a “how to” for reporting ndc - wedi “how to” for reporting ndc in health care claims may 1,...

A “How To” for Reporting NDC

in Health Care Claims

May 1, 2013

Kelly Butler, Emdeon

Gloria Davis, QSI/NextGen Healthcare

Jennifer Loftis, Blue Cross Blue Shield Florida

Nancy Spector, American Medical Association

Objectives

2

●Address when NDC is reported

●Review data elements for NDC

●Review how to report data elements

●Discuss examples

●Provide resources

Problem Statements

3

●When do I report NDC?

●What data do I report when I have to report

NDC?

●How do I determine what quantities to report for

NDC?

When to Report NDC

When to Report NDC

5

●NDC information is reported when required

by federal or state regulation or when the

submitter determines it will support the claim

and adjudication process.

● In general, NDC is reported for Healthcare

Common Procedure Coding System

(HCPCS) codes for physician-administered

drugs and biologics.

●NDC is required to be reported on Medicaid

claims, and Medicare claims when Medicaid

is the secondary payer.

What Data is Reported for NDC

Different Types of NDC Reporting

7

●Professional claim

● Institutional claim

●Unspecified codes

●Compound drugs

Professional Claim

8

●Segments reported

–SV1 – Service procedure information

–LIN – Drug information

–CTP – Drug quantity

Service Procedure Information

9

●SV1

–SV101-1 – Qualifier (“HC”) indicates

procedure code is a HCPCS or CPT code

–SV101-2 – Procedure code

–SV103 – Qualifier for the procedure units

–SV104 – Procedure units

Calculating Procedure Units

10

● Procedure units are determined by the HCPCS

description

● Not all short HCPCS descriptions define the units

● Examples:

–J0131 Injection, acetaminophen, 10 mg

If 10 mg were given, then service unit = 1

–J1610 Injection, glucagon hydrochloride, per 1 mg

If 5 mg were given, then service unit = 5

Drug Identification

11

● LIN

–LIN02 – Qualifier (“N4”) indicates code is NDC

–LIN03 – NDC

● NDCs are reported in a 5-4-2 format

– If NDC is not 5-4-2, zeros are added at the

beginning of the appropriate section

● 1234-5678-91 = 01234-5678-91

● 12345-678-91 = 12345-0678-91

● 12345-6789-1 = 12345-6789-01

Quantity Information

12

● CTP

–CTP04 – NDC unit count

–CTP05-1 – Unit of measure

● Units of Measure are:

–F2 – International unit

–GR – Gram

–ME – Milligram

–ML – Milliliter

–UN – Unit

Calculating NDC Quantity

13

● The NDC quantity can be identified by the NDC

description and the quantity administered

● The NDC quantity and unit of measure are closely

related

● For example:

– If milliliters are administered, then total number

administered is the quantity reported

– “Each” or “ea” in the NDC description indicates a vial

or tablet, which is a quantity of 1

Calculating NDC Quantity

14

● Examples:

–0002-1407-01, Quinidine gluconate, 10ml/vial

If 10 ml were given, then NDC unit = 10

If 5 ml given, then NDC unit = 5

–00069-0058-02, Heparin sodium, 1000 USPS/ML

(10 ml/vial)

If 1 ml was given, then NDC unit = 1

–00409-1135-02, Morphine sulfate, 25 mg/ml

If 25 mg were given, then NDC unit = 1

Example

15

A patient is given an injection in the physician’s office of

500 mg Ampicillin sodium, which is reconstituted from a

500 mg vial of powder.

Therefore:

HCPCS: J0290 (Injection, Ampicillin sodium, 500 mg)

NDC: 00781-9407-78

HCPCS unit: 1

NDC quantity: 1

Unit of measure: UN

Example

16

Loop Segment Data Element Data Reported

2400 SV1 SV101-1 HC

SV101-2 J0290

SV103 UN

SV104 1

2410 LIN LIN02 N4

LIN03 00781940778

2410 CTP CTP04 1

CTP05-1 UN

Institutional Claim

17

●Segments reported

–SV2 – Service procedure information

–LIN – Drug information

–CTP – Drug quantity

Example

18

A patient in the hospital is given a 1000 mg dose of

Ceftriaxone where two 500 mg vials of powder are

reconstituted.

Therefore:

HCPCS: J0696 (Injection, ceftriaxone sodium, 250

mg)

NDC: 00409-7338-01

HCPCS unit: 4

NDC quantity: 2

Unit of measure: UN

Example

19


2400 SV1 SV202-1 HC

SV202-2 J0696

SV204 UN

SV205 4

2410 LIN LIN02 N4

LIN03 00409733801

2410 CTP CTP04 2

CTP05-1 UN

Unspecified Codes

20

● Need to report a description when the procedure code

is and “unspecified” code

● Submitter can also include a description if they think

the procedure code does not sufficiently identify the

procedure performed

● Description is reported in SV101-7/SV202-7

● What meets the requirement for a description?

–Not defined in the implementation guide

–Most payers accept the NDC code or name of drug

Example

21

A patient is given an injection in the physician’s office of

500 mg of Aloprim, which is reconstituted from a 500 mg

vial of powder.

