NC Medicaid National Drug Code (NDC) Seminar November 2007 Presented by: EDS

Objectives Understand NDC Guidelines Become Familiar with Billing Requirements Utilize Additional Resources

Who? Physicians Nurse Practitioners Nurse Midwives Federally Qualified Health Centers Rural Health Centers Local Health Departments

Who? Dialysis Treatment Centers (non-hospital-based) Satellite Dialysis Centers Out-of-State Dialysis Centers 340b Providers

What? National Drug Code (NDC) Assigned to Drug upon FDA approval Unique Three Segment Number Universal Product Identifier NDC will be required on claims for drugs covered under the Physician’s Drug Program (PDP)

When? Effective with Dates of Service on or after December 28, 2007

Where? NDC is found on package/vial NDC is located here (10-digit format) 9999-9999-99 DRUG NAME

Why? Deficit Reduction Act of 2005 Federal Legislation Medicaid Drug Rebate Program

Medicaid Drug Rebate Program Drug Manufacturers must sign National Medicaid Drug Rebate Agreement with Centers for Medicare and Medicaid Services (CMS) Required for states to receive Federal funding for outpatient drugs dispensed to Medicaid patients Approximately 550 pharmaceutical companies currently participate in this program. Forty nine states, (Arizona is excluded), and the District of Columbia cover drugs under the Medicaid Drug Rebate Program.

Medicaid Drug Rebate Program If Manufacturers do not sign this agreement, their drugs will NOT be covered by Medicaid These drugs are known as non-rebatable

Medicaid Drug Rebate Program NC Medicaid Pharmacy Program has operated under Drug Rebate Program since 1991 Average Annual Savings: ? 30%

Drug Rebate Labeler Codes http://www.ncdhhs.gov/dma/pharmacy.htm Quick Pharmacy Links Active Drug Rebate Labeler Codes Updates Quarterly First 5 digits of NDC identify participating Labelers in Rebate Program

Drug Rebate Labeler Codes Expanded example

NDC Segments 11 Digit Format 99999-9999-99

NDC Segments 11 Digit Format 99999-9999-99 Labeler

99999-9999-99 Product Code NDC Segments 11 Digit Format Tylenol, morphene Product Code

99999-9999-99 Package Code NDC Segments 11 Digit Format 50 count, 100 count, 200 count Pre package syringe? Package Code

NDC Formats NDC can be displayed in 10 digit format Proper billing requires 11 digit NDC in 5-4-2 format

NDC Required Format 5-4-2 Format 99999-9999-99 5 - 4 - 2

Converting NDCs 10 digit formats include: 4-4-2 5-3-2 5-4-1 Requires strategically placed zero to convert to 11 digit format

Converting 4-4-2 to 5-4-2 Example: Zyprexa 10 mg vial 10 digit NDC: 0002-7597-01 11 digit conversion: 00002 -7597-01

Converting 5-3-2 to 5-4-2 Example: Xolair 150 mg vial 10 digit NDC: 50242-040-62 11 digit conversion? 50242- 0040 -62

How Will My Claim Pay? Pricing based on HCPCS code and units Edits and Audits will remain in place

How do I know if my HCPCS Requires an NDC? www.ncdhhs.gov/dma/fee/phy_drug.pdf Physician’s Drug Program Fee Schedule Asterisk represents NDC Requirement

PDP Fee Schedule

PDP Fee Schedule

NDC Exceptions Vaccines Radiopharmaceuticals Some Immune Globulins

PDP Fee Schedule

Invoices J2353 J3490 J3590 J9999 If only one NDC is dispensed per HCPCS…..

Your Claim can be Billed Electronically! Invoices Your Claim can be Billed Electronically!

