Bene hero

Home infusion injectable guidelines

The following educational information is provided to facilitate timely and accurate claim filing for reduction of billing errors, rework of claims, and prompt payment of home infusion therapy services for TRICARE.

TRICARE Policy (TRM Chapter 3, Section 6, II, B, 1) requires the use of appropriate “J” HCPCS codes and the specific NDC # for pricing using 95% of the AWP.

Recurring billing errors have been identified and are listed here:

  1. Use of Miscellaneous “J” codes (e.g., J3490, J3590, and J9999) when specific “J” codes are available.
  2. Non-compliance with billing guidelines (e.g., paper CMS-1500 or electronic HIPAA 837).
  3. Entry of NDC quantities in the HCPCS quantity field.
  4. Failure to provide the NDC#.
  5. Failure to provide the NDC Unit of Measure.
  6. Failure to provide the NDC Quantity.

Instructions below should improve your timely and accurate claims resolution and payment:

A. NDC field
Each NDC must be reported as an 11-digit code unique to the manufacturer of the specific drug or product administered to the patient, using a 5-4-2 format (i.e., 5 digits, followed by 4 digits, followed by 2 digits) 99999999999.

Some NDCs may be in a 10-digit format. The chart below illustrates how to convert the code into 11-digits. (Hyphens in the example below are for illustration only.)

10-Digit Format on Package

10-Digit Format on Example

11-Digit Format

11-Digit Format Example

4-4-2

9999-9999-99

5-4-2

099999-9999-99

5-3-2

99999-999-99

5-4-2

99999-0999-99

5-4-1

99999-9999-9

5-4-2

99999-9999-09

B. NDC Units/Quantity field
The quantity of each submitted NDC must be a numeric value greater than zero. In most cases, the NDC quantity will be different from the HCPCS billed units. To determine the correct NDC quantity, refer to the data column titled CF (conversion factor) on the Noridian Crosswalk Table. This table is updated monthly by CMS.

Identify your “J” code and correlating NDC# for your combination record, divide the number of billed HCPCS units by the CF; and enter the resulting number as the NDC Quantity.

NOTE (1): Whenever a Miscellaneous “J” code is used, the CF is NOT valid. In these cases your entry of the NDC Quantity is the sole source of quantity to be priced based on the AWP.
NOTE (2): “J” code HCPCS Quantities must always be stated in “whole” numbers. NDC Quantities can be stated in up to three places to the right of the decimal. When pricing, the NDC Quantity is “rounded” to the nearest “whole” number.

C. NDC Measurement (Package/Unit Indicator) field
The unit of measurement (UOM) for each NDC must be submitted. Noridian Crosswalk Table assumes the conversion of Units NOT Packages. If using the conversion factor on the Noridian Crosswalk Table, the UOM should always be submitted as “Units”. (UN, ML, or GR for electronic HIPAA 837 and “U” for paper CMS-1500 claims).

If you are one of the many providers enjoying the benefits of electronic claim filing, the following data elements should be used to submit the NDC information in the HIPAA-standard ASC X12 837 claims format:

  • LIN03-product/srevic-NDC (11-digit format).
  • CTP04-NDC units (must be numeric value greater than 0 (up to 3 decimal places allowed).
  • CTP05-1-NDC unit of measurement (UN, ML, GR, or F2). The UN, ML, and GR are priced as units. The F2 is priced as a package. However, you should avoid using the F2 value if possible.

Some things to remember when filing claims for home infusion medications:

  • Make sure the NDC number, units, and unit of measurement are listed on the gray line above the HCPCS code if you are filing using a CMS-1500 claim form.
  • Report the NDC number in the 11-digit format.
  • Use the Noridian Crosswalk Table to convert the HCPCS units into NDC units: submit the UOM as units (UN, ML, or GR).
  • Place of service must be “home”.
  • If Infusion therapy is performed in an Ambulatory Infusion Suite, place of service must be “office” and the HCPCS must be submitted with modifier “SS”