Presented by the EDS Provider Field Consultantsprovider.indianamedicaid.com/media/28972/ndc requirements for...NDC Requirements for Medical Claims Presented by the EDS Provider Field

NDC Requirements for Medical Claims

Presented by the EDS Provider Field Consultants

October 2007

2 October 2007NDC Requirements for Medical Claims

NDCs Required for Billing Procedure CodesAgenda

• Overview

• Professional Claim Types

• Institutional Claim Types

• Codes that Require National Drug Codes

• About the NDC

• NDC Configuration

• NDC Quantity

• Billing Instructions

• Web interChange

• Reimbursement Policy

• Remittance Advice

• Compounds

• Multiple NDCs

• Edits

• Q & A


Overview

• BT200713 announced that The Federal Deficit Reduction Act of 2005 mandates that State Medicaid programs, including Indiana Health Coverage Programs (IHCP) require the submission of National Drug Codes (NDCs) on claims submitted with certain procedure codes for physician-administered drugs.

• This mandate affects all providers who submit electronic or paper claims for procedure-coded drugs. Because the state may pay up to the 20 percent Medicare B co-payment for dual-eligible individuals, the NDC will also be required on Medicare crossoverclaims for all applicable procedure codes.


Professional Claim Types

• This requirement is applicable to claims with a date of service on or after August 1, 2007, and applies to professional claims, including the paper CMS-1500 and electronic 837P including:

–Batch claims

–Professional Medicare crossover claims

–Web interChange claims

–Paper CMS-1500 claims


Institutional Claim Types

• The IHCP will implement the NDC requirement for institutional outpatient claims January 1, 2008

• Look for information in a forthcoming publication


Codes that Require National Drug Codes

• Communicated to providers via a table in BT200713

• Published in an update to the table in BR200726

• Reviewed and updated on an annual basis, or as determined by the Office of Medicaid Policy and Planning (OMPP)


About the NDC

• Medication listed under Section 510 of the U.S. Federal Food, Drug, and Cosmetic Act is assigned a unique 11-digit, three-segment number, known as the National Drug Code (NDC)

• The first segment, known as the labeler code, is assigned by the Food and Drug Administration (FDA) – A labeler is any firm that manufactures, repacks, or distributes a drug

product

– This segment must contain five numbers

• The second segment, known as the product code, identifies a specific drug, strength, and dosage form of that drug– This segment must contain four numbers

• The third segment, known as the package code, identifies the package size – This segment must contain two numbers

• Additional information regarding NDCs is located at http://www.fda.gov/cder/ndc/

http://www.fda.gov/cder/ndc/


About the NDC (cont.)

• Providers must bill the NDC on the label of the drug that is administered – Claims that are not billed with the actual NDC administered are:

• Considered aberrant

• Subject to auditing and possible recoupment


NDC Example

• Examples of where a provider might find the NDC on the package:


NDC Configuration Example

NDC From Label IHCP Required Format

65293-001-01 65293-0001-01

0703-8771-03 00703-8771-03

00002-1420-1 00002-1420-01


About the NDC Quantity

• The procedure code billing units and NDC quantity do not always have a one-to-one relationship. The NDC quantity is based on the strength of the drug administered per unit, and the designated strength of the procedure code.

• The NDC quantity billed must be reflective of the procedure codequantity billed on the claim.


NDC/Procedure Code Quantity Examples

Table 3 – Examples of Procedure Code Quantity to NDC Quantity

Procedure Code

Procedure Code

Description

Procedure Code

Strength or Amount

Procedure Code

Quantity Billed

NDC Dose/Volume

NDC Quantity

Billed

NDC Unit Qualifier

J9035Injection,

Bevacizumab, 10 mg

10 mg 1 100 mg/4 ml 0.4 ML

J2505Injection,

Pegfilgrastim, 6 mg

6 mg 1 6 mg/0.6 ml 0.6 ML

J9355 Trastuzumab, 10 mg 10 mg 1 440 mg .0227 UN

J9265 Paclitaxel 30 mg 30 mg 1 100 mg/16.7

ml 5.01 ML

J7030

Infusion, Normal Saline Solution, 1000

ml

1000 ml 1 1000 ml 1000 ML


Billing Instructions – CMS-1500

• The NDC and NDC quantity are mandatory for procedure codes on PG 154, optional for all others

• To report the NDC on the CMS-1500 claim form, providers must enter the following information into the shaded portion of fields 24A to 24H

1. Enter the NDC qualifier of N42. Enter the NDC 11-digit numeric code3. Enter the drug description4. Enter the NDC Unit qualifier

