Forms and Documents

Correctly coded claim forms facilitate the claims process and decrease the likelihood of having claims denied. Below is a list of downloadable forms, interactive files, and other documents designed to facilitate successful claim submissions. Examples of claim forms that you may use when billing for Cathflo and related services are included as well.

CMS-1500 Form

UB-92 Form

FDA Approval Letter

Note: Select the appropriate billing code when filing all claims. Billing codes should be based on diagnosis and the services provided.

Indication: For restoration of function to central venous access devices (CVADs) as assessed by the ability to withdraw blood.

Safety Information: Cathflo Activase should not be administered to patients with known hypersensitivity to Alteplase or any component of the formulation. In the clinical trials, the most serious adverse events reported after treatment were sepsis, gastrointestinal bleeding, and venous thrombosis. Cathflo Activase should be used with caution in the presence of known or suspected infections in the catheter.

Please see full Prescribing Information.