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National Drug Code requirements for physician-administered drugs

 

National Drug Code requirements for physician-administered drugs

Questions and answers

  
Answer
Our system does not accommodate a CPT/HCPCS for the Revenue Codes that now require one. Can we continue billing with these codes without a CPT/HCPCS?

No. If you do bill without a CPT/HCPCS, services billed under those Revenue Codes will deny.

If the NDC is not rebateable or I am not sure which NDC was used, can I pick another NDC under the J-Code and bill with it?

No. The NDC submitted to Medicaid must be the actual NDC number on the package or container from which the medication was administered. It is considered a fraudulent billing practice to bill using an NDC other than the one administered. ​

If NDC is not reported, will my claim deny?

Only the detail line that required NDC reporting will deny. Other services billed on the claim will process as usual. ​

How will NDC information be billed on electronic and paper claims forms?

See quick tips about reporting NDC on professional and institutional claims in paper and electronic formats. You can also refer to the provider guidelines for your program. ​

How do I bill for a drug when only a partial vial was administered?
If the drug is packaged in a multi-dose vial (can be used for more than one patient), then only bill DMAP for the units administered. 
 
If the drug is packaged in a single dose vial that cannot be used for multiple injections, payment is allowed for the amount of the drug or biological discarded along with the amount administered, up to the maximum number of allowed units. The units billed must correspond with the smallest dose (vial) available for purchase from the manufacturer(s) that could provide the appropriate dose for the patient.
 
When calculating the NDC units, the HCPCS procedure code units should be converted to the NDC units, using the proper decimal units. For example, if a patient received only 2 mg of Zofran and you used the NDC which for Zofran 2 mg/ml in a 2 ml vial, the billing would look like this: HCPCS J2405 (ondansetron hydrochloride, per 1 mg) 2 units NDC 00173044202 ML1. ​
If the physician administered a vial of medication to a patient, do I bill the NDC units in grams, milliliters, or units?
It depends on how the manufacturer and CMS have determined the rebate unit amount. The rule of thumb is:
If a drug comes in a vial in powder form and has to be reconstituted before administration, then bill each vial (unit/each) used. (UN)
If a drug comes in a vial in a liquid form, bill in milliliters. (ML)
Grams are usually used when an ointment, cream, inhaler, or a bulk powder in a jar are dispensed. This unit of measure will primarily be used in the retail pharmacy setting and not for physician-administered drug billing. (GR)
International Units will mainly be used when billing for Factor VIII-Antihemophilic Factors. (F2)
For example:
 
A patient received 4 mg Zofran IV in the physician's office. The NDC you used was 00173-0442-02, which is Zofran 2 mg/ml in solution form. There are 2 milliliters per vial.
  • You would bill J2405 (ondansetron hydrochloride, per 1 mg) with 4 HCPCS units.
  • Since this drug comes in a liquid form, you would bill the NDC units as 2 milliliters. (ML2)
A patient received 1 gram of Rocephin IM in the physician's office. The NDC of the product used was 00004-1963-02, which is Rocephin 500 mg vial in a powder form that you needed to reconstitute before the injection.
  • You would bill J0696 (ceftriaxone sodium, per 250 mg) with 4 HCPCS units.
  • Since this drug comes in powder form, you would bill the NDC units as 2 Units (also called 2 Each). (UN2)

Please note: NDCs listed above have hyphens between the segments for easier visualization. When submitting NDCs on claims, submit as an eleven digit number with no hyphens or spaces between segments. ​

Are the HCPCS code units different from the NDC units?
Yes. Use the HCPCS code and service units as you have in the past; this is the basis for your reimbursement.
 
NDC units are based upon the numeric quantity administered to the patient and the unit of measurement. The unit of measurement (UOM) codes are:
  • F2 = International Unit
  • GR= Gram
  • ML = Milliliter
  • UN = Unit (Each)
The actual metric decimal quantity administered and the unit of measurement are required for billing. If reporting a fraction, use a decimal point. For example: Three 0.5ml vials are dispensed, the correct quantity to bill is 1.5 ml.
Do I need to include units for both the HCPCS code and the NDC?

Yes. Provider reimbursement is based on the HCPCS description and units of service. The state's mandated rebate submission is based on the NDC and those units. ​

What is an NDC and how do I enter it on claims?
The NDC is the number which identifies a drug. The NDC number consists of 11 digits in a 5-4-2 format. The first 5 digits identify the manufacturer of the drug and are assigned by the Food and Drug Administration. The remaining digits are assigned by the manufacturer and identify the specific product and package size.
 
Some packages will display fewer than 11 digits, but leading "0"s can be assumed and need to be used when billing. For example:
NDC on label
Configuration on label
NDC in required 5-4-2 format
05678-123-01
5-3-2
05678-0123-01
5678-0123-01
4-4-2
05678-0123-01
05678-0123-1
5-4-1
05678-0123-01
 
The NDC is found on the drug container (i.e. vial, bottle, tube). The NDC submitted to Medicaid must be the actual NDC number on the package or container from which the medication was administered.
 
