Review Sample Cms 1500 Form For Jetrea - Jetrea Care printable pdf download

Review Sample Cms 1500 Form For Jetrea - Jetrea Care

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)*

Effective October 1, 2015, enter the appropriate ICD-10 diagnosis code.

For example:

• H43.821 (Right Eye)

• H43.822 (Left Eye)

• H43.823 (Bilateral)

*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

OCRVMA0272

Review Sample Cms 1500 Form For Jetrea - Jetrea Care