Nv_billing_ndc_reference o110707-wip090908.doc

National Drug Code (NDC) Billing Reference
(for Nevada Medicaid and Nevada Check Up Claims)
Fee For Service Billing Requirement Effective January 1, 2008
The Deficit Reduction Act (DRA) of 2005 requires State Medicaid programs to collect rebates for physician/outpatient-facility administered drugs by January 1, 2008. To facilitate this, beginning January 1, 2008, Medicaid will require an NDC and an
NDC quantity for each claim line with a physician/outpatient-facility administered drug.
For rebateable drugs, Medicaid will pay for the drug only if the manufacturer is
participating in the Federal Drug Rebate Program. The CMS website provides a
complete list of rebateable drugs (see “Drug Product Data [zip, 570kb] posted at
).
Affected Provider Types and Claim Types
DRA requirements apply to paper forms CMS-1500 and UB-04, and to electronic transactions 837P and 837I. Provider types affected by this change are: 12, 14, 17, 20, 21, 22, 24, 25, 27, 29, 36, 45, 64, 72, 74 and 77. Claims Pricing
Beginning January 1, 2008, payment for physician/outpatient-facility administered drugs
will be based on the NDC and NDC quantity — not on HCPCS codes and units.
Payment is calculated by using the following lowest cost algorithm: average wholesale
price minus 15%; or federal upper limit; or State maximum allowable cost; or
Department of Justice minus 15%; or gross amount due (submitted) or usual and
customary (submitted).
Please note: Claims received at First Health Services December 10, 2007, through
December 31, 2007, will be processed per the lowest cost algorithm noted above if only
NDC and NDC quantity are submitted. Claims submitted with J Codes through
December 31 will be processed with current J Code payment methodology.
Providers may bill for administration of the drug using the appropriate CPT code.
Managed Care Claims
Federal regulations regarding NDC do not apply to Medicaid Managed Care programs. NDC Breakdown
An NDC consists of 11 digits separated into 3 sections by a hyphen: XXXXX-XXXX-XX NDC Billing Reference for Nevada Medicaid and Nevada Check Up Claims The first 5 digits identify the drug manufacturer, the next 4 digits identify the product and the last 2 digits identify the package size. Leading Zeros on the Claim
A drug’s container label may display less than 11 NDC digits. Leading “0s” must be
added to each section to make 11 digits total when submitting the claim to First Health
Services. For specific billing instructions, see thr the
epending on the type of claim you are submitting.
Unit of Measure
The NDC Billing Unit Standard was created to eliminate translation conflicts between manufacturers, CMS and State Medicaid programs. It designates three units of measure to describe all drugs: “UN” (unit), “ML” (milliliter), “GR” (gram) and “F2” (international unit). Each drug’s container label displays the appropriate unit of measure for that drug. The drug’s unit of measure is used to help calculate NDC quantity. Calculating NDC Quantity
If a drug’s HCPCS quantity is provided, it must be converted to NDC quantity before entering it on the claim. Below are examples of how to calculate the NDC quantity of commonly administered drugs. NDC quantity is expressed in metric units. You may enter a partial unit using up to three decimal places (e.g., 0.625). UN GR ML F2
Examples
− Two 1.5ml injections of Lidocaine 1% are NDC Billing Reference for Nevada Medicaid and Nevada Check Up Claims UN GR ML F2
Examples
− One cefazolin (powder for injection) 1gm − Two ceftriaxone (powder for injection) injection) (15 units per vial) are NDC quantity 2 − 2mls of Intal 20mg/ml nebulizing solution − 0.5ml of Morphine Sulfate 20mg/ml oral − One 60ml bottle of Lindane 1% Lotion is − One 150ml bottle of Amoxicillin (powder Reconstitution (powder for oral suspension) − One bottle of Zmax 2gm oral suspension − One Promethazine 25mg suppository is NDC Billing Reference for Nevada Medicaid and Nevada Check Up Claims UN GR ML F2
Examples
− One Intal 8.1gm meterdose inhaler is − One Desmopressin 5ml nasal inhaler is − One 5ml bottle of Timoptic- XE is NDC − Two cephalexin 500mg oral capsules are − One Lorazepam 0.5mg oral tablet is NDC − Two 1mg Kytril tablets are NDC quantity HCPCS Units and NDC Quantity Equivalents
The following table provides quantity conversion examples of HCPCS units to NDC
quantity. Please note that it is not designed to include all available NDCs, rather, it
represents the most common HCPCS codes submitted to Nevada Medicaid as well as the
top twenty multi-source drugs identified by CMS.
