A “How To” for Reporting NDC
in Health Care Claims
Kelly Butler, Emdeon
Gloria Davis, QSI/NextGen Healthcare
Jennifer Loftis, Blue Cross Blue Shield Florida
Nancy Spector, American Medical Association
May 1, 2013
Objectives
● Address when NDC is reported
● Review data elements for NDC
● Review how to report data elements
● Discuss examples
● Provide resources
2
Problem Statements
● When do I report NDC?
● What data do I report when I have to report
NDC?
● How do I determine what quantities to report for
NDC?
3
When to Report NDC
When to Report NDC
● NDC information is reported when required
by federal or state regulation or when the
submitter determines it will support the claim
and adjudication process.
● In general, NDC is reported for Healthcare
Common Procedure Coding System
(HCPCS) codes for physician-administered
drugs and biologics.
● NDC is required to be reported on Medicaid
claims, and Medicare claims when Medicaid
is the secondary payer.
5
What Data is Reported for NDC
Different Types of NDC Reporting
● Professional claim
● Institutional claim
● Unspecified codes
● Compound drugs
7
Professional Claim
● Segments reported
–SV1 – Service procedure information
–LIN – Drug information
–CTP – Drug quantity
8
Service Procedure Information
● SV1
–SV101-1 – Qualifier (“HC”) indicates
procedure code is a HCPCS or CPT code
–SV101-2 – Procedure code
–SV103 – Qualifier for the procedure units
–SV104 – Procedure units
9
Calculating Procedure Units
● Procedure units are determined by the HCPCS
description
● Not all short HCPCS descriptions define the units
● Examples:
– J0131 Injection, acetaminophen, 10 mg
If 10 mg were given, then service unit = 1
– J1610 Injection, glucagon hydrochloride, per 1 mg
If 5 mg were given, then service unit = 5
10
Drug Identification
● LIN
– LIN02 – Qualifier (“N4”) indicates code is NDC
– LIN03 – NDC
● NDCs are reported in a 5-4-2 format
– If NDC is not 5-4-2, zeros are added at the
beginning of the appropriate section
● 1234-5678-91 = 01234-5678-91
● 12345-678-91 = 12345-0678-91
● 12345-6789-1 = 12345-6789-01
11
Quantity Information
● CTP
– CTP04 – NDC unit count
– CTP05-1 – Unit of measure
● Units of Measure are:
– F2 – International unit
– GR – Gram
– ME – Milligram
– ML – Milliliter
– UN – Unit
12
Calculating NDC Quantity
● The NDC quantity can be identified by the NDC
description and the quantity administered
● The NDC quantity and unit of measure are closely
related
● For example:
– If milliliters are administered, then total number
administered is the quantity reported
– “Each” or “ea” in the NDC description indicates a vial
or tablet, which is a quantity of 1
13
Calculating NDC Quantity
● Examples:
– 0002-1407-01, Quinidine gluconate, 10ml/vial
If 10 ml were given, then NDC unit = 10
If 5 ml given, then NDC unit = 5
– 00069-0058-02, Heparin sodium, 1000 USPS/ML
(10 ml/vial)
If 1 ml was given, then NDC unit = 1
– 00409-1135-02, Morphine sulfate, 25 mg/ml
If 25 mg were given, then NDC unit = 1
14
Example
A patient is given an injection in the physician’s office of
500 mg Ampicillin sodium, which is reconstituted from a
500 mg vial of powder.
Therefore:
HCPCS: J0290 (Injection, Ampicillin sodium, 500 mg)
NDC: 00781-9407-78
HCPCS unit: 1
NDC quantity: 1
Unit of measure: UN
15
Example
Loop
Segment
Data Element
Data Reported
2400
SV1
SV101-1
HC
SV101-2
J0290
SV103
UN
SV104
1
LIN02
N4
LIN03
00781940778
CTP04
1
CTP05-1
UN
2410
2410
LIN
CTP
16
Institutional Claim
● Segments reported
–SV2 – Service procedure information
–LIN – Drug information
–CTP – Drug quantity
17
Example
A patient in the hospital is given a 1000 mg dose of
Ceftriaxone where two 500 mg vials of powder are
reconstituted.