Therefore:

HCPCS: J3490 (Unclassified drugs)

NDC: 67457-0187-50

HCPCS unit: 1

NDC quantity: 1

Unit of measure: UN

Example

22


2400 SV1 SV101-1 HC

SV101-2 J3490

SV101-7 67457018750

SV103 UN

SV104 1

2410 LIN LIN02 N4

LIN03 67457018750

2410 CTP CTP04 1

CTP05-1 UN

Example

23


2400 SV1 SV101-1 HC

SV101-2 J3490

SV101-7 Aloprim

SV103 UN

SV104 1

2410 LIN LIN02 N4

LIN03 67457018750

2410 CTP CTP04 1

CTP05-1 UN

Compound Drugs

24

●Each drug is reported on a separate service

line

●LIN02, LIN03, CTP04, and CTP05 are reported

for each compound

●REF – Prescription or Compound Drug

Association Number must be reported

–REF01 – Qualifiers “VY” for Link Sequence

Number and “XZ” for Pharmacy Prescription

Number

–REF02 – Prescription or reference number

Example

25

A patient is in the physician’s office for

reprogramming and refill of an implantable pain

pump. The compound drug includes 200 mg

Hydromorphone USP (drug A), 500 mg

Bupivacaine USP (drug B), and 33.3 mg Baclofen

USP (drug C), which are all measured by weight.

Example

26

Therefore:


HCPCS unit: 1

Drug A NDC: 38779-0524-05 (Hydromorphone)

NDC quantity: 0.5

Unit of measure: GR

Drug B NDC: 38779-0731-04 (Bupivacaine)

NDC quantity: 0.2

Unit of measure : GR

Drug C NDC: 38779-0388-04 (Baclofen)

NDC quantity: 0.033

Unit of measure: GR

Example

27


2400 SV1 SV101-1 HC

SV101-2 J3490

SV101-7 Hydromorphone

SV103 UN

SV104 1

2410 LIN LIN02 N4

LIN03 38779052405

2410 CTP CTP04 0.5

CTP05-1 GR

REF REF01 VY

REF02 123456789

Example (cont.)

28


2400 SV1 SV101-1 HC

SV101-2 J3490

SV101-7 Bupivacaine

SV103 UN

SV104 1

2410 LIN LIN02 N4

LIN03 38779073104

2410 CTP CTP04 0.2

CTP05-1 GR

REF REF01 VY

REF02 123456789

Example (cont.)

29


2400 SV1 SV101-1 HC

SV101-2 J3490

SV101-7 Baclofen

SV103 UN

SV104 1

2410 LIN LIN02 N4

LIN03 38779038804

2410 CTP CTP04 0.033

CTP05-1 GR

REF REF01 VY

REF02 123456789

Other Consideration

Rejected Claims

31

●Review ERAs and claims status (277CA)

responses to identify issues with submissions

–Missing data

–Incorrect data

●Codes

–Claim Adjustment Reason Codes

–Remittance Advice Remark Codes

–Claim Status Codes

More Examples

33

A patient in an outpatient setting receives 120 mg of

Xgeva (denosumab).

Therefore:

HCPCS: J0897 (Injection, denosumab, 1 mg)

NDC: 55513-0730-01 (Xgeva 120 mg/1.7 ml soln)

HCPCS unit: 120

NDC quantity: 1

Unit of measure: ML (1.7 ml = 1 vial)

34


2400 SV1 SV101-1 HC

SV101-2 J0897

SV103 UN

SV104 120

2410 LIN LIN02 N4

LIN03 55513073001

2410 CTP CTP04 1

CTP05-1 ML

35

A patient in a physician office receives a 1 ml injection of

lidocaine.

Therefore:


NDC: 00409-4278-01 (Lidocaine HCL 0.5% soln)

HCPCS unit: 1

NDC quantity: 1

Unit of measure: ML

36


2400 SV1 SV101-1 HC

SV101-2 J3490

SV101-7 00409427801

SV103 UN

SV104 1

2410 LIN LIN02 N4

LIN03 00409427801

2410 CTP CTP04 1

CTP05-1 ML

37

A patient in a physician office receives an injection of 30

units of bleomycin.

Therefore:

HCPCS: J9040 (Injection, bleomycin sulfate, 15 units)

NDC: 63323-0137-20 (Bleomycin Sulfate 30 Unit

SOLR)

HCPCS unit: 2

NDC quantity: 1

Unit of measure: UN

38


2400 SV1 SV101-1 HC

SV101-2 J9040

SV103 UN

SV104 2

2410 LIN LIN02 N4

LIN03 63323013720

2410 CTP CTP04 1

CTP05-1 UN

39

A patient in a physician office receives an injection of 100

mg of Zaltrap.

Therefore:

HCPCS: J9999 (Not otherwise classified,

antineoplastic drugs)

NDC: 00024-5840-01 (Zaltrap 100 mg/4 ml soln)

HCPCS unit: 1

NDC quantity: 4

Unit of measure: ML

40


2400 SV1 SV101-1 HC

SV101-2 J9999

SV101-7 Zaltrap

SV103 UN

SV104 1

2410 LIN LIN02 N4

LIN03 00024584001

2410 CTP CTP04 4

CTP05-1 ML

41

A specialty pharmacy provides a 30-day supply of oral

chemotherapy of Temodar, which comes as 15 capsules

of 100 mg.

Therefore:

HCPCS: J8700 (Temozolomide, oral, 5 mg)

NDC: 54868-5350-00 (Temodar 100 mg caps)

HCPCS unit: 300

NDC quantity: 15

Unit of measure: UN

42


2400 SV1 SV101-1 HC

SV101-2 J8700

SV103 UN

SV104 300

2410 LIN LIN02 N4

LIN03 54868535000

2410 CTP CTP04 15

CTP05-1 UN

Resources

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● ASC X12 Technical Reports Type 3 -

http://store.x12.org/store/

–Health Care Claim: Professional (837P),

005010X222A1

–Health Care Claim: Institutional (837I),

005010X223A2

● Your payers and/or billing vendor

● Your state Medicaid



Thank You!

WEDI 837 Subworkgroup

Always Recruiting New Members! Co-Chairs

Kelly Butler: [email protected] Nancy Spector: [email protected]

Gloria Davis: [email protected]

www.wedi.org

45

mailto:[email protected]





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