Included in CMS/JCAHO Core Measures for CAP*

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1 Inluded in S/JHO ore esures for P* TELRO illing nd oding Guide orest Lortories, In. * TELRO (eftroline fosmil) is one of the reommended -ltm ntiiotis for ommunity-quired Pneumoni in Immunoompetent Ptients Non-IU Ptients. PN-, -. Speifitions nul for Ntionl Hospitl Inptient Qulity esures, Version.0. Dishrges 0-0- (Q) through 0-0- (Q). Joint ommission on redittion of Helthre Orgniztions (JHO) is now known s The Joint ommission. S=enters for edire nd ediid Servies. TELRO is registered trdemrk used y orest Lortories, In.

2 Introdution This guide hs een designed to provide helthre professionls with informtion relted to the insurne reimursement environment for TELRO (eftroline fosmil). In this guide, you will find informtion on: TELRO (eftroline fosmil) Inditions nd Usge Dosge nd dministrtion Storge Informtion Importnt Sfety Informtion ull Presriing Informtion TELRO Reimursement oding Interntionl lssifition of Diseses th Revision linil odifition (ID--) Dignosis odes Interntionl lssifition of Diseses th Revision linil odifition (ID--) Proedure odes Ntionl Drug odes (NDs) Helthre ommon Proedure oding System (HPS) odes Not Otherwise lssified HPS odes urrent Proedurl Terminology (PT) Drug dministrtion odes Pyor overge edire ediid ommeril Insurers heklist for lim Sumission Informtion urrent s of Jnury 0. Pyor Reimursement edire ediid ommeril Insurers Smple S-00 lim orm How physiin offies my ill for produt not ssigned permnent HPS ode Smple S-0 (U-0) lim orm How hospitl filities my ill for produt ssigned pss-through HPS ode The TELRO Reimursement Hotline provides helthre professionls with nswers to generl questions out TELRO insurne overge nd reimursement. reimursement hotline ssoite will reserh overge nd verify enefits, provide oding nd illing informtion, s well s investigte nd provide ess informtion. overge nd pyment depend on ptient s individul insurne pln. Therefore, it is reommended tht n individul s insurne enefits for overge of TELRO e verified. TELRO Reimursement Hotline -- ville ondy-ridy :00 to :00 P (Estern Time) x: --00 Visit The TELRO Reimursement Hotline provides ssistne with: Reimursement Verifition of enefit nd overge informtion Verifition of third-prty insurne overge for ptients presried or requiring TELRO Identifition of insurne forms nd/or douments tht re required s well s phone/fx numer or wesite to otin forms Identifition of prior uthoriztion nd step-edit requirements oding nd illing ID-- Dignosis odes ID-- Proedure odes Ntionl Drug odes (NDs) Helthre ommon Proedure oding System (HPS) TELRO permnent J-ode: J0 IV dministrtion, infusion odes orest Lortories, In. nnot gurntee pyment of ny lim. oding, overge, nd reimursement my vry signifintly y the pyor, pln, ptient, nd setting of re. tul overge nd reimursement deisions re mde y individul pyors following the reeipt of lims. or dditionl informtion, ustomers should onsult with their pyors for ll relevnt oding, reimursement, nd overge requirements. It is the sole responsiility of the provider to selet the proper ode nd ensure the ury of ll lims sumitted for reimursement. ll servies must e medilly pproprite nd properly supported in the ptient medil reord.

3 TELRO Inditions nd Usge TELRO is indited for the tretment of ptients with the following infetions used y suseptile isoltes of the designted miroorgnisms. ommunity-quired teril Pneumoni: TELRO is indited for the tretment of ommunityquired teril pneumoni (P) used y suseptile isoltes of the following Grm-positive nd Grm-negtive miroorgnisms: Streptoous pneumonie (inluding ses with onurrent teremi), Stphyloous ureus (methiillin-suseptile isoltes only), Hemophilus influenze, Klesiell pneumonie, Klesiell oxyto, nd Esherihi oli. ute teril Skin nd Skin Struture Infetions: TELRO is lso indited for the tretment of ute teril skin nd skin struture infetions (SSSI) used y suseptile isoltes of the following Grm-positive nd Grm-negtive miroorgnisms: Stphyloous ureus (inluding methiillinsuseptile nd -resistnt isoltes), Streptoous pyogenes, Streptoous gltie, Esherihi oli, Klesiell pneumonie, nd Klesiell oxyto. To redue the development of drug-resistnt teri nd mintin the effetiveness of TELRO nd other ntiteril drugs, TELRO should e used to tret only SSSI or P tht re proven or strongly suspeted to e used y suseptile teri. pproprite speimens for miroiologil exmintions should e otined in order to isolte nd identify the ustive pthogens nd to determine their suseptiility to eftroline. When ulture nd suseptiility informtion re ville, they should e onsidered in seleting or modifying ntiteril therpy. In the sene of suh dt, lol epidemiology nd suseptiility ptterns my ontriute to the empiri seletion of therpy. Dosge nd dministrtion The reommended dose of TELRO is 00 mg dministered every hours y intrvenous (IV) infusion over hour in ptients yers of ge. The durtion of therpy should e guided y the severity nd site of infetion nd the ptient s linil nd teriologil progress. The reommended dosge nd dministrtion y infetion is desried in the tle elow. Reommended Durtion Infusion Time of Totl ntimiroil Infetion Dosge requeny (hours) Tretment ute teril Skin nd 00 mg Every hours - dys Skin Struture Infetion (SSSI) ommunity-quired 00 mg Every hours - dys teril Pneumoni (P) The reommended dosge of TELRO in ptients with renl impirment is desried in the tle elow. Estimted rl (ml/min) Reommended Dosge Regimen for TELRO >0 No dosge djustment neessry >0 to 0 00 mg IV (over hour) every hours to 0 00 mg IV (over hour) every hours End-stge renl disese, inluding hemodilysis 00 mg IV (over hour) every hours retinine lerne (rl) estimted using the okroft-gult formul. End-stge renl disese is defined s rl < ml/min. TELRO is hemodilyzle; thus TELRO should e dministered fter hemodilysis on hemodilysis dys. Storge TELRO vils should e stored refrigerted t to ( to ). Unrefrigerted, unreonstituted TELRO n e stored t tempertures not exeeding º (º) for no more thn dys. Plese see Importnt Sfety Informtion on the following pges nd enlosed full Presriing Informtion. Studies hve shown tht the onstituted solution in the infusion g should e used within hours when stored t room temperture or within hours when stored under refrigertion t to ( to ).