You may administer a drug that does not match the concentration or strength of the following examples. The NDC quantity you submit will be based on the actual drug administered. Example: Adenosine injection (Adenoscan® 3mg/ml) NDC Billing Reference for Nevada Medicaid and Nevada Check Up Claims HCPCS Units and NDC Quantity Equivalents
HCPCS NDC
HCPCS Description
Common Brand/Generic Name and Strength
Quantity Measure
J0152 INJECTION, ADENOSINE FOR DIAGNOSTIC USE, 30MG J0170 INJECTION, ADRENALIN, EPINEPHRINE, UP TO 1ML J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50MG J0690 INJECTION, CEFAZOLIN SODIUM, 500MG J0696 INJECTION, CEFTRIAXONE SODIUM, PER 250MG J1030 INJECTION, METHYLPREDNISOLONE ACETATE, 40MG J1055 INJECTION, MEDROXYPROGESTERONE ACETATE J1100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, J1200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 5 MG J1260 INJECTION, DOLASETRON MESYLATE, 10MG J1631 INJECTION, HALOPERIDOL DECANOATE, PER 50MG AMPUL HALDOL DECANOATE (AMP) 100MG/ML - 1ML J1644 INJECTION, HEPARIN SODIUM, PER 1000 UNITS VIAL HEPARIN SODIUM (M.D.V.)1000U/ML -1ML J1885 INJECTION, KETOROLAC TROMETHAMINE, PER 15MG J2175 INJECTION, MEPERIDINE HYDROCHLORIDE, PER J2250 INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1MG VIAL MIDAZOLAM HCL (VIAL) 5MG/ML - 0.2ML J2405 INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1MG J2469 INJECTION, PALONOSETRON HCL, 25MCG J2550 INJECTION, PROMETHAZINE HCL, UP TO 50MG J3301 INJECTION, TRIAMCINOLONE ACETONIDE, PER 10MG NDC Billing Reference for Nevada Medicaid and Nevada Check Up Claims HCPCS Units and NDC Quantity Equivalents
HCPCS NDC
HCPCS Description
Common Brand/Generic Name and Strength
Quantity Measure
J3420 INJECTION, VITAMIN B-12 CYANOCOBALAMIN UP VIAL CYANOCOBALAMIN (U.S.P.) 1000MCG/ML - J3475 INJECTION, MAGNESIUM SULFATE, PER 500MG J7190 FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) J7192 FACTOR VIII (ANTIHEMOPHILIC FACTOR, VIAL KOGENATE FS (APPROX. 250 IU/VIAL) 1IU ADMINISTERED THROUGH DME, UNIT DOSE, 1MG J7644 IPRATROPIUM BROMIDE, INHALATION SOLN., FDA- ADMINISTERED THRU DME, UNIT DOSE FORM, PER MG J9040 BLEOMYCIN SULFATE, 15 UNITS (POWDER FOR VIAL BLEOMYCIN SULFATE (S.D.V.,USP) 15UN VIAL PARAPLATIN (VIAL) 450MG/45ML - 45ML VIAL CYTARABINE (VIAL) 100MG POWDER FOR INJ J9217 LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), VIAL METHOTREXATE SODIUM VIAL, 25MG/ML -1ML NDC Billing Reference for Nevada Medicaid and Nevada Check Up Claims Bill Actual NDC Used
Bill the NDC for the actual drug that is administered. Billing an NDC from a reference file, e.g., Redbook, when it is not the actual drug administered is considered fraudulent billing. Multi-ingredient Compounds
For multi-ingredient compounds, list each component separately, on its own claim line. Using the appropriate CPT code, providers may bill one administration fee per compound. Third Party Liability (TPL) and Medicare Crossover Claims
Even though other payors may not require the NDC and NDC quantity, these must be included on claims that will be presented to Medicaid or automatically cross over to Medicaid for payment beginning January 1, 2008. On claims where the other payor requires HCPCS and HCPCS units on the claim, the drug’s HCPCS code and units, and its NDC and NDC quantity must be on the same claim line when the claim is presented to Medicaid. Further Instructions on First Health Services Website
Other NDC-related materials on First Health Services’ website, include: Web Announcements and Quarterly Newsletter articles about NDC are released as new information becomes available. Questions?
Please email your NDC questions to First Health Services a NDC Billing Reference for Nevada Medicaid and Nevada Check Up Claims

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