Hyalgan Cms-1450/ub-04 Sample Claim Form printable pdf download

Hyalgan Cms-1450/ub-04 Sample Claim Form

HYALGAN CMS-1450/UB-04 SAMPLE CLAIM FORM

Box 46: Service Units

Box 44: HCPCS Code

Enter number of HYALGAN units

Enter HCPCS code for HYALGAN

administered

J7321—Hyaluronan or derivative,

HYALGAN or SUPARTZ, for intra-

Example:

articular injection, per dose

1 service unit for each dose

Box 42: Revenue Code

Box 44: CPT Code

Enter appropriate revenue code

Enter appropriate CPT code and modifier

Example:

0636 attached to HCPCS code J7321

20610—Arthrocentesis, aspiration,

and/or injection; major joint or bursa

[eg, shoulder, hip, knee joint, subacromial bursa]

Box 66: Diagnosis Code

Enter appropriate IICD-10-CM diagnosis

Example:

M17.0 Bilateral primary osteoarthritis of

the knee

M17.0

Box 74: Principal Procedure Code & Date

Enter principal ICD-10-CM procedure code and date of administration

Example:

81.92 for injection of therapeutic substance into joint or ligament

DISCLAIMER: HYALGAN Sample Claim Form CMS-1450/UB-04 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 338-02.2016-4

Hyalgan Cms-1450/ub-04 Sample Claim Form