Sample CMS-1500 Claim FOrm Physician Office (Medicare and non-medicare payers) This document is provided for your guidance only. Please call Dendreon ON Call at 1-877-336-3736 to verify coding and claim information for specific payers. Box 19: Enter appropriate product information, if required by the payer: • For Medicare Claims: Leave blank • For Medicaid Claims: Enter NDC 30237890006 • For Medicare-Medicaid Crossover Claims: Enter NDC 30237890006 • For Medicare-Secondary Claims: Enter NDC 30237890006 if Q2043 is not accepted Note: Coding requirements will vary for non-Medicare payers; check with payer to confirm. Box 21: Enter appropriate ICD-9-CM diagnosis code(s) as documented in the medical record: • For Medicare Claims: You must report: – 185 — Malignant neoplasm of prostate AND – At least one of the following ICD-9 codes: 196.1, 196.2, 196.5, 196.6, 196.8, 196.9, 197.0, 197.7, 198.0, 198.1, 198.5, 198.7, or 198.82 • For Non-Medicare Claims: Enter appropriate diagnosis code according to payer-specific coding guidance YY YY YY YY YY YY YY YY MM DD YY MM DD YY Q2043 1 XXX XX 1 MM DD YY MM DD YY 96413 1 XXX XX 1 Box 24D: • For Medicare Claims: Enter appropriate HCPCS code; eg: – Q2043 PROVENGE, per dose The Centers for Medicare & Medicaid Services has reversed its policy for coverage of the administration of PROVENGE. Providers can now bill for PROVENGE infusions, effective for dates of service on or after June 30, 2011. Providers will need to contact their regional Medicare Administrative Contractor (MAC) to obtain the code they should use to bill for the infusion and instructions on how to file retroactive claims for dates of service on or after June 30, 2011. 96413 is provided as an example only. Q2043 is all inclusive and represents all routine costs except for its cost of administration. ©2011 Dendreon Corporation. All rights reserved. December 2011. Printed in the U.S.A. Dendreon, the Dendreon logo, and PROVENGE are registered trademarks of Dendreon Corporation. P-A-08.11-150.01-C www.provenge.com Box 24G: Enter appropriate number of service units per payer-specific guidance; eg, “1” unit for Q2043 for Medicare patients in physician office setting. Dendreon ON Call is available to assist with determining coding requirements for Provenge infusions. For more information, please contact Dendreon ON Call at 1-877-336-3736. • For Non-Medicare Claims: Enter appropriate HCPCS and CPT codes; eg: – Q2043 PROVENGE, per dose – 96413 — Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug – 96415 — Chemotherapy administration, intravenous infusion technique; each additional hour (Report 96415 when the infusion time is greater than 30 minutes past the first hour) Note: Coding requirements will vary; check with payer to confirm. Sample Claim Form 1500 Alternate scenario WHen using nOc hcpcs codes: