Sample UB-04 Form for RENFLEXIS™ (infliximab-abda) | Merck … · Title: Sample UB-04 Form for...
1
1 2 4 TYPE OF BILL FROM THROUGH 5 FED. TAX NO. a b c d DX ECI 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 A B C A B C D E F G H I J K L M N O P Q a b c a b c a b c d ADMISSION CONDITION CODES DATE OCCURRENCE OCCURRENCE OCCURRENCE OCCURRENCE SPAN OCCURRENCE SPAN CODE DATE CODE CODE CODE DATE CODE THROUGH VALUE CODES VALUE CODES VALUE CODES CODE AMOUNT CODE AMOUNT CODE AMOUNT TOTALS PRINCIPAL PROCEDURE a. OTHER PROCEDURE b. OTHER PROCEDURE NPI CODE DATE CODE DATE CODE DATE FIRST c. d. e. OTHER PROCEDURE NPI CODE DATE DATE FIRST NPI b LAST FIRST c NPI d LAST FIRST UB-04 CMS-1450 7 10 BIRTHDATE 11 SEX 12 13 HR 14 TYPE 15 SRC DATE 16 DHR 18 19 20 FROM 21 25 22 26 28 23 27 CODE FROM DATE OTHER PRV ID THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF. b . INFO BEN. CODE OTHER PROCEDURE THROUGH 29 ACDT 30 32 31 33 34 35 36 37 38 39 40 41 42 REV. CD. 43 DESCRIPTION 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49 52 REL 51 HEALTH PLAN ID 53 ASG. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI 57 58 INSURED’S NAME 59 P. REL 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO. 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME 66 67 68 69 ADMIT 70 PATIENT 72 73 74 75 76 ATTENDING 80 REMARKS OTHER PROCEDURE a 77 OPERATING 78 OTHER 79 OTHER 81CC CREATION DATE 3a PAT. CNTL # 24 b. MED. REC. # 44 HCPCS / RATE / HIPPS CODE PAGE OF APPROVED OMB NO. 0938-0997 e a 8 PATIENT NAME 50 PAYER NAME 63 TREATMENT AUTHORIZATION CODES 6 STATEMENT COVERS PERIOD 9 PATIENT ADDRESS 17 STAT STATE DX REASON DX 71 PPS CODE QUAL LAST LAST National Uniform Billing Committee NUBC ™ OCCURRENCE QUAL QUAL QUAL CODE DATE A B C A B C A B C A B C A B C a b a b Sample UB-04 (also known as CMS 1450) Claim Form for Hospital Outpatient Department Billing: RENFLEXIS ® (infliximab-abda) for Injection, for Intravenous Use 100 mg Before prescribing RENFLEXIS, please read the Prescribing Information, including the Boxed Warning about serious infections and malignancies. The Medication Guide also is available. Copyright © 2020 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. All rights reserved. US-SBT-00762 03/20 The suggestions contained on this form are compiled from sources believed to be accurate for the Medicare Part B program, but Merck makes no representation that the information is accurate or that it will comply with the requirements of any particular MAC or payer. You are solely responsible for determining the billing and coding requirements applicable to any payer or MAC. Diagnosis codes should be selected only by a health care professional. The information provided here is not intended to be conclusive or exhaustive, and is not intended to replace the guidance of a qualified professional advisor or any instructions provided by a payer or MAC. Billing and coding requirements may vary or change over time, so it is important to regularly check these requirements with each payer or MAC. Merck makes no warranties or guarantees, expressed or implied, concerning the accuracy or appropriateness of this information for your particular use and cautions that changes in public and private payer billing requirements occur frequently. The use of this information does not guarantee payment or that any payment received will cover your costs. CMS, US Centers for Medicare & Medicaid Services; HCPCS, Healthcare Common Procedure Coding System; CPT, Current Procedural Terminology. CPT © 2020 American Medical Association. All rights reserved. CPT ® is a registered trademark of the American Medical Association.; MAC, Medicare Administrative Contractor. Locator 44 Please note that different payers may have different coding requirements for RENFLEXIS (infliximab-abda). Check with the payer for information on billing and coding if you have questions. The guidance below applies to Medicare Part B claims. Check with the payer for billing and coding information for commercial claims. For claims with dates of service on or after April 1, 2018: • Use Q5104 to bill for RENFLEXIS (infliximab-abda). For infusion procedure: • The infusion time corresponds to CPT ® codes 96413 and 96415. (Some payers may prefer use of 96365 and 96366. Check with the applicable payer.) Locator 42 • Enter appropriate revenue code for each line item. • Drugs that are billed with HCPCS codes usually require revenue code 0636— Drugs requiring detailed coding. Locator 43 • For each line item, enter the description of the revenue code used. • For the line item for RENFLEXIS (infliximab-abda), also enter the drug’s brand and generic names. Locator 46 • Enter the number of units administered in this field. • Note that 1 unit equals 10 mg of RENFLEXIS for Q5104 (used to bill for RENFLEXIS [infliximab-abda] for dates of service on or after April 1, 2018). Locator 67 • Enter appropriate diagnosis code(s).