Do not bill for one manufacturer's product and dispense another. The benefits of accurate billing include reduced audit, telephone calls and manufacturers' dispute of their rebate invoices.
 
It is considered a fraudulent billing practice to bill using an NDC other than the one administered.
What Revenue Code(s) must I use for billing hospital outpatient drugs?

Revenue Codes 251-259 and 634-636 will require a CPT/HCPCS code and NDC reporting. ​

Where do I find information on specific HCPCS code billing information?

Refer to Oregon Administrative Rule 410-130-0180 (Drugs) in the Medical-Surgical Program administrative rulebook. ​

How do I know if an NDC is rebateable?

When you need to report NDCs for outpatient physician-administered drug services, you must use the 11-digit NDC listed on the drug packaging. To find out if the NDC is rebateable, search for the NDC in the CMS drug rebate file (click on "Drug Product Data"). If the NDC is on file, it is rebateable. ​

Do I need to submit an NDC on claims that I purchased as 340B discounted prices?
Yes. The 340B Drug Pricing Program resulted from the enactment of the Veterans Health Care Act of 1992, which is Section 340B of the Public Health Service Act. Providers are able to acquire drugs through that program at significantly discounted rates. Because of the discounted acquisition cost, these drugs are not eligible for the Medicaid Drug Rebate Program.
 
State Medicaid programs are obligated to ensure that rebates are not claimed on 340B drugs. The DRA 2005 does not exclude 340B drugs; therefore, all providers must also meet these requirements. In order for providers to identify 340B drugs dispensed in an outpatient or clinic setting, the National Medicaid Electronic Data Interchange HIPAA workgroup has recommended use of the "UD" modifier. Oregon Medicaid has instructed its providers to also bill with the "UD" modifier in its supplemental billing guides. ​
Are Medicare crossover claims included in the NDC reporting requirements?

Yes. Because the state may pay a portion of the Medicare crossover claim (e.g., Medicare coinsurance/deductibles and drug procedure codes not covered by Medicare), physician-administered drug claims for Medicare-Medicaid recipients also require NDCs with the HCPCS codes. ​

Do vaccines/immunizations require an NDC?

No. DMAP does not include vaccines in the rebate requirements. However, other payers may have different requirements. This quick reference includes examples of the codes and descriptors used for billing vaccines.

Which codes require NDC reporting?
The only CPT codes that require NDC information are immune globulin codes 90281 through 90399. Generally, diagnostics, radiopharmaceuticals and vaccines are exempt from the NDC reporting requirements.
 
DMAP will require NDC reporting for drugs billed using HCPCS codes, including:
  • A,C, J, Q (except for contrast materials, codes Q9951-Q9968), and S codes. "Not otherwise classified" (NOC) and "Not otherwise specified" (NOS) drug codes (e.g., J3490, J999 and C9399).
  • For hospitals, Revenue Center Codes 251-259 and 634-636 will require a CPT/HCPCS code and NDC reporting. ​
Are hospitals required to report the NDC?

Yes, for outpatient services only. Inpatient services are not included in the DRA and do not require NDC reporting. ​

Who is included in "physician-administered" drugs?

Any medical practitioner whose licensed scope of practice includes administration of drugs. ​

What is the Drug Rebate Program?

The Medicaid Drug Rebate Program was created by the Omnibus Budget Reconciliation Act of 1990 (OBRA '90) and became effective 1/1/1991. The law requires that drug manufacturers enter into an agreement with CMS to provide rebates for their drug products that Medicaid pays for.

Outpatient Medicaid pharmacy providers have billed with NDC's and submitted for rebates since 1991. The DRA has expanded the rebate requirement to physician-administered drugs. ​

Why do I have to bill with National Drug Codes (NDCs) in addition to Healthcare Common Procedure Coding System (HCPCS) codes?
The Deficit Reduction Act of 2005 (DRA) requires state Medicaid programs to collect rebates on physician-administered drugs for outpatient services in order to receive federal funding for coverage of these drugs.
 
Since there are often several NDCs linked to a single HCPCS code, the Centers for Medicare and Medicaid Services (CMS) consider the use of NDC numbers critical to correctly identify the drug and manufacturer in order to invoice and collect the rebates. ​

Billing resources

  
National Drug Code reporting tips
National Drug Code reporting webinar
Codes Requiring NDC Information (Procedure Group 6069)
NCPDP Unit of Measure (UOM) List

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Need help?

  • If you have questions about claims billed to DMAP, contact the DMAP Pharmacy Program.
  • If you have questions about NDC reporting for claims billed to OHP health plans, contact the plan​.
  • Health plans with questions about NDC reporting should contact their DMAP Encounter Data Liaison.
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