4 TELRO Importnt Sfety Informtion ontrinditions TELRO is ontrindited in ptients with known serious hypersensitivity to eftroline or other memers of the ephlosporin lss. nphylxis nd nphyltoid retions hve een reported with eftroline. Wrnings nd Preutions Hypersensitivity Retions Serious nd osionlly ftl hypersensitivity (nphylti) retions nd serious skin retions hve een reported with et-ltm ntiterils. efore therpy with TELRO is instituted, reful inquiry out previous hypersensitivity retions to other ephlosporins, peniillins, or rpenems should e mde. If this produt is to e given to peniillin- or other et-ltm-llergi ptient, ution should e exerised euse ross sensitivity mong et-ltm ntiteril gents hs een lerly estlished. If n llergi retion to TELRO ours, the drug should e disontinued. Serious ute hypersensitivity (nphylti) retions require emergeny tretment with epinephrine nd other emergeny mesures tht my inlude irwy mngement, oxygen, intrvenous fluids, ntihistmines, ortiosteroids, nd vsopressors s linilly indited. lostridium diffiile-ssoited Dirrhe lostridium diffiile-ssoited dirrhe () hs een reported for nerly ll systemi ntiteril gents, inluding TELRO, nd my rnge in severity from mild dirrhe to ftl olitis. reful medil history is neessry euse hs een reported to our more thn months fter the dministrtion of ntiteril gents. If is suspeted or onfirmed, ntiterils not direted ginst. diffiile should e disontinued, if possile. Diret ooms Test Seroonversion Seroonversion from negtive to positive diret ooms test result ourred in 0/ (0.%) of ptients reeiving TELRO nd / (.%) of ptients reeiving omprtor drugs in the four pooled Phse trils. No dverse retions representing hemolyti nemi were reported in ny tretment group. If nemi develops during or fter tretment with TELRO, drug-indued hemolyti nemi should e onsidered. If drug-indued hemolyti nemi is suspeted, disontinution of TELRO should e onsidered nd supportive re should e dministered to the ptient if linilly indited. orest Lortories, In. nnot gurntee pyment of ny lim. oding, overge, nd reimursement my vry signifintly y the pyor, pln, ptient, nd setting of re. tul overge nd reimursement deisions re mde y individul pyors following the reeipt of lims. or dditionl informtion, ustomers should onsult with their pyors for ll relevnt oding, reimursement, nd overge requirements. It is the sole responsiility of the provider to selet the proper ode nd ensure the ury of ll lims sumitted for reimursement. ll servies must e medilly pproprite nd properly supported in the ptient medil reord. Development of Drug-Resistnt teri Presriing TELRO in the sene of proven or strongly suspeted teril infetion is unlikely to provide enefit to the ptient nd inreses the risk of the development of drug-resistnt teri. dverse Retions In the four pooled Phse linil trils, serious dverse events ourred in /00 (.%) of ptients reeiving TELRO nd 00/ (.%) of ptients reeiving omprtor drugs. Tretment disontinution due to dverse events ourred in /00 (.%) of ptients reeiving TELRO nd / (.%) of ptients reeiving omprtor drugs with the most ommon dverse events leding to disontinution eing hypersensitivity for oth tretment groups t rte of 0.% in the TELRO group nd 0.% in the omprtor group. No dverse retions ourred in greter thn % of ptients reeiving TELRO. The most ommon dverse retions ourring in >% of ptients reeiving TELRO in the pooled Phse linil trils were dirrhe, nuse, nd rsh. Drug Intertions No linil drug-drug intertion studies hve een onduted with TELRO. There is miniml potentil for drugdrug intertions etween TELRO nd YP0 sustrtes, inhiitors, or induers; drugs known to undergo tive renl seretion; nd drugs tht my lter renl lood flow. Use in Speifi Popultions TELRO hs not een studied in pregnnt women. Therefore, TELRO should only e used during pregnny if the potentil enefit justifies the potentil risk to the fetus. It is not known whether eftroline is exreted in humn milk. euse mny drugs re exreted in humn milk, ution should e exerised when TELRO is dministered to nursing womn. Sfety nd effetiveness in peditri ptients hve not een estlished. euse elderly ptients, those yers of ge, re more likely to hve deresed renl funtion nd eftroline is exreted primrily y the kidney, re should e tken in dose seletion in this ge group nd it my e useful to monitor renl funtion. Dosge djustment for elderly ptients should therefore e sed on renl funtion. Dosge djustment is required in ptients with moderte (rl >0 to 0 ml/min) or severe (rl to 0 ml/min) renl impirment nd in ptients with end-stge renl disese (rl < ml/min). The phrmokinetis of eftroline in ptients with hepti impirment hve not een estlished. Plese lso see enlosed full Presriing Informtion.

5 TELRO Reimursement oding ID-- Dignosis odes Providers should use urrent ID-- odes to report ptient s dignosis on lim sumissions. orret oding is the responsiility of the provider sumitting lim for the item or servie. Plese hek with the pyor to verify oding or speil illing requirements. elow is list of possile ID-- dignosis odes tht my e resonly relted to dignosis within the produt s pproved lel: ID-- Dignosis ode -.XX 0.XX-.XX Desription Diseses of the respirtory system teril pneumoni-designted pthogens only Infetions of skin nd suutneous tissue (designted pthogens limited to SSSI) 0.0 Other Streptoous (use for Streptoous pyogenes nd Streptoous gltie only) 0. ethiillin-suseptile Stphyloous ureus (SS) 0. Stphyloous ureus (methiillin-resistnt Stphyloous ureus [RS]) 0.0 Klesiell pneumonie (skin infetion) 0. Esherihi oli (skin infetion) ID-- Proedure odes Providers should use urrent ID-- proedure odes to report mjor proedure when it is performed in the hospitl inptient setting. t lest one ID-- proedure ode is required on hospitl inptient lims long with the pproprite dignosis odes. orret oding is the responsiility of the provider sumitting lim for the item or servie. Plese hek with the pyor to verify oding or speil illing requirements. elow is n exmple of possile ID-- proedure ode relted to proedure performed within the produt s pproved lel: ID-- Proedure ode Ntionl Drug odes (NDs) NDs help physiins nd pyors identify speifi produt pkge sizes. TELRO is supplied in single-use, ler glss vils ontining either 00 mg or 00 mg of sterile eftroline fosmil powder. The ND numers for TELRO re listed elow: TELRO Pkge Size ND 00 mg individul vil rton ontining 0 vils Desription. Injetion of ntiioti TELRO Pkge Size Some pyors require physiins to use -digit NDs when sumitting drug on lim form. onverting the 0-digit ND for TELRO to n -digit ND requires the use of leding zero in the produt ode setion of the ND (ie, the middle setion): ND 00 mg individul vil rton ontining 0 vils Other Grm-negtive orgnisms (use for Klesiell oxyto only).x Postopertive infetion 0-Digit ND Exmple -Digit ND Exmple With Leding Zero TELRO TELRO -Digit ND 0-Digit ND With Leding Zero Note: Informtion in prentheses dded for lrifition We reommend verifying helth pln s oding poliies prior to ontting the orest Reimursement Hotline. orest Lortories, In. nnot gurntee pyment of ny lim. oding, overge, nd reimursement my vry signifintly y the pyor, pln, ptient, nd setting of re. tul overge nd reimursement deisions re mde y individul pyors following the reeipt of lims. or dditionl informtion, ustomers should onsult with their pyors for ll relevnt oding, reimursement, nd overge requirements. It is the sole responsiility of the provider to selet the proper ode nd ensure the ury of ll lims sumitted for reimursement. ll servies must e medilly pproprite nd properly supported in the ptient medil reord. enters for edire nd ediid Servies. ID- Provider Dignosti nd Proedure odes. Downlods: Version ull nd revited ode Titles Effetive Otoer, 0. V LONG_SHORT_DX000 file. Informtion ville on essed Deemer, 0.

