Provider coding & billing information

Transcription

1 Includes new ICD-9 codes for acquired hemophilia and ICD-10 codes for 2013 Provider coding & billing information A guide to coding & reimbursement for NovoSeven RT Models are for illustrative purposes only.

2 1 Indications and Usage NovoSeven RT (Coagulation Factor VIIa [Recombinant] Room Temperature Stable) is indicated for the treatment of bleeding episodes in hemophilia A or B patients with inhibitors to FVIII or FIX and in patients with acquired hemophilia; prevention of bleeding in surgical interventions or invasive procedures in hemophilia A or B patients with inhibitors to FVIII or FIX and in patients with acquired hemophilia; treatment of bleeding episodes in patients with congenital FVII deficiency and prevention of bleeding in surgical interventions or invasive procedures in patients with congenital FVII deficiency. Important Safety Information Warning: Serious thrombotic adverse events are associated with the use of NovoSeven RT outside labeled indications. Arterial and venous thrombotic and thromboembolic events following administration of NovoSeven RT have been reported during postmarketing surveillance. Clinical studies have shown an increased risk of arterial thromboembolic adverse events with NovoSeven RT when administered outside the current approved indications. Fatal and non-fatal thrombotic events have been reported. Discuss the risks and explain the signs and symptoms of thrombotic and thromboembolic events to patients who will receive NovoSeven RT. Monitor patients for signs or symptoms of activation of the coagulation system and for thrombosis. Safety and efficacy of NovoSeven RT has not been established outside the approved indications. Please see additional Important Safety Information on pages 19 and 20. Please see accompanying Prescribing Information.

3 2 Introduction The lives of healthcare providers can be hectic. That s why Novo Nordisk aims to bring ease to the administration challenges of insurance reimbursement so you can spend more time providing quality care. This guide is designed to help you secure maximum reimbursement for NovoSeven RT by carefully navigating the coding and billing process. It includes: Coding NovoSeven RT reimbursement claims Applying for prior authorization Contents Coding for NovoSeven RT... 4 Prior authorization Reimbursement considerations Appeals and denials Reimbursement considerations Responding to denial of coverage For additional information regarding coding, billing, or reimbursement for NovoSeven RT, call NOVO-777 ( ) or talk to your NovoSeven RT representative

4 3 Please see Important Safety Information on pages 19 and 20. Please see accompanying Prescribing Information.

5 Coding for NovoSeven RT 4 Coding for NovoSeven RT Note: For the purposes of this guide, the term provider office will refer to any setting in which NovoSeven RT is administered (hospital, hemophilia treatment center, etc). Coverage Bypassing agents such as NovoSeven RT can be covered as a medical benefit through a health plan, or a pharmacy or specialty benefit through a drug plan. Medicare, Medicaid, and almost all private insurance plans should cover NovoSeven RT for patients who meet coverage criteria. Some insurers may require a prior authorization or ask for additional information before making a coverage decision. Coverage criteria for Medicare and Medicaid are dictated by federal and state requirements. Coverage rules and payment methods vary by insurer and type of healthcare provider. For more information regarding reimbursement for NovoSeven RT, refer to page 12. Claim forms There are 2 forms that may be used to submit a claim for NovoSeven RT reimbursement. The type of form depends on the provider office administering treatment: To secure reimbursement for NovoSeven RT, a properly coded claim form must be submitted. Claims must include the following: Patient diagnosis codes: these codes have been revised recently to better facilitate reimbursement for patients with hemophilia - see Diagnosis codes, pages 5 and 6 Physician procedure codes Drug codes Units of NovoSeven RT used (micrograms or milligrams) Revenue codes (if applicable) The next several pages contain reimbursement codes that are applicable to NovoSeven RT. However, many insurers have unique coding and claims submission requirements. Check individual plan requirements before coding and submitting a claim form. For guidance inputting codes on your claim form, refer to the fold-out page inside the back cover of this guide Form HCFA 1450 (UB-04) HCFA 1500 Provider office Hospital, hemophilia treatment center, other specialty clinic Physician s office, home health agency

