Providers may only be reimbursed for physician-administered drugs and
biologicals whose manufacturers participate in the Centers for Medicare &
Medicaid Services (CMS) Drug Rebate Program and that show as active on the CMS
list for the date of service the drug is administered. All Medicaid (both
fee-for-service and managed care), Children with Special Health Care Needs
(CSHCN) Services Program, and Family Planning providers must submit an National
Drug Code (NDC) for professional or outpatient claims submitted with clinician
administered drug codes. The only exception is for vaccines, devices, and
radiopharmaceuticals administered by a provider in outpatient settings.
Provider types impacted by the NDC requirement include:
- Primary care providers
- Specialty care providers
- Outpatient hospital departments
- Federally qualified health centers
- Rural health centers
- All other outpatient providers administering drugs to patients
Texas Medicaid defines clinician-administered drugs as physician-administered
drugs for procedure codes listed on the NDC-to-HCPCS Crosswalk.
Beginning June 1, 2015, the NDC Unit of Measure and NDC Quantity fields will be
required on claims for physician-administered drugs.
- Providers should submit the pharmacy unit of measure
in the “NDC Unit of Measure” field on the claim, and use the
value in Column J (“NDC Package Measure”) from the Texas
NDC-to-HCPCS Crosswalk to report the Unit of Measure on the
claim form. Refer to the Texas NDC-to-HCPCS Crosswalk to
convert the Healthcare Common Procedure Coding System (HCPCS)
unit to NDC units.
- Review the “HCPCS Description”, “NDC Label”, and “NDC
Package Measure” columns of the NDC-to-HCPCS Crosswalk to
calculate the NDC quantity.
- Providers can refer to the
VDP NDC Requirements for Clinician-Administered Drugs Provider
Training for examples of NDC requirements on all claim
Providers can refer to the Texas Vendor Drug Program (VDP) website at
the Texas NDC-to-HCPCS Crosswalk, which identifies relationships between NDCs
and HCPCS codes. The file is published at least quarterly.
Physician-administered drugs that do not have an appropriate NDC to HCPCS
combination for the procedure code that is submitted will not be reimbursed by
the following programs:
- Medicaid fee-for-service
- CSHCN Services Program
- Texas Women’s Health Program (TWHP)
- Medicaid Family Planning
- The Expanded Primary Health Care (EPHC) Program
- Managed Care Organization (MCO) encounters for