6 PT. TYPE NTL # O ILL. ED. RE. # STTEENT OVERS PERIOD ED. TX. PTIENT NE PTIENT RESS d e 0 IRTHDTE DISSION ONDITION S DTE HR TYPE SR DHR DT 0 STT 0 STTE OURRENE OURRENE OURRENE OURRENE OURRENE SPN OURRENE SPN DTE DTE DTE DTE VLUE S 0 VLUE S VLUE S OUNT OUNT OUNT d REV. D. DESRIPTION HPS / RTE / HIPPS SERV. DTE SERV. UNITS TOTL HRGES N-OVERED HRGES REL. SG. 0 PYER NE HELTH PLN ID PRIOR PYENTS EST. OUNT DUE INO EN. OTHER PRV ID INSURED S NE P.REL 0 INSURED S UNIQUE ID GROUP NE INSURNE GROUP. TRETENT UTHORIZTION S DOUENT ONTROL NUER EPLOYER NE DX DIT 0 PTIENT PPS DX RESON DX EI PRINIPL PROEDURE. OTHER PROEDURE. OTHER PROEDURE DTE DTE DTE TTENDING QUL LST IRST. OTHER PROEDURE d. OTHER PROEDURE e. OTHER PROEDURE DTE DTE OPERTING QUL DTE LST IRST 0 RERKS OTHER QUL LST IRST OTHER QUL d LST IRST U-0 S-0 PPROVED O. THE ERTIITIONS ON THE REVERSE PPLY TO THIS ILL ND RE DE PRT HEREO. Ntionl Uniform LI TELRO Reimursement Helthre ommon Proedure oding System (HPS) Level II ode HPS odes re -digit lphnumeri odes tht re ssigned to drugs y the enters for edire * nd ediid Servies (S). When illing for drug, pyors require physiins to indite, on the lim, the quntity of produt dministered to the ptient, expressed in the numer of units desried y the HPS ode. S hs ssigned TELRO new, unique J-ode: J0. This ode is effetive Jnury, 0 nd should e used for reimursement of servies provided in hospitl outptient settings, physiin offie settings, nd freestnding IV infusion enters. Note tht S disontinued nd deleted HPS ode for TELRO nd repled it with the permnent HPS ode J0. 0 TELRO HPS ode Desription Setting of re J0 Injetion, eftroline fosmil, 0 mg Outptient (edire) No longer pplile s of Jnury, 0 (Use J0) PT. NTL #. ED. illing for Wstge Physiins nd hospitls re expeted to shedule ptients in RE. suh # wy tht they n use drugs STTEENT OVERS PERIOD ED. TX. most effiiently, in linilly pproprite mnner. Drug wstge my e doumented in the ptient s medil reord with the dte, time, mount wsted, nd reson for wstge. Eh pyor my hve different poliies regrding drug PTIENT NE PTIENT RESS wstge nd my require physiins nd hospitls to inlude the mount of produt dministered nd the mount d 0 IRTHDTE DISSION ONDITION S DTE HR TYPE SR DHR DT 0 STT 0 STTE disrded when line-item illing for TELRO. It is reommended to verify the drug wstge requirements of the speifi helth pln. inlly, some pyors request tht physiins nd hospitls identify ny disrded produt y ppending the JW modifier to the lim. OURRENE OURRENE OURRENE OURRENE OURRENE SPN OURRENE SPN DTE DTE DTE DTE Exmple TELRO S-0 HPS illing for Wsted Produt: VLUE S 0 VLUE S VLUE OUNT OUNT OUNT REV. D. DESRIPTION HPS / RTE / HIPPS SERV. DTE SERV. UNITS TOTL HRGES N-OVERED HRG d J0 [no. of units] J0 JW [no. of units] illing for ultiple Doses in Single Dy In the outptient settings in whih TELRO is overed under edire Prt (ie, hospitl outptient, physiin offies, nd freestnding IV infusion enters), the two dministered doses should e illed t the sme time. The medil neessity for the two doses needs to e doumented on the illing form (ie, the ptient hs one of the indited onditions nd dosing regimen is lled for y the lel). linis should refer to the TELRO lel for pproprite dosing. 0 PGE O RETION DTE TOTLS D E G H I J K L N O P Q NU illing ommittee Enter pproprite numer of servie units: Using J0, report the numer of units of TELRO used To report the numer of units of TELRO wsted, ppend JW modifier to the lim J0 Informtion to Inlude With Use of HPS odes ND Drug nme Dose of produt Quntity dministered Route of dministrtion Pkging (eg, single-dose vil) 0 PGE O RETION DTE TOTLS 0 PYER NE HELTH PLN ID REL. INO SG. PRIOR PYENTS EST. OUNT DUE EN. * ommeril pyors nd stte ediid progrms my lso require use of the permnent J-ode nd/or ND. Plese review the riteri for eh speifi pln to identify if J-ode is neessry for illing nd oding. orest Lortories, In. nnot gurntee pyment of ny lim. oding, overge, nd reimursement my vry signifintly y the pyor, pln, ptient, nd setting of re. tul overge nd reimursement deisions re mde y individul pyors following the reeipt of lims. or dditionl informtion, ustomers should onsult with their pyors for ll relevnt oding, reimursement, nd overge requirements. It is the sole responsiility of the provider to selet the proper ode nd ensure the ury of ll lims sumitted for reimursement. ll servies must e medilly pproprite nd properly supported in the ptient medil reord. OTHER PRV ID INSURED S NE P.REL 0 INSURED S UNIQUE ID GROUP NE INSURNE GROUP. TRETENT UTHORIZTION S DOUENT ONTROL NUER EPLOYER NE 0 DX D E G H

7 PPROVED Y NTIONL UNIOR LI OITTEE 0/0 PI PI. EDIRE EDIID TRIRE HPV GROUP E OTHER. INSURED S I.D. NUER (or Progrm in Item ) HPUS HELTH PLN LK LUNG (edire #) (ediid #) (Sponsor s SSN) (emer ID#) (SSN or ID) (SSN) (ID). PTIENT S NE (Lst Nme, irst Nme, iddle Initil). PTIENT S IRTH DTE. INSURED S NE (Lst Nme, irst Nme, iddle Initil). PTIENT S RESS (No., Street). PTIENT RELTIONSHIP TO INSURED. INSURED S RESS (No., Street) Self Spouse hild Other ITY STTE. PTIENT STTUS ITY STTE Single rried Other ZIP TELEPHONE (Inlude re ode) ZIP TELEPHONE (Inlude re ode) ull-time Prt-Time Employed Student Student. OTHER INSURED S NE (Lst Nme, irst Nme, iddle Initil) 0. IS PTIENT S ONDITION RELTED TO:. INSURED S POLIY GROUP OR E NUER. OTHER INSURED S POLIY OR GROUP NUER. EPLOYENT? (urrent or Previous). INSURED S DTE O IRTH. OTHER INSURED S DTE O IRTH. UTO IDENT?. EPLOYER S NE OR SHOOL NE PLE (Stte). EPLOYER S NE OR SHOOL NE. OTHER IDENT?. INSURNE PLN NE OR PROGR NE d. INSURNE PLN NE OR PROGR