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Sample UB-04 Claim Form INFUSION ROOM/CHEMOTHERAPY SERVICES Single Drug with unique separately payable HCPCS Drug classification supports assignment of Chemotherapy Administration HCPCS has K status indicator meaning that the drug is separately payable under OPPS MM/DD/YY Column 47 Total Charges Indicate the facility s actual charges for products and procedures. Column 43 Description Description of services/products provided* Chemotherapy Injected Antineoplastic hormonal injection Drugs/Detail Code Alfa Non-ESRD 1000 units 96402 J0885 X Product Revenue Codes Enter appropriate revenue code for product administered Ex. 250General Pharmacy 636 - Drugs That Require Detail Coding Enter the number of units of each product/service administered* Column 44 Product/Procedure Code s Enter the appropriate HCPCS or CPT codes plus modifiers if applicable to identify the product/ service administered Procedure Revenue Codes type of service/procedure XXX. XX Column 46 Service Units Column 42 Revenue Code s provided* 123 Main Street Anytown Anystate 12345 Smith Jane D. Diagnosis Codes Box 67 code corresponding to a particular patient s diagnosis. This Billing Instruction Sheet is intended as a reference for potential coding billing and associated services. It is not intended to be a directive nor is it a suggestion about the likelihood of obtaining reimbursement. Physicians and staff may deem other codes or policies more appropriate. Providers should select the coding options that most accurately reflect a patient s condition their internal system guidelines payer requirements practice patterns and the services rendered* National Provider Identifier Box 56 Note see also Boxes 76 77 78 79. Column 43 Description Description of services/products provided* Chemotherapy Injected Antineoplastic hormonal injection Drugs/Detail Code Alfa Non-ESRD 1000 units 96402 J0885 X Product Revenue Codes Enter appropriate revenue code for product administered Ex. 250General Pharmacy 636 - Drugs That Require Detail Coding Enter the number of units of each product/service administered* Column 44 Product/Procedure Code s Enter the appropriate HCPCS or CPT codes plus modifiers if applicable to identify the product/ service administered Procedure Revenue Codes type of service/procedure XXX. 250General Pharmacy 636 - Drugs That Require Detail Coding Enter the number of units of each product/service administered* Column 44 Product/Procedure Code s Enter the appropriate HCPCS or CPT codes plus modifiers if applicable to identify the product/ service administered Procedure Revenue Codes type of service/procedure XXX. XX Column 46 Service Units Column 42 Revenue Code s provided* 123 Main Street Anytown Anystate 12345 Smith Jane D. XX Column 46 Service Units Column 42 Revenue Code s provided* 123 Main Street Anytown Anystate 12345 Smith Jane D. Diagnosis Codes Box 67 code corresponding to a particular patient s diagnosis. This Billing Instruction Sheet is intended as a reference for potential coding billing and associated services.