Billing with National Drug Codes (NDCs)
Blue Cross and Blue Shield of Texas (BCBSTX) does not require inclusion of the National Drug Code (NDC) along with the applicable Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT®) code(s), except on claim submissions for unlisted or “Not Otherwise Classified” (NOC) physician-administered and physician-supplied home infusion therapy drugs.
BCBSTX currently accepts NDC for billing of all physician-administered and physician-supplied drugs in accordance with the NDC schedule posted on the BCBSTX Provider website under “Drugs”. Including the NDC on claims helps provide a more consistent pricing methodology for payment and will also facilitate better management of drug-associated costs. For information about how to add the additional NDC and other required elements, please refer to the BCBSTX Provider website at bcbstx.com/provider. BCBSTX will continue to accept the HCPCS or CPT code elements without NDC information (excluding unlisted or “Not Otherwise Classified” drugs).
Claims should be submitted with the exact NDC that appears on the product administered. The NDC is found on the medication’s packaging and must be submitted in the 5digit-4digit-2digit format.
Please note: A drug’s container label may display less than 11 NDC digits. An asterisk may appear in either a product code or package code as a place holder for any leading zeros. Zeros must be added to each section to make 11 digits total when submitting the NDC code on the claim to BCBSTX. Decimal points are acceptable in the NDC unit field. Each container label displays the appropriate unit of measure for that drug.
Please remember the following to help ensure proper submission of valid NDCs and related information: The NDC must be submitted along with the applicable HCPCS or CPT procedure code(s).
The NDC must be in the proper format (11 numeric characters, no spaces or special characters).
The NDC must be active for the date of service.
The appropriate qualifier, unit of measure, number of units, and price per unit also must be included, as indicated below.
BCBSTX utilizes a claims payment audit process (during initial claim payment and post payment) to validate the number of units administered against the submitted charges of medications. This audit process applies to claims for medications billed with Healthcare Common Procedure Coding System (HCPCS) codes, Current Procedural Terminology (CPT®) code(s), and National Drug Code (NDC).
The audit reviews claims to identify possible overbilling errors that exceed standard dosing thresholds. It may result in denying the portion of these claims that exceeds maximum dosing levels based on the product labeling, Food and Drug Administration (FDA) dosing guidelines; peer reviewed or published medical literature for each drug.
PAPER CLAIM GUIDELINES
In the shaded portion of the line-item field 24A-24G on the CMS-1500, enter the qualifier N4 (left- justified), immediately followed by the NDC.* Next, enter the appropriate qualifier for the correct dispensing unit (F2 – international unit mainly used for Factor VIII-Antihemophilic Factor; GR – gram, generally used for ointments, creams, inhaler or bulk powder in a jar; ML – milliliter, if drug comes in a vial in liquid form; UN – unit, if drug comes in a vial in powder form and has to be reconstituted; followed by the quantity and the price per unit, as indicated in the example below.
*Note: The HCPCS/CPT code corresponding to the NDC is entered in field 24D.
EXAMPLE NDC BILLING SCENARIO : To assist you with billing with NDCs, below is an example scenario.
What was administered?
In our sample scenario, a patient received Decitabine 50 mg.
What’s on the package label?
The NDC is found on the medication’s packaging. The drug’s container label may display less than 11 NDC digits. An asterisk may appear in either a product code or package code as a place holder for any leading zeros. Each container label displays the appropriate unit of measure for that drug.
Decitabine is supplied in a single-dose 50mg per vial. Here is an example of the NDC information that you may see when you are preparing to bill: 62856-0600-01 Dacogen, 50mg SOLR Unit of Measure = UN
What to include on the claim: When entered on your claim, the NDC must follow the 5digit-4digit-2digit format, any leading zeros must be added to each segment to make 11 digits total. The NDC must be in the proper format (11 numeric characters, no spaces or special characters).
For our example scenario:
The NDC is 62856-0600-01 (the qualifier is N4)
The unit of measure is UN, since the drug came in a single dose and does not specify the ML The quantity (number of NDC units administered) is 1
The quantity (number of J-code units administered) is 1
The HCPCS code is J0894
NDC Billing Instructions
Molina EDI Help Desk reports that claims are being rejected because more than one NDC code is being billed on one service line. Below you will find instructions on billing multiple NDC codes for the same drug on a claim.
For more detailed information on billing NDC codes, please see the BMS website at
www.dhhr.wv.gov/bms under the heading “HCPCS/Drug Codes”.
NDC’s must be configured in what is referred to as a 542 format. The first segment must include five digits, the second segment must include four digits, and the third segment must include 2 digits. If an NDC is missing a number on the product label, the appropriate number of zeros must be added at the beginning of the segment. Only the NDC as specified on the label of the product that is administered to the member is to be billed. Every NDC must be billed with an N4 qualifier before the NDC with no hyphens or spaces, the unit qualifier such as F2 (International Unit), GR (Gram), ML (Milliliter), and UN (Unit) and the NDC quantity. Billing instructions are available at www.dhhr.wv.gov/bms & Molina Medicaid Solutions at www.wvmmis.com. Important: All NDC charges must have the specific date of service the listed drug was adminis-tered and all NDC drug charges must be listed individually.