NE 0d. RESERVED OR LOL USE d. IS THERE THER HELTH ENEIT PLN? If yes, return to nd omplete item -d. RED K O OR EORE OPLETING & SIGNING THIS OR.. INSURED S OR UTHORIZED PERSON S SIGNTURE I uthorize. PTIENT S OR UTHORIZED PERSON S SIGNTURE I uthorize the relese of ny medil or other informtion neessry pyment of medil enefits to the undersigned physiin or supplier for to proess this lim. I lso request pyment of government enefits either to myself or to the prty who epts ssignment servies desried elow. elow. DTE. DTE O URRENT: ILLNESS (irst symptom) OR. I PTIENT HS HD SE OR SIILR ILLNESS.. DTES PTIENT UNLE TO WORK IN URRENT OUPTION INJURY (ident) OR GIVE IRST DTE PREGNNY(LP) TO. NE O REERRING PROVIDER OR OTHER SOURE.. HOSPITLIZTION DTES RELTED TO URRENT SERVIES. TO. RESERVED OR LOL USE 0. OUTSIDE L? $ HRGES. DIGSIS OR NTURE O ILLNESS OR INJURY (Relte Items,, or to Item E y Line). EDIID RESUISSION ORIGINL RE..... PRIOR UTHORIZTION NUER.... DTE(S) O SERVIE.. D. PROEDURES, SERVIES, OR SUPPLIES E.. G. H. I. J. rom To PLE O (Explin Unusul irumstnes) DIGSIS DYS EPSDT OR mily ID. RENDERING SERVIE EG PT/HPS ODIIER POINTER $ HRGES UNITS Pln QUL. PROVIDER ID. #. EDERL TX I.D. NUER SSN EIN. PTIENT S OUNT.. EPT SSIGNENT?. TOTL HRGE. OUNT PID 0. LNE DUE (or govt. lims, see k) $ $ $. SIGNTURE O PHYSIIN OR SUPPLIER. SERVIE ILITY LOTION INORTION. ILLING PROVIDER INO & PH # INLUDING DEGREES OR REDENTILS (I ertify tht the sttements on the reverse pply to this ill nd re mde prt thereof.).... DTE NU Instrution nul ville t: PPROVED O-0-0 OR S-00 (0-0) HPUS HELTH PLN LK LUNG (edire #) (ediid #) (Sponsor s SSN) (emer ID#) (SSN or ID) (SSN) (ID). PTIENT S NE (Lst Nme, irst Nme, iddle Initil). PTIENT S RESS (No., Street). PTIENT S IRTH DTE. PTIENT RELTIONSHIP TO INSURED Self Spouse hild Other. INSURED S NE (Lst Nme, irst Nme, iddle Initil). INSURED S RESS (No., Street) ITY STTE. PTIENT STTUS Single rried Other ZIP TELEPHONE (Inlude re ode) ull-time Prt-Time ( ) TELRO Reimursement Employed Student Student. OTHER INSURED S NE (Lst Nme, irst Nme, iddle Initil) 0. IS PTIENT S ONDITION RELTED TO:. OTHER INSURED S POLIY OR GROUP NUER. EPLOYENT? (urrent or Previous). OTHER INSURED S DTE O IRTH. UTO IDENT? PLE (Stte). EPLOYER S NE OR SHOOL NE. OTHER IDENT? d. INSURNE PLN NE OR PROGR NE 0d. RESERVED OR LOL USE ITY STTE ZIP TELEPHONE (Inlude re ode) ( ). INSURED S POLIY GROUP OR E NUER. INSURED S DTE O IRTH. EPLOYER S NE OR SHOOL NE. INSURNE PLN NE OR PROGR NE d. IS THERE THER HELTH ENEIT PLN? PTIENT ND INSURED INORTION If yes, return to nd omplete item -d. 00 HELTH INSURNE LI OR ( ) RED K O OR EORE OPLETING & SIGNING THIS OR.. PTIENT S OR UTHORIZED PERSON S SIGNTURE I uthorize the relese of ny medil or other informtion neessry to proess this lim. I lso request pyment of government enefits either to myself or to the prty who epts ssignment elow. Exmple TELRO S-00 lim orm HPS illing for Wsted Produt: DTE. DTE O URRENT:. RESERVED OR LOL USE ( ) ( ) ILLNESS (irst symptom) OR INJURY (ident) OR PREGNNY(LP). NE O REERRING PROVIDER OR OTHER SOURE. RRIER PTIENT ND INSURED INORTION PHYSIIN OR SUPPLIER INORTION. I PTIENT HS HD SE OR SIILR ILLNESS. GIVE IRST DTE. DIGSIS OR NTURE O ILLNESS OR INJURY (Relte Items,, or to Item E y Line) DTE(S) O SERVIE.. D. PROEDURES, SERVIES, OR SUPPLIES E. rom To PLE O (Explin Unusul irumstnes) DIGSIS SERVIE EG PT/HPS ODIIER POINTER. EDERL TX I.D. NUER SSN EIN. PTIENT S OUNT.. EPT SSIGNENT? (or govt. lims, see k). SIGNTURE O PHYSIIN OR SUPPLIER INLUDING DEGREES OR REDENTILS (I ertify tht the sttements on the reverse pply to this ill nd re mde prt thereof.). J0 J0 J W. INSURED S OR UTHORIZED PERSON S SIGNTURE I uthorize pyment of medil enefits to the undersigned physiin or supplier for servies desried elow.. DTES PTIENT UNLE TO WORK IN URRENT OUPTION TO. HOSPITLIZTION DTES RELTED TO URRENT SERVIES TO. EDIID RESUISSION ORIGINL RE... TOTL HRGE. OUNT PID 0. LNE DUE $ $ $.... DTE Hotline t: --- NU Instrution nul ville t: PPROVED O-0-0 OR S-00 (0-0) 0. OUTSIDE L? $ HRGES. PRIOR UTHORIZTION NUER. SERVIE ILITY LOTION INORTION. ILLING PROVIDER INO & PH #. G. H. I. J. DYS EPSDT OR mily ID. RENDERING $ HRGES UNITS Pln QUL. PROVIDER ID. # or more informtion on produt wstge illing requirements, plese ontt the orest Reimursement ( ) PHYSIIN OR SUPPLIER INORTION urrent Proedurl Terminology (PT) Drug dministrtion ode PT odes re -digit numeri odes estlished y the merin edil ssoition () tht desrie professionl medil proedures nd servies. TELRO is dministered every hours s n intrvenous (IV) infusion over hour. The following possile PT odes my e pproprite to report TELRO dministrtion servies sed on site of servie: PT ode Desription IV infusion for therpy, prophylxis, or dignosis (speify sustne or drug); initil, up to hour 0 Home infusion/speilty drug dministrtion, per visit (up to hours) Pyors my require physiins to report different drug dministrtion ode when illing for TELRO. It is reommended to verify helth pln s oding poliies. The orest Reimursement Hotline n provide helthre professionls with nswers to generl questions out TELRO overge nd reimursement t: --- Revenue odes Revenue odes pture fility ost dt y deprtment, whih the fility uses for ost-reporting purposes. Some pyors request tht providers report revenue odes on lim forms. Hospitl outptient deprtments my report the following possile revenue odes for TELRO : Revenue ode Desription 00 Generl phrmy 00 Intrvenous therpy, generl 0 Drugs requiring detiled oding orest Lortories, In. nnot gurntee pyment of ny lim. oding, overge, nd reimursement my vry signifintly y the pyor, pln, ptient, nd setting of re. tul overge nd reimursement deisions re mde y individul pyors following the reeipt of lims. or dditionl informtion, ustomers should onsult with their pyors for ll relevnt oding, reimursement, nd overge requirements. It is the sole responsiility of the provider to selet the proper ode nd ensure the ury of ll lims sumitted for reimursement. ll servies must e medilly pproprite nd properly supported in the ptient medil reord. Hospitl Outptient PPS. Revenue odes. Revenue ode to ost enter rosswlk. Informtion ville on essed Septemer, 00.

