This information is intended to support appropriate claims completion when submitting claims for Mycamine. 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 Manual.2
| Form Locator 42 |
Revenue Codes
- Used for hospital inpatient and outpatient 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
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| Form Locator 43 |
Description
- Used for hospital inpatient and outpatient 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 Mycamine or other drugs used during patient encounter
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| 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 reflected in medical record documentation
- Modifiers may be appended directly to HCPCS and CPT3 codes in this field without a preceding dash
- Include J2248 to report use of Mycamine
- Some payers may require Mycamine to be reported on the same claim as its administration. It is important to confirm claims requirements on a payer-specific basis
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| Form Locator 46 |
Service Units
- Used for hospital inpatient and outpatient services
- Report the number of times services or procedures being reported were performed during the encounter reflected in medical record documentation
- One unit of the code for Mycamine represents 1 mg (partial vial). Report the appropriate number of units based on the amount of Mycamine provided to the patient. To report use of an entire 50-mg vial, it is appropriate to report 50 units of J2248
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| Form Locators 67 and 67A-67Q |
Diagnosis Codes
- Used for hospital inpatient and outpatient services
- Report appropriate code(s) based on patient diagnoses and conditions reflected in medical record documentation
- Field 67 is typically for the patient’s principal diagnosis
- Fields 67A-67Q are for additional conditions
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| Form Locators 74 and 74A-74E |
Procedure Codes
- Used for hospital inpatient services
- Report appropriate code based on services provided during patient encounter reflected in medical record documentation
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