CMS-1500 (8/05) Form, Shaded Field 24A-G
The following types of supplemental information are accepted in a shaded claim line of the CMS 1500 (8/05) form field 24A-G:
• Anesthesia duration
• Narrative description of unspecified/miscellaneous/unlisted codes
• National Drug Codes (NDC) for drugs
• Vendor Product Number–Health Industry Business Communications Council (HIBCC)
• Product Number Health Care Uniform Code Council–Global Trade Item Number (GTIN), formerly Universal Product Code (UPC) for products
• UPN for contracted medical supplies
The following qualifiers are to be used when reporting these services.
7 Anesthesia information
ZZ Narrative description of unspecified/miscellaneous/unlisted codes
N4 National Drug Codes (NDC)
The following qualifiers are to be used when reporting NDC units:
F2 International Unit
GR Gram
ME Milligram
ML Milliliter
UN Unit
VP Vendor Product Number- Health Industry Business Communications Council (HIBCC) Labeling Standard
OZ Product Number Health Care Uniform Code Council – Global Trade Item Number (GTIN)
Universal product Number
HI Health Care Industry Bar Code (HIBC)
EO GTIN EAN/UCC
UP Consumer Package Code U.P.C.
EN European Article Number (EAN)
UK U.P.C./EAN Shipping Container Code
ON Customer Order Number
To enter supplemental information, begin at 24A by entering the qualifier and then the information. Do not enter a space between the qualifier and the supplemental information. When reporting a service that does not have a qualifier, enter two blank spaces before entering the information.
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More than one supplemental item can be reported in a single shaded claim line IF the information is related to the un-shaded claim line item it is entered on. When entering more than one supplemental item, enter the first qualifier at the start of 24A followed by the number, code, or other information. Do not enter a space between the qualifier and the supplemental information. Do not enter hyphens or spaces within the HIBCC, or GTIN number/code. After the entry of the first supplemental item, enter three blank spaces and then the next qualifier and number, code, or other information. Do not enter a space between the qualifier and the supplemental information. Do not enter hyphens or spaces within the HIBCC, or GTIN number/code.
Examples:
Anesthesia
Unlisted, Non-specific, or Miscellaneous CPT or HCPC Code
Vendor Product Number- HIBCC
Product Number Health Care Uniform Code Council – GTIN
Universal Product Number (UPN) for contracted disposable incontinence and medical supplies
NDC Format
An NDC number on a drug container consists of digits in a 5-4-2 format. Hyphens (-) separate the number into three segments. Although an NDC on a drug container may have fewer than 11 digits, an 11-digit number must be entered on the claim. An NDC entered on the claim must have five digits in the first segment, four digits in the second segment, and two digits in the last segment. The first five digits of an NDC identify the manufacturer of the drug and are assigned by the Food and Drug Administration (FDA).
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The remaining digits are assigned by the manufacturer and identify the specific product and package size. Placeholder zeros must be entered on the claim wherever digits are needed to complete a segment.
Here are examples of entering placeholder zeroes on the claim: Package NDC Zero Fill 11-digit NDC
1234-1234-12 (01234-1234-12) 01234123412
12345-123-12 (12345-0123-12) 12345012312
2-22-2 (00002-0022-02) 00002002202
National Drug Codes (NDC) for drugs
National Drug Code (NDC)
The National Drug Code (NDC) is required to be billed on claim forms for drugs administered by physicians, outpatient hospitals, and dialysis centers.
NDC codes must be reported when CHWP is the secondary or tertiary payer as well.
When to Report the NDC code on the CMS1500 and UB04 Claim Forms:
1. Physician Administered Drugs - when billing for drugs using the J-code HCPCS, the claims must include the J-code HCPCS, a valid 11-digit NDC, as well as the quantity
administered using the correct unit of measure. This does not include physician administered drugs for inpatient services, immunizations and radiopharmaceuticals. 2. Outpatient Hospital Claims - for bill types 131 and 135, when billing for revenue codes
0250, 0251, 0252, 0257, 0258, 0259 and 0637, claims must include the J-code HCPCS, a valid 11-digit NDC, as well as the quantity administered using the correct unit of
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3. Dialysis Claims - for bill types 0721, when billing for revenue codes 0250, claims must include a valid 11-digit NDC, as well as the quantity administered using the correct unit of measure.
How to Report the NDC code
I. Professional Claims
The NDC number reported must be the actual NDC number on the package or container from which the medication was administered.
837P (Electronic submission)
For electronic claims that are submitted using the 837P, the NDC codes must be included in Loop 2410 data element LIN03 of the LIN segment. The quantity must be in Loop 2410 CTP04 and the unit of measure (UOM) code in Loop 2410 CTP05-01. The unit price must be populated in Loop 2410 CTP03 but can be entered with a value of zero.
CMS1500 (Paper submission)
1. For paper claims, the NDC code, unit of measure and quantity must be entered in the shaded area of box 24A. The NDC number submitted must be the actual NDC number on the package or container from which the medication was administered.
2. Begin by entering the qualifier N4 immediately followed by the 11-digit NDC number. The NDC codes must be in the 5-4-2 format required by HIPAA guidelines, do not report hyphens. It may be necessary to pad NDC numbers with zeroes in order to report eleven digits.
3. Next enter the two digit unit of measurement qualifier immediately followed by the numeric quantity administered to the patient. The Unit Quantity with a floating decimal for fractional units is limited to three (3) digits to the right of the decimal point.
4. A maximum of seven (7) positions to the left of the floating decimal may be reported. 5. When reporting a whole number, do not key the floating decimal.
