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

National drug code information is now being used during the claims process to ensure the most accurate and up-to-date pricing for medical drugs, based on the date of service. This applies to all professional offices, clinics and practitioners who provide and bill medical drugs.

Other ancillary providers such as hemophilia network providers, home infusion therapy providers, ambulatory infusion centers, Walgreens Specialty Pharmacy, limited distribution drug specialty pharmacies and durable medical equipment providers are also required to provide the NDC information, as well as the quantity, for claims processing.

Note: Healthcare Common Procedure Coding System and Current Procedural Terminology^® codes and quantities are required on all drug claims, as required by HIPAA.

The claims billing submissions information and formats described below can also be found in the provider manuals on web-DENIS.

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) 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 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).

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 HCPCS or CPT code.
• The NDC must follow the “5digit4digit2digit” format (11 numeric characters with no spaces or special characters). The NDC must be active for the date of service.
• To submit electronic claims (ANSI 837P), report the following information:
  
  

Field name	Field description	ANSI (Loop 2410) – Ref Desc
Product ID Qualifier	Enter “N4” in this field.	LIN02
National Drug CD	Enter the 11-digit NDC assigned to the drug administered.	LIN03
NDC Units	Enter the quantity (number of units) for the prescription drug.	CTP04
NDC Unit / MEAS	Enter the unit of measure of the prescription drug given (GR, UN or ML).	CTP05-1



• To submit paper claims, enter the NDC information in field 24 of the CMS-1500 claim form. 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 or ML), followed by the quantity and the price per unit, as indicated in the example below.

Here are two claims billing examples:

• The format for billing should be:
  N4 + NDC code + 3 Spaces+ unit of measure + quantity
  Example: N450242005306   ML50

• The format for billing should be:
  N4 + NDC code + 3 Spaces+ unit of measure + quantity
  Example: N468817013450   UN3

 
Keep the following in mind:

• 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.
• In previous articles, we mentioned the use of “ME” (milligrams); however, milligrams as a unit of measure will not be accepted.

BCBSM has also expanded the NDC quantity field to house 11 digits, which translates to 8 places before the decimal and 3 places after the decimal to large quantity units. Example: 99999999.999

Clarification: Converting an NDC from 10 to 11 digits
Previously, we communicated the following information about converting a 10-digit NDC to an 11-digit NDC: “If the NDC on the package label has fewer than 11 digits, you must add leading zeroes to total 11 digits.”

We’d like to provide additional details, as follows:

Many national drug codes are displayed on drug packaging in a 10-digit format. Proper billing of an NDC requires an 11-digit number in a 5-4-2 format. Converting NDCs require a strategically placed zero, depending on the 10-digit format. The following table shows common 10-digit NDC formats indicated on packaging and the appropriate conversion to an 11-digit format. The correctly formatted additional “0” is in bold and underlined in the following examples.

Note: Hyphens indicated below are only used to illustrate the various formatting examples for NDCs. Do not use hyphens when entering the NDC in your claim.

None of the information included in this article should be considered legal advice. As such, it is the provider’s responsibility to ensure that all coding and documentation are done in accordance with applicable state and federal laws and regulations.