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Provider Notice issued 02/08/13
Chemotherapy agents for the treatment of cancer
Non-chemotherapy drugs administered for conditions associated with the chemotherapy and submitted with the cancer-related diagnosis
Baclofen
Lupron
RhoGAM
Synagis
Tysabri
Change in Reporting National Drug Codes (NDCs) for Outpatient Expensive Drugs and Renal Dialysis Injectable Drugs Effective March 1, 2013
| To: | Participating Hospitals – Chief Executive Officers, Chief Financial Officers, and Patient Accounts Managers; Renal Dialysis Facilities; and Ambulatory Surgical Treatment Centers (ASTCs) |
| Date: | February 8, 2013 |
| Re: | Change in Reporting National Drug Codes (NDCs) for Outpatient Expensive Drugs and Renal Dialysis Injectable Drugs Effective March 1, 2013 |
Federal law requires Medicaid programs to collect rebates on all claims for outpatient drugs, including claims billed by non-pharmacy providers. In order to collect rebates, the claim must contain accurate NDCs and the quantity of the drug administered at an NDC level. The department has required hospitals, renal dialysis facilities, and ASTCs since July 1, 2008, to report NDCs on claims containing certain expensive drugs and renal dialysis injectable drugs. However, as a result of Public Act 097-0689, referred to as the Save Medicaid Access and Resources Together (SMART) Act, the department is making changes to outpatient billing requirements in order to obtain the information necessary to collect rebates on outpatient billed drugs.
It sometimes may be necessary for providers to bill multiple NDCs for a single HCPCS code. This may happen when two different strengths of the same drug are needed in order to administer the appropriate dose. This will also be necessary when multiple vials of the same drug are used to administer the appropriate dose, and the vials are manufactured by different manufacturers. When a provider uses more than one NDC for a drug, the provider must include all NDCs on the claim.
Effective with claims containing a "Through Date" of service on and after March 1, 2013, providers will be required to detail revenue code line reporting when billing for more than one NDC per HCPCS code in conjunction with revenue codes 0634, 0635, and 0636. Duplicate revenue codes identifying the same HCPCS code but different NDCs on the same claim are not to have the HCPCS Units and Charges rolled into the first Revenue Code line. Each Revenue Code line must contain detailed reporting. For renal dialysis injectable drugs, including Epoetin Alfa (Epogen), the add-on will be calculated based on the HCPCS units for each individual Revenue Code line. At this time, for Revenue Codes 0634 and 0635, the department will still require the reporting of Value Code 68 with the total number of units administered.
As mentioned above, this outpatient billing policy applies to drugs for which the department allows an add-on payment: certain injectable drugs billed in conjunction with outpatient renal dialysis claims (category of service 25/Revenue Codes 0634, 0635 & 0636); and certain expensive drugs administered in the hospital outpatient or ASTC setting (category of service 24/Revenue Code 0636). These drugs are referenced on separate fee schedules on the department's Web site.
Medicaid claim processing guidelines for reporting multiple NDCs when more than one NDC is billed for a single HCPCS code:
HIPAA 837 Institutional Transaction:
The HCPCS Code is reported in Loop ID 2400.
| Segment | Instruction |
|---|---|
| Segment SV201 | Enter the national code. |
| Segment SV202-1 | Enter qualifier 'HC'. |
| Segment SV202-2 | Enter the HCPCS code. |
| Segment SV202-3 | Enter the UD modifier if you obtained the drug under the 340B program. |
| Segment SV203 | Line item charge amount. If you obtained the drug under the 340B program, this amount is to be your actual acquisition cost. |
| Segment SV204 | Enter qualifier 'UN'. |
| Segment SV205 | Enter the quantity. |
The NDC is reported in Loop ID 2410.
