Interactive CMS-1500 Tutorial

Below is a sample CMS-1500 claim form for physician office administration. Expand the marked field letter accordions to reveal corresponding line-item instructions and billing outputs from the REBLOZYL tool to help complete the CMS-1500 form.

CMS-1500 tutorial form

This sample form is for informational purposes only. In addition to coding specifics, some payers may require additional information, such as a drug purchase invoice or documentation of medical necessity.

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 patient. Bristol Myers Squibb and its agents make no guarantee regarding reimbursement for any service or item.

tutorial-icon-a

Many payers require detailed information about the drug in Box 19. Typically, payers require the drug name, total dosage and strength, method of administration, 11-digit NDC, and basis of measurement.

tutorial-icon-b

Enter the ICD-10-CM code.

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NDC information is required in the shaded area above the line on which a drug is reported in 24D. The NDC is preceded by the qualifier N4 and followed by the quantity qualifier (UN) and the quantity administered beginning in position 14.

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
tutorial-icon-d

Enter the appropriate HCPCS code for REBLOZYL, and CPT code and other appropriate CPT code(s)* for drug administration services.

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.

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Enter the diagnosis code reference letter or number from Box 21 that relates to the date of service and the services or procedures performed that is entered on that same line under 24D.

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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.

This sample form is for informational purposes only. In addition to coding specifics, some payers may require additional information, such as a drug purchase invoice or documentation of medical necessity.

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 patient. Bristol Myers Squibb and its agents make no guarantee regarding reimbursement for any service or item.