6 5 Diagnosis codes Currently, claim forms must include an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code. Prior ICD-9-CM versions had no specific code for acquired hemophilia. Pursuant to the efforts of a partnership including Dr. Craig Kessler of Georgetown University Medical Center, Dr. Ellinor Peerschke of Mount Sinai Hospital and Medical Center, and Novo Nordisk, the ICD-9-CM codes have been revised to address patients with acquired hemophilia. These specifications will carry over into the next generation of ICD-10-CM codes, scheduled to become effective on October 1, Other congenital factor deficiencies, including Factor VII, continue to be grouped in ICD-9-CM and ICD-10-CM coding. At right are the new ICD-9-CM codes that may be most appropriate for patients treated with NovoSeven RT: *NovoSeven RT indication. Please see Important Safety Information on pages 19 and 20. Please see accompanying Prescribing Information. ICD-9-CM diagnosis code Description 286.0* Hemophilia A (Factor VIII deficiency) 286.1* Hemophilia B (Factor IX deficiency) Hemophilia C (Factor XI deficiency) 286.3* * Other hereditary factor deficiency (including Factor VII) Acquired hemophilia Autoimmune hemophilia Autoimmune inhibitors to clotting factors Secondary hemophilia Antiphospholipid antibody with hemorrhagic disorder Lupus anticoagulant (LAC) with hemorrhagic disorder Systemic lupus erythematosus (SLE) inhibitor with hemorrhagic disorder Excludes: - antiphospholipid antibody, finding without diagnosis (795.79) - antiphospholipid antibody syndrome (289.81) - antiphospholipid antibody with hypercoagulable state (289.81) - LAC finding without diagnosis (795.79) - LAC with hypercoagulable state (289.81) - SLE inhibitor finding without diagnosis (795.79) - SLE inhibitor with hypercoagulable state (289.81)

7 6 Diagnosis codes (cont d) ICD-9-CM diagnosis code Description ICD-10-CM diagnosis code Description Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors Antithrombinemia Antithromboplastinemia Antithromboplastino genemia Hyperheparinemia Increase in: - anti-ii (prothrombin) - anti-viiia - anti-ixa If none of these codes specifically apply to your patient, select the code that best describes your patient s condition. Also consider diagnosis codes that are specific to the hemorrhage site. D66* Hemophilia A (Factor VIII deficiency) D67* Hemophilia B (Factor IX deficiency) D68.1 Hemophilia C (Factor XI deficiency) D68.2* D68.31 D Other hereditary factor deficiency (including Factor VII) Hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors Acquired hemophilia Autoimmune hemophilia Autoimmune inhibitors to clotting factors Secondary hemophilia A new generation of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes are scheduled to go into effect on October 1, These codes will carry over the new improved hemophiliarelated classifications recently created for ICD-9-CM. D D Antiphospholipid antibody with hemorrhagic disorder Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors For a quick-reference card of NovoSeven RT codes, refer to the fold-out page inside the back cover of this guide *NovoSeven RT indication.

8 7 Physician procedure codes When NovoSeven RT is administered as part of a procedure performed by a physician, a Current Procedural Terminology (CPT-4)* code must be included. Drug codes Use the following Healthcare Common Procedural Coding System (HCPCS) code to bill for NovoSeven RT: The following procedure codes may apply to administration of NovoSeven RT: Drug HCPCS code Description Procedure CPT code Description Infusion of drug Therapeutic, prophylactic, or diagnostic injection of drug; intravenous, single or initial substance (specify NovoSeven RT) NovoSeven RT J7189 Factor VIIa (Coagulation Factor, Recombinant) per 1-µg equivalent Infusion of drug Unlisted therapeutic, prophylactic, or diagnostic injection or infusion (specify NovoSeven RT) * 5-digit CPT codes, nomenclature, and other data are copyright 2001 of the American Medical Association (AMA). All rights reserved. No fee schedules, basic unit, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Please see Important Safety Information on pages 19 and 20. Please see accompanying Prescribing Information.

