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Sample CMS-1450 Claim Form
Medicare—Hospital Outpatient
The diagnosis and procedure codes below are provided as examples
only for the refill and maintenance of an implantable infusion pump.
The NAVIGATOR Reimbursement and Access Program™ provides information to help with proper coding and
reimbursement. The healthcare provider is responsible for determining appropriate codes for an individual patient for
related and/or separate procedures. For questions regarding coding and reimbursement, please call the
NAVIGATOR Program at 1.855.PRIALT1 (774.2581).
1 Fields 42 and 43
2 Field 44
Enter the appropriate revenue codes and descriptions corresponding to HCPCS codes in
field 44
636 — Drugs/Detail Code
510 — Outpatient Clinic Visit
270 — Medical Surgical Supplies
Other revenue codes may be acceptable and vary by location.
__
__
4
6
5 FED. TAX NO.
8 PATIENT NAME
9 PATIENT ADDRESS
a
11 SEX
31
OCCURRENCE
CODE
DATE
12
DATE
32
OCCURRENCE
DATE
CODE
18
19
20
34
OCCURRENCE
CODE
DATE
33
OCCURRENCE
DATE
CODE
Note: Do not report 62367-62370 in conjunction
with 95990, 95991. For refilling and maintenance
of a reservoir or an implantable infusion pump
for spinal or brain drug delivery without
reprogramming, see 95990, 95991.
a
c
ADMISSION
13 HR 14 TYPE 15 SRC 16 DHR 17 STAT
62370: With reprogramming and refill
(requiring skill of a physician or other qualified
healthcare professional)a
TYPE
OF BILL
7
STATEMENT COVERS PERIOD
FROM
THROUGH
b
b
10 BIRTHDATE
62369: With reprogramming and refill
__
3a PAT.
CNTL #
b. MED.
REC. #
2
__
1
Enter the appropriate HCPCS and CPT codes —
PRIALT (ziconotide) intrathecal infusion will be
reported with HCPCS code J2278 which will map
to APC 1694 for separate payment.
CONDITION CODES
24
22
23
21
35
CODE
38
25
26
39
CODE
27
36
CODE
OCCURRENCE SPAN
FROM
THROUGH
40
CODE
VALUE CODES
AMOUNT
d
28
e
29 ACDT 30
STATE
37
OCCURRENCE SPAN
FROM
THROUGH
41
CODE
VALUE CODES
AMOUNT
VALUE CODES
AMOUNT
a
42 REV. CD.
1
b
2
3
c
E
1
d
44 HCPCS / RATE / HIPPS CODE
43 DESCRIPTION
510
Outpatient Clinic Visit
636
Pump Reprogramming and Refill
45 SERV. DATE
95991
62369
5
636
Drugs/Detail Code
270
Medical Surgical Supplies
6
7
8
9
10
11
12
13
14
17
18
19
20
21
22
PAGE
23
OF
50 PAYER NAME
49
1
2
1
J2278
500
A4220
1
M
15
16
48 NON-COVERED CHARGES
3
4
PL
4
47 TOTAL CHARGES
1
2
3
46 SERV. UNITS
52 REL.
INFO
SA
6
7
8
9
12
13
14
15
18
19
20
21
22
TOTALS
A
A
B
OTHER
B
C
PRV ID
C
62 INSURANCE GROUP NO.
61 GROUP NAME
59 P. REL 60 INSURED’S UNIQUE ID
A
A
B
B
C
C
65 EMPLOYER NAME
64 DOCUMENT CONTROL NUMBER
63 TREATMENT AUTHORIZATION CODES
A
A
B
B
C
66
DX
67
I
A
J
69 ADMIT
70 PATIENT
DX
REASON DX
PRINCIPAL PROCEDURE
a.
74
CODE
DATE
4
c.
337.20
OTHER PROCEDURE
CODE
DATE
B
K
a
b
OTHER PROCEDURE
CODE
DATE
b.
OTHER PROCEDURE
CODE
DATE
e.
c
D
M
71 PPS
CODE
OTHER PROCEDURE
CODE
DATE
E
N
75
72
ECI
F
O
76 ATTENDING
G
P
OTHER PROCEDURE
CODE
DATE
77 OPERATING
NPI
5
PRIALT® (ziconotide) intrathecal infusion
NDC 18860-0722-10, 100 mcg/mL, 5 mL IT
b
LAST
c
79 OTHER
d
UB-04 CMS-1450
APPROVED OMB NO.
78 OTHER
LAST
H
Q
68
73
QUAL
FIRST
NPI
LAST
81CC
a
80 REMARKS
Enter the appropriate ICD-9-CM diagnosis code
eg, 337.20 (complex regional pain syndrome type 1,
unspecified). Other diagnosis codes may
be acceptable.
C
C
L
LAST
d.
