Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MassHealth Renal Dialysis Clinic Bulletin 4 August 2008 TO: Renal Dialysis Clinics Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Reporting National Drug Code (NDC) Information for Physician-Administered Drugs by Dialysis Clinics on Institutional Claims Background To meet compliance standards outlined in the Deficit Reduction Act (DRA) of 2005, effective September 15, 2008, MassHealth will be requiring renal dialysis clinics to submit national drug codes (NDCs) with NDC units and appropriate descriptors on Medicare crossover claims billed on the UB04 or 837I for drugs paid by HCPCS Q4081 and J0895. This information will be required for claims with dates of submission on or after September 15, 2008. Claims that do not have this information will be denied, or subject to recoupment. Reminder The requirement to supply NDCs, NDC units, and descriptors for HCPCS Q4081 and J0895 on professional claims has been in effect since January 1, 2008. Claims not Impacted This requirement does not apply to claims that are paid as part of a bundled rate. MassHealth is not requiring an NDC for vaccines, radiopharmaceuticals or contrast media at this time. Reasons for Reporting NDCs The federal government requires state Medicaid agencies to maximize the collection of rebates from drug manufacturers. In order to collect these rebates, MassHealth must positively identify the manufacturer and metric quantity of the drugs dispensed. The Level II HCPCS codes used for billing by physicians do not contain sufficient information and are therefore unusable for this purpose. Accordingly, the Centers for Medicare and Medicaid Services require states to ensure that Providers bill using NDC codes for physician-administered drugs and that the states collect and report on NDC codes. (continued on next page) MassHealth Renal Dialysis Clinic Bulletin 4 August 2008 Page 2 Reimbursement Policy MassHealth's coverage and pricing procedures have not changed with regard to medications administered in the clinical setting. Provider reimbursement is based on the HCPCS description and units of service. Use the HCPCS code and service units as you have in the past; this is the basis for your reimbursement. About NDCs The NDC is a universal number that identifies a drug. The NDC number consists of 11 digits in a 5-4-2 format. The first 5 digits identify the manufacturer of the drug and are assigned by the Food and Drug Administration. The remaining digits are assigned by the manufacturer and identify the specific product and package size. Some packages will display less than 11 digits, but leading zeroes can be assumed and need to be used when billing. For example: XXXX-XXXX-XX = 0XXXX-XXXX-XX XXXXX-XXX-XX = XXXXX-0XXX-XX XXXXX-XXXX-X = XXXXX-XXXX-0X The NDC is found on the drug container (vial, bottle, tube, etc). The NDC submitted to MassHealth must be the actual NDC number on the package or container from which the medication was administered. Do not bill for one manufacturers' product and dispense another. NDC units are based upon the numeric quantity administered to the patient and the unit of measurement. The unit of measurement (UOM) codes are: F2 = International Unit GR=Gram ML = Milliliter UN = Unit (Each) The actual metric decimal quantity administered and the unit of measurement are required for billing. If reporting a fraction, use a decimal point. For example: If three 0.5-ml vials are dispensed, the correct quantity to bill is 1.5 ml. Billing using the 837I Submit HCPCS codes as usual and add NDC and quantity information as identified in the table on the next page. (continued on next page) MassHealth Renal Dialysis Clinic Bulletin 4 August 2008 Page 3 Billing using the 837I (cont.) If you bill electronically using the 837I transaction, complete the Drug Identification and Drug Pricing segments in Loop 2410 following the instructions below. Loop 2410 Segment LIN 02 Element Name Product or Service ID Qualifier Information If billing for a national drug code (NDC), enter the product or service ID qualifier. Loop 2410 Segment LIN 03 Element Name Product or Service ID Information If billing for drugs, include the NDC. An NDC is not required for vaccines. Loop 2410 Segment CTP 03 Element Name Unit Price Information If an NDC was entered in LIN03, include the unit price for the NDC billed. Loop 2410 Segment CTP 04 Element Name Quantity Information If an NDC was submitted in LIN03, include the quantity for the NDC billed. Loop 2410 Segment CTP 05-1 Element Name Unit or Basis for Measurement Code Information If an NDC was submitted in LIN03, include the unit or basis for measurement code for the NDC billed using the appropriate code qualifier: F2 — International unit GR — Gram ML — Milliliter UN — Unit Billing using the UB-04 The instructions are copied from the National Uniform Billing Committee (NUBC) website at www.nubc.org. Using the Revenue Description Field (Form Locator 43) on the UB-04: • Report the N4 qualifier in the first two (2) positions, left-justified, followed immediately by the 11 character National Drug Code number in the 5-4-2 format (no hyphens). • Immediately following the last digit of the NDC (no delimiter), is the Unit of Measurement Qualifier. The Unit of Measurement Qualifier codes are as follows: o F2-International Unit o GR-Gram o ML-Milliliter o UN-Unit (continued on next page) MassHealth Renal Dialysis Clinic Bulletin 4 August 2008 Page 4 Billing using the UB-04 (cont.) • Immediately following the Unit of Measurement Qualifier, you will find the unit quantity with a floating decimal for fractional units limited to three digits (to the right of the decimal) • Any spaces unused for the quantity are left blank. Note that the decision to make all data elements left-justified was made to accommodate the largest quantity possible. The Description Field on the UB-04 is 24 characters in length. An example of the methodology is illustrated below. N 4 1 2 3 4 5 6 7 8 9 0 1 U N 1 2 3 4 . 5 6 7 Questions MassHealth has posted frequently asked questions about this requirement on the MassHealth Web site at www.mass.gov/masshealth. Once there, click on Information for MassHealth providers, then click on National Drug Code (NDC) Requirements for Physician Administered Medication. If you have any questions about the information in this bulletin, please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974.