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Please see page 2 for Indication and Important Safety Information. Please click here for full Prescribing Information. Miscellaneous coding and billing reference sheet: Hospital outpatient setting Sample UB-04 CMS-1450 claim form 2 for ADAKVEO ® (crizanlizumab-tmca) for IV infusion Hospital outpatient administration Although this sheet provides information that should facilitate the claims process, all coding information is for reference purposes only. Novartis does not guarantee payment. The health care billing environment is constantly evolving to keep pace with scientific advances and financial constraints. Information specific to billing and coding is subject to change and should be verified for each patient prior to treatment. A provider should contact patients’ payers directly for any revised or additional requirements, information, or guidance. IMPORTANT INFORMATION: The coding, coverage, and payment information contained herein is gathered from various resources, general in nature, and subject to change without notice. Third-party payment for medical products and services is affected by numerous factors. It is always the provider’s responsibility to determine the appropriate health care setting, and to submit true and correct claims for those products and services rendered. Providers should contact third-party payers for specific information on their coding, coverage, and payment policies. Information and materials are provided to assist health care providers, but the responsibility to determine coverage, reimbursement, and appropriate coding for a particular patient and/or procedure remains at all times with the provider. ADAKVEO Support at PANO | Phone: 1-800-282-7630 Monday-Friday, 9 AM to 8 PM ET | hcp.novartis.com/access/ 1 2 4 TYPE OF BILL FROM THROUGH 5 FED. TAX NO. a b c d DX ECI 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 A B C A B C D E F G H I J K L M N O P Q a b c a b c a b c d ADMISSION CONDITION CODES DATE OCCURRENCE OCCURRENCE OCCURRENCE OCCURRENCE SPAN OCCURRENCE SPAN CODE DATE CODE CODE CODE DATE CODE THROUGH VALUE CODES VALUE CODES VALUE CODES CODE AMOUNT CODE AMOUNT CODE AMOUNT TOTALS PRINCIPAL PROCEDURE a. OTHER PROCEDURE b. OTHER PROCEDURE NPI CODE DATE CODE DATE CODE DATE FIRST c. d. e. OTHER PROCEDURE NPI CODE DATE DATE FIRST NPI b LAST FIRST c NPI d LAST FIRST UB-04 CMS-1450 7 10 BIRTHDATE 11 SEX 12 13 HR 14 TYPE 15 SRC DATE 16 DHR 18 19 20 FROM 21 25 22 26 28 23 27 CODE FROM DATE OTHER PRV ID THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF. b . INFO BEN. CODE OTHER PROCEDURE THROUGH 29 ACDT 30 32 31 33 34 35 36 37 38 39 40 41 42 REV. CD. 43 DESCRIPTION 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49 52 REL 51 HEALTH PLAN ID 53 ASG. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI 57 58 INSURED’S NAME 59 P. REL 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO. 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME 66 67 68 69 ADMIT 70 PATIENT 72 73 74 75 76 ATTENDING 80 REMARKS OTHER PROCEDURE a 77 OPERATING 78 OTHER 79 OTHER 81CC CREATION DATE 3a PAT. CNTL # 24 b. MED. REC. # 44 HCPCS / RATE / HIPPS CODE PAGE OF APPROVED OMB NO. 0938-0997 e a 8 PATIENT NAME 50 PAYER NAME 63 TREATMENT AUTHORIZATION CODES 6 STATEMENT COVERS PERIOD 9 PATIENT ADDRESS 17 STAT STATE DX REASON DX 71PPS CODE QUAL LAST LAST National Uniform Billing Committee NUBC ™ OCCURRENCE QUAL QUAL QUAL CODE DATE A B C A B C A B C A B C A B C a b a b 0510 Clinic DX D57.1 ADAKVEO (crizanlizumab-tmca) infusion 300mg 96365 11152019 1 $$ 0636 N400078088361ME300 J3490,J3590 or C9053 11152019 1 $$ Enter the appropriate revenue code corresponding with the HCPCS code in box 44, which is required for billing the unclassified HCPCS code, and 0510 for clinic services (eg, 0636 revenue code for pharmacy drugs that require detailed coding). Enter a detailed drug description for the payer. The N4 indicator is listed first, the 11-digit National Drug Code number is listed second, a code describing the unit of measurement qualifier is listed third (eg, ME for milligrams), and the unit quantity is listed at the end. Example: N400078088361ME300 Enter the appropriate, not-otherwise- classified HCPCS code for ADAKVEO use as required by the payer. J3490, Unclassified drug; 3 or J3590, Unclassified biologics; 4 may be appropriate. C9053 1 may be appropriate for Medicare Part B as well as other types of payers. To report the administration procedure, enter an appropriate CPT code (eg, 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; initial, up to 1 hour). 5 Enter the total number of units of service. For ADAKVEO, payers may request that the miscellaneous code be billed at 1 unit. Please note that the appropriate number of units for an unclassified drug may vary by payer. For Medicaid, the units may vary by state also. Some payers may refer to the actual quantity administered via Box 43 and Box 80. Enter the total amount the facility actually charged for the product. Enter the appropriate ICD-10-CM diagnosis code (eg, D57.1 for Sickle cell disease without crisis). Code to the highest level of specificity. Enter the drug name, the route of administration, and the amount administered. This can be required by payers when billing a miscellaneous HCPCS code. Box 42: Box 43: Box 44: Box 46: Box 47: Box 67A-67Q: Box 80: 42 43 44 46 47 67 A-Q 80 NEW C-CODE (C9053) 1 For ADAKVEO ® (crizanlizumab-tmca) Effective April 1, 2020