Therefore:
HCPCS: J0696 (Injection, ceftriaxone sodium, 250
mg)
NDC: 00409-7338-01
HCPCS unit: 4
NDC quantity: 2
Unit of measure: UN
18
Example
Loop
Segment
Data Element
Data Reported
2400
SV1
SV202-1
HC
SV202-2
J0696
SV204
UN
SV205
4
LIN02
N4
LIN03
00409733801
CTP04
2
CTP05-1
UN
2410
2410
LIN
CTP
19
Unspecified Codes
● Need to report a description when the procedure code
is and “unspecified” code
● Submitter can also include a description if they think
the procedure code does not sufficiently identify the
procedure performed
● Description is reported in SV101-7/SV202-7
● What meets the requirement for a description?
– Not defined in the implementation guide
– Most payers accept the NDC code or name of drug
20
Example
A patient is given an injection in the physician’s office of
500 mg of Aloprim, which is reconstituted from a 500 mg
vial of powder.
Therefore:
HCPCS: J3490 (Unclassified drugs)
NDC: 67457-0187-50
HCPCS unit: 1
NDC quantity: 1
Unit of measure: UN
21
Example
Loop
Segment
Data Element
Data Reported
2400
SV1
SV101-1
HC
SV101-2
J3490
SV101-7
67457018750
SV103
UN
SV104
1
LIN02
N4
LIN03
67457018750
CTP04
1
CTP05-1
UN
2410
2410
LIN
CTP
22
Example
Loop
Segment
Data Element
Data Reported
2400
SV1
SV101-1
HC
SV101-2
J3490
SV101-7
Aloprim
SV103
UN
SV104
1
LIN02
N4
LIN03
67457018750
CTP04
1
CTP05-1
UN
2410
2410
LIN
CTP
23
Compound Drugs
● Each drug is reported on a separate service
line
● LIN02, LIN03, CTP04, and CTP05 are reported
for each compound
● REF – Prescription or Compound Drug
Association Number must be reported
–REF01 – Qualifiers “VY” for Link Sequence
Number and “XZ” for Pharmacy Prescription
Number
–REF02 – Prescription or reference number
24
Example
A patient is in the physician’s office for
reprogramming and refill of an implantable pain
pump. The compound drug includes 200 mg
Hydromorphone USP (drug A), 500 mg
Bupivacaine USP (drug B), and 33.3 mg Baclofen
USP (drug C), which are all measured by weight.
25
Example
Therefore:
HCPCS: J3490 (Unclassified drugs)
HCPCS unit: 1
Drug A NDC: 38779-0524-05 (Hydromorphone)
NDC quantity: 0.5
Unit of measure: GR
Drug B NDC: 38779-0731-04 (Bupivacaine)
NDC quantity: 0.2
Unit of measure : GR
Drug C NDC: 38779-0388-04 (Baclofen)
NDC quantity: 0.033
Unit of measure: GR
26
Example
Loop
Segment
Data Element
Data Reported
2400
SV1
SV101-1
HC
SV101-2
J3490
SV101-7
Hydromorphone
SV103
UN
SV104
1
LIN02
N4
LIN03
38779052405
CTP04
0.5
CTP05-1
GR
REF01
VY
REF02
123456789
2410
2410
LIN
CTP
REF
27
Example (cont.)
Loop
Segment
Data Element
Data Reported
2400
SV1
SV101-1
HC
SV101-2
J3490
SV101-7
Bupivacaine
SV103
UN
SV104
1
LIN02
N4
LIN03
38779073104
CTP04
0.2
CTP05-1
GR
REF01
VY
REF02
123456789
2410
2410
LIN
CTP
REF
28
Example (cont.)