Compound Drugs J3490 Invoices still required when billing compounds

Recap NDC Required on Claims beginning Date of Service December 28, 2007 NC Medicaid Only Covers Rebatable Drugs NDC Must be Reported in 5-4-2 Format

Reporting your National Drug Code (NDC) to Medicaid Claims Processing Reporting your National Drug Code (NDC) to Medicaid Marianne has given you the base knowledge you will need to work with NDCs. National Drug Code (NDC) I want to give you the direction you will need to add – NDC to your claims. This is an - Addition -- to your claims. None of the other requirements are being changed by this – the forms have already been reformatted. NDC is going to be added to those blocks and form locators of your claims that Medicaid claims did not already use. Just to review --

NDC Review NDC Required on Claims beginning Date of Service December 28, 2007 NC Medicaid Only Covers Drugs Rebatable NDC Must be Reported in Format 5-4-2 3 things I want to make sure you got from Marianne –

NDC is . . . An addition to current claim elements Placement on claims CMS-1500 - Delineated Block 24 UB - FL 43 Electronic Claims - Populates 2410 Loop HIPPA Implementation Guide

Data Elements Qualifier – N4 11 Digit NDC Unit of Measure NDC Units Value (Quantity) Example: 1234567.123 Discuss the quantity decimal point part

Units of Measure (UOM) F2 (international unit) GR (gram) ML (milliliter) UN (unit) Determining drug units Each vial of powder for reconstitution should be billed as one unit. Combination drug packages that are dispensed in an unbreakable package should be billed as one unit. Bulk powders should be billed in grams (g). Liquids, suspensions, solutions, large-volume IV solutions, irrigations, etc., should be billed in milliliters (ml). Small-volume injectables (piggybacks) in solution, injectables in solution (vials) and pre-filled syringes should be billed in milliliters (ml). Use the actual metric package size when it is available from the manufacturer or distributor. If this measurement is unavailable, the following standard conversions should be used: ∗ One fluid ounce equals 30 ml. ∗ One pint equals 480 ml. ∗ One ounce equals 30 g. ∗ One pound equals 454 g. ∗ One liter equals 1000 ml. Let’s look at how we are going to put the 4 elements to report the NDC on the claim ---

Elements 00009737604 N4 ML 1 What is missing from the NDC ----- NO Hypens!!!!!!!!!!!!!!!!!! Depo Provera ---

Paper Claim Elements Qualifier - N4 NDC - Limited number per HCPCS Three per CMS 1500 Ten per UB Unit of Measure (UOM) Quantity Qualifiers – when we first introduced NPI we introduced qualifiers --

CMS-1500 Submit information in Boxes 24A-H Upper Shaded Portion of the Delineated Line Additional Information: www.nucc.org National Uniform Claim Committee

CMS – 1500 with 1 NDC The CMS 1500 utilizes the shaded area of Line 24 left justified in line 24A using the N4 qualifier followed immediately by the NDC followed by three (3) spaces followed by one of the four (4) qualifiers for unit of measurement followed immediately by the quantity. The actual verbiage from the instruction manual concerning the spaces follows: More than one supplemental item can be reported in the shaded lines of Item Number 24. Enter the first qualifier and number/code/information at 24A. After the first item, enter three blank spaces and then the next qualifier and number/code/information. The four (4) unit of measure qualifiers are: FL - International Unit GR - Gram ML - Milliliter UN - Unit(s)

00009737604 – DEPO-PROVERA 150 MG/ML SYRN N400009737604 ML1 left justified in line 24A using the N4 qualifier followed immediately by the NDC followed by three (3) spaces followed by one of the four (4) qualifiers for unit of measurement followed immediately by the quantity.

CMS – 1500 with 2 NDCs The actual verbiage from the instruction manual concerning the spaces follows: More than one supplemental item can be reported in the shaded lines of Item Number 24. Enter the first qualifier and number/code/information at 24A. After the first item, enter three blank spaces and then the next qualifier and number/code/information. The four (4) unit of measure qualifiers are: FL - International Unit GR - Gram ML - Milliliter UN - Unit(s)

2 NDCs Same labeler – Same drug -- BUT N400703301812 ML50 N400703301513 ML10 Moving on to a UB example --- Same labeler – Same drug -- BUT Different strength – Different vial size

