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Effective January 1, 2015

 National Drug Code (NDC)

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

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

340B/PHS Providers

Providers that administer drugs purchased under the Health Resources Services Administration's 340B Program are required to include a 'U8' modifier on their professional or outpatient institutional claims.  Beginning July 1, 2016, the 'U8' modifier, and only the 'U8' modifier, will be used to exclude claims from the drug rebate invoices that are sent to drug manufacturers.  Use of the 'U8' modifier will prevent the 'duplicate discounts' that are prohibited under the 340B program.

Programs

The following programs require that claims for clinician-administered drugs use appropriate NDC to HCPCS combination or they will not be reimbursed:

  • 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 clinician-administered drugs.

Texas Medicaid defines clinician-administered drugs as physician-administered drugs for procedure codes listed on the NDC-to-HCPCS Crosswalk.  

NDC Unit of Measure and Quantity Fields

Beginning June 1, 2015, the NDC Unit of Measure and NDC Quantity fields are required on claims for clinician-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[CS1]  for examples of NDC requirements on all claim types.

Providers can refer to the Texas Vendor Drug Program (VDP) website at http://www.txvendordrug.com/cad/[T2]  for the Texas NDC-to-HCPCS Crosswalk, which identifies relationships between NDCs and HCPCS codes as well as the correct NDC unit of measure. The file is published at least quarterly.  

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 types.

 NDC Helpful Links

 NDC News Articles

 

Note: The information on this web page applies to claims submitted to TMHP for processing. For claims processed by a Medicaid managed care organization (MCO), providers must refer to the MCO for information about benefits, limitations, prior authorizations, and reimbursement.  

   
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