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Workers’ Compensation Board

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CMS-1500 Requirements

All CMS-1500 submissions (whether submitted through an XML submission partner or sent directly to the Board) require a medical narrative and/or attachment.

CMS-1500 Field Matrix and Examples

Field Matrix

CMS-1500 Examples

Medical Billing Forms Crosswalk

Medical Narrative Requirements

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 mandatory elements to include with most narratives: the patientís 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.

A chart outlining the legally required elements providers may comment on, according to their specialty, is shown below.
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.

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 providerís own medical narrative report is acceptable, if it includes work status, causal relationship and temporary impairment percentage. Examples of narrative reports are shown below.

Attachment Requirements

CMS-1500 Required Attachments
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) adobe pdf )
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.

XML Submissions

Providers and XML submission partners will be required to follow specific technical processes and XML submission formats. Review the XML 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.