The following information is provided to facilitate timely and accurate claim filing for the prompt payment of provider office injectables.
Per TRICARE, claims that include drugs that are administered other than oral method will be priced from the Medicare average sale price list. Drugs that do not appear on this list will be priced at the lesser of billed charges or 95% of the Average Wholesale Price (AWP). TRICARE requires the use of appropriate CPT/HCPC codes and the specific NDC number for pricing using 95% of the AWP.
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: 99999-9999-99). Some NDCs may be in a 10-digit format. If the NDC is not submitted in the correct format, the claim will be denied.
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.
The unit of measurement for each NDC must be submitted:
Before considering using an unlisted or NOC procedure code, you should determine if there is another more specific code that could be indicated to describe the procedure or service being provided. If there is not a more specific code available, you are required to submit the appropriate documentation to justify the use of the unlisted procedure code and to describe the procedure or service rendered.
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 |
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.
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. Learn more
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.
