The NDC is only required on outpatient hospital claims and physician claims.
The NDC does not require a claim detail in addition to outpatient line items with revenue and Healthcare Common Procedure Coding System (HCPCS) codes. Instead, the NDC is added to the existing claim detail.
The NDC is required only when a claim includes a HCPCS code that is listed on the Palmetto Government Business Association (GBA) crosswalk file for the date that the drug was administered. Providers can find the crosswalk files at www.palmettogba.com.
Providers should enter the NDC quantity that is consistent with the procedure quantity submitted when converted to a valid American National Standards Institute (ANSI) 4010 X12 Health Insurance Portability and Accountability Act (HIPAA) unit of measure (UOM).
Following are two examples of how providers should report NDC data:
Example 1—HCPCS and NDC quantity are the same:
A physician bills for 75 units of botulinum toxin with HCPCS description “BOTULINUM TOXIN TYPE A, PER UNIT” and NDC label “Botox 100 U.” Both the HCPCS quantity and the NDC UOM refer to units. TMHP would reimburse based on the amount billed (75 units) and not the NDC package size (100 units). The claim form would contain the following:
· HCPCS code: J0585.
· HCPCS quantity: 75.
· NDC: 00023-1145-01.
· NDC UOM: UN (unit).
· NDC quantity: 75.
Example 2—HCPCS and NDC quantity are different:
Physician bills for 500mg of ampicillin with HCPCS description “Injection, Ampicillin Sodium, 500mg“ and NDC label “Ampicillin Sodium (U.S.P.) 500 mg.” In this case, the amount of drug administered is part of the HCPCS description, so the HCPCS quantity refers to the number of 500mg packages, while the NDC UOM must still provide the amount. TMHP would reimburse for one 500-mg package. The claim would contain the following:
· HCPCS code: J0290.
· HCPCS quantity: 1 (represents one 500mg package).
· NDC: 00781-3407-95.
· NDC UOM: GR (gram, because mg is not a valid X12 UOM).
· NDC quantity: 0.5.
For more information, call the TMHP Contact Center at 1-800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 1-800-568-2413.