 
 58  28  Total Charge  N  9  54-63 
 58  30  Amount Paid  N  8  65-72 
 59  33  Billing Provider Phone Number Area Code  N  3  69-71 
 59  33  Billing Provider Phone Number  N  9  73-82 
 60  32  Name of Facility Where Services Rendered  A/N  26  26-51 
 60  33  Physician/Supplier Billing Name  A/N  29  53-82 
 61  32  Address of Facility Where Services Rendered  A/N  26  26-51 
 61  33  Physician/Supplier Address  A/N  29  53-82 
 62  31  Physician/Supplier Signature [SIGNATURE ON FILE or BLANK]  A  17  08-24 
 62  32  City, State and ZIP Code of Facility  A/N  26  26-51 
 62  33  City, State and ZIP Code of Billing Provider  A/N  29  53-82 
 63  32a  Facility NPI Number  N  10  27-36 
 63  33a  Billing Provider NPI Number  N  10  54-63 
Notes:
  • Type: M = mark (X), A = alpha, N = numeric, A/N = alphanumeric
  • Total number of lines per claim is 67. This means that if there is only one cliam in the file, it would be comprised of 67 lines. Similarly, if there are say three claims in a file, it would contain 3 x 67 = 201 lines in it.
  • The boxes not mentioned are not populated.

Enabling PIF mode:

By default, the EMR generates billing information in human-readable superbills. However, you may change the output mode to machine-readable "Print Image" format (PIF) on the following screen in the customization area:



Fields Mapping and Usage:

The PIF configuration options in the EMR are self-explanatory, except the Use Carrier instead of Plan in box 11c and 9d mapping option highlighted below.



In the Use Carrier instead of Plan in box 11c and 9d mapping option, the "Carrier" and "Plan" refers to the two fields present in insurance blocks on the General form of every chart within the EMR whereas the 11c and 9d are the INSURANCE PLAN NAME OR PROGRAM NAME boxes on the CMS-1500. By default, the system uses "Plan" field to populate these two boxes respectively. However, some practices do not use the "Plan" field and just enter plan details directly on the "Carrier" field, as shown below. If this is the case with you, just tick the Use Carrier instead of Plan in box 11c and 9d checkbox to switch the fields. However, we recommend keeping it default because "Carrier" name and "Plan" name are usually different things and that the value of "Carrier" field would be separately needed to populate SEND TO name at the top of the CMS-1500 form.



Note that the Carrier names and their respective Plans can be added to favorite list in the Insurance Companies section under Ancillaries/Menus tab in the customization area. It is a one-time procedure that is surely worth the effort.



Once you add the insurance companies to favorite list, they would become available as a dropdown menu right within the insurance blocks on the General form. The favorite lists facilitate fast and easy data entry and also prevent typing errors.



Apart from the above settings, please be aware that the system looks for signing physician's NPI number and Tax ID (SSN or EIN) in the list of three possible IDs associated with a user. If it finds an NPI number, it includes it as the NPI number for both rendering and billing providers on boxes 24j and 33a. Similarly, if it finds the physician's SSN or EIN number, it includes it on the box 25 of CMS1500 form. Therefore make sure you have the NPI number and appropriate Tax ID listed on the user's profile.



The same also applies to clinic/facility NPI number. That is, the system looks for clinic NPI number in the list of two possible IDs associated with a clinic. If found, it includes the value in box 32a of the CMS1500 form. Also note that by default, the system uses rendering physician's Tax ID for box 25. However, if you want the clinic's EIN number to be used as Tax ID in box 25, you may tick Use clinic's Tax ID instead of rendering provider's Tax ID in box 25 option on the configuration choices shown in the first screenshot above. In this case, you must also add the clinic's EIN number along with its NPI number so that it could be read, as shown in the below screenshot.


What if the rendering and billing providers are not the same person, such as in case of a group practice? In that case you may tick the option Use Name/NPI of ___ instead of rendering provider's Name/NPI in box 33 on the PIF customization screen and then select the user from dropdown that you want to see as billing provider. Also note that if billing provider is a legal entity such as LLC, a workaround would be to first add a dummy user to the system with the name of that LLC and then select that user from the dropdown in question.


As for the name and NPI number of referring provider for box 17 and 17b, it is taken from the Referred by field on the encounter form, as shown below.



Please note that just like insurance companies you can build a favorite list of physicians in the Physicians section under Ancillaries/Menus tab in the customization area. This would allow fast data entry and prevent typing errors. Also note that the Referred by field on the encounter form is associated with the type of encounter. It becomes editable automatically when one of the "Office Consultation" or "Confirmatory Consult" types are selected from the encounter type dropdown list. If you prefer this field to show enabled for all encounter types, you can easily change the setting in the customization area as shown below.



Finally, the "Place of Service" code for boxes 24b is taken from the encounter Type field on the encounter form, as shown below.



You can also template the "Place of Service" codes in the Visit Types favorite list under Ancillaries/Menus tab in the customization area so that it automatically gets inserted on the encounter form when the corresponding visit type is selected from the dropdown menu. Again, this would allow fast data entry and prevent typing errors.





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