UB N4 Qualifier 11 Digit NDC Unit of Measure (UOM) NDC Units Enter data elements in FL 43: N4 Qualifier 11 Digit NDC Unit of Measure (UOM) NDC Units Additional Information: www.nubc.org National Uniform Billing Committee

UB with 1 NDC 1. Report the N4 qualifier in the first two (2) positions, left justified, 2. followed immediately by the 11 character NDC number in the 5-4-2 format. Immediately following the last character of the NDC (no delimiter space or otherwise) 3. the Unit of Measurement Qualifier 4. immediately followed by the quantity with a floating decimal with a limit of 3 characters to the right of the decimal point. The Unit of Measure Qualifiers available are as follows: F2 - International Unit GR - Gram ML - Milliliter UN - Unit The decision to make all data elements left justified was made to accommodate the largest quantity possible especially for hemophiliac drugs that can be dispensed in very large dosages.

58468012201 – HECTOROL 4 MCG/2 ML AMPUL Report the N4 qualifier in the first two (2) positions, left justified, followed immediately by the 11 character NDC number in the 5-4-2 format. Immediately following the last character of the NDC (no delimiter space or otherwise) the Unit of Measurement Qualifier immediately followed by the quantity with a floating decimal with a limit of 3 characters to the right of the decimal point. J code – 1270 in FCL 44

UB with 1 NDC Report the N4 qualifier in the first two (2) positions, left justified, followed immediately by the 11 character NDC number in the 5-4-2 format. Immediately following the last character of the NDC (no delimiter space or otherwise) the Unit of Measurement Qualifier immediately followed by the quantity with a floating decimal with a limit of 3 characters to the right of the decimal point.

00517234010 – VENOFER 20MG/ML Report the N4 qualifier in the first two (2) positions, left justified, followed immediately by the 11 character NDC number in the 5-4-2 format. Immediately following the last character of the NDC (no delimiter space or otherwise) the Unit of Measurement Qualifier immediately followed by the quantity with a floating decimal with a limit of 3 characters to the right of the decimal point.

UB with 1 NDC

Elements 60977000101 N4 ML 2 Now for on electronic filing

837 Instructions Primary Resource: HIPAA Implementation Guide http://www.wpc-edi.com/ Populate NDC information in 2410 Loop NC Companion Guide: Supplemental Information Where on the website Provider links / HIPPA / Related Links on right hand side

NCECS Webtool Additional Fields Created: NDC NDC Units Units of Measure not required on NCECS Webtool

Webtool CMS - 1500 00009737604 1

Example – Depo Provera

Example – Depo Provera

Webtool - UB 58468012201 10

Example - Hecterol

Next – Secondary claims

Secondary Claims NDC required on secondary claims Exception - Professional Medicare Crossovers Professional crossovers are Phase II of NDC project

When Will My Claim Deny? NDC is invalid or incorrectly formatted NDC is terminated/expired No NDC reported with HCPCS NDC is non-rebatable NDC not specific to HCPCS code Depo NDC for Hectol Into for EOB codes ---------------

New EOB Codes created for NDC Program

EOB 8989 Description: NDC INVALID Resolution: VERIFY AND ENTER THE CORRECT NDC AND SUBMIT AS A NEW CLAIM

EOBs 8990 - 8999 Description: IF REPORTING MULTIPLE NDCs, IDENTIFIES WHICH NDC IS INVALID Resolution: VERIFY AND ENTER THE CORRECT NDC AND SUBMIT AS A NEW CLAIM

EOB 9011 Description: NDC WAS TERMINATED FOR THE DETAIL DATE OF SERVICE BILLED Resolution: VERIFY AND ENTER THE CORRECT NDC AND SUBMIT AS A NEW CLAIM EOBs 9012 - 9021

EOB 9992 Description: NDC MISSING Resolution: VERIFY AND ENTER THE CORRECT NDC AND SUBMIT AS A NEW CLAIM

EOB 9496 Description: NDC IS NON-REBATABLE Resolution: VERIFY AND ENTER THE CORRECT NDC AND SUBMIT AS A NEW CLAIM EOBs 9497 - 9506 Adjustment – for Non-rebatable NDC – medical review

