Sample CMS-1500 02/12 (ICD-10-CM)
AMELUZ (5-aminolevulinic acid hydrochloride) gel, 10%)
®
Box 19 Additional Information: Enter the
appropriate drug identifying information as
required by payer; eg, brand and generic drug
name, National Drug Code (NDC) 11-digit
format 2 Grams (1 tube)
Note: Additional information may also be sent
via attachment electronically or other format
as allowed by payer
Box 21 Diagnosis: Enter
the appropriate
diagnosis code; eg, ICD10-CM: L57.0 for actinic
keratosis. Final code
depends on medical
record documentation
9
Note: Other diagnoses
codes may apply
454.x
AMELUZ (5-aminolevulinic acid HCL gel, 10%), Dose 2Gr,(1 tube)
NDC 70621010101, with photodynamic therapy (PDT)
0
L57.0
XXXXXX
MM DD YY
MM DD YY
11
J3490
A
XXX XX
1
MM DD YY
MM DD YY
11
96567
A
XXX XX
1
MM DD YY
MM DD YY
11
9921 x
A
XXX XX
1
25
Box 24D Procedures/Services/Supplies: Enter the
appropriate CPT/HCPCS codes and modifiers; eg,
- Drug: J3490 for drug name
- Administration: 96567 for PDT
- Visit: 9921x-25 for level x physician visit that is
separately identifiable from the drug application
and PDT service (If Applicable)
Box 24E Diagnosis
Pointer: Enter the
letter (A–J) that
corresponds to the
diagnosis in Box 21
PLEASE PRINT OR TYPE
Box 23 Prior
Authorization:
Enter the payer
authorization
number as
obtained prior to
services rendered
Box 24G Units: Enter the appropriate
number of units of service; eg, J3490
has no specific unit value; therefore,
a “1” is typically entered in this field
Note: Some payers may provide
alternate guidance
APPROVED OMB-0938-1197 FORM 1500 (02-12)