New National Drug Code NDC Billing Requirement for Pharmacy Claims Submissions UB04837I

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New National Drug Code (NDC) Billing Requirement
for Pharmacy Claims Submissions (UB04/837I)

• Keith Hayashi, R.Ph.
• Department of Medical Assistance Services
• June 3, 2008

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Presentation Outline

• Overview
• Schedule
• Implementation

3
Overview

• Section 6002 of the 2005 Deficit Reduction Act
  (DRA) requires states to collect and submit
  utilization and coding information for single and
  multi-source physician-administered drugs.

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Physician-Administered Drugs in Physician Settings

• Trained hospitals health systems
• Submitted invoices to manufacturers for rebates
  on Crossover single source, physician-administered
  drugs using HCPCS codes (J-codes) in August
  2006.
• Retrospectively invoiced manufacturers back to
  June 2003 for rebates on past Crossover claims
  for physician-administered drugs (DMAS continues
  to invoice manufacturers).
• Began collecting rebates on all multi-source,
  physician-administered drugs submitted on the CMS
  1500 and the ACS X12 837P effective July 1, 2007.
  
• The quantity of each NDC and units of Measure was
  required effective January 1, 2008.

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Physician-Administered Drugs in Outpatient
Hospital Settings

• January 1, 2008 Mandate was to become effective
• December 12, 2007 DMAS sent letter to CMS
  requesting an 18-month extension
• Cited the burden placed on hospitals health
  systems in terms of costs, systems vendor
  issues
• Virginia Hospital and Healthcare Association
  reviewed draft letter
• CMS granted a 6-month extension
• (July 1, 2008)

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Timeline (Continued)

• April 2008 DMAS requested another
  extension--until January 1, 2009
• May 2008 CMS denied request
• July 1, 2008 IMPLEMENTATION DATE

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Implementation Bottom Line

• Effective July 1, 2008, DMAS will require
  hospital providers who bill drug products
  administered in an outpatient hospital setting to
  include National Drug Code (NDC) information for
  the drug dispensed on all electronic (ASC X12N
  Health Care Claim Institutional 837I) and paper
  claim (Universal Billing (UB) form) submissions.

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DMAS Actions to Date

• Formed workgroup with hospitals
• VHHA participation
• Distributed a Medicaid Memo on April 2, 2008

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Valid NDCs

• Correctly formatted number using the 5-4-3 format
  (e.g., 99999888877)
• 11 digit code unique to the manufacturer of the
  specific drug or product administered to the
  recipient
• If compound medication with more than 1 NDC in
  the medication dispensed, each NDC must be
  submitted as a separate claim line to include
  both prescription and over-the-counter
  ingredients.
• Each claim line submitted with pharmacy revenue
  codes 0250-0259 0630-0639 will require the NDC
  information.
• Outpatient hospital claims submitted without a
  valid NDC will have the revenue code line reduced
  to a non-covered service line.

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Paper Claim Form (UB04)
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Locator 42 (Revenue Code)

• Enter Revenue Code

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Locator 43 (Description)

• Enter the NDC qualifier of N4
• The 11-digit NDC number
• The unit of measurement
• Metric decimal quantity or unit
• Do not enter a space or hyphen between the
  qualifier NDC, nor within the NDC nor between
  the Unit of Measurement qualifier nor the unit
  quantity.

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Locator 43 (continued)

• If same RX is dispensed in different package
  sizes, each package size MUST be listed
  separately using the revenue code, N4 qualifier
  and all required information on separate lines.
• Different package sizes of the same drug will NOT
  be viewed as a duplicate claim by the system.

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Example of Locator 43 (Description)

• Reminder- No spaces or hyphens

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Locator 44 (HCPCS/Rate/HIPPS Code)

• Enter the HCPCS code, if available.
• Invalid HCPCS codes will result in the claim
  being denied.

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Locator 46 (Serv Units)

• Enter the HCPCS units when a HCPCS code is in
  Locator 44.

• Locator 46. Serv Units- This is currently being
  done, there is no change

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Converting NDCs from 10-Digits to 11-digits
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Submitting NDC-Related Data Via the 837
Institutional Claim Format (ASC X12 837I V4010 A1)
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Procedure Code Units

• Defined in the 2400 loop, segment SV2, composite
  data element SV202.
• No NDCs should be sent in this segment.
• SV202 must contain the HCPCS code, if one exists.
• SV204 defines the Unit Base of Measurement Code.
  Units must be defined as Unit, Days, or
  International Unit.
• SV205 defines the quantity based on the Basis of
  Measurement in SV204.

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Drug Identification

• NDC should be sent in the 2410 loop LIN segment.
• 2410 loop can be repeated 25 times within a
  service line.
• DMAS will capture only the 1st occurrence of the
  LIN segment for each revenue line.
• When billing for a compound Rx, then each
  applicable NDC must be sent as a separate revenue
  line

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Loop 2410 (Continued)

• LIN identifies the NDC
• LIN02 must contain the qualifier N4
• LIN03 must contain the NDC in the 5-4-2 format
• CTP identifies drug pricing
• CTP03drug unit price- DMAS will not be
  validating nor using, providers can default a
  value since the segment is required.
• CTP04 NDC quantity
• CTP05 composite unit of measure
• CTP05-1 unit or basis for measurement code
• For complete information please refer to the 837I
  Guide

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Systems Testing

• Systems Testing-Paper Claims
• Bonnie Winn (804-786-2621) or bonnie.winn_at_dmas.vir
  ginia.gov
• Electronic Claims Testing
• EDI Technical Help Desk
• (800-924-6741)

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Additional Resources

• 837I Companion Guide https//virginia.fhsc.com/hip
  aa/CompanionGuides.asp
• DMAS Provider Helpline
• [phone] (Richmond)
• [phone]
• This presentation and Medicaid Memo (April 2,
  2008) are available on DMASs website
  www.dmas.virginia.gov

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Questions
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THANK YOU!