Sample CMS 1450 Form—Hospital Outpatient Department (HOPD)

REGEMC006_Qcode_C_R1_E4U-0116 6/6/12 3:39 PM Page 2
Sample CMS 1450 Form—Hospital Outpatient Department (HOPD)
Note: The information presented below is based on the paper claim format; please adopt this information to electronic equivalent fields in
your software systems. The coding information discussed in this document and sample form is provided for informational purposes only, is
subject to change, and should not be construed
as legal advice. The codes listed below may not
apply to all patients or to all health plans;
providers should exercise independent clinical
judgment when selecting codes and submitting
claims to accurately reflect the services and
products furnished to a specific patient.
Boxes 42 and 43, Revenue Code
Enter the appropriate revenue code and
revenue code description for service.
636
510
Drugs requiring detailed coding
Outpatient Clinic
Q2046
67028-RT
2
1
Box 44, Procedure Code
Enter the appropriate CPT* code to denote
intravitreal injection.
Enter appropriate modifiers, –LT or –RT, to
denote specific eye or modifier –50 for
bilateral injection.
Product Code
Enter HCPCS code Q2046 to represent
EYLEA product for dates of service on or
after July 1, 2012.†
Note: State Medicaid agencies and some private
payers may require providers to report EYLEA’s
NDC (61755-0005-02) in addition to HCPCS code
Q2046; however, the NDC is not required for
Medicare claims.
Box 46, Units
Q2046 has a unit descriptor of 1 mg; report
2 units of the code when billing for
1 single-use vial of EYLEA.
Box 67, Diagnosis Code
Enter the appropriate ICD-9-CM code for the
patient’s diagnosis/condition.
Have a billing or reimbursement question related to EYLEA® (aflibercept) Injection?
Reimbursement Specialists are available Monday–Friday 9 AM–8 PM Eastern Time.
Call 1-855-EYLEA-4U (1-855-395-3248) and select option 4.
Or visit www.EYLEA4uproviderportal.com.
*CPT copyright 2011 American Medical Association. All rights reserved. CPT is a registered trademark
of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use.
Fee schedules, relative value units, conversion factors and/or related components are not assigned by
the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly
or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data
contained or not contained herein.
†
For information on billing for EYLEA for dates of service before July 1, 2012, please contact a
Reimbursement Specialist.
EYLEA® is a registered trademark of, and EYLEA 4USM is a service mark of, Regeneron Pharmaceuticals, Inc.
777 Old Saw Mill River Road
Tarrytown, NY 10591-6707
© 2012, Regeneron Pharmaceuticals, Inc.
E4U-0116
Printed in the USA
All rights reserved
6/12
REGEMC006_Qcode_C_R1_E4U-0116 6/6/12 3:38 PM Page 1
ALERT: EYLEA® (aflibercept) Injection
new reimbursement code—Q2046
The Centers for Medicare and Medicaid Services (CMS)
issued a Q-code for EYLEA effective July 1, 2012
This new code is a temporary billing code that is specific for EYLEA® (aflibercept) Injection
and may help with the billing and reimbursement process for EYLEA.
A permanent J-code is expected to be assigned later in 2012.
HCPCS code
Q2046
Description
Injection,
aflibercept, 1 mg*
Billing unit
2
Effective date
July 1, 2012
With the new Q-code for EYLEA, the unit descriptor has changed
*With the 1 mg descriptor, it is important to indicate “2” billing units on the claim form.
Previous description:
Injection, aflibercept, 2 mg
New description:
Injection, aflibercept, 1 mg
Therefore, you must now indicate 2 billing units on the claim form.
Medicare will recognize Q2046 in the physician office, hospital outpatient, and ambulatory surgical
center (ASC) settings. Coding requirements of other payers may vary. Many non-fee-for-service Medicare
payers will also recognize Q2046 in these settings
If adopted by these payers, Q2046 may replace the following codes currently being used to bill EYLEA:
• C9291 (Injection, aflibercept, 2 mg vial) • J3490 (unclassified drugs) • J3590 (unclassified biologics)
Conducting a benefits investigation for your patient through EYLEA 4USM can help determine which
payers will allow usage of the Q-code
The potential benefits of a Q-code
May help streamline the EYLEA reimbursement and billing process
May minimize potential for additional documentation/manual review requirements
May eliminate 5010-related issues associated with the
miscellaneous codes J3490 and J3590
See reverse side for a sample CMS 1450 form.