Version 20.3

Overview

This article serves as a guide to users regarding the use of NDC Numbers (NDCs) and Units of Measurement (UOM) when billing medications and vaccines administered in the office, as required on claims by most insurance payers. Before managing the tables that house this information, it is important to make sure that each payer that requires NDCs to be reported on claims is assigned as such in the Insurance Payer Setup. After making sure the payers are set up correctly, you will learn the correct NDC and UOM format and where medication and vaccine NDCs and UOM are pulled from.

Review Payer Setup for NDC Inclusion and Unit of Measurement/Unit Type Format

1. Navigate to the Insurance Payer List: Billing tab > Payers.
2. Select the Payer.
3. Click the Edit button.
4. Click the Payer Coding Rules tab.
5. Select the checkbox to Include NDC on vaccine products. 
6. If the payer requires a specific Unit Type for vaccines, select the default from the Unit type for included NDCs on vaccine products drop-down menu.

• The standard reportable NDC Units of Measurement, as dictated by the National Uniform Claim Committee, NUCC, include:
  • F2: International Unit
  • GR: Gram
  • ME: Milligram
  • ML: Milliliter
  • UN: Unit

1. Click the Save button.

NDC Number Format

Each NDC Number must be reported as an 11-digit code using a 5-4-2 format (5 digits, followed by 4 digits, followed by 2 digits [99999999999]). The chart below illustrates how to convert the 10-digit code provided on the packaging to an 11-digit code based on the 10-digit number's format. The hyphens in the example below are for illustration only. If the NDC is not submitted in the correct format, the claim will be denied.

Medication NDCs and Units of Measurement

Medications, such as Albuterol, should be billed with the corresponding NDC number and Unit of Measurement. This information must be added to the CPT Code Table in order for the code to be billed properly. To add NDCs and Units of Measurement to medications:

1. Navigate to the CPT Code Table: Clinical or Billing tab > Procedure (CPT) Codes. The CPT Code table is displayed.
2. Search for and select the medication CPT Code. 

1. Click the Edit button.
2. In the NDC ID field, enter the 11-digit NDC Number and Dose (Unit of Measurement). For example, 00487950125 UN1 where the format is:

• 11-digit NDC Number
• One space separating the NDC number and the unit/basis of measurement qualifier
• Unit/basis of measurement qualifier
• Quantity

NDC Quantity

The quantity of each NDC must be a numeric value greater than zero. In most cases, the NDC quantity will be different from the HCPCS billed units.

Where do Vaccine NDCs and Units of Measurement pull from in OP?

In order for NDCs and Units of Measurement to be billed for vaccines, the practice must first be aware of its own status. The practice status determines where the NDC numbers and Units of Measurement are pulled from when vaccines are billed. The practice statuses are:

• Practices that are fully live with OP: These are practices that are using OP for Practice Management, Billing, and EHR.
• Practices that are not fully live with OP: These are practices that are implementing OP in a Split Go Live method. These practices Go Live with Practice Management and Billing first, but are not yet live with EHR. 

Practices that are Fully Live with OP

Practices that are Not Fully Live with OP

Billing Using the Electronic Claim Format

The following data elements should be used to submit the NDC Information in the HIPAA-standard ACS X12N8347 electronic claims format:

For Loop 2400:

• SV101 CPT/HCPCS code
• SV104CPT/HCPCS units

For Loop 2410:

• LIN03 NDC (11-digit format)
• CTP04 NDC Quantity
• CTP05-1 NDC Unit or Basis for Measurement Code

Loop 2400 of the 837 looks like:

• CPT Code - 90680 2400 SV101 90680
• CPT DUTS- 1 - SV104 1

Loop 2410 of the 837 looks like:

• NDC - 00006404741 2410 LIN03 00006404741 
• NDC Drug Quantity - 2 - CPT04 2 
• NDC UOM - ML - CPT04-1 ML

The complete 837 instructions are available in the HIPAA Implementation Guide on the Washington Publishing website at www.wpc-edi.com.

Billing Using the CMS-1500 Form

If you bill on paper using the CMS-1500 form, use the shaded area of fields 24A-24G to report the NDC information in the following order. See the CMS-1500 Manual for additional information at www.nucc.org.

