Interactive UB-04 (CMS-1450) Tutorial

Below is a sample UB-04 (CMS-1450) claim form for hospital outpatient administration. Expand the marked field letter accordions to reveal the corresponding line-item instructions and billing outputs from the REBLOZYL tool to help complete the CMS-1450 form.

CMS-1450 tutorial form

This sample form is for informational purposes only. UB-04 is used for reimbursement of REBLOZYL administered in an institutional setting, such as a hospital, a clinic, or an ambulatory surgical center. Providers must submit a UB-04 claim form documenting the drug administered and associated services.

A claim for REBLOZYL should include the following:
  • A proper HCPCS code to define the drug and billing unit
  • The quantity of billing units provided to the patient
  • A CPT code that indicates how the physician administered the drug

The accurate completion of reimbursement- or coverage-related documentation is the responsibility of the healthcare provider and the patient. Bristol Myers Squibb and its agents make no guarantee regarding reimbursement for any service or item.

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4-digit revenue code that best describes the service provided, in accordance with hospital billing policy. CMS recommends using revenue code 0636 (drugs requiring detailed coding).

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Enter the modifier "N4" followed by the 11-digit NDC. Beginning with the position 14 enter the unit of measure (UN) and the quantity administered.

For example,

use "N459572077501UN300"

for one 75-mg vial, and

use “N459572071101UN100”

for one 25-mg vial.

75-mg vial(s):
XXXX
NDC: 59572-0775-01
25-mg vial(s):
XXXX
NDC: 59572-0711-01
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Enter HCPCS code for REBLOZYL and code for the outpatient service; modifier[s],* if applicable.

It is required to enter J0896 and JW modifier on a separate line to record waste. Alternatively, if no wastage, enter J0896 and JZ modifier to attest there were no discarded amounts.

J-Code
J0896
CPT Code*
XXXX

*Any outpatient red blood cell transfusions given to address hemoglobin levels in patients with beta thalassemia or MDS entail their own set of HCPCS and CPT codes and revenue codes. Certain level II HCPCS codes and CPT codes require the use of modifiers to improve coding accuracy.

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75-mg vial
Administered Units
Waste Units
25-mg vial
Administered Units
Waste Units

Each non-zero value shown in the table above must be entered on a separate line on the claim form.

Additionally, it is required to enter the JW modifier in the same line where waste units are reported. Alternatively, if no wastage, enter the JZ modifier in the same line where administered units are reported to attest there were no discarded amounts.

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Enter the ICD-10-CM code.

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Some payers require detailed information about the drug in line 80. Typically, payers require the drug name, total dosage and strength, method of administration, 11-digit NDC, and basis of measurement.

This sample form is for informational purposes only. UB-04 is used for reimbursement of REBLOZYL administered in an institutional setting, such as a hospital, a clinic, or an ambulatory surgical center. Providers must submit a UB-04 claim form documenting the drug administered and associated services.

A claim for REBLOZYL should include the following:
  • A proper HCPCS code to define the drug and billing unit
  • The quantity of billing units provided to the patient
  • A CPT code that indicates how the physician administered the drug

The accurate completion of reimbursement- or coverage-related documentation is the responsibility of the healthcare provider and the patient. Bristol Myers Squibb and its agents make no guarantee regarding reimbursement for any service or item.