9 8 Additional codes for hospital-based procedures If NovoSeven RT is administered in the hospital inpatient or outpatient setting, claims should also include ICD-9-CM procedure codes and revenue codes as described below. Note: These codes should be used on form HCFA-1450 (UB-04) only. The ICD-9-CM procedure codes most commonly used for the administration of NovoSeven RT are: Insurers may require NovoSeven RT to be billed with one of the following revenue codes to cover supplies and services provided in the inpatient and outpatient settings: Charge category Revenue code Description Pharmacy 250 Pharmacy: general classification Hospitalbased procedure ICD-9-CM procedure code Description Hospital blood service 380 Blood: general classification Infusion of drug Transfusion of coagulation factors/transfusion of antihemophilic factor Hospital blood service 387 Blood: other derivatives Infusion of drug Injection or infusion of other therapeutic or prophylactic substance Drugs that require specific identification 636 Use of this code is reserved for drugs that require specific identification. This code is necessary when submitting Medicare claims for NovoSeven RT provided in a hospital

10 9 Avoiding coding errors The coding instructions on pages 4-8 should help limit the number of coding errors associated with NovoSeven RT reimbursement claims. Use these additional tips to double-check all claim forms before submitting: Ensure that HCPCS drug codes match up with diagnosis codes The NovoSeven RT drug code (J7189) usually requires an ICD-9-CM code of 286.X (ICD-10-CM codes will be D66-D68.X) Billing and coding are extremely important administrative issues for hospitals, clinics, and physicians. To help ease the challenges associated with the billing and coding process, stay abreast of procedure codes associated with healthcare charges. The next generation of ICD codes (ICD-10-CM) are scheduled to take effect on October 1, 2013 Ensure that HCPCS drug codes have an associated procedure code Be aware of codes that have time components and other requirements associated with them Get any questions regarding coding or time components answered at the time of prior authorization Document the answers to your questions to avoid coding errors in the future Please see Important Safety Information on pages 19 and 20. Please see accompanying Prescribing Information.

11 Prior authorization 10 Prior authorization Prior authorization is a process used by insurers to validate that there is a medical need for a specific product or service. When prior authorization is required, additional information must be provided to determine if the insurer will agree to coverage. Prior authorization may be required for NovoSeven RT, depending on the terms of the patient s insurance coverage. When contacting your patient s insurer for prior authorization, have the following information available: Patient s name Insurance identification number/group number Patient s date of birth Physician s provider number (if physician is a participating provider) Date(s) of service ICD-9-CM/ICD-10-CM and CPT codes for the procedure(s) performed See pages 5-8 for codes applicable to NovoSeven RT HCPCS and NDC codes for the drug(s) administered See page 7 for the HCPCS code applicable to NovoSeven RT Medical/utilization review Prior authorization is usually a simple process, requiring only a phone call, fax, or form. However, sometimes an insurer may request additional information for a medical/utilization review. The medical/ utilization review department will then review the requested information to ensure one of the following requirements for NovoSeven RT is met: Treatment of bleeding episodes in hemophilia A and B with inhibitors Patients with inhibitors to Factor VIII or Factor IX, or those with acquired hemophilia Prevention of bleeding in surgical interventions or invasive procedures Patients with inhibitors to Factor VIII or Factor IX, or those with acquired hemophilia Treatment of bleeding episodes in congenital Factor VII deficiency Patients with congenital/hereditary Factor VII deficiency, and prevention of bleeding in surgical interventions or invasive procedures in those patients Failure to obtain prior authorization when required may result in denied claims for the provider office and/or higher out-of-pocket costs for the patient

12 11 Please see Important Safety Information on pages 19 and 20. Please see accompanying Prescribing Information.

13 Reimbursement considerations 12 Reimbursement considerations Hospital inpatient Medicare In addition to reimbursement for hospital services, Medicare provides a separate reimbursement for blood clotting factors administered in the hospital inpatient setting. These clotting factors are reimbursed at 106% of the average sale price (ASP). Medicaid and private insurance plans Some Medicaid agencies and many private insurance plans also provide separate reimbursements for clotting factors in the inpatient setting. Those payments are typically based on the published average wholesale price (AWP). Coding requirements may vary by insurer. To secure payment, inpatient Medicare claims for NovoSeven RT must contain the following: Patient diagnosis code Revenue code (NovoSeven RT revenue code: 636) Drug code (NovoSeven RT drug code: J7189)