Loop
Segment
Data Element
Data Reported
2400
SV1
SV101-1
HC
SV101-2
J3490
SV101-7
Baclofen
SV103
UN
SV104
1
LIN02
N4
LIN03
38779038804
CTP04
0.033
CTP05-1
GR
REF01
VY
REF02
123456789
2410
2410
LIN
CTP
REF
29
Other Consideration
Rejected Claims
● Review ERAs and claims status (277CA)
responses to identify issues with submissions
–Missing data
–Incorrect data
● Codes
–Claim Adjustment Reason Codes
–Remittance Advice Remark Codes
–Claim Status Codes
31
More Examples
A patient in an outpatient setting receives 120 mg of
Xgeva (denosumab).
Therefore:
HCPCS: J0897 (Injection, denosumab, 1 mg)
NDC: 55513-0730-01 (Xgeva 120 mg/1.7 ml soln)
HCPCS unit: 120
NDC quantity: 1
Unit of measure: ML (1.7 ml = 1 vial)
33
Loop
Segment
Data Element
Data Reported
2400
SV1
SV101-1
HC
SV101-2
J0897
SV103
UN
SV104
120
LIN02
N4
LIN03
55513073001
CTP04
1
CTP05-1
ML
2410
2410
LIN
CTP
34
A patient in a physician office receives a 1 ml injection of
lidocaine.
Therefore:
HCPCS: J3490 (Unclassified drugs)
NDC: 00409-4278-01 (Lidocaine HCL 0.5% soln)
HCPCS unit: 1
NDC quantity: 1
Unit of measure: ML
35
Loop
Segment
Data Element
Data Reported
2400
SV1
SV101-1
HC
SV101-2
J3490
SV101-7
00409427801
SV103
UN
SV104
1
LIN02
N4
LIN03
00409427801
CTP04
1
CTP05-1
ML
2410
2410
LIN
CTP
36
A patient in a physician office receives an injection of 30
units of bleomycin.
Therefore:
HCPCS: J9040 (Injection, bleomycin sulfate, 15 units)
NDC: 63323-0137-20 (Bleomycin Sulfate 30 Unit
SOLR)
HCPCS unit: 2
NDC quantity: 1
Unit of measure: UN
37
Loop
Segment
Data Element
Data Reported
2400
SV1
SV101-1
HC
SV101-2
J9040
SV103
UN
SV104
2
LIN02
N4
LIN03
63323013720
CTP04
1
CTP05-1
UN
2410
2410
LIN
CTP
38
A patient in a physician office receives an injection of 100
mg of Zaltrap.
Therefore:
HCPCS: J9999 (Not otherwise classified,
antineoplastic drugs)
NDC: 00024-5840-01 (Zaltrap 100 mg/4 ml soln)
HCPCS unit: 1
NDC quantity: 4
Unit of measure: ML
39
Loop
Segment
Data Element
Data Reported
2400
SV1
SV101-1
HC
SV101-2
J9999
SV101-7
Zaltrap
SV103
UN
SV104
1
LIN02
N4
LIN03
00024584001
CTP04
4
CTP05-1
ML
2410
2410
LIN
CTP
40
A specialty pharmacy provides a 30-day supply of oral
chemotherapy of Temodar, which comes as 15 capsules
of 100 mg.
Therefore:
HCPCS: J8700 (Temozolomide, oral, 5 mg)
NDC: 54868-5350-00 (Temodar 100 mg caps)
HCPCS unit: 300
NDC quantity: 15
Unit of measure: UN
41
Loop
Segment
Data Element
Data Reported
2400
SV1
SV101-1
HC
SV101-2
J8700
SV103
UN
SV104
300
LIN02
N4
LIN03
54868535000
CTP04
15
CTP05-1
UN
2410
2410
LIN
CTP
42
Resources
● ASC X12 Technical Reports Type 3 http://store.x12.org/store/
– Health Care Claim: Professional (837P),
005010X222A1
– Health Care Claim: Institutional (837I),
005010X223A2
● Your payers and/or billing vendor
● Your state Medicaid
44
Thank You!
WEDI 837 Subworkgroup
Always Recruiting New Members!
Co-Chairs
Kelly Butler: [email protected]
Nancy Spector: [email protected]
Gloria Davis: [email protected]
www.wedi.org
45
Questions?