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Office injectable guidelines

National drug code (NDC) pricing and filing tips

The following educational information is provided to facilitate timely and accurate claim filing for the prompt payment of provider office injectables. The guidance offered here has been developed and made available to providers in an effort to support the reduction of billing errors, rework of claims, as well as diminish the possibility of payment error and recoupment of office injectables for TRICARE.

Per the TRM Chapter 1, Section 15, para 3.3.1.1 - 3.3.1.2, medical claims that include drugs that are administered other than oral method will be priced from the Medicare Average Sale Price (ASP) file.  Drugs that do not appear on the ASP will be priced at the lesser of billed charges or 95% of the AWP. TRICARE Policy requires the use of appropriate CPT/ or HCPC codes and the specific NDC # for pricing using 95% of the AWP.

Average sales price can be found using the subscription service below:

Average wholesale prices found using the subscription services below:


Providers must choose their own method of obtaining the appropriate pricing for the drug by NDC.

Each NDC must be reported as an 11-digit code unique to the manufacturer of the specific drug or product administered to the beneficiary, 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 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

If the NDC is not submitted in the correct format, the claim will be denied.

NDC quantity
The quantity of each NDC must be a numeric value greater than zero. In most cases, the NDC quantity will be different from the HCPCS billed units.

NDC unit of measurement
The unit of measurement (UOM) for each NDC must be submitted.

  • F2 = international unit
  • GR = gram
  • ME = milligram
  • ML = milliliter
  • UN = unit

Billing using the electronic claim format

The following data elements should be used to submit the NDC information in the HIPAA-standard ASC X12N 837 electronic claims format.

Loop 2400

Loop 2410

SV101 CPT/HCPCS code

LIN03 NDC (11-digit format)

SV104 CPT/HCPCS units

CPT04 NDC quantity

CPT05-1 NDC unit or basis for measurement code

 

Example

Loop

Segment

Value

RotaTeq rotavirus vaccine
CPT code - 90680
CPT DUTS - 1
NDC - 00006404741
NDC drug quantity - 2
NDC UOM - ML

2400

SV101

9680

SV104

1

2410

LIN03

00006404741

CPT04

2

CPT05-1

ML

The complete 837 instructions are available in the HIPAA Implementation Guide.

Billing using the paper claim form

If you bill on paper using the CMS-1500 form, use the shaded area of Fields 24A-24G to report the NDC information in the following order: qualifier, NDC code, one space, unit/basis of measurement qualifier, quantity. The number of digits for the quantity is limited to eight digits before the decimal and three digits after the decimal. If entering a whole number, do not use a decimal. Do not use commas.

Examples:

1234.56
2
9999999.999
NDC claim line

See the CMS-1500 Manual [MR1] for additional information.

TRICARE provider claims billing tips for injectables

  • If you are billing for injectables, please be aware that electronic billing does accommodate two digits behind the decimal point for a more refined calculation of the dosage (See example below).
  • If you bill on paper using the CMS-1500 form, please use the shaded area of Fields 24A-24G to report the NDC information in the following order: qualifier, NDC code, one space, unit/basis of measurement qualifier, quantity. The number of digits for the quantity is limited to eight digits before the decimal point and two digits after the decimal. If entering a whole number, there is no need for the decimal and please do not use commas.

 Claim line

Providers are required to indicate the correct dosage value in the NDC drug quantity field on the claim form. In some cases, the drug value may not be a whole number. If this is the case, fractional or decimal units are appropriate to bill.

Below is an example of a vaccine where the drug quantity is a fraction or less than 1.0 ML

Menactra (Meningitis Vaccine) was the number 1 vaccine identified for billing errors related to the NDC Drug Quantity field.   The recommended dosage for this vaccine is 0.5 ml; this drug quantity (0.5) should be billed in the NDC Drug qty field on the claim.  Many providers billed 1.0 (1.0 ML) in the Drug Quantity Field resulting in overpayments.

Example

Procedure Code

Procedure Code Service Units

NDC

NDC Drug Quantity

NDC Unit Of Measurement – ML

90734

1

 

4928105890

 

0.5

 

ML

 

 

[MR1] nucc.org