Hyalgan Cms-1500 Sample Claim Form printable pdf download

Hyalgan Cms-1500 Sample Claim Form

HYALGAN CMS-1500 SAMPLE CLAIM FORM

Box 21: Diagnosis Code

Enter appropriate ICD-10-CM

diagnosis

Example:

M17.0 - Bilateral Osteoarthritis of the

knee

Box 24D: HCPCS Code

Enter HCPCS code for HYALGAN

J7321—Hyaluronan or derivative,

M17.0

HYALGAN or SUPARTZ, for

intra-articular injection, per dose

Box 24G: Days or Units

Enter number of HYALGAN

Box 24D: CPT Code

units administered

Enter appropriate CPT code

Example:

and modifier

1 service unit for each dose

Example:

20610—Arthrocentesis,

aspiration, and/or injection;

major joint or bursa [eg,

shoulder, hip, knee joint,

subacromial bursa]

DISCLAIMER: HYALGAN Sample Claim Form CMS-1500 is intended solely for use as a resource tool to assist physician office and hospital outpatient

billing staff regarding reimbursement issues. Any determination about if and how to seek reimbursement should be made only by the appropriate

members of the physician office or hospital outpatient staff in consultation with the physician and in consideration of the procedure performed or

therapy provided to a specific patient. Fidia Farmaceutici S.p.A/Interpace BioPharma do not recommend or endorse the use of any particular diagnosis

or procedure code(s) and makes no determination if or how reimbursement may be available. Of important note, reimbursement codes and payment,

as well as health policy/legislation are subject to continual change; information contained in this version of the HYALGAN Reimbursement Guide is

current as of March 2016.

FID 338-02.2016-2

Hyalgan Cms-1500 Sample Claim Form