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December 2017
Report national drug code number on Medicare Advantage PPO drug claims for accurate processing
National drug code information is 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 any claim submitted on the professional 1500 (HCFA) claim form and ANSI 837P where a medical drug was provided.
This process has been utilized for several years for commercial PPO and Blue Care Network plans.
Although it isn’t required to include the NDC and NDC units on a claim, we recommend you include them to expedite accurate claims processing. Note: Healthcare Common Procedure Coding System and Current Procedural Terminology® codes and quantities are required on all drug claims, as required by Health Insurance Portability and Accountability Act of 1996.
NDC formatting
Many NDCs 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 requires 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 red in the following examples.
Note: Hyphens indicated below are used only to illustrate the various formatting examples for NDCs. Don’t use hyphens when entering the NDC in your claim.
10-digit format on package |
10-digit format example |
11-digit format |
11-digit converted example |
4-4-2 |
0002-7597-01
Zyprexa 10 mg vial |
5-4-2 |
00002-7597-01 |
5-3-2 |
50242-040-62
Xolair 150 mg vial |
5-4-2 |
50242-0040-62 |
5-4-1 |
60575-4112-1
Synagis 50 mg vial |
5-4-2 |
60575-4112-01 |
Finding the NDC and unit of measure
An asterisk may appear as a placeholder for any leading zeroes in the NDC found on the medication’s packaging. 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 should 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 need to be reconstituted before administration, bill each vial (UN).
- For drugs that come 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 tips and general guidelines for proper submission of valid NDCs and related information on professional claims:
- The NDC should be submitted along with the applicable HCPCS or CPT code.
- The NDC should follow the “5digit4digit2digit” format (11 numeric characters with no spaces or special characters).
- 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
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