Report national drug code number on professional drug claims for accurate processing

BCBSM is launching an initiative to process professional medical drug claims at the national drug code level with the specific quantity that correlates to the NDC. This means that we’ll ask health care providers to submit NDC codes on claims for these drugs, starting May 1, 2013.

This initiative will ensure the most accurate and up-to-date pricing of medical drugs, based on the date of service. Since this is a major change, we are rolling it out in three phases.

The initial phase will begin May 1, when we request you include NDCs and the appropriate quantities on claims for informational purposes. Today, you already submit this information for some medical claims – those reporting not otherwise classified procedure codes J3490 or J3590, for example. During this initial phase, we will continue to process professional medical drug claims based on the procedure code and quantity, to give health care providers time to adjust their billing processes.

The second phase will begin Aug. 1, 2013. At that time, BCBSM will provide a list of drugs we will begin to process at the national drug code level and the specific quantities that correlate with the NDCs.

The third phase will begin Nov. 1. We will require the national drug code on all professional medical drugs claims at that time.

Finding the NDC and Unit of Measure
The national drug code is found on a medication’s packaging. An asterisk may appear as a placeholder for any leading zeroes. The container label also displays the appropriate unit of measure for that drug. The unit of measure is by weight (grams: GR), volume (milliliter: ML) (milligram: ME) or count (unit: UN). Each dispensed dose must be converted into one of these, following the manufacturer’s unit of measure. International units (F2) must be converted to standard measurements (GR, ML, ME and UN).

• For drugs that come in a vial in powder form that needs to be reconstituted before administration, bill each vial (UN).
• For drugs that comes in a vial in liquid form, bill in milliliters (ML).
• For topical forms of medicine (e.g., cream, ointment, bulk powder in a jar), bill in grams (GR or ME).

Submitting the NDC on claims
Here are some quick tips and general guidelines to assist you with proper submission of valid NDCs and related information on professional claims:

• The NDC must be submitted along with the applicable Healthcare Common Procedure Coding System or Current Procedural Terminology^® code.
• The NDC must follow the “5digit4digit2digit” format (11 numeric characters with no spaces or special characters). If the NDC on the package label is fewer than 11 digits, you must add leading zeroes to total 11 digits.
• The NDC must be active for the date of service.
• To submit electronic claims (ANSI 837P), report the following information:

• To submit paper claims, enter the NDC information in field 24 of the CMS-1500 claim. In the shaded portion of field 24A-24G, enter the qualifier “N4” left-justified, immediately followed by the national drug code. Next, enter the appropriate qualifier for the correct dispensing unit (GR, UN, ML or ME), followed by the quantity and the price per unit, as indicated in the example below.
• The format for billing should be:
  N4 + NDC code + 3 Spaces+ unit of measure + quantity
  Example: N4555103026710 ML5.5

• Reimbursement for discarded drugs applies only to single use vials. Discarded amounts of drugs in multi-use vials are not eligible for payment.
• For home infusion therapy and specialty drugs, health care providers must continue to submit claims with national drug code and National Council for Prescription Drug Programs quantities electronically.