| Segment | Instruction |
|---|---|
| Segment LIN02 | Enter qualifier 'N4'. |
| Segment LIN03 | Enter NDC without hyphens |
| Segment CTP04 | Enter quantity. |
| Segment CTP05 | Enter unit of measurement. |
Incorrect Billing:
LX*1
SV2*0634*HC*Q4081*1207.80*UN*671
DTP*472*D8*20111003
LIN**N4*55513012601
CTP****20.9*ML
LX*2
SV2*0634*HC*Q4081*0*UN*0
DTP*472*D8*20111003
LIN**N4*55513012601
LX*3
SV2*0634*HC*Q4081*0*UN*0
DTP*472*D8*20111003
LIN**N4*55513014801
LX*4
SV2*0636*HC*J2501*864*UN*72
DTP*472*D8*20111003
LIN**N4*0004463701
CTP****27*ML
LX*5
SV2*0636*HC*J2501*0*UN*0
DTP*472*D8*20111003
LIN**N4*00074165801
Correct Billing:
LX*1
SV2*0634*HC*Q4081*198*UN*110
DTP*472*D8*20111003
LIN**N4*55513012601
CTP****5.5*ML
LX*2
SV2*0634*HC*Q4081*297*UN*165
DTP*472*D8*20111003
LIN**N4*55513012601
CTP****5.5*ML
LX*3
SV2*0634*HC*Q4081*712.80*UN*396
DTP*472*D8*20111003
LIN**N4*55513014801
CTP****9.9ML
LX*4
SV2*0636*HC*J2501*504*UN*42
DTP*472*D8*20111003
LIN**N4*0004463701
CTP****21*ML
LX*5
SV2*0636*HC*J2501*360*UN*30
DTP*472*D8*20111003
LIN**N4*00074165801
CTP****6ML
CTP – NDC Drug Quantity segment required based on the 5010 837I guidelines.
UB04 Institutional Transaction:
The HCPCS code and NDC information is reported within the Revenue Code service line. Refer to the UB04 Billing Manual for assistance.
Incorrect Billing:
| FL 42 Revenue Code | FL 43 NDC Reporting | FL 44 HCPCS and Modifier | FL 45 Service Line Date | FL 46 Service Units | FL 47 Total Charges |
|---|---|---|---|---|---|
| 0634 | N455513012601ML20.9 |
Q4081 |
031011 |
671 |
1207 80 |
| 0634 | N455513026701 |
Q4081 |
031011 |
0 |
00 |
| 0634 | N455513014801 |
Q4081 |
031011 |
0 |
00 |
| 0636 | N400074463701ML27 |
J2501 |
031011 |
72 |
864 00 |
| 0636 | N400074165801 |
J2501 |
031011 |
0 |
00 |
Correct Billing:
| FL 42 Revenue Code | FL 43 NDC Reporting | FL 44 HCPCS and Modifier | FL 45 Service Line Date | FL 46 Service Units | FL 47 Total Charges |
|---|---|---|---|---|---|
| 0634 | N455513012601ML5.5 |
Q4081 |
031011 |
110 |
198 00 |
| 0634 | N455513026701ML5.5 |
Q4081 |
031011 |
165 |
297 00 |
| 0634 | N455513014801ML9.9 |
Q4081 |
031011 |
396 |
712 80 |
| 0636 | N400074463701ML21 |
J2501 |
031011 |
42 |
504 00 |
| 0636 | N400074165801ML6 |
J2501 |
031011 |
30 |
360 00 |
NDC Drug Quantity required based on the UB04 coding guidelines.
340B Billing Requirements for Outpatient Renal Dialysis and Expensive Drugs:
This notice supersedes the informational notice Clarification Regarding Billing for 340B Purchased Drugs dated May 30, 2012. Effective with claims containing a "Through Date" of service on and after March 1, 2013, providers submitting outpatient institutional claims for renal dialysis injectable drugs or designated expensive drugs are to identify 340B purchased drugs by reporting modifier "UD" in Form Locator 44 of the UB04 or Loop 2400 of the 837I. Modifier "UD" must be the first modifier listed following the procedure code. This policy will also apply to Medicare crossover claims.
Hospitals, renal dialysis facilities, and ASTCs are required to bill the department their actual acquisition cost for their 340B drugs, with the exception of expensive drugs and drugs on Medicare crossover claims.
340B Billing Requirements for Drugs on Fee-for-Service Claims
Effective with dates of service on and after March 1, 2013, providers submitting fee-for-service claims (837P or HFS 2360) for the following drugs must also identify 340B purchased drugs by reporting modifier "UD". Providers must bill the department their actual acquisition cost for the drug.
In the near future, the department will reimburse a $12.00 dispensing fee for all drugs identified as 340B that are billed in conjunction with a designated expensive drug or renal dialysis injectable drug.
Any questions regarding this notice may be directed to your facility's medical assistance consultant in the Bureau of Comprehensive Health Services at 1-877-782-5565.
Theresa A. Eagleson, Administrator
Division of Medical Programs