• F2 – International Unit• GR – Gram• ML – Milliliter• UN – Unit

5. Enter the NDC Quantity (Administered/Billed Amount) in the format 9999.99


Web interChange


Reimbursement Policy

• The reimbursement policy is not changing

• Claims for these drugs continue to be priced by using the submitted procedure code and procedure code units


Remittance Advice

• The remittance advice (RA) will not display the NDC submitted on the claim

• Other resources to obtain denied claim information are:

–Access Web interChange

–Utilize the 276/277 transactions

–Contact EDS Customer Service


Compounds

• When billing compounds, only one NDC can be used per procedure code –For this situation, providers should use the NDC of the

ingredient that most closely matches the procedure code description

–This is often the active, most expensive ingredient

• Please note that the policy regarding compounded drugs will be changing on 1/1/2008


Multiple NDCs

• At times it may be necessary for providers to report multiple NDCs for a single procedure code

• For codes that involve multiple NDCs, provider must bill:– The initial procedure code, procedure code units, NDC and NDC

units, and the unit qualifier utilizing a KP modifier

– The second, and any subsequent line item(s) with the same procedure code, must be billed utilizing the KQ modifier

– This will cause the system to bypass the duplicate logic

– See table 4 in BT200713 for an example


Edit 0129 – Quantity dispensed or billed information is missing

• This edit will post and deny when the NDC quantity is not present but is required

• The procedure code billing units and NDC quantity do not always have a one-to-one relationship–The NDC quantity is based on:

• Strength of the drug administered per unit

• Designated strength of the procedure code


Edit 0217 – NDC number is missing

• This edit will post and deny a claim where the provider does not include an NDC for a procedure code that requires one.


Edit 0218 – NDC number is not in a valid format

• This edit will post and deny when the NDC is not equal to 11 numerals

• The provider should check their NDC configuration if this error is received

• Remember, the NDC must be in the 5-4-2 configuration


Edit 0810 – NDC Unit Qualifier (unit of measure) is missing

• This edit will post and deny claims where the unit of measure is missing

• Valid units of measure are:–F2 – International Unit

–GR – Gram

–ML – Milliliter

–UN – Unit


Edit 1016 – Non-Participating Manufacturer• Edit 1016 will post and deny claims where there is no active rebate agreement in place on the DOS for the NDC on the claim.

• The IHCP cannot reimburse for procedure codes that are represented by a non-rebating NDC.

• Providers are responsible for ensuring that the NDC of the drug that they are administering is from a rebating manufacturer.

• Drug rebates are on a labeler basis, so if the first five digits of the NDC are on the list, then it is considered rebating.

• CMS maintains a list of rebating labelers located at: http://www.cms.hhs.gov/MedicaidDrugRebateProgram/10_DrugComContactInfo.asp. Providers can also contact their wholesaler or drug supplier to determine if products supplied are from CMS rebating labelers.

http://www.cms.hhs.gov/MedicaidDrugRebateProgram/10_DrugComContactInfo.asp




Edit 4003 – Less than effective drugs are not covered under Indiana Health Program

• The IHCP does not pay for drugs that are less than effective, also known as DESI drugs. Providers can find additional information about how drugs are determined to be less than effective at: http://www.cms.hhs.gov/MedicaidDrugRebateProgram/12_LTEIRSDrugs.asp.

• A list of non-covered, less than effective drugs (DESI) is located at: http://www.cms.hhs.gov/MedicaidDrugRebateProgram/downloads/des.pdf

http://www.cms.hhs.gov/MedicaidDrugRebateProgram/12_LTEIRSDrugs.asp



http://www.cms.hhs.gov/MedicaidDrugRebateProgram/downloads/des.pdf


Edit 4004 – This NDC is not on file

• Edit 4004 will post and deny on claims where the NDC is in the correct format (11 numerals) but is not on the drug file

• If the provider feels that the NDC they are using is valid, they should contact their drug wholesaler with this question

• EDS receives more than 300,000 drugs on a weekly drug file that is sent by First DataBank–This file is used for drug reference information, which includes

NDC information


Edit 4007 – Non-Covered NDC due to CMS Termination

• This edit will post and deny on claims where the NDC CMS termination date is less than the date of service

• The CMS termination date originates from CMS –This date signifies that the NDC is

no longer available in the market and that all lots of the NDC have passed their expiration date

• This information is also received through the drug file from FDB


Edit 4300 – Invalid NDC to procedure code combination

• This edit will post and deny claims where the NDC submitted on the claim is not associated to the procedure code billed


Questions

October 2007

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Presented by the EDS Provider Field Consultantsprovider.indianamedicaid.com/media/28972/ndc requirements for...NDC Requirements for Medical Claims Presented by the EDS Provider Field