EOB 9904 Description: CMS 1500 CLAIM WITH MORE THAN 3 NDC’S PER PROCEDURE CODE Resolution: MUST BE BILLED ELECTRONICALLY Going to Billing Tips ----------

Helpful Hints to Assist You with Claims Billing Tips Helpful Hints to Assist You with Claims AVRS – first suggestion ---

Automated Voice Response System (AVRS) 1-800-723-4337 Verify NDC Coverage: Option 3 Responses: Covered Non-rebatable Not Allowed Covered – Is rebatable NON-rebatable – no agreement with labler, invalid NDC , terminated NDC Not Allowed – is a hold over to the pharmacy program – the NDC is not covered under the pharmacy program. - only a few NDCs - that could be covered by the PDP this means – the NDC is not covered in the pharmacy program. It maybe covered by the Physician Drug Program, so you will need to call PVS to have that specific NDC verified. Example:This is the NDC that we had turned off since it was covered in the PDP. 50242013468 - Herceptin (this one appears as Deny) If the AVRS states the drug is not allowed, then further research maybe needed since some drugs may not be covered in the pharmacy program that are covered as a medical benefit.  Note: The HCPCS code must also be valid and covered by N.C. Medicaid. Refer to the fee schedule list of covered PDP drugs, on DMA’s Web site at http://www.ncdhhs.gov/dma/fee/fee.htm

Guidelines Remain Consistent Carolina Access Prior Approval Co-Payments Remittance and Status Report (RA) Adjustment Process Carolina Access Referrals Carolina Access referral requirements remain consistent with current guidelines. Prior Approval - Is referring to the recipient not the drug --------- Medicaid prior approval requirements remain consistent with current guidelines. All drugs that require prior approval will continue to do so. Basic Med 6-12 (ACS is the Pharmacy program –m nothing to do with this program.) Co-payments Medicaid co-payment criteria remain consistent with current guidelines. For detailed co-payment information, please see the Basic Medicaid Billing Guide, Section 2. Remittance and Status Report (RA) There will be no changes to the current components of the N.C. Medicaid Remittance and Status Report (RA). Adjustment Process – refer to EOB 9496 – That after trying all rebatable options only the non-rebatable drug works for a specific patient and you are looking for Medical review --- From Sharon email on 08/30/2007 – The adjustments should not deny for term date.    Only new day claims should deny.    An example of a new day claim being submitted would be for retroactive eligibility....we should not cover the NDC if the term date is greater than 365 days in the past.     The term date is the last lot expiration date (the drug has expired).   This date is available on the drug file (DD screen) and there can be future term dates listed. 

Billing Tips Do not use hyphens when reporting NDC on claims If NDCs on package and vial differ, report NDC on package Bill the NDC of the drug actually dispensed No substitutes Even if on the packagng Multi-packaged vials, etc 3. If same medication is produced by 2 different labelers (one with agreement, one without) you must report NDC of the dispensed drug. If you are out of the one brand and use the other, you must report the NDC of the drug actually dispensed. You cannot substitute. Consequences: denied claims, sanctions and termination of provider agreement.

www.palmettogba.com/palmetto . . . Billing Tips NDC Unit Conversions www.palmettogba.com/palmetto . . . For CMS – 1500s 3 NDCs allowed (EOB 9904) UBs and 837s - Up to 10 NDC codes and corresponding units allowed per HCPCS code NOTE: if the NDC conversion is not correct – and since we are processing from the HCPCS The claims will not deny for an incorrectly calculated quantity. IMPORTANT that you have the correct NDC for the HCPCS - is rebatable and the N4 is there…

Billing Tips (cont.) FQHC/RHC Providers – use the C Suffix Modify office procedures Check your inventory for labeler codes All other Guidelines remain the same On paper – 3 for 1500 – Do not wrap detail lines 10 for UB – 10 for electronic Rhogam – has already been called in as one of the non-rebatable labelers – solution – find a different labeler ---