Sample CMS1450 (UB-04) Claim Form

Sample CMS1450 (UB-04) Claim Form
For Use with a Drug that does have a HCPCS/Pass-Through Code Assigned
Under Medicare’s APC System for Hospital Outpatient Services
MM/DD/YY
Smith, Jane, D.
MM/DD/YY F
Column 47 — Total Charges
• Indicate the facility’s actual charges for
products and procedures.
Column 43 — Description
• Description of services/products
provided
• Drug Name, Strength, NDC#
0510
0636
Clinic
Drug Name 11111-2222-33
Column 42 — Revenue Code(s)
Enter appropriate revenue codes for services
provider. List all revenue codes in ascending
numerical order.
Product Revenue Codes:
• Revenue Code 0636 (“Drugs that
require detail coding”) should be
used. Please note: revenue code
requirements may vary by payor.
Check with payor to determine the
appropriate revenue code for billing.
MM/DD/YY
123 Main Street, Anytown, Anystate 12345
96409
CXXXX
MM/DD/YY
MM/DD/YY
Column 44 —Product/Procedure Code(s):
Product Code:
• Indicate the appropriate HCPCS/
pass-through code for the drug
administered.
X
$$$ $$
X
$$$ $$
Column 46 — Service Units
• Enter the number of units of each
product/service administered.
Procedure Code:
• Enter the CPT code that represents the
administration procedure
performed.
Procedure Revenue Codes:
• CMS requires a revenue code for
each line item on the UB-04 form.
CMS instructs billers to use the most
appropriate revenue code for the
setting where the service is performed
(i.e. 0360 - operating room; or 0510, clinic)
National Provider Identifier (Box 56)
• Enter appropriate NPI as assigned by CMS
(Note: see also Boxes 76, 77, 78, 79)
XXX.XX
Diagnosis Codes (Box 67)
• Enter appropriate ICD-9-CM diagnosis
code corresponding to a particular patient’s diagnosis.
This Billing Instruction Sheet is intended as a reference for potential coding, billing and
associated services. It is not intended to be a directive, nor is it a suggestion about the
likelihood of obtaining reimbursement. Physicians and staff may deem other codes or
policies more appropriate. Providers should select the coding options that most
accurately reflect a patient’s condition, their internal system guidelines, payer
requirements, practice patterns, and the services rendered.