Important: All NDC charges must have the specific date of service the listed drug was adminis-tered and all NDC drug charges must be listed individually.
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 (other than compounds, see BMS website), providers must bill the procedure code with KP modifier and the corresponding procedure code NDC qualifier, NDC, NDC unit qualifier, and NDC units. The claim line must be billed with the charge for the amount of the drug dispensed for the NDC identified on the line. The second line item with the same procedure code must be billed utilizing KQ modifier, the procedure code units, charge and NDC information for this portion of the drug.
How to convert a 10 digit NDC to 11 digits
NDC codes are traditionally segmented into three distinct digit groups. The first identifies the manufacturer or labeler of the drug in question. The second specifies the exact dosage and form. Finally, the third segment is used to identify the “package code” assigned by the labeler – whether a package contains 20 or 50 capsules, for example.
Converting 10-digit NDC numbers to the requisite 11 digits required for claim submission is a small matter of adding a well-placed zero to one of these three segments. But NDC numbers for different drugs follow different formats. There’s a simple set of rules to help place the zero in the correct location.
· For a 10 digit NDC in the 4-4-2 format, add a 0 in the 1st position.
· For a 10 digit NDC in the 5-3-2 format, add a 0 in the 6th position.
· For a 10 digit NDC in the 5-4-1 format, add a 0 in the 10th position.
In table form, that looks like this:
10-Digit Format on Package 10-Digit Format Example 11-Digit Format 11-Digit Format Example
4-4-2 9999-9999-99 5-4-2 09999-9999-99
5-3-2 99999-999-99 5-4-2 99999-0999-99
5-4-1 99999-9999-9 5-4-2 99999-9999-09
Note that the resulting 11-digit NDC number to be used in the bill always follows a 5-4-2 pattern.
One more thing to remember: The hyphens in this table are used, only, to illustrate the segmentation inherent to the NDC format. When reporting a NDC on a claim form, NEVER use hyphens.
Billing with National Drug Codes
BCBSTX reimburses claims submitted with National Drug Code (NDC) in accordance with the NDC Fee Schedule posted on the BCBSTX provider website under “Drugs.” To locate this information, click the Standards & Requirements tab, then select General Reimbursement Information, enter password, then scroll down to the Reimbursement Schedules and Related Information area, then go to Professional or Ancillary (as appropriate) and select the Blue Choice PPOSM and HMO Blue Texas Schedules offering, then select 2014 Schedules effective July 1, 2014, then select Drugs. The NDC Fee Schedule is updated monthly on the first of each month.
Lower-cost generic medications may be reimbursed with a larger margin compared to higher-cost generic and brand medications. Effective June 1, 2014, BCBSTX revised the methodology utilized for determining the allowables for Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT®’) codes associated with multiple NDCs, including vaccines. The HCPCS or CPT code allowable generally will be equivalent to the lowest NDC allowable associated with the HCPCS or CPT code.
When drugs are billed under the medical benefit on professional/ancillary electronic (ANSI 837P) and paper (CMS-1500) claims, it is important to include NDCs and related data. Using NDCs on medical claims facilitates more accurate payment and better management of drug costs based on what was dispensed. Physicians and ancillary providers are encouraged to include NDC information on claims.
BCBSTX requires inclusion of the NDC along with the applicable HCPCS or CPT code(s) on claim submissions for unlisted or “Not Otherwise Classified” (NOC) physician or ancillary provider administered and supplied drugs. BCBSTX will continue to accept the HCPCS or CPT code elements without NDC information (excluding unlisted or “Not Otherwise Classified” drugs).
As a reminder, when submitting NDCs on professional/ancillary electronic (ANSI 837P) and paper (CMS-1500) claims to BCBSTX, you must also include the following related information:
• The applicable HCPCS or CPT code
• Number of HCPCS/CPT units
• NDC qualifier (N4)
• NDC unit of measure (UN – Unit, ML – Milliliter, GR – Gram, F2 – International Unit)
• Number of NDC units (up to three decimal places)
• Your billable charge/price per unit
Attention electronic claim submitters: If you have converted to ANSI 5010, there should be no additional software requirements when NDCs are included on electronic claims. However, please verify with your software vendor to confirm that your Practice Management System accepts and transmits the NDC data fields appropriately. If you use a billing service or clearinghouse to submit electronic claims on your behalf, please check with them to ensure that NDC data is not manipulated or dropped inadvertently.
Prevnar Immunization
Effective 12/30/2011 Prevnar 13® is available for WV Medicaid members over the age of 50. Prevnar 13® is FDA approved for adults 50+ years of age to help prevent pneumococcal pneu-monia, meningitis, and bacteremia caused by 13 strains of S pneumonia. CPT code 90670 is to be billed for adult vaccinations; the reimbursement includes the cost of administration – the im-munization administration codes are not to be billed separately for adult vaccines. Prevnar 13® is currently available for children up to the age of 6 through the Vaccines for Chil-dren (VFC) Program. As with all VFC vaccines, bill the administration code with your charge for the service and the vaccine code with the SL modifier to indicate the vaccine was provided under
the VFC Program at no cost.