August 2012

Volume 1 No.1

Drug Reimbursement Coding and Pricing Advisory™ Sodium Chloride Injection, USP, 0.9% – by Me Important Information: Billing options for Sodium Chloride Injection,

USP, 0.9% - by M

nc

When billing for Sodium Chloride Injection, USP, 0.9% – by (non-hospital use) using the CMS-1500 form:

in the physician’s 10 mL drugs

If accepted use A4216 Sterile water, saline, and/or dextrose, If A4216 is NOT accepted use the miscellaneous J-Code, J3490

When billing under the Hospital OPPS (Outpatient Prospective Payment System) with a miscellaneous code then you must bill using C9399 drugs and biologicals on the CMS-1450 (UB-04) form.

HOW TO BILL FOR nc Sodium Chloride Injection, USP, 0.9% - by M USING THE CMS-1500 and CMS-1450 (UB-04) FORM Medication Information CMS-1500 Form Column 24D: Indicate the appropriate HCPCS code for Sodium Chloride Injection, USP, 0.9% – Column 24D. Use A4216 Sterile water, saline, and/ ed drugs. use J3490 Un

Inc. in if accepted, if not

CMS-1450 (UB-04) Form Column 44: Enter C9399 Unclassi ed drugs and biologicals in Column 44.

1

Medication Information CMS-1500 Form Box19 or Column 24A: When using A4216 or J3490, indicate the full name of the medication administered including strength (if applicable) (e.g., Sodium Chloride Injection, USP, 0.9%). When billing with J3490 you must also include the NDC (National Drug Code, e.g., 64253-0202-30) on the package used in Box 19 or Column 24A, the NDC is optional if using A4216. Please note: check with payer regarding correct placement of Medication Information.

CMS-1450 (UB-04) Form Column 43: When using C9399, indicate the full name of the medication administered including strength (if applicable) (e.g., Sodium Chloride Injection, USP, 0.9%) and include the NDC (National Drug Code, e.g., 64253-0202-30) on the package used in Column 43.

Medication Charge CMS-1500 Form Column 24F or CMS-1450 (UB-04) Column 47: The NDCs below should also be used when billing under the pharmacy benefit. NDC * 64253-0202-21

Catalog Number MSD-0221

64253-0202-22

MSD-0222

64253-0202-52

MSD-0252

64253-0202-23

MSD-0223

64253-0202-25

MSD-0225

64253-0202-33

MSD-0233

Product Sodium Chloride Injection, USP, 0.9% Sodium Chloride Injection, USP, 0.9% Sodium Chloride Injection, USP, 0.9% Sodium Chloride Injection, USP, 0.9% Sodium Chloride Injection, USP, 0.9% Sodium Chloride Injection, USP, 0.9%

Concentration

Fill Volume

AWP**

9 mg/mL

1 mL fill in 6 mL Syringe

$2.65 /syringe

9 mg/mL

2 mL fill in 6 mL Syringe

$2.92 /syringe

9 mg/mL

2.5 mL fill in 6 mL Syringe

$2.99 /syringe

9 mg/mL

3 mL fill in 6 mL Syringe

$3.07 /syringe

9 mg/mL

5 mL fill in 6 mL Syringe

$3.51 /syringe

9 mg/mL

3 mL fill in 12 mL Syringe

$3.40 /syringe

2

64253-0202-35

MSD-0235

64253-0202-30

MSD-0230

Sodium Chloride Injection, USP, 0.9% Sodium Chloride Injection, USP, 0.9%

9 mg/mL

5 mL fill in 12 mL Syringe

$3.75 /syringe

9 mg/mL

10 mL fill in 12 mL Syringe

$4.02 /syringe

*Note that the product’s NDC code has been “zero-filled” to ensure creation of an 11-digit code that meets CMS standards. The zero-fill location is indicated in bold. **Current AWP Prices are based on information listed in the National Data Sources

Medication Quantity CMS-1500 Form Column 24G: Indicate the quantity of medication administered in Column 24G. Enter the number of units of the NDC used. For A4216 enter 1 unit per every 10 mLs of Sodium Chloride Injection, USP, 0.9% used. For J3490 enter 1 unit per each syringe used. Please Note: billable units may vary by payer, please check with your payer for appropriate billable units to be used.

CMS-1450 (UB-04) Form Column 46 For C9399 enter 1 unit per each syringe in Column 46.

3

SAMPLE

CLAIM

DRUG WITH or WITHOUT AN ASSIGNED HCPCS DRUG CODE STOCKED BY PHYSICIAN and ADMINISTERED IN THE OFFICE CARRIER

1500 HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 PICA

PICA MEDICAID

(Medicare #)

(Medicaid #)

TRICARE CHAMPUS (Sponsor’s SSN)

GROUP HEALTH PLAN (SSN or ID)

CHAMPVA

(Member ID#)

3. PATIENT’S BIRTH DATE MM DD YY

2. PATIENT’S NAME (Last Name, First Name, Middle Initial)

Smith, Jane N.

