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

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

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

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

5. 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)

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

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

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

9. 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.

10. 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

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

12. Drug Rebate Labeler Codes
Quick Pharmacy Links
Active Drug Rebate Labeler Codes
Updates Quarterly
First 5 digits of NDC identify participating Labelers in Rebate Program

13. Drug Rebate Labeler Codes
Expanded example

14. NDC Segments
11 Digit Format

15. NDC Segments
11 Digit Format
Labeler

16. 99999-9999-99 Product Code NDC Segments 11 Digit Format
Tylenol, morphene
Product Code

17. 99999-9999-99 Package Code NDC Segments 11 Digit Format
50 count, 100 count, 200 count
Pre package syringe?
Package Code

18. NDC Formats NDC can be displayed in 10 digit format
Proper billing requires 11 digit NDC in format

19. NDC Required Format
5-4-2 Format

20. 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

21. Converting 4-4-2 to 5-4-2 Example: Zyprexa 10 mg vial
10 digit NDC:
11 digit conversion:

22. Converting 5-3-2 to 5-4-2 Example: Xolair 150 mg vial
10 digit NDC:
11 digit conversion?

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

24. How do I know if my HCPCS Requires an NDC?
Physician’s Drug Program Fee Schedule
Asterisk represents NDC Requirement

25. PDP Fee Schedule

26. PDP Fee Schedule

27. NDC Exceptions
Vaccines
Radiopharmaceuticals
Some Immune Globulins

28. PDP Fee Schedule

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

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

31. Compound Drugs
J3490
Invoices still required when billing compounds

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

33. 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 --

34. 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 –

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

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

37. 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 ---

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

39. 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 --

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

41. 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)

42. 00009737604 – DEPO-PROVERA 150 MG/ML SYRN
N 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.

43. 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)

44. 2 NDCs Same labeler – Same drug -- BUT
N ML50 N ML10
Moving on to a UB example ---
Same labeler – Same drug -- BUT
Different strength – Different vial size

45. 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:
National Uniform Billing Committee

46. 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 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.

47. 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 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

48. 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 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.

49. – 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 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.

50. UB with 1 NDC

51. Elements N4 ML 2
Now for on electronic filing

52. 837 Instructions Primary Resource: HIPAA Implementation Guide
Populate NDC information in 2410 Loop
NC Companion Guide: Supplemental Information
Where on the website Provider links / HIPPA / Related Links on right hand side

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

54. Webtool CMS 1

55. Example – Depo Provera

56. Example – Depo Provera

57. Webtool - UB 10

58. Example - Hecterol

59. Next – Secondary claims

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

61. 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

62. New EOB Codes created for NDC Program

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

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

65. 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

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

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

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

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

70. Automated Voice Response System (AVRS)
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.
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

71. 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 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. 

72. 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.

73. www.palmettogba.com/palmetto . . .
Billing Tips
NDC Unit Conversions
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…

74. 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 ---