14 13 Hospital outpatient/hemophilia treatment center Medicare Under Medicare s outpatient prospective payment system (OPPS), hospitals receive fixed payments for outpatient services provided. However, clotting factors are considered separately payable drugs and are reimbursed separately at a percentage of ASP. Infusion at home Most Medicare, Medicaid, and private insurance plans reimburse for clotting factors used in the home. Every plan is different. Carefully check each plan before advising a patient on reimbursements for clotting factors administered in the home. Additionally, clotting factors covered by Medicare Part B are subject to a furnishing fee that is reimbursed on top of the ASP-based payment. Private insurance plans Most private insurance plans reimburse for outpatient services based on charges, discounted charges, costs, or per diem payments. Some private insurance plans will reimburse for NovoSeven RT in addition to payment for services provided. Refer to the individual plan for specific terms and conditions. Please see Important Safety Information on pages 19 and 20. Please see accompanying Prescribing Information.

15 14 Reimbursement tips Submitting accurate reimbursement claims can help limit the number of delayed and denied claims. Use the tips below to help ensure the accuracy of claims for NovoSeven RT: Benefit plans vary, so always be sure to verify each patient s insurance benefit Always verify prior authorization requirements with insurers Confirm the preferred method for claims submission Confirm where the claim should be submitted Determine the amount of time required to process prior authorization File claims promptly and be sure all coding is accurate Consider supplying a letter of medical necessity Follow up with insurers to encourage timely claims processing Monitor and identify reasons for denied claims through explanations of benefits Document all communications with insurers regarding prior authorization and denied claims Be familiar with the appeals process and be prepared to provide supporting documentation For further assistance, call NOVO-777 ( ) or talk to your NovoSeven RT representative.

16 15 Please see Important Safety Information on pages 19 and 20. Please see accompanying Prescribing Information.

17 Appeals and denials 16 Appeals and denials When a reimbursement claim is denied, an appeal may be filed to persuade the insurance company to reverse its decision and provide coverage. The first step to filing an appeal is to determine the reason it was denied. Reviewing the explanation of benefits After a claim is submitted to the patient s insurance plan, the provider office will receive an explanation of benefits, which contains information regarding approved and denied payments. If the cause of the denial is still unclear after reviewing the explanation of benefits, call the insurer for more information. To help limit denied claims, refer to page 9 for tips on avoiding coding errors Review the explanation of benefits to determine the reason for the denial; it will include a coded description of the reason for the denial. Common causes of denied claims from private insurers include: Failure to obtain prior authorization Improper coding or missing information (patient ID number, signatures, etc) Lack of documentation to support medical necessity Confusion around dosing (submitting dosages in incorrect units) If you determine that the denial was not due to a claim submission error, you may need to resubmit the claim with materials to document medical necessity.

18 17 Writing an appeal letter When filing an appeal, it may be necessary to include an appeal letter to validate the patient s medical necessity. To streamline your appeals process, Novo Nordisk offers several pre-written appeal letters for responding to denial of NovoSeven RT coverage. Refer to page 18 to see these sample letters, which you can use as a guide when you are writing your own appeal letters. For questions regarding denied claims and additional help with the appeals process, call NOVO-777 ( ). An insurer that receives a number of appeals for the same reason may re-evaluate its process to align with new customer needs Appeals tips Proper and complete documentation is essential to a successful appeal. Use the following tips to help navigate the appeals process: Be familiar with the rules and appropriate procedures to follow Document events as they occur Refer to the sequence of events when writing a summary of the situation Communicate clearly and precisely Don t give up if the appeal is not reviewed to your satisfaction, continue to pursue it Please see Important Safety Information on pages 19 and 20. Please see accompanying Prescribing Information.

