Sample UB-04 (also known as CMS 1450) Claim Form for... Department Billing: KEYTRUDA (pembrolizumab) for Injection 50 mg

Sample UB-04 (also known as CMS 1450) Claim Form for Hospital Outpatient
Department Billing: KEYTRUDA® (pembrolizumab) for Injection 50 mg
__
Note: for questions on billing if a portion of a package __
is wasted, consult the applicable payor’s policy regarding wastage.
__
1
4
3a PAT.
CNTL #
b. MED.
REC. #
2
6
5 FED. TAX NO.
8 PATIENT NAME
9 PATIENT ADDRESS
a
Locator 42
b
10 BIRTHDATE
11 SEX
DATE
ADMISSION
13 HR 14 TYPE 15 SRC 16 DHR 17 STAT
• E nter appropriate revenue code for each line item.
• Drugs that are billed with HCPCS codes usually
require revenue code 0636—Drugs requiring
detailed coding.
31
OCCURRENCE
CODE
DATE
32
OCCURRENCE
CODE
DATE
33
OCCURRENCE
DATE
CODE
a
b
38
18
7
STATEMENT COVERS PERIOD
FROM
THROUGH
a
b
12
TYPE
OF BILL
19
20
21
Locator 43
c
CONDITION CODES
24
22
23
25
26
27
• F or each line item, enter the description of the
revenue code used.
• F or the KEYTRUDA line item, also enter
the drug’s branda and generic names.
34
OCCURRENCE
CODE
DATE
35
CODE
36
CODE
OCCURRENCE SPAN
FROM
THROUGH
39
CODE
40
CODE
VALUE CODES
AMOUNT
Locator 46
d
28
e
29 ACDT 30
STATE
• W
hen using an unspecified
HCPCS code, enter only 1 unit
in this field.
37
OCCURRENCE SPAN
FROM
THROUGH
a
b
41
CODE
VALUE CODES
AMOUNT
VALUE CODES
AMOUNT
b
c
d
42 REV. CD.
44 HCPCS / RATE / HIPPS CODE
43 DESCRIPTION
45 SERV. DATE
46 SERV. UNITS
47 TOTAL CHARGES
48 NON-COVERED CHARGES
49
1
1
2
2
3
3
4
4
5
5
6
6
7
7
Locator 44
8
9
8
• U
se the appropriate unspecified HCPCS code to
bill for KEYTRUDA.
• The infusion time corresponds to CPT code 96413.
10
11
12
13
9
10
11
12
13
14
14
15
15
16
16
17
17
18
18
19
19
20
20
21
21
22
22
PAGE
23
OF
TOTALS
CREATION DATE
50 PAYER NAME
52 REL.
INFO
51 HEALTH PLAN ID
53 ASG.
BEN.
23
55 EST. AMOUNT DUE
54 PRIOR PAYMENTS
56 NPI
A
57
A
B
OTHER
B
PRV ID
C
Locator 66
C
58 INSURED’S NAME
• E nter appropriate ICD-9-CM
diagnosis code(s).
A
B
C
62 INSURANCE GROUP NO.
61 GROUP NAME
59 P. REL 60 INSURED’S UNIQUE ID
A
B
C
65 EMPLOYER NAME
64 DOCUMENT CONTROL NUMBER
63 TREATMENT AUTHORIZATION CODES
A
A
B
B
C
C
66
DX
67
I
A
J
69 ADMIT
70 PATIENT
DX
REASON DX
PRINCIPAL PROCEDURE
a.
74
CODE
DATE
B
C
D LocatorE80
F
K
L
N
O
M
a Enterb the following:
c
a
• D
rug name: [KEYTRUDA (pembrolizumab)]
• R oute of administration
• N
DC: 0006-3029-02
• T he dosage provided
OTHER PROCEDURE
CODE
DATE
b.
OTHER PROCEDURE
CODE
DATE
e.
71 PPS
CODE
OTHER PROCEDURE
CODE
DATE
G
P
b
72
ECI
75
76 ATTENDING
NPI
LAST
c.
OTHER PROCEDURE
CODE
DATE
d.
OTHER PROCEDURE
CODE
DATE
77 OPERATING
UB-04 CMS-1450
81CC
a
APPROVED OMB NO. 0938-0997
78 OTHER
b
LAST
c
79 OTHER
d
LAST
NUBC
™
National Uniform
Billing Committee
68
73
QUAL
FIRST
NPI
LAST
80 REMARKS
H
Q
c
QUAL
FIRST
NPI
QUAL
FIRST
NPI
QUAL
FIRST
THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.
The suggestions contained on this form are compiled from sources believed to be accurate for the Medicare Part B program, but Merck makes no representation that the
information is accurate or that it will comply with the requirements of any particular Medicare Administrative Contractor (MAC) or payor. You are solely responsible for determining
the billing and coding requirements applicable to any payor or MAC. Diagnosis codes should be selected only by a health care professional. The information provided here is not
intended to be conclusive or exhaustive, and is not intended to replace the guidance of a qualified professional advisor or any instructions provided by a payor or MAC. Billing and
coding requirements may vary or change over time, so it is important to regularly check these requirements with each payor or MAC. Merck makes no warranties or guarantees,
expressed or implied, concerning the accuracy or appropriateness of this information for your particular use and cautions that changes in public and private payor billing
requirements occur frequently. The use of this information does not guarantee payment or that any payment received will cover your costs.
ONCO-1108274-0011 08/14