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

Please remember that BCBSM will begin processing Walgreens’ Specialty Pharmacy and limited distribution drug specialty pharmacy network providers’ claims at the national drug code level Oct. 25, 2013.

As we explained last month, this is part of our initiative to process all medical drug claims at the national drug code level. Home infusion therapy providers, ambulatory infusion centers and hemophilia care providers’ claims have been processing at the national drug level for some time.

This NDC processing 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 will continue rolling this initiative out in phases.

We’ve already requested that you include NDCs and the appropriate quantities on claims for informational purposes, the way you have in the past for not-otherwise-classified procedure codes. We continue to process individual provider professional medical drug claims based on the procedure code and quantity, to give health care providers time to adjust their billing processes.  

We plan to begin processing individual provider professional medical drug claims at the NDC level Feb. 1, 2014. This applies to physicians, advanced practice nurses, physician assistants, immunization pharmacies and durable medical equipment providers. If the date changes, we will communicate that to you.

For these providers, we will implement NDC pricing in stages. We’ll start with a select group of codes that we will publish on web-DENIS. After a few months of adjusting to this process, we will expand this effort to all medical drug claims for these providers.

We will continue to communicate these changes as they arise.

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 portionof 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.