Services provided | To be reimbursed directly for medications provided during a visit/stay |
---|---|
Ambulatory surgery center (ASC) | Include in medical claim |
Emergency room | Include in medical claim |
Home health | Include in medical claim |
Hospital or other inpatient setting | Include in medical claim |
Medical or dental provider/clinic |
|
Pharmacy | Pharmacy submits claim through PBM |
Skilled nursing facility (SNF) | Include in medical claim |
Urgent care | Include in medical claim |
Vaccines |
|
Infusion medications |
|
Drug administration codes billed without an accompanying HCPCS drug code will be denied. When a provider bills the administration code and another provider is to be reimbursed for the drug code, the administering provider must include a charge on their claim with a phantom drug code for a penny ($.01) or less, depending on system limitations.
National Drug Codes (NDCs) must be included on all medical drug claims with a HCPCS code that starts with "J". Claims billed with a J code that do not have NDC information will be rejected with a request to complete the additional claim fields. This requirement applies to drugs administered in an:
- Outpatient facility setting
Office by a physician or other health care professional
The 11-digit NDC number must be accompanied by the basis of measurement (UN, ML, etc.) and the NDC drug units. The claim should also include the corresponding HCPCS and CPT codes and the units administered for each code.
The 11-digit NDC number is in a 5-4-2-digit format, NNNNN-NNNN-NN, that is assigned to each drug product approved by the Food and Drug Administration (FDA). The NDC is usually found on the drug label or outer packaging. The number on the packaging may be less than 11 digits. An asterisk may appear as a placeholder for any leading zeros. The label also displays information about the NDC unit of measure for that drug. The three segments in the number indicate the following:
- First segment– Identifies the company that manufactures or distributes the drug (assigned by the FDA)
- Second segment– Identifies the product, its specific strength, dosage form and formulation of a drug (assigned by the drug manufacturer)
Third segment– Identifies the package size and type (assigned by the drug manufacturer)
You must enter the NDC on your claim in the 11-digit billing format with no spaces, hyphens or other characters. If the NDC on the package label is less than 11 digits, you must add a leading zero to the appropriate segment to create a 5-4-2 configuration. See the examples below:
Label configuration | Add leading zero, remove hyphens |
---|---|
4-4-2 (xxxx-xxxx-xx) | 0xxxxxxxxxx |
5-3-2 (xxxxx-xxx-xx) | xxxxx0xxxxx |
5-4-1 (xxxxx-xxxx-x) | xxxxxxxxx0x |
Unit of measurement requirements: The unit of measurement codes are also required to be submitted. Please use these codes for all claim forms:
- F2 – International unit (products described as IU/vial or micrograms)
- ML – Milliliter (e.g., liquid, solution or suspension)
- UN – Unit (e.g., powder for injection (needs to be reconstituted), pellet, kit, patch, tablet, device)
- ME – Milligram (e.g., drugs where the units, if converted to grams, would have too many decimal places and would not be accepted on the claim submittal)
- GR – Gram (e.g., ointments, creams, inhalers or bulk powder in a jar)