CMS-1500 Completion Guide

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Reimbursement Services
Benefit Verification
Benefit Verification Process

Sample Summary of Benefits

Benefit Verification Q & A
Prior Authorization
Prior Authorization Assistance Process

Sample Summary
of Benefits
Billing and Claims Assistance
Coding and Claims Processing

Overview of Required Documentation for Mycamine

Relevant Codes for Mycamine

Quarterly Coding and Billing Reference Sheets

CMS-1500 Completion Guide

Sample CMS-1500 Claim Form

CMS-1450 Completion Guide

Sample CMS-1450 Claim Form

Claims and Billing Assistance Process

Appealing Claims

Billing and Claims
Q & A

CMS-1500 Completion Guide

This information is intended to support appropriate claims completion when submitting claims for Mycamine. It is important to confirm payer-specific claims completion requirements and accepted procedure and diagnosis codes before submitting claims. For general billing instructions on the CMS-1500, reference the appropriate Medicare Claims Processing Manual.¹

Items 17, 17a, 17b	Name of Referring Provider Document the name, UPIN, and NPI of the physician requesting or ordering the services for the patient The NPI of the referring physician is required information in 17B
Item 19	Reserved for Local Use Used to capture additional data to support claims review, including: Concise descriptions of services billed using unlisted procedure codes Applicable modifiers if multiple modifiers are required for a CPT² or HCPCS code Sometimes used to report prior authorization numbers for private payers and Medicaid plans
Item 21	Diagnosis Codes Report appropriate code(s) based on patient diagnoses and conditions reflected in medical record documentation Codes should be entered in priority order and to the highest level of specificity
Item 23	Prior Authorization Number Used for various purposes by Medicare Sometimes used to report prior authorization numbers for private payers and Medicaid plans
Item 24	Shaded Portion If required by state for Medicaid drug rebate processes, may be used to capture NDC for Mycamine or other drugs used during patient encounter For Mycamine, enter “N4” followed by 11-digit NDC; for example, to report use of one 50-mg vial of Mycamine: N400469325010
Item 24D	Procedures, Services, or Supplies Report appropriate procedure or drug codes based on services provided during patient encounter reflected in medical record documentation Up to 4 modifiers can be reported following the CPT or HCPCS code 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
Item 24E	Diagnosis Pointer Report the number (1,2,3, or 4) corresponding to the diagnosis code from Item 23 that is most relevant to the service or procedure described
Item 24G	Days or Units 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
Item 24J	Rendering Provider ID Document the NPI of the physician rendering services to the patient in the unshaded portion
Item 32a	NPI Document the NPI of the service facility
Item 33a	NPI Document the NPI of the billing provider or group

1. http://www.cms.hhs.gov/Manuals/IOM/list.asp

2. Current Procedural Terminology (CPT), Professional Edition, 2009. American Medical Association, 2008. All rights reserved. No fee schedules, basic units, relative
values, or related listings are included in CPT. The AMA assumes no responsibility for the data contained herein. CPT is a registered trademark of the American
Medical Association.

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