Sample CMS 1500 Form for Claims Submitted by Physician Offices
Transcription
Sample CMS 1500 Form for Claims Submitted by Physician Offices
Sample CMS 1500 Form Sample CMS 1500 Form for Claims Submitted by Physician Offices 1. Diagnosis Code (Box 21): Enter the appropriate ICD-9-CM diagnosis code. For example: • 379.27 (Vitreomacular adhesion, vitreomacular traction)* *Excludes: traction detachment with vitreoretinal organization (361.81). 2. Product Code (Box 24D): Enter the permanent J-code. • J7316 3. Units (Box 24G): 4 billing units for one JETREA® injection Note: State Medicaid agencies, secondary payers, and some private payers may require providers to report the NDC (24856-0001-01) of JETREA in addition to HCPCS code J7316; however, the NDC is not required for Medicare claims. 4. Procedure Code (Box 24D): CPT code for intravitreal injection and appropriate modifier: • 67028-RT (Intravitreal injection of a pharmacological agent); right eye OR • 67028-LT (Intravitreal injection of a pharmacological agent); left eye General Tips for Clean Claim Submission • Determine if precertification or prior authorization is required before service can be rendered • Submit accurate and complete patient information • Follow payer requirements for punctuation and character limits for electronic claim submission • Promptly submit claims within the timeframe set by the payer OCRVMA0192