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TO:                         Outpatient Hospital Providers Billing Medications with HCPCS

 

FROM:                  Kathleen P. Allyn, Deputy Administrator

         

Outpatient hospital claims for medications reported with HCPCS (Healthcare Common Procedure Coding System) codes for dates of service on or after February 1, 2004 must include the NDC of the medication supplied, units dispensed, and basis of measurement for each HCPCS medication.

 

This requirement:

·         also applies to cancer drugs with HCPCS codes

·         applies to claims submitted electronically and on the paper UB-92 form

·         does not apply to Medicare claims which “crossover” to Medicaid as the secondary payer

 

The HCPCS medications which will require NDC information are listed in the current HCPCS Level II Expert manual, Appendix 3, alphabetically by both generic and brand or trade name with corresponding HCPCS codes.

 

Claims with incomplete NDC information will be denied with EOB 628 – “NDC required….”

 

The collection of the NDC information will allow Medicaid to collect rebates due from drug manufacturers, resulting in significant cost saving to Idaho’s Medicaid Program. This requirement is supported by the federal Centers for Medicare and Medicaid Services (CMS), which is encouraging all states to develop systems to claim drug rebates for the Medicaid programs. See State Medicaid Director Letter #03-002, at: http://www.cms.hhs.gov/states/letters/smd031403.pdf.

 

Electronic Claims

 

PES SOFTWARE:

The HIPAA compliant fields needed to report NDC information are already available for providers using the EDS billing software PES (Provider Electronic Solutions). Please use the following guidelines:

 

Complete the Service and RX tab fields using the following guidelines.

 

Service Tab:

·         Date of Service

·         Revenue code – Use revenue code 634 or 635 for epoetin, or 636 (“drugs requiring special coding”), and include the HCPCS and NDC information.

·         Billed Amount – enter total charges for the revenue code billed.

·         Units - the number of times you provided the HCPCS medication for that date of service (not the grams, milligrams, or number of tablets).

·         Basis of measurement will be UN (unit) – software defaults to UN.

·         Unit Rate – not required.

·         Procedure - enter the 5 digit HCPCS code.

·         Modifiers – not required.

·         RX Ind - enter Y and the RX tab will pop up, which must be completed.

RX Tab:

·         NDC - Enter the 11 digit NDC number.

·         Prescription Number – not required.

·         Units – Enter the units dispensed that you are billing for. You may want to refer to the HCPCS manual, