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Hospital Outpatient ­ 2009 Billing Instruction Sheet

Item NplateTM (Romiplostim) Revenue Code Medicare: 0636, drugs requiring detailed coding Other Payors: 0250, general pharmacy (or 0636 if required by a given payor) Modifier N/A Coding Guidance (HCPCS/CPT1/ICD-9-CM2) Notes C9245, injection, romiplostim, 10 mcg

J3590, Unclassified biologic OR Another unclassified drug/supply code if required by a given payor RE, Furnished in full compliance with FDA-mandated Risk Evaluation and Mitigation Strategy (REMS)

List drug name, dosage, and NDC number in Box 80 (or corresponding field for electronic claims) when billing with unclassified or miscellaneous HCPCS codes. CMS created modifier "RE" for dates of service on or after January 1, 2009. However, as of January 8, 2009, instructions for its use have not yet been released. Contact your local Medicare contractor or the NplateTM NEXUS for more information. 96372 replaces 90772 as of January 1, 2009. The code descriptor remains the same. Example: 287.31, immune thrombocytopenic purpura

Administration

Appropriate revenue code 96372, Therapeutic, prophylactic for the cost center in which or diagnostic injection (specify substance the service is performed. or drug); subcutaneous or intramuscular N/A Appropriate ICD-9-CM code(s) for patient condition

Diagnosis/ Condition

1

2

Current Procedural Terminology (CPT). CPT codes © 2008 American Medical Association. All rights reserved. CPT is a trademark of the AMA. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. International Classification of Diseases, 9th Revision, Clinical Modification.

The information provided in this section is of a general nature and for informational purposes only. Coding and coverage policies change periodically and often without warning. The responsibility to determine coverage and reimbursement parameters, and appropriate coding for a particular patient and/or procedure is always the responsibility of the provider or physician. The information provided in this section should in no way be considered a guarantee of coverage or reimbursement for any product or service.

Contact NplateTM NEXUS at 1-877-Nplate1 (1-877-675-2831) for assistance. www.nplate.com

© 2009 Amgen. All rights reserved. MC42145-A 2-09 P44015A

Completing the CMS 1450 for Hospital Outpatient

__

1

Sample UB-04 (CMS 1450) Form __ Hospital Outpatient Administration for Dates of Service on or after 1/1/09

2

__

4 TYPE OF BILL

Anytown Hospital 100 Main Street Anytown, Anystate 01010

a

3a PAT. CNTL # b. MED. REC. #

5 FED. TAX NO.

6

STATEMENT COVERS PERIOD FROM THROUGH

7

8 PATIENT NAME

b

Smith, Jane

12 DATE

9 PATIENT ADDRESS

a

123 Main Street, Anytown, Anystate 12345

21

b 18 19 20

10 BIRTHDATE

11 SEX

ADMISSION 13 HR 14 TYPE 15 SRC 16 DHR 17 STAT

31 OCCURRENCE CODE DATE

a b

32 OCCURRENCE CODE DATE

33 OCCURRENCE DATE CODE

34 OCCURRENCE CODE DATE

35 CODE

SeRvICe25uNITS (Box 46) 28 29 ACDT 30 26 27 STATE Report units of service. Medicare: C9245 corresponds to SPAN 36 OCCURRENCE SPAN OCCURRENCE FROM CODE FROM THROUGH 10THROUGH mcg. Other payors: Check with payor or NplateTM NEXUS for guidance.

CONDITION CODES 24 22 23 VALUE CODES AMOUNT

c

d

e

37

a b

38

39 CODE

40 CODE

VALUE CODES AMOUNT

41 CODE

VALUE CODES AMOUNT

a b c d

42 REV. CD.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

43 DESCRIPTION

44 HCPCS / RATE / HIPPS CODE

45 SERV. DATE

46 SERV. UNITS

47 TOTAL CHARGES

48 NON-COVERED CHARGES

0636 Drugs/detailed coding 0510 Clinic

C9245 96372

MMDDYY MMDDYY

X Y

XXXXX XXXXX

TOTAL CHARGeS (Box 47) 1 Report appropriate charges 2 for product used and related 3 procedures.

4 5

49

ReveNue CODeS (Box 42) AND DeSCRIPTIONS (Box 43) Product Medicare: Use revenue code 0636, drugs requiring detailed coding. Other Payors: Use revenue code 0250, general pharmacy (or 0636 if required by a given payor). Related administration procedure Use most appropriate revenue code for cost center where services were performed (eg, 0510, clinic).

PRODuCT AND PROCeDuRe CODeS (Box 44) Product Medicare: Use C9245, Injection, romiplostim, 10mcg Other Payors: Use J3590, unclassified biologic or another unclassified drug/supply code if required by a given payor. Related administration procedure Use CPT code representing procedure performed, such as 96372, therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular Effective January 1, 2009, 96372 replaces 90772. The code descriptor remains the same.

6 7 8 9 10 11 12 13

NOTe: 15 CMS created a new modifier, RE, Furnished in full 16 compliance with FDA-mandated Risk Evaluation 17 and Mitigation Strategy (REMS), which is effective January 1, 2009. As of January 8, 2009, CMS 18 19 has not yet issued instructions for the modifier's use. Contact your local contractor or the NplateTM 20 NEXUS for more information. 21

22 23

14

PAGE

50 PAYER NAME

OF

51 HEALTH PLAN ID

CREATION DATE

52 REL. INFO

53 ASG. BEN.

TOTALS

55 EST. AMOUNT DUE

54 PRIOR PAYMENTS

56 NPI 57

OTHER PRV ID

A B C

A B C

A B C

DIAGNOSIS CODeS (Box 67) Enter appropriate ICD-9-CM diagnosis code(s) corresponding to patient's diagnosis, such as 287.31. 63 TREATMENT AUTHORIZATION CODES

58 INSURED'S NAME

59 P REL 60 INSURED'S UNIQUE ID .

61 GROUP NAME

62 INSURANCE GROUP NO.

A B C

64 DOCUMENT CONTROL NUMBER

65 EMPLOYER NAME

A B C

A B C

66 DX

69 ADMIT 70 PATIENT DX REASON DX PRINCIPAL PROCEDURE a. 74 CODE DATE

67 I

XXX.XX

A J

OTHER PROCEDURE CODE DATE

B K a

b

C L

b. e.

c

71 PPS CODE OTHER PROCEDURE CODE DATE

D M

E N

75

72 ECI

F O a

76 ATTENDING

NPI

G P b

NPI

H Q c

QUAL

FIRST

68

73

LAST

c.

OTHER PROCEDURE CODE DATE

d.

OTHER PROCEDURE CODE DATE 81CC a

b c d

OTHER PROCEDURE CODE DATE

80 REMARKS

Product Name XXX mg XXXXX-XXXXXX

PRODuCT INfO (Box 84) LAST For non-Medicare payors only: When billing NPI 78 OTHER with an unclassifed or miscellaneous HCPCS code, enter product LAST dosage, name, 79 (mg) NPI and NDC, noting total amountOTHER of LAST product used.

TM

77 OPERATING

QUAL

FIRST

QUAL

FIRST

QUAL

FIRST

UB-04 CMS-1450

APPROVED OMB NO. 0938-0997

NUBC

National Uniform Billing Committee

THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.

This sample form is intended as a reference for coding and billing for product and associated services. It is not intended to be a directive, nor does the use of the recommended codes guarantee reimbursement. Physicians and staff may deem other codes or policies more appropriate. Providers should select the coding options that most accurately reflect their internal system guidelines, payor requirements, practice patterns, and the services rendered.

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