19 Sample appeal letters 18 Response letter for precertification denial prior to infusion Response letter for claim denial after infusion [Office Letterhead Provider Name and Address Date Payer Name Payer Address Attn: Appeals Department [Office Letterhead Provider Name and Address Date Payer Name Payer Address Attn: Appeals Department Re: Patient Name Policy ID/Group Number Precertification Denial] Re: Patient Name Policy ID/Group Number Date of Service Disputed Amount] Dear Sir/Madam: The precertification for our patient referenced above was denied on [date]. The reason for denial, as indicated on the Report to Provider, was [list reason(s) for denial]. I disagree with this determination and request an appeal of the denied precertification. NovoSeven RT is indicated for the treatment of bleeding episodes in hemophilia A or B patients with inhibitors to FVIII or FIX and in patients with acquired hemophilia; prevention of bleeding in surgical interventions or invasive procedures in hemophilia A or B patients with inhibitors to FVIII or FIX and in patients with acquired hemophilia; treatment of bleeding episodes in patients with congenital FVII deficiency and prevention of bleeding in surgical interventions or invasive procedures in patients with congenital FVII deficiency. In my opinion, NovoSeven RT is medically necessary for the treatment of my patient s condition. Enclosed is clinical documentation supporting my choice of NovoSeven RT. I request that you reconsider and reverse the precertification denial. Dear Sir/Madam: The claim for our patient referenced above was denied on [date]. The reason for denial, as indicated on the Report to Provider, was [list reason(s) for denial]. I disagree with this determination and request an appeal of the denied claim. NovoSeven RT is indicated for the treatment of bleeding episodes in hemophilia A or B patients with inhibitors to FVIII or FIX and in patients with acquired hemophilia; prevention of bleeding in surgical interventions or invasive procedures in hemophilia A or B patients with inhibitors to FVIII or FIX and in patients with acquired hemophilia; treatment of bleeding episodes in patients with congenital FVII deficiency and prevention of bleeding in surgical interventions or invasive procedures in patients with congenital FVII deficiency. [Patient name] was treated with NovoSeven RT for [indication/date of service]. In my opinion, NovoSeven RT was medically necessary for the treatment of my patient s condition. Enclosed is clinical documentation supporting the use of NovoSeven RT. I request that you reconsider and reverse the claim denial. Sincerely, [Physician Name] Sincerely, [Physician Name]

20 19 Indications and Usage NovoSeven RT (Coagulation Factor VIIa [Recombinant] Room Temperature Stable) is indicated for the treatment of bleeding episodes in hemophilia A or B patients with inhibitors to FVIII or FIX and in patients with acquired hemophilia; prevention of bleeding in surgical interventions or invasive procedures in hemophilia A or B patients with inhibitors to FVIII or FIX and in patients with acquired hemophilia; treatment of bleeding episodes in patients with congenital FVII deficiency and prevention of bleeding in surgical interventions or invasive procedures in patients with congenital FVII deficiency. Important Safety Information Warning: Serious thrombotic adverse events are associated with the use of NovoSeven RT outside labeled indications. Arterial and venous thrombotic and thromboembolic events following administration of NovoSeven RT have been reported during postmarketing surveillance. Clinical studies have shown an increased risk of arterial thromboembolic adverse events with NovoSeven RT when administered outside the current approved indications. Fatal and non-fatal thrombotic events have been reported. Discuss the risks and explain the signs and symptoms of thrombotic and thromboembolic events to patients who will receive NovoSeven RT. Monitor patients for signs or symptoms of activation of the coagulation system and for thrombosis. Safety and efficacy of NovoSeven RT has not been established outside the approved indications. Thrombotic events following the administration of NovoSeven RT occurred in 0.28% of bleeding episodes treated, with the incidence in acquired hemophilia of 4% and in hemophilia patients of 0.20% in clinical trials within the approved indications. Fatal and non-fatal thrombotic events have been identified through postmarketing surveillance following NovoSeven RT use for each of the approved indications. Please see additional Important Safety Information on page 20. Please see accompanying Prescribing Information.