• Qualifier
• 11-digit NDC Number
• One space separating the NDC number and the unit/basis of measurement qualifier
• Unit/basis of measurement qualifier
• Quantity: The number of digits for the quantity is limited to eight digits before the decimal and three digits after the decimal. If entering a whole number, do not use a decimal. If entering a unit less that one, do not include a zero. Do not use commas. Examples:
  • 1234.56
  • 2
  • 9999999.999
  • .5 (not 0.5 or .50)

Version 20.2

Overview

This article serves as a guide to users regarding the use of NDC Numbers (NDCs) and Units of Measurement (UOM) when billing medications administered in the office and vaccines as required on claims by most insurance payers. Before managing the tables that house this information, it is important to make sure that each payer that requires NDCs to be reported on claims is assigned as such in the Insurance Payer Setup. After making sure the payers are set up correctly, you will learn the correct NDC and UOM format and where medication and vaccine NDCs and UOM are pulled from.

Review Payer Setup

1. Navigate to the Billing tab
2. Click the Payers button. The Insurance Payers List is displayed.
3. Select the Payer.
4. Click the Edit button.
5. In the lower section of the Basic Information tab, select the Include NDC on vaccine products checkbox. This includes the NDC on Medications administered in the office when coded.
6. Click the Save button.

NDC Number Format

Each NDC Number must be reported as an 11-digit code unique to the manufacturer of the specific drug or product administered to the beneficiary using a 5-4-2 format (i.e. 5 digits, followed by 4 digits, followed by 2 digits [99999999999]). The chart below illustrates how to convert the 10-digit code into an 11-digit code based on the 10-digit number's format. The hyphens in the example below are for illustration only. If the NDC is not submitted in the correct format, the claim will be denied.

NDC Unit of Measurement Format

The standard reportable NDC Units of Measurement, as dictated by the National Uniform Claim Committee, NUCC, include:

• F2: International Unit
• GR: Gram
• ME: Milligram
• ML: Milliliter
• UN: Unit

Medication NDCs and Units of Measurement

Medications, such as Albuterol, should be billed with the corresponding NDC number and Unit of Measurement. This information must be added to the CPT Code Table in order for the code to be billed properly. To add NDCs and Units of Measurement to medications:

1. Navigate to the Clinical or Billing tab
2. Click the Procedure (CPT) Codes button. The CPT Code table is displayed.
3. Search for and select the medication CPT Code. 

1. Click the Edit button.
2. In the NDC ID field, enter the 11-digit NDC Number and Dose (Unit of Measurement). For example, 00487950125 UN1 where the format is:

• 11-digit NDC Number
• One space separating the NDC number and the unit/basis of measurement qualifier
• Unit/basis of measurement qualifier
• Quantity

NDC Quantity

The quantity of each NDC must be a numeric value greater than zero. In most cases, the NDC quantity will be different from the HCPCS billed units.

Vaccine NDCs and Units of Measurement

In order for NDCs and Units of Measurement to be billed for vaccines, the practice must be aware of its own status. The practice status determines where the NDC numbers and Units of Measurement are pulled from when vaccines are billed. The practice statuses are:

• Practices that are fully live with OP: These are practices that are using OP for Practice Management, Billing, and EHR.
• Practices that are not fully live with OP: These are practices that are implementing OP in a Split Go Live method. These practices Go Live with Practice Management and Billing first, but are not yet live with EHR. 

Practices that are Fully Live with OP

Practices that are Not Fully Live with OP

Billing Using the Electronic Claim Format

The following data elements should be used to submit the NDC Information in the HIPAA-standard ACS X12N8347 electronic claims format:

For Loop 2400:

• SV101 CPT/HCPCS code
• SV104CPT/HCPCS units

For Loop 2410:

• LIN03 NDC (11-digit format)
• CTP04 NDC Quantity
• CTP05-1 NDC Unit or Basis for Measurement Code

Loop 2400 of the 837 looks like:

• CPT Code - 90680 2400 SV101 90680
• CPT DUTS- 1 - SV104 1

Loop 2410 of the 837 looks like:

• NDC - 00006404741 2410 LIN03 00006404741 
• NDC Drug Quantity - 2 - CPT04 2 
• NDC UOM - ML - CPT04-1 ML

The complete 837 instructions are available in the HIPAA Implementation Guide on the Washington Publishing website at www.wpc-edi.com.

Billing Using the Paper Claim Form

If you bill on paper using the CMS-1500 form, use the shaded area of fields 24A-24G to report the NDC information in the following order:

• Qualifier
• 11-digit NDC Number
• One space separating the NDC number and the unit/basis of measurement qualifier
• Unit/basis of measurement qualifier
• Quantity

Claim Example:

See the CMS-1500 Manual for additional information at www.nucc.org.