8 TELRO Reimursement Pyor overge edire TELRO is likely to e eligile for overge under edire Prt when it is used in the hospitl inptient setting of re, if the drug represents ost to the hospitl, nd the drug is resonle nd neessry for the dignosis or tretment of the illness or injury for whih it is dministered, ording to epted stndrds of medil prtie TELRO my e overed y edire Prt when it is used in Skilled Nursing ility (SN) if: the drug represents ost to the SN; is neessry for the dignosis or tretment of the illness or injury for whih it is dministered, ording to epted stndrds of medil prtie; nd the ptient meets the eligiility requirements. The SN eligiility requirements inlude tht ptient must hve een n inptient of hospitl for medilly neessry sty of t lest three onseutive lendr dys, nd must hve een trnsferred to prtiipting SN within 0 dys fter hospitl dishrge. In order to e overed, the extended-re servies reeived must e needed for ondition whih ws treted during the ptient s qulifying hospitl sty, or for ondition whih rose while in the SN for tretment of ondition for whih the enefiiry ws previously treted in hospitl. If ll of these requirements re met regrding tretment, TELRO is likely to e eligile for overge under edire Prt Drugs dministered y physiin, in either the physiin s offie or freestnding lini, whih represent ost to the physiin s prtie, re generlly overed under edire Prt if () they re resonle nd neessry for the dignosis or tretment of the illness or injury for whih they re dministered, ording to epted stndrds of medil prtie; () they re not usully selfdministered; nd () they meet the requirements for overge of items s inident to physiin s servie. The generl requirements for overge under the inident to provision re tht the drug e of form tht is not usully self-dministered, tht the drug e furnished y physiin, nd tht the drug must e dministered y physiin or y uxiliry personnel employed y the physiin nd under the physiin s personl supervision. sed on these riteri, drugs suh s TELRO, when dministered y physiins in either the physiin s offie or freestnding lini, re likely to e eligile for edire Prt overge nd pyment orest Lortories, In. nnot gurntee pyment of ny lim. oding, overge, nd reimursement my vry signifintly y the pyor, pln, ptient, nd setting of re. tul overge nd reimursement deisions re mde y individul pyors following the reeipt of lims. or dditionl informtion, ustomers should onsult with their pyors for ll relevnt oding, reimursement, nd overge requirements. It is the sole responsiility of the provider to selet the proper ode nd ensure the ury of ll lims sumitted for reimursement. ll servies must e medilly pproprite nd properly supported in the ptient medil reord. TELRO my e overed y edire Prt when dministered in hospitl outptient deprtment if the drug represents ost to the hospitl; is resonle nd neessry for the dignosis or tretment of n illness or injury for whih it is dministered, ording to epted stndrds of medil prtie; nd is not usully self-dministered edire hs not issued unique Ntionl overge Determintion (ND) for TELRO. Lol edire dministrtive ontrtors (formerly isl Intermediries nd rriers) my mke lol overge deisions (LDs) for TELRO. Some lol ontrtors my pulish LDs or other overge instrution through rtiles nd ulletins tht relte to TELRO. However, the sene of pulished overge poliy does not men tht there is no overge for TELRO or more informtion on edire overge of TELRO, ontt the orest Reimursement Hotline t: --- ediid TELRO is eligile for overge under most stte ediid progrms. However, overge will vry from stte to stte s eh ediid progrm estlishes its own eligiility stndrds nd determines the type, mount, durtion, nd sope of servies. Some ediid progrms my over TELRO s medil enefit, phrmy enefit, or oth. In ddition, stte ediid progrms my pply overge nd utiliztion restritions suh s prior uthoriztion or more informtion on ediid overge of TELRO, ontt the orest Reimursement Hotline t: --- ommeril Insurers Third-prty pyors, inluding HO plns, mnged re orgniztions, indemnity plns, nd others my provide overge for TELRO. However, speifi overge requirements nd restritions depend on ptient s enefits nd will vry sed on pln type nd provider site of servie. Some pyors estlish forml pulished poliies, ut the lk of pulished poliy from prtiulr pyor does not men tht TELRO is not overed y tht pyor. In ddition, ommeril pyors my over physiin-dministered drugs s medil enefit, phrmy enefit, or oth. Eh enefit is dministered seprtely nd my hve different dedutile, o-pyment, nd/or oinsurne strutures or more informtion on ommeril overge of TELRO, ontt the orest Reimursement Hotline t: --- edire lims Proessing nul, hpter, Setion 0. See the edire enefits Poliy nul, hpter, setion 0 for further informtion. edire enefits Poliy nul, hpter, Setion 0. Informtion ville on gov/nuls/io/itemdetil.sp?filtertype=none&filterydid=&sortydid=&sortorder= sending&itemid=s0&intnumperpge=0. essed Septemer, 00.

