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TelaraSupportTM at 1-877- (1-877-783-5272) to obtain specific coding guidance. How Supplied Dosage 07 01 30 X x Anytown AS 203 555-1234 01010 Signature on file 3. Item 21 Indicate diagnosis using the appropriate ICD-10-CM code 0. 01 01 45 57894-061-03 90 57894-060-02 90 mg Vial Doe, John B. 57894-060-03 45 mg Vial 000-00-1234 3914 Spruce Street 2. Item 19 Some payers may ask providers to specify name, dosage strength, NDC, and method of admin.

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