21 20 Important Safety Information (cont d) Patients with disseminated intravascular coagulation (DIC), advanced atherosclerotic disease, crush injury, septicemia, or concomitant treatment with activated or nonactivated prothrombin complex concentrates (apccs/pccs) have an increased risk of developing thrombotic events in association with NovoSeven RT treatment. Caution should be exercised when administering NovoSeven RT to patients with an increased risk of thromboembolic complications. These include, but are not limited to, patients with a history of coronary heart disease, liver disease, post-operative immobilization, elderly patients, and neonates. In each of these situations, the potential benefit of treatment with NovoSeven RT should be weighed against the risk of these complications. Development of antibodies against FVII has been reported in FVII-deficient patients after treatment with NovoSeven RT. FVII-deficient patients should be monitored for prothrombin time (PT) and FVII coagulant activity before and after administration of NovoSeven RT. Use with caution in patients with known hypersensitivity to NovoSeven RT, its components, or mouse, hamster, or bovine proteins. Laboratory coagulation parameters (PT/INR, aptt, FVII:C) have shown no direct correlation to achieving hemostasis. In clinical trials, the most common adverse events of NovoSeven RT therapy are pyrexia, hemorrhage, injection site reaction, arthralgia, headache, hypertension, hypotension, nausea, vomiting, pain, edema, and rash.

22 Flip open this page for direction on where to input codes for forms HCFA 1500 and HCFA 1450 (UB-04). Also, refer to the attached Quick-reference card to quickly find the reimbursement codes that apply to NovoSeven RT. It is perforated and removable for your convenience.

23 52 REL. INFO 53 ASG. BEN. HCFA 1500 HCFA 1450 (UB-04) ICD-9-CM * diagnosis code Field 21 and 24E Revenue code Field 42 HCPCS drug code (J7189) and CPT procedure code Field 44 PLEASE DO NOT STAPLE IN THIS AREA HEALTH INSURANCE CLAIM FORM APPROVED OMB PICA PICA IN ITEM 1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER 1a. INSURED S I.D. NUMBER (FOR PROGRAM 1) HEALTH PLAN BLK LUNG (Medicare #) (Medicaid #) (Sponsor s SSN) (VA File #) (SSN or ID) (SSN) (ID) CARRIER 1 2 3a PAT. 4 TYPE CNTL # OF BILL b. MED. REC. # 6 STATEMENT COVERS PERIOD 7 5 FED. TAX NO. FROM THROUGH 8 PATIENT NAME a 9 PATIENT ADDRESS a b b c d e 10 BIRTHDATE 11 SEX ADMISSION CONDITION CODES 12 DATE 13 HR 14 TYPE 15 SRC 16 DHR 29 ACDT STAT STATE 2. PATIENT S NAME (Last Name, First Name, Middle Initial) 3. PATIENT S BIRTH DATE MM DD YY M SEX F 4. INSURED S NAME (Last Name, First Name, Middle Initial) 31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37 CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH a a 5. PATIENT S ADDRESS (No., Street) CITY ZIP CODE TELEPHONE (Include Area Code) 9. OTHER INSURED S NAME (Last Name, First Name, Middle Initial) a. OTHER INSURED S POLICY OR GROUP NUMBER b. OTHER INSURED S DATE OF BIRTH MM DD YY ( ) c. EMPLOYER S NAME OR SCHOOL NAME d. INSURANCE PLAN NAME OR PROGRAM NAME M SEX F STATE 6. PATIENT RELATIONSHIP TO INSURED Self Spouse Child Other 8. PATIENT STATUS Single Married Other Employed Full-Time Part-Time Student Student 10. IS PATIENT S CONDITION RELATED TO: a. EMPLOYMENT? (CURRENT OR PREVIOUS) YES NO b. AUTO ACCIDENT? PLACE (State) YES NO c. OTHER ACCIDENT? YES NO 10d. RESERVED FOR LOCAL USE 7. INSURED S ADDRESS (No., Street) CITY STATE ZIP CODE TELEPHONE (INCLUDE AREA CODE) 11. INSURED S POLICY GROUP OR FECA NUMBER a. INSURED S DATE OF BIRTH MM DD YY ( ) b. EMPLOYER S NAME OR SCHOOL NAME c. INSURANCE PLAN NAME OR PROGRAM NAME d. IS THERE ANOTHER HEALTH BENEFIT PLAN? SEX M F PATIENT AND INSURED INFORMATION b VALUE CODES 40 VALUE CODES 41 VALUE CODES CODE AMOUNT CODE AMOUNT CODE AMOUNT a b c d 42 REV. CD. 43 DESCRIPTION 44 HCPCS / RATE / HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES b READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENT S OR AUTHORIZED PERSON S SIGNATURE I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. YES NO If yes, return to and complete item 9 a-d. 13. INSURED S OR AUTHORIZED PERSON S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below SIGNED DATE SIGNED DATE OF CURRENT: MM DD YY ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY(LMP) 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY MM DD YY GIVE FIRST DATE MM DD YY FROM TO NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY FROM TO RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES YES NO DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 23. PRIOR AUTHORIZATION NUMBER PAGE 50 PAYER NAME OF 51 HEALTH PLAN ID CREATION DATE TOTALS 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI A B C D E DATE(S) OF SERVICE Place Type PROCEDURES, SERVICES, OR SUPPLIES From To DIAGNOSIS of of (Explain Unusual Circumstances) MM DD YY MM DD YY CODE Service Service CPT/HCPCS MODIFIER 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? (For govt. claims, see back) 31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof.) SIGNED DATE (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88) YES NO 32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE RENDERED (If other than home or office) F G H I J K DAYS EPSDT OR Family RESERVED FOR CHARGES EMG COB LOCAL USE $ UNITS Plan 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE $ $ $ 33. PHYSICIAN S, SUPPLIER S BILLING NAME, ADDRESS, ZIP CODE & PHONE # PIN# GRP# PLEASE PRINT OR TYPE FORM HCFA-1500 (12-90), FORM RRB-1500, FORM OWCP-1500 PHYSICIAN OR SUPPLIER INFORMATION A 57 B OTHER C PRV ID 58 INSURED S NAME 59 P.REL 60 INSURED S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO. A B C 63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME A B C C DX 67 A B C D E F G H I J K L M N O P Q 69 ADMIT 70 PATIENT 71 PPS DX REASON DX a b c CODE ECI a b c 74 PRINCIPAL PROCEDURE a. OTHER PROCEDURE b. OTHER PROCEDURE 75 CODE DATE CODE DATE CODE DATE 76 ATTENDING NPI QUAL LAST FIRST c. OTHER PROCEDURE d. OTHER PROCEDURE e. OTHER PROCEDURE CODE DATE CODE DATE 77 OPERATING NPI QUAL CODE DATE LAST FIRST 81CC 80 REMARKS a 78 OTHER NPI QUAL b LAST FIRST c 79 OTHER NPI QUAL d LAST FIRST UB-04 CMS-1450 OMB APPROVAL PENDING THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF. National Uniform 2005 NUBC NUBC Billing Committee LIC F RESET A B C A B C A B HCPCS drug code (J7189) Field 24D CPT procedure code Field 24D ICD-9-CM * diagnosis code Field 66 ICD-9-CM * procedure code Field 74 *ICD-9-CM diagnosis codes are scheduled to be replaced by ICD-10-CM codes on October 1, Please see Important Safety Information on pages 19 and 20. Please see accompanying Prescribing Information.