9 TELRO Reimursement Pyor Reimursement edire Prt TELRO Hospitl Inptient Deprtment Servies pid under the edire Hospitl Inptient Prospetive Pyment System (PPS) re ssigned to edire Severity Dignosis Relted Group (S-DRG). Eh S-DRG is linked to pyment mount tht represents the pyment for ll servies provided during ptient s sty in the hospitl. The ost of tretment for TELRO is undled into the S-DRG pyment nd is not eligile for seprte reimursement from edire in the inptient setting TELRO Skilled Nursing ility SN servies re pid y edire under prospetive pyment system (PPS). The SN PPS undles ll servies into per diem rte, whih inludes most dministered drugs. Pyment for TELRO would e undled into the per diem rte nd is not eligile for seprte reimursement from edire in the Skilled Nursing ility Setting TELRO dministrtion Servies: Hospitl Inptient Deprtment edire Prt reimursement for TELRO drug dministrtion servies provided in the hospitl inptient setting is undled into the S-DRG PPS pyment. The ost of tretment for TELRO is undled into the S-DRG pyment nd is not eligile for seprte reimursement from edire in the inptient setting edire Prt Pyment for TELRO nd relted dministrtion servies will vry y setting of re. TELRO Physiin lini or most physiin-dministered produts eligile for edire overge, edire sets n llowle pyment mount, updted qurterly, t verge Sles Prie (SP) +%., edire reimursement is sed on the lesser of this llowle mount or tul hrges s follows: physiin linis re reimursed for 0% of the llowle mount, nd the ptient or ptient s seondry insurer is responsile for the remining 0% oinsurne 0 TELRO: Hospitl Outptient Deprtment Servies pid under the edire Hospitl Outptient Prospetive Pyment System (OPPS) re ssigned to n multory Pyment lssifition (P) ode. Eh P ode is linked to pyment mount. ultiple Ps my e illed per single ptient enounter. ertin newly D-pproved drugs nd iologis my e grnted trnsitionl pss-through sttus nd unique -ode, with the drug eing reimursed t SP +%, if S deems these drugs new for edire purposes. In ddition, seprte pyments re mde for some drugs, iologils, nd devies. ost drugs tht do not hve pss-through sttus, nd re seprtely reimursed y edire under the P system, re pid t SP +% in 0 nd djusted qurterly. TELRO hs een grnted pss-through sttus for lendr Yer (Y) 0. s result, in Y 0 TELRO will e reimursed t SP +%. TELRO dministrtion Servies: Skilled Nursing ility edire Prt reimursement for TELRO drug dministrtion servies provided in the Skilled Nursing ility setting is undled into the SN PPS pyment. The ost of tretment for TELRO is undled into the SN PPS pyment nd is not eligile for seprte reimursement from edire in the Skilled Nursing ility setting edire lims Proessing nul, hpter, Setion 0. edire lims Proessing nul, hpter, Setion 0. orest Lortories, In. nnot gurntee pyment of ny lim. oding, overge, nd reimursement my vry signifintly y the pyor, pln, ptient, nd setting of re. tul overge nd reimursement deisions re mde y individul pyors following the reeipt of lims. or dditionl informtion, ustomers should onsult with their pyors for ll relevnt oding, reimursement, nd overge requirements. It is the sole responsiility of the provider to selet the proper ode nd ensure the ury of ll lims sumitted for reimursement. ll servies must e medilly pproprite nd properly supported in the ptient medil reord. The SP is lulted qurterly sed on dt sent to S from the mnufturers within 0 dys of the lose of the qurter. Sine S releses SP priing informtion 0 dys efore the eginning of eh lendr qurter, the SP dt from one qurter will not e le to ftor into the very next qurter. ontrtors my ontt S for pyment limits on new drugs not inluded in the qurterly SP or Not Otherwise lssified () files ville on the S wesite. If the pyment limit is ville, ontrtors will sustitute the limit provided y S for the priing sed on W or invoie priing. or more informtion, refer to edire lims Proessing nul, hpter, Setions 0.., 0.., nd 0. nd visit gov/rprtdrugvgslesprie/0_overview.sp#topofpge. essed Septemer, 00. edire lims Proessing nul, hpter, Setion edire Prt (edil Insurne). Informtion ville on medire-sis/medire-enefits/prt-.spx. essed Novemer 0, 00. ederl Register Vol, No 0, Novemer 0, 0. Hospitl Outptient Prospetive Pyment System Y 0 inl Rule. pp. -.

10 TELRO Reimursement TELRO dministrtion Servies: Physiin edire reimursement for TELRO drug dministrtion servies provided in the physiin setting is sed on the ntionl physiin fee shedule tht is djusted for geogrphi vritions nd updted nnully. edire reimursement is sed on the lesser of the djusted fee shedule mount or tul hrges s follows: physiins re reimursed for 0% of the llowle mount, nd the ptient or ptient s seondry insurer is responsile for the remining 0% oinsurne TELRO dministrtion Servies: Hospitl Outptient Deprtment Drug dministrtion PT odes re ssigned to Ps ording to their linil nd resoure requirements. Severl drug dministrtion odes my mp to single P. Ps for drug dministrtion servies re updted yerly y S or more informtion on edire reimursement for TELRO, ontt the orest Reimursement Hotline t: ---. ediid ediid pyment for TELRO nd ssoited drug dministrtion servies typilly vries y setting of re. lso, ediid is lwys the pyor of lst resort; therefore, it is seondry to edire or ny third prty tht my e lile for medil pyments or medil support on the enefiiry s ehlf. TELRO Physiin Physiin Reimursement for TELRO provided in the physiin offie setting vries y stte ediid progrm. Some ediid progrms my se reimursement on SP +%. Others my se reimursement on perent mrk-up or mrk-down of SP, WP, or W. Drug reimursement rtes my e updted on monthly, qurterly, or yerly sis. Until the SP is estlished for TELRO, ediid progrms my utilize temporry reimursement rte suh s W, similr to edire. Drug dministrtion rtes vry y stte ediid progrm, with mny sttes sing reimursement on sttewide fee shedule tht my e updted on qurterly or nnul sis ommeril Pyors ny plns restrit ptients to selet network of providers nd hve ontrtul rrngements with these in-network providers. TELRO Physiin ommeril pyor reimursement for TELRO my e sed on perent mrk-up of SP similr to edire reimursement methodologies. Pyment my lso e sed on perent mrk-up or mrk-down of WP or W. Until the SP is estlished for TELRO, ommeril pyors my utilize temporry reimursement rte suh s W, similr to edire. Drug dministrtion rtes my e sed on ommon fee shedule similr to edire s physiin fee shedule or on ontrted rtes TELRO ility suh s Hospitl Outptient Deprtment, Hospitl Inptient Deprtment, or Skilled Nursing ility Reimursement for TELRO my e sed on perent mrk-up of SP similr to edire reimursement methodologies. Pyment my lso e sed on perent mrk-up or mrk-down of WP or W or fility-speifi ost-to-hrge rtios. Until the SP is estlished for TELRO, ommeril pyors my utilize temporry reimursement rte suh s W, similr to edire. Drug dministrtion rtes my e sed on ommon fee shedule similr to the edire physiin fee shedule, fility-speifi ost-tohrge rtios, per diem methodologies, or other ontrted rtes or more informtion on ommeril pyor reimursement for TELRO, ontt the orest Reimursement Hotline t: ---. TELRO ility suh s Hospitl Outptient Deprtment, Hospitl Inptient Deprtment, or Skilled Nursing ility Reimursement for TELRO provided in hospitl outptient, hospitl inptient, or SN settings lso vries y stte ediid progrm. or instne, pyment my e sed on perentge of SP, WP, W, or fility-speifi ost-to-hrge rtios. Drug dministrtion rtes my e sed on fee shedule, ontrted rtes, ost-to-hrge rtios, or fility-speifi per diem methodologies or more informtion on ediid reimursement for TELRO, ontt the orest Reimursement Hotline t: ---. orest Lortories, In. nnot gurntee pyment of ny lim. oding, overge, nd reimursement my vry signifintly y the pyor, pln, ptient, nd setting of re. tul overge nd reimursement deisions re mde y individul pyors following the reeipt of lims. or dditionl informtion, ustomers should onsult with their pyors for ll relevnt oding, reimursement, nd overge requirements. It is the sole responsiility of the provider to selet the proper ode nd ensure the ury of ll lims sumitted for reimursement. ll servies must e medilly pproprite nd properly supported in the ptient medil reord. edire Prt (edil Insurne). Informtion ville on medire-sis/medire-enefits/prt-.spx. essed Novemer 0, 00.

