The coding information in this sample form is provided for informational purposes only, is subject to change, and should not be construed as legal advice. Sample Health Insurance Claim Form 1500 Procedure Codes: Use appropriate CPT code for OPT (67221). Use CPT code 67225 for second eye if both eyes treated during same session. Drug Code: Enter unique HCPCS J-code (J3396) for Visudyne (verteporfin for injection). S 362.52 P M A Diagnosis Code: If the diagnosis is exudative senile macular degeneration, then the appropriate ICD-9-CM diagnosis code is: 362.52. E L 67221 RT A 67225 LT A J3396 A 150 Units: Enter appropriate number of units (150) of Visudyne (verteporfin for injection) used (J-code J3396). PLEASE PRINT OR TYPE APPROVED OMB-0938-1197 FORM 1500 (02-12) Please see Important Safety Information on back page and full Prescribing Information provided. US/VID/13/0002_SampleClaim_110413_v2.indd 1 1/9/14 5:16 PM Indications and Usage Visudyne® (verteporfin for injection) is indicated for the treatment of predominantly classic subfoveal choroidal neovascularization due to age-related macular degeneration, pathologic myopia, or presumed ocular histoplasmosis. There is insufficient evidence to indicate Visudyne® for the treatment of predominantly occult subfoveal choroidal neovascularization. Important Safety Information Visudyne is contraindicated for patients with porphyria or known hypersensitivity to any component of Visudyne. Infusion-related transient back pain occurred with Visudyne only. Verteporfin infusion induces temporary photosensitivity; patients should avoid exposure of skin and eyes to direct sunlight or bright indoor light for 5 days. To prevent extravasation, avoid fragile hand veins in favor of larger antecubital veins. Severe vision decrease (≥4 lines) was reported within 7 days in 1% to 5% of patients. Partial recovery occurs in some patients. Do not re-treat these patients until vision completely recovers to pretreatment levels and potential benefits and risks of subsequent treatment are carefully weighed. The most frequently reported adverse events (10% to 30% incidence) were injection site reactions (including extravasation and rashes), blurred vision, decreased visual acuity, and visual field defects. Please see full Prescribing Information provided. Visudyne is a registered trademark of Novartis AG. Bausch + Lomb and Valeant are trademarks of Valeant Pharmaceuticals International, Inc. or its affiliates. All other product/brand names are trademarks of their respective owners. ©2014 Valeant Pharmaceuticals North America LLC US/VID/13/0002_SampleClaim_110413_v2.indd 2 US/VID/13/0002 1/9/14 5:16 PM