24 NovoSeven RT reimbursement codes Quick-reference card ICD-9-CM diagnosis codes Hemophilia A (Factor VIII deficiency) Hemophilia B (Factor IX deficiency) Other factor deficiency (includes Factor VII) Acquired, autoimmune, or secondary hemophilia ICD-10-CM diagnosis codes D66 - Hemophilia A (Factor VIII deficiency) D67 - Hemophilia B (Factor IX deficiency) D Other factor deficiency (includes Factor VII) D Acquired, autoimmune, or secondary hemophilia CPT-4 codes Therapeutic, prophylactic, or diagnostic injection of drug; intravenous, single or initial substance Unlisted therapeutic, prophylactic, or diagnostic injection or infusion ICD-9-CM procedure codes (hospital only) Transfusion of coagulation factors/transfusion of antihemophilic factor Injection or infusion of other therapeutic or prophylactic substance Revenue codes (hospital only) Pharmacy: general classification Blood: general classification Blood: other derivatives NovoSeven RT drug identification code for hospital Medicare claims NovoSeven RT HCPCS code: J7189

25 For questions or assistance regarding NovoSeven RT billing, coding, or reimbursement, call NOVO-777 ( ) NovoSeven is a registered trademark of Novo Nordisk Health Care AG Novo Nordisk Printed in the U.S.A June 2012