Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 43

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attaChMent 2: indePendent diagnoStiC teSting f aCilitieS
(Continued)
a. Standards Qualifications
Provide the date this Independent Diagnostic Testing Facility met all current CMS standards (mm/dd/yyyy)
B. CPt-4 and hCPCS Codes
If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
CheCk one
Change
add
delete
date
(mm/dd/yyyy)
All codes reported here must be for diagnostic tests that an IDTF is allowed to perform. Diagnostic tests
that are clearly surgical in nature, which must be performed in a hospital or ambulatory surgical center,
should not be reported. Clinical laboratory and pathology codes should not be reported. This page may be
copied for additional codes or equipment.
Model nuMBer
CPt–4 or hCPCS Code
eQuiPMent
(Required)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
CMS-855B (07/11)
42

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