Professional

ApexEDI Professional Print Image Mapping CMS-1500 (60 lines X 80 Columns)

Resources

Sample Print Image File

Print Image Mapping CSV

Field Name Line Column Length Value
Payer Name 1 40 35
Payer ID 1 75 5
Payer Address 2 40 35
Payer Address 2 3 40 35
PICA 5 7 20
Payer City, State Zip 4 40 35 SLC, UT #####-####
Medicare 7 1 1 X
Medicaid 7 8 1 X
Tricare Champus 7 15 1 X
ChampVA 7 24 1 X
Group Health Plan 7 31 1 X
FECA 7 39 1 X
Other 7 45 1 X
Insured's ID 7 50 31
Patient Name 9 1 29 Last, First M
Patient DOB 9 31 10
Patient Sex Female 9 47 1 X
Patient Sex Male 9 42 1 X
Insured Name 9 50 30 Last, First M
Patient Address 11 1 29
Patient City 13 1 29
Patient State 13 27 2
Patient Zip 15 1 13 #####-####
Patient Phone 15 15 15 ### ###-###
Patient Relationship Self 11 33 1 X
Patient Relationship Spouse 11 38 1 X
Patient Relationship Child 11 42 1 X
Patient Relationship Other 11 47 1 X
Insured Address 11 50 30
Insured City 13 50 23
Insured St 13 75 2
Insured Zip 15 50 10 #####-####
Patient Status Single 13 35 1 X
Patient Status Married 13 41 1 X
Patient Status Other 13 47 1 X
Patient Status Employed 15 35 1 X
Patient Status Full-Time Student 15 41 1 X
Patient Status Part-Time Student 15 47 1 X
Insured Phone 15 65 12 ### ###-####
Other Insured Name 17 1 29 Last, First M
Other Insured Policy Number 19 1 29
Other Insured Date Of Birth 21 2 15
Other Insured Sex Female 21 24 1 X
Other Insured Sex Male 21 18 1 X
Other Insured Employer 23 1 29
Other Insured Plan 25 1 29
Patient Condition Employment No 19 41 1 X
Patient Condition Employment Yes 19 35 1 X
Patient Condition Auto No 21 41 1 X
Patient Condition Auto Yes 21 35 1 X
Patient Condition Accident State 21 46 2
Patient Condition Other No 23 41 1 X
Patient Condition Other Yes 23 35 1 X
Reserved For Local Use 25 30 20
Insured Policy Number 17 50 30
Insured DOB 19 53 12
Insured Sex Female 19 75 1 X
Insured Sex Male 19 68 1 X
Insured Employer 21 50 30
Insured Plan 23 50 30
Other Plan No 25 57 1 X
Other Plan Yes 25 52 1 X
Patient Signature Date 28 38 12 ##/##/####
Patient Signature 28 6 28
Insured Signature 28 56 24
Date Of Current Illness 31 2 10 ## ## ##
Date Of Same or Similar Illness 31 37 12 ## ## ##
Unable To Work Date To 31 54 12 ## ## ##
Unable To Work Date From 31 68 12 ## ## ##
Referring Physician Name 33 1 27 Last, First M
Referring Physician ID Qualifier 32 30 2
Referring Physician ID 32 33 22
Referring Physician NPI 33 33 22
Hospitalization Date From 33 54 12 ## ## ##
Hospitalization Date To 33 68 12 ## ## ##
Reserved For Local Use 35 1 50
Lab Charge 35 62 9
Lab Charge No 35 57 1 X
Lab Charge Yes 35 52 1 X
Diagnosis Code 1 37 3 10
Diagnosis Code 2 39 3 10
Diagnosis Code 3 37 30 10
Diagnosis Code 4 39 30 10
Medicaid Resubmit Code 37 50 12
Medicaid Original Ref 37 63 17
Prior Authorization 39 50 30
Date(s) of Service From 43-53 1 8 ## ## ##
Date(s) of Service To 43-53 10 9 ## ## ##
Place of Service 43-53 19 3
EMG 43-53 22 2
Procedures Services or Supplies 43-53 26 6
Modifier A 43-53 33 2
Modifier B 43-53 36 2
Modifier C 43-53 39 2
Modifier D 43-53 42 2
Diagnosis Pointer 43-53 45 4
Charges 43-53 50 8
Days or Units 43-53 59 4
EPSDT 43-53 63 2
ID Qualifier 42-52 65 2
Rendering Provider ID 42-52 68 13
Rendering Provider NPI 43-53 68 13
Remarks 42-52 2 60
NDC Code 42-52 2 60
EIN 55 19 1 X
Tax ID 55 2 15
SS# 55 17 1 X
Patient Account 55 23 15
Accept Assignment No 55 43 1
Accept Assignment Yes 55 38 1
Total Charge 55 52 9
Balance Due 55 70 9
Amount Paid 55 62 8
Physician Signature Date 60 6 10
Physician Signature 59 1 22
Billing Provider Phone 56 66 30
Facility Name 57 23 27
Facility Address 58 23 27
Facility City, State and Zip 59 23 27
Facility NPI 60 24 11
Facility ID 60 35 16
Billing Provider Name 57 50 30
Billing Provider Address 58 50 31
Billing Provider City, State and Zip 59 50 30
Billing Provider NPI 60 51 10
Billing Provider ID 60 62 21