4 Field 74
56 NPI
57
58 INSURED’S NAME
Enter the number of units billed that correspond to
the vial size used. J2278 is billed per 1 mcg. 100 or
500 units should be reported depending on the vial
administered. Contact your Medicare contractor and/
or all other contracted/non-contracted payer(s) for
any questions regarding filling guidelines for coverage,
coding, and payment direction.
23
55 EST. AMOUNT DUE
54 PRIOR PAYMENTS
3 Field 46
11
17
53 ASG.
BEN.
95991: Refilling and maintenance of implantable pump or
reservoir for drug delivery, spinal (intrathecal, epidural), or brain
(intraventricular), includes electronic analysis of pump, when
performed (requiring skill of a physician or other qualified
healthcare professional)a
10
16
CREATION DATE
51 HEALTH PLAN ID
5
95990: Refilling and maintenance of implantable pump or
reservoir for drug delivery, spinal (intrathecal, epidural), or
brain (intraventricular), includes electronic analysis of pump,
when performed
QUAL
FIRST
NPI
QUAL
FIRST
NPI
QUAL
FIRST
THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.
NUBC
™
National Uniform
Billing Committee
LIC9213257
5 Field 80
Billing with a specific HCPCS code allows for faster
payment through electronic billing. Manual billing may
still be required in certain circumstances. In those
cases it may be necessary to provide the following
information for payment:
Report the NDC, quantity of the drugs administered
(expressed in unit of measure applicable to the drug
or biological), and the date the drug was administered
to the patient.
MS Manual System, Publication 100-4, Medicare Claims Processing Manual, chapters 17 (Rev. 2368, 12-16-11) and 20
C
(Rev. 2299, 9-08-11), addresses the payment of claims for infusion drugs furnished through an implanted DME infusion pump.
a
*Reimbursement information provided by Jazz Pharmaceuticals is gathered from third-party sources and is presented for illustrative purposes only. This
information does not constitute reimbursement or legal advice, and Jazz Pharmaceuticals makes no representation or warranty regarding this information
or its completeness, accuracy, or timeliness. Laws, regulations, and payer policies concerning reimbursement are complex and change frequently, and service
providers are responsible for all decisions relating to coding and reimbursement submissions. Accordingly, Jazz Pharmaceuticals strongly recommends that
you consult with your payers, reimbursement specialist, and/or legal counsel regarding coding, coverage, and reimbursement matters.
Click here for full Prescribing Information, including BOXED Warning.
INDICATION STATEMENT
PRIALT® (ziconotide) intrathecal infusion is indicated for the management of severe chronic pain in
patients for whom intrathecal therapy is warranted, and who are intolerant of or refractory to other
treatment, such as systemic analgesics, adjunctive therapies, or intrathecal morphine.
IMPORTANT SAFETY INFORMATION
PRIALT is contraindicated in patients with a preexisting history of psychosis.
Severe psychiatric symptoms and neurological impairment may occur during
treatment with PRIALT. Monitor patients and discontinue PRIALT in the event
of serious neurological or psychiatric signs or symptoms.
PRIALT is contraindicated in patients with:
• A known hypersensitivity to ziconotide or any of its formulation components.
• Any
other concomitant treatment or medical condition that would render IT administration
hazardous, such as the presence of infection at the microinfusion injection site, uncontrolled
bleeding diathesis, and spinal canal obstruction that impairs circulation of cerebrospinal fluid
(CSF).
• A pre-existing history of psychosis.
Advise patients of the signs and symptoms of meningitis, such as fever, headache, stiff neck, altered
mental status, nausea, vomiting, and occasionally seizures. Reduced levels of consciousness and
creatine kinase (CK) elevations have occurred in patients taking PRIALT. Monitor serum CK
periodically. For patients being withdrawn from intrathecal opiates, gradually taper over a few
weeks and replace with a pharmacologically equivalent dose of oral opiates. The most frequently
reported adverse reactions (≥25%) in clinical trials (n=1254 PRIALT-treated patients) were
dizziness, nausea, confusional state, and nystagmus. Slower titration of PRIALT may result in fewer
serious adverse reactions and discontinuations for adverse reactions.
PRIALT is not intended for intravenous (IV) administration. PRIALT is for use only in the
Medtronic SynchroMed® II Infusion System and the CADD-Micro Ambulatory Infusion Pump.
Click here for full Prescribing Information, including BOXED Warning.
PRIALT is a registered trademark of Jazz Pharmaceuticals plc or its subsidiaries.
NAVIGATOR Reimbursement and Access Program is a
trademark of Jazz Pharmaceuticals plc or its subsidiaries.
SynchroMed is a registered trademark of Medtronic, Inc.
© 2014 Jazz Pharmaceuticals plc or its subsidiaries.
PRI-0092-01 Rev0114
Reimbursement and Access Program™