MM

5. PATIENT’S ADDRESS (No., Street)

OTHER 1a. INSURED’S I.D. NUMBER

FECA BLK LUNG (SSN)

4. INSURED’S NAME (Last Name, First Name, Middle Initial)

M

F

123 Main Street

Self STATE

Anytown

Child

Spouse

Single

X

(

12345

123 Main Street STATE

CITY

Married

Anytown

Other

TELEPHONE (Include Area Code)

ZIP CODE

7. INSURED’S ADDRESS (No., Street)

Other

8. PATIENT STATUS

USA

Smith, Jane N.

X

6. PATIENT RELATIONSHIP TO INSURED

CITY

123-45-6789

(ID)

SEX

DD YY

(For Program in Item 1)

USA

ZIP CODE

)

Employed

X

Full-Time Student

Part-Time Student

TELEPHONE (Include Area Code)

(

12345

)

9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)

10. IS PATIENT’S CONDITION RELATED TO:

11. INSURED’S POLICY GROUP OR FECA NUMBER

a. OTHER INSURED’S POLICY OR GROUP NUMBER

a. EMPLOYMENT? (Current or Previous)

a. INSURED’S DATE OF BIRTH MM DD YY

b. OTHER INSURED’S DATE OF BIRTH MM DD YY

b. AUTO ACCIDENT?

SEX

X

YES

F

M c. EMPLOYER’S NAME OR SCHOOL NAME

c. OTHER ACCIDENT?

Box 19 or Column 24A:

NO

PLACE (State)

NO

NO

PL

Indicate the name, strength (if

d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

10d. RESERVED FOR LOCAL USE

applicable) and for J3490 claims

YES

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below.

include the NDC number of

National Provider Identifier MM DDassigned YY DATE SIGNED Enter appropriate NPI as by CMS

(Accident) OR Sodium ChlorideINJURY Injection, PREGNANCY(LMP)

MM DD YY GIVESee FIRST also DATE boxes (Note: 24, 32 and 33)

ILLNESS (First symptom) OR

15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY MM DD YY FROM TO

SA M

14. DATE OF CURRENT: MM DD YY

USP, 0.9%, 64253-0202-30

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY FROM TO

17a.

17b. NPI

19. RESERVED FOR LOCAL USE

20. OUTSIDE LAB?

Sodium Chloride,0.9% 64253-0202-30

YES

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line) 1.

2. 24. A. MM

1 MM

If yes, return to and complete item 9 a-d.

NO

13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below.

medication administered Signature on File Example:

SIGNED

F

b. EMPLOYER’S NAME OR SCHOOL NAME

c. INSURANCE PLAN NAME OR PROGRAM NAME

X

YES

d. INSURANCE PLAN NAME OR PROGRAM NAME

SEX M

E

X

YES

PATIENT AND INSURED INFORMATION

MEDICARE

$ CHARGES NO

22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO.

3.

DATE(S) OF SERVICE From To DD YY MM DD

YY

DD YY MM DD YY

B. C. PLACE OF SERVICE EMG

11

4. D. PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER

23. PRIOR AUTHORIZATION NUMBER

E. DIAGNOSIS POINTER

Column 24F-

3 4 5 25. FEDERAL TAX I.D. NUMBER

SSN EIN

SIGNED

DATE

I. ID. QUAL.

xx

NPI of Column 24G- Quantity

Medication Used

Enter appropriate HCPCS Code

Example:

Example:

NPIfor Enter 1 unit per 10 mLs

A4216 Sterile water, saline, and/

A4216 and Enter 1 unitNPIper

27. ACCEPT ASSIGNMENT? (For

govt. claims, see back)

32. SERVICE FACILITY LOCATION INFORMATION

a.

NPI

NPI

1 syringe for J3490

or J3490 Unclassified drugs

26. PATIENT’S ACCOUNT NO.

NO

NPI Please note: The number of billing

28. TOTAL CHARGE $

29. AMOUNT PAID

33. BILLING PROVIDER INFO & PH #

NUCC Instruction Manual available at: www.nucc.org

a.

30. BALANCE DUE

unitsxxx required xx may $ vary by payer $

(

John Brown, M.D. 111 Hospital Drive Anytown, USA 12345 b.

J. RENDERING PROVIDER ID. #

NPI

Services or Supplies

YES 31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof.)

H.

Plan

Column 24D- Procedures,

or dextrose, diluent/flush, 10 mL

6

G.

UNITS

$$$$

A4216 or J3490

2

F.

