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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.39 Clinician-Administered Drugs : 9.2.39.5 Single-Dose Vials Calculation Examples

9.2.39.5
Below are three examples of how to calculate the HCPCS and NDC billing units using single-dose vials.
1)
A patient receives 4 mg Zofran IV in the physician’s office. The NDC of the product used is 00173-0442-02 (Zofran 2 mg/ml in solution form). There are 2 milliliters per vial. The provider should bill J2405 for ondansetron hydrochloride with 4 HCPCS units and the NDC units submitted should be 2 ML.
2)
A patient receives 8mg of Avastin IV in the physician’s office. The NDC of the product used is 50242-060-01 (Avastin 25mg/ml). The provider should bill J9035 for bevacizumab with 0.8 HCPCS unit. The NDC unit is 0.32 ML.
3)
A patient receives 1 gm Rocephin IM in the physician’s office. The NDC of the product used is 00004-1963-02 (Rocephin 500 mg vial in a powder form that is reconstituted prior to the injection). The provider should bill J0696 for ceftriaxone sodium with 4 HCPCS units. The NDC units are 2 UN because this NDC is in powder form.
 
HCPCS Code and Unit found in description
HCPCS CODE BILLING UNIT(s) = Dose divided by units found in HCPCS code description
Determining Conversion Factor (CF) = HCPCS unit from code description divided by NDC unit from vial/box
NDC BILLING UNIT(s) = HCPCS Units x CF
Quantity Information Required on Claim (HCPCS & NDC)

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