1. No category

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