11 TELRO Reimursement S-00 lim orm Physiin Note: or dul eligile lims (ie, lims for ptients with oth edire nd ediid) nd ertin ommeril lims, providers must inlude ND informtion in positions 0- of ox. See edire lims Proessing nul, hpter, ville t edire dministrtive ontrtors (s) my require dditionl informtion thn wht is indited elow. est prtie is to defer to s illing nd reimursement guidelines to ensure timely nd urte pyment. HELTH INSURNE LI OR PPROVED Y NTIONL UNIOR LI OITTEE 0/0 PI TRIRE HPUS (Sponsor s SSN) GROUP HELTH PLN (SSN or ID) HPV (emer ID#) OTHER. INSURED S I.D. NUER E LK LUNG (SSN). PTIENT S NE (Lst Nme, irst Nme, iddle Initil). PTIENT S IRTH DTE. PTIENT S RESS (No., Street). PTIENT RELTIONSHIP TO INSURED Self ITY STTE hild Spouse. INSURED S NE (Lst Nme, irst Nme, iddle Initil) Single rried Other ( Employed ull-time Student Prt-Time Student TELEPHONE (Inlude re ode) ( ). OTHER INSURED S NE (Lst Nme, irst Nme, iddle Initil) 0. IS PTIENT S ONDITION RELTED TO:. INSURED S POLIY GROUP OR E NUER. OTHER INSURED S POLIY OR GROUP NUER. EPLOYENT? (urrent or Previous). INSURED S DTE O IRTH. OTHER INSURED S DTE O IRTH. UTO IDENT? PLE (Stte). OTHER IDENT?. EPLOYER S NE OR SHOOL NE d. IS THERE THER HELTH ENEIT PLN? RED K O OR EORE OPLETING & SIGNING THIS OR.. PTIENT S OR UTHORIZED PERSON S SIGNTURE I uthorize the relese of ny medil or other informtion neessry to proess this lim. I lso request pyment of government enefits either to myself or to the prty who epts ssignment elow. ILLNESS (irst symptom) OR INJURY (ident) OR PREGNNY(LP) If yes, return to nd omplete item -d.. INSURED S OR UTHORIZED PERSON S SIGNTURE I uthorize pyment of medil enefits to the undersigned physiin or supplier for servies desried elow.. I PTIENT HS HD SE OR SIILR ILLNESS.. DTES PTIENT UNLE TO WORK IN URRENT OUPTION GIVE IRST DTE TO ox : Enter the pproprite ID-- dignosis ode.. NE O REERRING PROVIDER OR OTHER SOURE. HOSPITLIZTION DTES RELTED TO URRENT SERVIES TO. Enter the pproprite numer of units for the dministrtion PT ode.... RESERVED OR LOL USE 0. OUTSIDE L?. DIGSIS OR NTURE O ILLNESS OR INJURY (Relte Items,, or to Item E y Line). EDIID RESUISSION ORIGINL RE... PT. NTL #. ED. RE. # ED. TX. 0 IRTHDTE TE DISSION STT ST T HR TYPE SR DHR STT Non-edire pyors my require revenue ode 00. OURRENE DTE TE DTE TE OURRENE DTE TE OURRENE DTE TE $ HRGES. 0 OURRENE DTE TE ONDITION S 0 V VLUE S OUNT OURRENE SPN Report the pproprite revenue ode for the dministrtion proedure on the sme line item s the PT ode. d e DT 0 STTE OURRENE SPN VLUE S OUNT VLUE S OUNT d REV REV. D. HPS / RTE / HIPPS TE DESRIPTION SERV. V DTE V. TE SERV. UNITS TOTL HRGES N-OVERED HRGES. D. PROEDURES, SERVIES, OR SUPPLIES (Explin Unusul irumstnes) PT/HPS ODIIER E. DIGSIS POINTER. $ HRGES H. G. J. RENDERING PROVIDER ID. # ox D: Enter the I. EPSDT ID. mily Pln QUL. DYS OR UNITS pproprite HPS nd PT odes. Exmple: J0 (Injetion, eftroline fosmil, 0 mg) (IV infusion for therpy, prophylxis, or dignosis; initil, up to hour). EDERL TX I.D. NUER SSN EIN Other dministrtion odes my e pproprite.. SIGNTURE O PHYSIIN OR SUPPLIER INLUDING DEGREES OR REDENTILS (I ertify tht the sttements on the reverse pply to this ill nd re mde prt thereof.) DTE ox I-J: Ntionl Provider Identifier. PTIENT S OUNT.. EPT SSIGNENT? (or govt. lims, see k). SERVIE ILITY LOTION INORTION. TOTL HRGE $. OUNT PID ox : Enter the pproprite HPS nd PT odes. Exmple: J0 (Injetion, eftroline fosmil, 0 mg) (IV infusion for therpy, prophylxis, or dignosis; initil, up to hour) 0 0 ox : Enter the nme of the produt nd ND ode. Exmple: TELRO, Other dministrtion odes my e pproprite. $ ( ) 0 0 PGE P P GE.... PPROVED O-0-0 OR S-00 (0-0) O TOTLS RETION DTE 0 PYER PYER P YER NE REL. INO HELTH L LTH PLN ID SG. EN. ox -Q: Enter the primry dignosis ode on line, the seondry dignosis ode on line, tertiry on line, et. EST. OUNT DUE PRIOR PYENTS OTHER PRV ID INSURED S NE EPLOYER NE DOUENT ONTROL NUER TRETENT TRE UTHORIZTION UTHORIZ UTHORIZTION S I J DIT 0 PTIENT DX RESON DX PRINIPL PROEDURE. DTE K OTHER PROEDURE DTE L. D PPS OTHER PROEDURE DTE E N EI O TTENDING G P LST. OTHER PROEDURE DTE d. OTHER PROEDURE DTE e. OTHER PROEDURE DTE OPERTING LST OTHER d U-0 S-0 PPROVED O. OTHER LST H Q QUL IRST LST 0 INSURNE GROUP. GROUP NE INSURED S UNIQUE ID P. REL 0 INSURED 0 RERKS orest Lortories, In. nnot gurntee pyment of ny lim. oding, overge, nd reimursement my vry signifintly y the pyor, pln, ptient, nd setting of re. tul overge nd reimursement deisions re mde y individul pyors following the reeipt of lims. or dditionl informtion, ustomers should onsult with their pyors for ll relevnt oding, reimursement, nd overge requirements. It is the sole responsiility of the provider to selet the proper ode nd ensure the ury of ll lims sumitted for reimursement. ll servies must e medilly