This information is intended to support appropriate
claims completion when submitting claims for Vaprisol. It is important
to confirm claims completion requirements and accepted procedure and
diagnosis codes with the specific payer before submitting claims. For
general billing instructions on the UB-04 (CMS-1450), visit the National
Uniform Billing Committee Web site1 or reference the appropriate Medicare Claims Processing Manual2.
| Form Locator 42 | Revenue Codes - Used for hospital inpatient services
- Report appropriate revenue code to describe cost center for service or procedure
- Some payers may require certain combinations of revenue codes and HCPCS codes in some circumstances to facilitate claims processing and assignment of payment to services
|
| Form Locator 43 | Description - Used for hospital inpatient services
- Typically, not a required field; information included here assists in manual clerical review of claims
- If required by state for Medicaid drug rebate processes, may be used to capture NDC for Vaprisol or other drugs used during patient encounter
|
| Form Locator 44 | HCPCS Codes - Used for hospital inpatient and outpatient services
- Report appropriate procedure or drug codes based on services provided during patient encounter according to medical record documentation
- Modifiers may be appended directly to HCPCS and Current Procedural Terminology (CPT) codes3 in this field without a preceding dash
- Because Vaprisol does not have a unique HCPCS code, include J3490 to report its use
|
| Form Locator 46 | Service Units - Used for hospital inpatient services
- Report the number of times services or procedures being reported were performed during the encounter according to medical record documentation
- Guidelines for reporting number of units for J3490 vary by payer. Drugs reported with "Unclassified" codes are typically reported with one unit per single dose vial (SDV). Some payers may recommend reporting 1 unit of J3490 and completing Form Locator 80 to provide details about the quantity administered. Confirm payer-specific guidelines to ensure clean claim submission
|
| Form Locators 67 and 67A-67Q | Diagnosis Codes - Used for hospital inpatient services
- Report appropriate code(s) based on patient diagnoses and conditions according to medical record documentation
- Fields 67A-67Q are for additional conditions diagnosis
|
| Form Locators 74 and 74A-74E | Procedure Codes - Used for hospital inpatient services
- Report appropriate code based on services provided during patient encounter according to medical record documentation
|
| Form Locator 80 | Remarks - Used for hospital inpatient services
- Some payers may require completion of this field to report additional information related to any miscellaneous codes included on the form. To provide additional detail about Vaprisol, relevant information may include the drug name, NDC, dose administered, and route of administration. Confirm payer-specific guidelines to ensure clean claim submission
|