6. When reporting fractional units, you must enter the decimal as part of the entry.
Sample NDC:
Whole Number Unit:
N 4 1 2 3 4 5 6 7 8 9 0 1 U N 1 2 3 4 5 6 7 Fractional Unit:
N 4 1 2 3 4 5 6 7 8 9 0 1 U N 1 2 3 4 . 5 6 7
Below are the measurement qualifiers when reporting NDC units:
Measurement Qualifiers
F2 International Unit GR Gram
ML Milliliter UN Units
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Reporting Multiple NDCs on a Professional Claim
If submitting via paper and the drug administered is comprised of more than one ingredient, each NDC must be represented in the service lines. The HCPCS code should be repeated as necessary to cover each unique NDC code. Enter a KP modifier for the first drug of a multiple drug formulation and enter a modifier of KQ to represent the second or subsequent drug formulations.
If submitting electronically and the drug administered is comprised of more than one
ingredient, the compound drug should be reported by repeating the LIN and CTP segments in the 2410 drug identification loop.
II. Facility Claims
• Outpatient Hospital Claims - NDC code is required on outpatient hospital claims (type of
bill 131/135) when reporting revenue codes within series 025X and revenue code 0637.
• Freestanding Dialysis Claims - NDC is required when reporting the revenue code 0250
with bill type 0721.
837I (Electronic Submission)
For electronic claims that are submitted using the 837I, the NDC codes must be included in Loop 2410 data element LIN03 of the LIN segment. The quantity must be in Loop 2410 CTP04 and the unit of measure (UOM) code in Loop 2410 CTP05-01. The unit price must be populated in Loop 2410 CTP03 but can be entered with a value of zero.
UB04 (Paper Submission)
Facility claims that are submitted via paper should be submitted using the following format: 1. In Field 43 report the NDC qualifier of "N4" in the first two positions, left justified. The
NDC number submitted must be the actual NDC number on the package or container from which the medication was administered.
2. Begin by entering the qualifier N4 immediately followed by the 11-digit NDC number. The NDC codes must be in the 5-4-2 format required by HIPAA guidelines, do not enter hyphens. It may be necessary to pad NDC numbers with zeroes in order to report eleven digits.
3. Next enter the two digit unit of measurement qualifier immediately followed by the numeric quantity administered to the patient. The Unit Quantity with a floating decimal for fractional units is limited to three (3) digits to the right of the decimal point.
4. A maximum of seven (7) positions to the left of the floating decimal may be reported. 5. When reporting a whole number, do not key the floating decimal.
6. When reporting fractional units, you must enter the decimal as part of the entry.
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Whole Number Unit:
N 4 1 2 3 4 5 6 7 8 9 0 1 U N 1 2 3 4 5 6 7 Fractional Unit:
N 4 1 2 3 4 5 6 7 8 9 0 1 U N 1 2 3 4 . 5 6 7
Below are the measurement qualifiers when reporting NDC units:
Measurement Qualifiers
F2 International Unit GR Gram
ML Milliliter UN Units
Reporting Multiple NDC's on a Facility Claim:
You may report multiple line items of revenue codes and associated NDC numbers as follows: 1. Each line item must reflect the revenue code 0250 with the appropriate HCPCS; 2. Each line item must reflect a valid NDC per the NDC format; and
3. Each NDC reported must be unique or the revenue code line item will deny as a duplicate against the revenue code and NDC line item that matched it.
If submitting electronically, and the drug administered is comprised of more than one
ingredient, the compound drug should be reported by repeating the LIN and CTP segments in the 2410 drug identification loop.
Reporting Compound Drugs on a Facility Claim:
When reporting compound drugs, a maximum of five (5) lines are allowed and should be reported in the following manner:
1. List the most expensive ingredient first, followed by the rest of the ingredients.
2. On the first line for the compound drug, report the revenue code (0250), the valid NDC per the NDC format, the appropriate HCPCS for the drug that is administered, the total number of units administered for all drugs in the compound and the total charge for all of the drugs that are in the compound.
3. For each subsequent line, report only the NDC and the appropriate HCPCS related to the compound drug.
4. If one line for the compound drug denies, the entire compound drug will deny.
National Drug Code (NDC) FAQs: NDCs and the 340B Drug Pricing Program
Providers are encouraged to inquire with their authorized drug purchasing agent to determine if drugs are purchased under the 340B program.
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The amount listed on the Medi-Cal claim line should be equal to the total of the acquisition cost plus the dispensing/administration fee. It is not necessary to enter separate amounts on the claim.
Medi-Cal requires the NDC information for audit purposes to ensure that the 340B entities are charging the appropriate amount. As directed by the Health Resources and Services Administration (HRSA) Federal Register’s “Entity Guidelines”(Vol 59. No. 92, May 13, 1994, page 25112): “If a drug is purchased by or on behalf of a Medicaid
beneficiary, the amount billed may not exceed the entity’s actual acquisition cost for the drug, as charged by the manufacturer at a price consistent with the Veteran’s Health Care Act of 1992, plus a reasonable dispensing fee established by the State Medicaid agency.” Since 340B prices are set by NDC, state and federal auditors will use the NDC when evaluating whether or not a 340B entity is complying with HRSA rules.
Medi-Cal is using the UD modifier with the appropriate HCPCS Level I, II or III code, but claims will still require the N4 product qualifier and 11-digit NDC number for audit purposes. Providers that purchase drugs under the 340B program are required to bill Medi-Cal at the provider's acquisition cost and the state-established
dispensing/administration fee. In order for it to be verified when audited, the NDC number is required on the claim.
The claim line for a physician administered drug without an NDC will be denied, regardless of the presence of the UD modifier.
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