$ CHARGES

EPSDT DAYS Medication Charge Family OR

PHYSICIAN OR SUPPLIER INFORMATION

1.

NPI

)

b.

APPROVED OMB-0938-0999 FORM CMS-1500 (08-05)

© 2012 PO Box 290616 • WETHERSFIELD, CT 06109 • www.ReimbursementCodes.com

SAMPLE CMS-1450 (UB-04) FORM

How to bill for a drug without an assigned HCPCS for hospital outpatient departments __

__

4

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

2

__

1

__

6

5 FED. TAX NO.

8 PATIENT NAME

a

b

10 BIRTHDATE

11 SEX

MM/DD/YY

31 OCCURRENCE CODE DATE

F

Smith, Jane N. 12

32

DATE

9 PATIENT ADDRESS

ADMISSION 13 HR 14 TYPE 15 SRC 16 DHR 17 STAT

OCCURRENCE

33

18

19

20

34 OCCURRENCE CODE DATE

OCCURRENCE

DATE CODE CODE DATE Column 43Description

CONDITION CODES 24 22 23

21

35 CODE

7

STATEMENT COVERS PERIOD FROM THROUGH

MM/DD/YY MM/DD/YY Anytown, Anystate 12345

123 Main Street

a

b

TYPE OF BILL

c

25

26

27

36 CODE

OCCURRENCE SPAN FROM THROUGH

d

e

29 ACDT 30 STATE

28

37

OCCURRENCE SPAN FROM THROUGH

Indicate name, strength and NDC of 38

39 CODE

medication administered Example: Sodium Chloride, Injection, USP, 0.9% 64253-0202-30

1 2

CODE Column 47Total AMOUNT Charges

40 CODE

VALUE CODES AMOUNT

Indicate the facility’s actual charges

c

for products and procedures

44 HCPCS / RATE / HIPPS CODE

43 DESCRIPTION

0636

Sodium Chloride, 0.9% 64253-0202-30

3

VALUE CODES

b d

42 REV. CD.

41

VALUE CODES AMOUNT

a

45 SERV. DATE

C9399

46 SERV. UNITS

MM/DD/YY

47 TOTAL CHARGES

XX

48 NON-COVERED CHARGES

49

$$ $$

1 2 3

Column 42- Revenue Code(s)

Column 44- Product/

Column 46- Service Units

Enter appropriate product/procedure revenue

Procedure Code(s):

Enter the number of units of each product/

code(s)

Product Code:

service administered.

Product Revenue Codes:

Indicate the appropriate

Example: Enter 1 unit for 1 syringe

Example: 0636 “Drugs that require detail coding”

HCPCS for the drug

Please note: The number of billing units

Please note: revenue code requirements may

administered

required may vary by payer

5 6 7 8 9

PL

10 11

vary by payor. Check with payor to determine

Example: C9399

the appropriate revenue code for billing.

Unclassified drugs

12 13 14

16

18 19 20

22

PAGE

23

OF

50 PAYER NAME

SA

21

A B C

58 INSURED’S NAME

52 REL. INFO

53 ASG. BEN.

7 8 9 10 11

14 15

Box 56 - National Provider Identifier

18 19

assigned by CMS (Note: see also Boxes 76, 77,78,79)

21

23

55 EST. AMOUNT DUE

56 NPI 57

A

OTHER

B

PRV ID

C

62 INSURANCE GROUP NO.

61 GROUP NAME

59 P. REL 60 INSURED’S UNIQUE ID

20

22

TOTALS

54 PRIOR PAYMENTS

16 17

Enter appropriate NPI as

CREATION DATE

51 HEALTH PLAN ID

6

13

M

17

5

12

and biologicals

15

4

E

4

A

A

B

B

C

C

65 EMPLOYER NAME

64 DOCUMENT CONTROL NUMBER

63 TREATMENT AUTHORIZATION CODES A

A

B

B

C

C

66 DX

67 I

A J

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

B K a

b

C L

OTHER PROCEDURE CODE DATE

b.

OTHER PROCEDURE CODE DATE

e.

c

D M

71 PPS CODE OTHER PROCEDURE CODE DATE

E N 75

72 ECI

F O 76 ATTENDING

G P NPI

LAST c.

OTHER PROCEDURE CODE DATE

d.

OTHER PROCEDURE CODE DATE

77 OPERATING

81CC a

UB-04 CMS-1450

78 OTHER

b

LAST

c

79 OTHER

d

LAST

APPROVED OMB NO.

68

73

QUAL FIRST

NPI

LAST 80 REMARKS

H Q

QUAL FIRST

NPI

QUAL FIRST

NPI

QUAL FIRST

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

NUBC

™

National Uniform Billing Committee

LIC9213257

© 2012 PO Box 290616 • WETHERSFIELD, CT 06109 • www.ReimbursementCodes.com