Transcript of Sample UB-04 Form for RENFLEXIS™ (infliximab-abda) | Merck … · Title: Sample UB-04 Form for...
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1 2 4 TYPEOF BILL
FROM THROUGH5 FED. TAX NO.
a
b
c
d
DX
ECI
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
A
B
C
A B C D E F G HI J K L M N O P Q
a b c a b c
a
b c d
ADMISSION CONDITION CODESDATE
OCCURRENCE OCCURRENCE OCCURRENCE OCCURRENCE SPAN OCCURRENCE SPANCODE DATE CODE CODE CODE DATE CODE THROUGH
VALUE CODES VALUE CODES VALUE CODESCODE AMOUNT CODE AMOUNT CODE AMOUNT
TOTALS
PRINCIPAL PROCEDURE a. OTHER PROCEDURE b. OTHER PROCEDURE NPICODE DATE CODE DATE CODE DATE
FIRST
c. d. e. OTHER PROCEDURE NPICODE DATE DATE
FIRST
NPI
b LAST FIRST
c NPI
d LAST FIRST
UB-04 CMS-1450
7
10 BIRTHDATE 11 SEX 12 13 HR 14 TYPE 15 SRC
DATE
16 DHR 18 19 20
FROM
21 2522 26 2823 27
CODE FROM
DATE
OTHER
PRV ID
THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.
b
.INFO
BEN.
CODEOTHER PROCEDURE
THROUGH
29 ACDT 30
3231 33 34 35 36 37
38 39 40 41
42 REV. CD. 43 DESCRIPTION 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49
52 REL51 HEALTH PLAN ID
53 ASG.54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI
57
58 INSURED’S NAME 59 P.REL 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.
64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME
66 67 68
69 ADMIT 70 PATIENT 72 73
74 75 76 ATTENDING
80 REMARKS
OTHER PROCEDURE
a
77 OPERATING
78 OTHER
79 OTHER
81CC
CREATION DATE
3a PAT.CNTL #
24
b. MED.REC. #
44 HCPCS / RATE / HIPPS CODE
PAGE OF
APPROVED OMB NO. 0938-0997
e
a8 PATIENT NAME
50 PAYER NAME
63 TREATMENT AUTHORIZATION CODES
6 STATEMENT COVERS PERIOD
9 PATIENT ADDRESS
17 STAT STATE
DX REASON DX 71 PPS
CODE
QUAL
LAST
LAST
National UniformBilling CommitteeNUBC
™
OCCURRENCE
QUAL
QUAL
QUAL
CODE DATE
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
a
b
a
b
Sample UB-04 (also known as CMS 1450) Claim Form for Hospital Outpatient Department Billing: RENFLEXIS® (infliximab-abda) for Injection, for Intravenous Use 100 mgBefore prescribing RENFLEXIS, please read the Prescribing Information, including the Boxed Warning about serious infections and malignancies. The Medication Guide also is available.
Copyright © 2020 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. All rights reserved. US-SBT-00762 03/20
The suggestions contained on this form are compiled from sources believed to be accurate for the Medicare Part B program, but Merck makes no representation that the information is accurate or that it will comply with the requirements of any particular MAC or payer. You are solely responsible for determining the billing and coding requirements applicable to any payer or MAC. Diagnosis codes should be selected only by a health care professional. The information provided here is not intended to be conclusive or exhaustive, and is not intended to replace the guidance of a qualified professional advisor or any instructions provided by a payer or MAC. Billing and coding requirements may vary or change over time, so it is important to regularly check these requirements with each payer or MAC. Merck makes no warranties or guarantees, expressed or implied, concerning the accuracy or appropriateness of this information for your particular use and cautions that changes in public and private payer billing requirements occur frequently. The use of this information does not guarantee payment or that any payment received will cover your costs.
CMS, US Centers for Medicare & Medicaid Services; HCPCS, Healthcare Common Procedure Coding System; CPT, Current Procedural Terminology. CPT © 2020 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.; MAC, Medicare Administrative Contractor.
Locator 44Please note that different payers may have different coding requirements for RENFLEXIS (infliximab-abda). Check with the payer for information on billing and coding if you have questions.The guidance below applies to Medicare Part B claims. Check with the payer for billing and coding information for commercial claims.For claims with dates of service on or after April 1, 2018:
• Use Q5104 to bill for RENFLEXIS (infliximab-abda).For infusion procedure: • The infusion time corresponds to CPT® codes 96413 and 96415. (Some payers may prefer use
of 96365 and 96366. Check with the applicable payer.)
Locator 42 • Enter appropriate revenue code for each
line item. • Drugs that are billed with HCPCS codes
usually require revenue code 0636—Drugs requiring detailed coding.
Locator 43 • For each line item, enter the description
of the revenue code used. • For the line item for RENFLEXIS
(infliximab-abda), also enter the drug’s brand and generic names.
Locator 46 • Enter the number of units administered in this field. • Note that 1 unit equals 10 mg of RENFLEXIS for
Q5104 (used to bill for RENFLEXIS [infliximab-abda] for dates of service on or after April 1, 2018).
Locator 67 • Enter appropriate
diagnosis code(s).
