Sample Hospital Claim for Myocardial Perfusion Imaging MUGA Scan by pluggtwo

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									Sample Hospital Claim for Myocardial Perfusion Imaging (MUGA Scan)
Anytown Medical Center
760 Main Street                                                                                         A712300                            131
City, State, Zip

Mary J. Scott                                               12 Nassau Street, City, State, Zip

09221923         F S     071803      12     9    1    00     01 729613




Mary J. Scott
12 Nassau Street
City, State, Zip


636       Pharmacy                                     J0152             111504         2
482       Stress test                                  93017             111504         1
341       NucMed/Dx                                    78473             111504         1       Form Locator 46: Service Units
343       NucMed/Dx R                                  A9502             111504         2       For drugs reported under revenue codes
                                                                                                259 and 636, the units indicated must be
                                                                                                consistent with the dosage rendered
001       Total Charges
        Form Locator 42: Revenue Codes                   Form Locator 44: HCPCS
        636-Pharmacy
        482-Stress Test                                  A9502 — Supply of radiopharmaceutical diagnostic imaging agent,
        341-NucMed/Dx                                    Technetium TC 99M Tetrofosmin, per Unit dose
        343-NucMed/Dx Radiopharmaceutical                J0152 — Injection, adenosine for diagnostic use, 30 mg
                                                         93015 — Cardiovascular stress test using maximal or submaximal
                                                         treadmill or bicycle exercise, continuous electrocardiographic monitor-
                                                         ing, and/or pharmacological stress; with physician supervision with inter-
                                                         pretation and report
                                                         78473 — Cardiac blood pool imaging, gated equilibrium; multiple studies,
                                                         wall motion study plus ejection fraction, at rest and stress (exercise
                                                         and/or pharmacologic), with or without additional quantification (MUGA)




Medicare                             015        333333                   Y    Y
Horizon BC                           280        48015                    Y    Y



Scott, Mary J.                                  01    157713126A
Scott, Mary J.                                  01    157713126

                                                                             Form Locators 68-75: Other Diagnosis Codes
             Form Locator 67: Principal Diagnosis Code                       Report all other diagnosis codes documented
             401.9 – Hypertension, NOS                                       in the patient chart/medical record



401.9        396.3       397.0       4293            4293

								
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