NDC Billing Instructions
Molina EDI Help Desk reports that claims are being rejected because more than one NDC code is being billed on one service line. Below you will find instructions on billing multiple NDC codes for the same drug on a claim.
For more detailed information on billing NDC codes, please see the BMS website at
www.dhhr.wv.gov/bms under the heading “HCPCS/Drug Codes”.
NDC’s must be configured in what is referred to as a 542 format. The first segment must include five digits, the second segment must include four digits, and the third segment must include 2 digits. If an NDC is missing a number on the product label, the appropriate number of zeros must be added at the beginning of the segment. Only the NDC as specified on the label of the product that is administered to the member is to be billed. Every NDC must be billed with an N4 qualifier before the NDC with no hyphens or spaces, the unit qualifier such as F2 (International Unit), GR (Gram), ML (Milliliter), and UN (Unit) and the NDC quantity. Billing instructions are available at www.dhhr.wv.gov/bms & Molina Medicaid Solutions at www.wvmmis.com. Important: All NDC charges must have the specific date of service the listed drug was adminis-tered and all NDC drug charges must be listed individually.
Important: All NDC charges must have the specific date of service the listed drug was adminis-tered and all NDC drug charges must be listed individually.
At times, it may be necessary for providers to report multiple NDCs for a single procedure code. For codes that involve multiple NDCs (other than compounds, see BMS website), providers must bill the procedure code with KP modifier and the corresponding procedure code NDC qualifier, NDC, NDC unit qualifier, and NDC units. The claim line must be billed with the charge for the amount of the drug dispensed for the NDC identified on the line. The second line item with the same procedure code must be billed utilizing KQ modifier, the procedure code units, charge and NDC information for this portion of the drug.
How to convert a 10 digit NDC to 11 digits
NDC codes are traditionally segmented into three distinct digit groups. The first identifies the manufacturer or labeler of the drug in question. The second specifies the exact dosage and form. Finally, the third segment is used to identify the “package code” assigned by the labeler – whether a package contains 20 or 50 capsules, for example.
Converting 10-digit NDC numbers to the requisite 11 digits required for claim submission is a small matter of adding a well-placed zero to one of these three segments. But NDC numbers for different drugs follow different formats. There’s a simple set of rules to help place the zero in the correct location.
· For a 10 digit NDC in the 4-4-2 format, add a 0 in the 1st position.
· For a 10 digit NDC in the 5-3-2 format, add a 0 in the 6th position.
· For a 10 digit NDC in the 5-4-1 format, add a 0 in the 10th position.
In table form, that looks like this:
10-Digit Format on Package 10-Digit Format Example 11-Digit Format 11-Digit Format Example
4-4-2 9999-9999-99 5-4-2 09999-9999-99
5-3-2 99999-999-99 5-4-2 99999-0999-99
5-4-1 99999-9999-9 5-4-2 99999-9999-09
Note that the resulting 11-digit NDC number to be used in the bill always follows a 5-4-2 pattern.
One more thing to remember: The hyphens in this table are used, only, to illustrate the segmentation inherent to the NDC format. When reporting a NDC on a claim form, NEVER use hyphens.
Please go thru the above for more updates on this simple and easy way.
Effective 12/30/2011 Prevnar 13® is available for WV Medicaid members over the age of 50. Prevnar 13® is FDA approved for adults 50+ years of age to help prevent pneumococcal pneu-monia, meningitis, and bacteremia caused by 13 strains of S pneumonia. CPT code 90670 is to be billed for adult vaccinations; the reimbursement includes the cost of administration – the im-munization administration codes are not to be billed separately for adult vaccines. Prevnar 13® is currently available for children up to the age of 6 through the Vaccines for Chil-dren (VFC) Program. As with all VFC vaccines, bill the administration code with your charge for the service and the vaccine code with the SL modifier to indicate the vaccine was provided under
the VFC Program at no cost.
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