CMS 1500 Form	UB-04 Form

One of the following CMS 1500 claim forms must be completed to obtain reimbursement. The following links with samples are provided for assistance in completing the appropriate form, (click on the links to view each form:)

• DRUG/PRODUCT ADMINISTERED - NO HCPCS DRUG/PRODUCT CODE ASSIGNED
• DRUG/PRODUCT WITH ASSIGNED HCPCS DRUG/PRODUCT CODE, STOCKED BY PHYSICIAN and ADMINISTERED AT THE OFFICE
• DRUG/PRODUCT ADMINISTRATION ONLY - (Patient obtains drug/product at pharmacy or specialty pharmacy supplies drug/product to the physician and physician administers)

PLEASE NOTE:

• HCPCS/CPT® Code for the drug/product being utilized must be placed in column 24D;
• Charge must be placed in column 24F;
• Quantity used (number of units, as per description of the HCPCS/CPT® Code chosen) must be placed in column 24G;

If an appropriate HCPCS Reimbursement Code for the drug/product utilized has not been issued by CMS, the following information must be provided on the CMS 1500 form:

1. In Column D put the appropriate Reimbursement Code for Non-Classified Drugs or Durable
    Medical Equipment/Supplies:

2. In Box 19 put the:

• Full name of the drug/product utilized, including strength, if applicable
• NDC (National Drug Code) number on the package used. This number is a 10- or 11-digit number that refers to the drug or product, strength, and package size produced by a certain drug manufacturer.

3. In Boxes 17, 24, 32 and 33:

• Enter the National Provider Identifier (NPI)

Administration Codes:

The Reimbursement Code(s) is only for the reimbursement of a medication and does not include the administration charge. All administration codes need to be billed on a separate line, i.e. 96372, 96401. The various Administration Codes and their descriptions can be found on the ReimbursementCodes.com website.

One of the following CMS 1500 claim forms must be completed to obtain reimbursement. The following links with samples are provided for assistance in completing the appropriate form:

• IMMUNIZATION ADMINISTRATION - FOR CHILD (NOT AN INFANT) DURING ROUTINE OFFICE VISIT
• IMMUNIZATION ADMINISTRATION - PRIMARY SERIES (DURING WELL-BABY VISIT/MULTIPLE VACCINES)
• IMMUNIZATION ADMINISTRATION - PRIMARY SERIES (NOT DURING ROUTINE OFFICE VISIT)
• VACCINE/TOXOID/IMMUNE GLOBULIN ADMINISTERED - NO VACCINE/TOXOID OR IMMUNE GLOBULIN CPT® CODE ASSIGNED

For Each Vaccine/Toxoid or Immune Globulin:

• The CPT® Code for the medication (Vaccine/Toxoid or Immune Globulin) being administered must be placed in column 24D.
• Medication charge must be placed in column 24F.
• Quantity of medication used (number of units), as per description of the Vaccine/Toxoid or Immune Globulin CPT® Code chosen, must be placed in column 24G.

If an appropriate CPT® Code for the vaccine/toxoid or immune globulin administered has not been issued by the AMA, the following information must be provided on the 1500 form:

1. In Column D the appropriate CPT® Code for Non-Classified Vaccines/Toxoids or Immune Globulins:
   • 90399: Unlisted Immune Globulin
   • 90749: Unlisted Vaccine/Toxoid
2. Also include in Box 19:
   • Full Name and strength of the vaccine/toxoid or immune globulin administered
   • NDC (National Drug Code) Number on the package used. This number is a 10 or 11 digit number that refers to the drug, strength and package size produced by a certain drug manufacturer.
3. In Boxes 17, 24, 32 and 33:
   • Enter the National Provider Identifier (NPI)

Administration Code:

If the medication to be billed is a vaccine, toxoid or immune globulin, include on a separate line, the appropriate administration code (i.e., 90471) on the CMS 1500 form. The Vaccine/Immune Globulin/Toxoid CPT® Code(s) is only for the reimbursement of a medication and does not include the administration charge. The various Vaccine/Immune Globulin/Toxoid Administration Codes and their descriptions can be found on the ReimbursementCodes.com website.

The following links with samples are provided for assistance in completing the UB-04 form. (click on the links to view each form)

• DRUG/PRODUCT ADMINISTERED – NO HCPCS OR PASS-THROUGH CODE ASSIGNED
• DRUG/PRODUCT WITH ASSIGNED HCPCS/PASS-THROUGH CODE ADMINISTERED
• EMERGENCY DEPARTMENT – SINGLE DRUG ADMINISTERED – STATUS "N" HCPCS CODE
• EMERGENCY DEPARTMENT – MULTIPLE DRUGS ADMINSTERED – STATUS "N" HCPCS CODE
• INFUSION ROOM/CHEMOTHERAPY SERVICES – STATUS "N" HCPCS CODE
• INFUSION ROOM/CHEMOTHERAPY SERVICES – STATUS "K" HCPCS CODE
• SELF ADMINISTERED DRUGS

Please Note - Guidelines for completing the UB-04 claim form:

Column 42: Revenue Code(s)

• Product Revenue Code(s) – appropriate product revenue code must be entered in box 42 (i.e. 250 "General Pharmacy", 636 "Drugs that require detail coding", etc.)
• Procedure Revenue Code(s) – appropriate procedure revenue code to identify service performed (i.e. 450 "ED Visit Level 4") and/or setting where service was performed (i.e. 360 "operating room", 510 "clinic", etc.)