pproprite nd properly supported in the ptient medil reord. DX NU Instrution nul ville t: 0. LNE DUE $. ILLING PROVIDER INO & PH # PHYSIIN OR SUPPLIER INORTION.. PLE O SERVIE EG ox : Enter the numer of units dministered (eg, 0 units if 00 mg dministered). DTE(S) O SERVIE rom To. PRIOR UTHORIZTION NUER... TYPE O ILL STTEENT OVERS PERIOD ox G: Enter the numer of units of TELRO dministered (eg, 0 units if 00 mg dministered). DTE. DTE O URRENT: 0d. RESERVED OR LOL USE. INSURNE PLN NE OR PROGR NE d. INSURNE PLN NE OR PROGR NE ox E: Doument the pproprite dignosis ode (s reported in ox ) for eh line item.. EPLOYER S NE OR SHOOL NE P P PTIENT TIENT RESS TIENT ZIP ) P P PTIENT TIENT NE TIENT STTE ITY TELEPHONE (Inlude re ode) ZIP. INSURED S RESS (No., Street) Other. PTIENT STTUS (or Progrm in Item ) (ID) EDIID (ediid #) edire dministrtive ontrtors (s) my require dditionl informtion thn wht is indited elow. est prtie is to defer to s illing nd reimursement guidelines to ensure timely nd urte pyment. ox : Enter the pproprite Revenue ode orresponding to the HPS ode J0 in ox (eg, 0 for phrmy, drugs tht require detiled oding). PI EDIRE (edire #) PTIENT ND INSURED INORTION. Note: or ertin pyors, providers must lso inlude the ND numer in ox. Speifi instrutions for formtting this field re ville in the edire lims Proessing nul, hpter, ville t RRIER 00 S-0 (lso referred to s U-0) lim orm Hospitl Outptient Setting QUL IRST QUL IRST QUL IRST THE ERTIITIONS ON THE REVERSE PPLY TO THIS ILL ND RE DE PRT HEREO. NU Ntionl Uniform illing ommittee LI

12 heklist Introdution for lim Sumission To This filitte guide hs timely een nd designed pproprite to provide reimursement, helthre physiins professionls nd with their informtion stff should relted ensure to tht the insurne oding nd reimursement doumenttion environment re omplete for TELRO nd urte. (eftroline Inluded fosmil). elow re In this some guide, helpful you reminders. will find informtion on: edire Prt lims: TELRO (eftroline fosmil) Inditions nd Usge Ensure Dosge tht nd eletroni dministrtion lims meet the requirements of lim implementtion guides dopted s ntionl stndrds Storge under Informtion the Helth Insurne Portility nd ountility t (HIP). Importnt Sfety Informtion edire dministrtive ontrtors (s) proess lims for ssigned sttes. Jurisdition is sed on the ull Presriing Informtion enefiiry s ddress on file with the Soil Seurity dministrtion. This will help to ensure lims re sent to TELRO the orret Reimursement ontrtor for proessing. oding Interntionl lssifition of Diseses th Revision linil odifition (ID--) Dignosis odes Interntionl lssifition of Diseses th Revision linil odifition (ID--) Proedure odes Ntionl Drug odes (NDs) Helthre ommon Proedure oding System (HPS) odes Not Otherwise lssified HPS odes urrent Proedurl Terminology (PT) Drug dministrtion odes Pyor overge edire ediid ommeril Insurers heklist for lim Sumission Pyor Reimursement edire ediid ommeril Insurers Smple S-00 lim orm How physiin offies my ill for produt not ssigned permnent HPS ode Smple S-0 (U-0) lim orm How hospitl filities my ill for produt ssigned pss-through HPS ode ll lims: Verify tht the ptient s identifition numer nd ll other informtion re entered orretly. Ensure tht the ptient s nme nd ddress mth the insurer s reords. Verify tht the provider s Ntionl Provider Identifier Numer(s) is inluded on the lim. Use the most pproprite ID-- dignosis odes ssoited with eh individul ptient s dignosis nd re. Ensure the medil reord ontins pproprite doumenttion to support the dignosis nd proedure odes sumitted on the lim. When illing for drugs, ensure the following informtion is provided on the lim form if required y the pyor: Nme of the drug, HPS ode, nd -digit ND numer requeny of dministrtion Route of dministrtion Numer of units dministered Use the orret PT nd/or HPS odes nd modifiers where nd when pproprite tht est desrie the tretment provided. Indite the setting where the servie ws provided (eg, physiin offie, hospitl outptient, or home). ile the lim in timely fshion. Provide omplete nd urte informtion upon request. Informtion urrent s of Jnury 0. orest Lortories, In. nnot gurntee pyment of ny lim. oding, overge, nd reimursement my vry signifintly y the pyor, pln, ptient, nd setting of re. tul overge nd reimursement deisions re mde y individul pyors following the reeipt of lims. or dditionl informtion, ustomers should onsult with their pyors for ll relevnt oding, reimursement, nd overge requirements. It is the sole responsiility of the provider to selet the proper ode nd ensure the ury of ll lims sumitted for reimursement. ll servies must e medilly pproprite nd properly supported in the ptient medil reord. TELRO is registered trdemrk used y orest Lortories, In.

13 0 orest Lortories, In /

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