SAMPLE CMS-1500 CLAIM FORM
The following is a partial view of a sample CMS-1500 claim form for a psychiatric diagnostic evaluation with elder maltreatment screen (measure 181).
1. CMS Measures Specification Manual – go.cms.gov/UmysQS
2. CMS QualityNet Help Desk: The QualityNet Help Desk is available Monday through Friday, 7 a.m.
to 7 p.m. Central Time, by telephone at 866-288-8912 (TTY 877-715-6222). Email inquiries may be sent
3. Quick reference guide for PQRS measures, procedure codes and G-codes –
4. Quality Improvement Programs section on the APA Practice Organization’s Practice Central website –
5. Critical Update: Quality Reporting for Medicare Providers in 2013 –
Putting Your Practice Assessment to Work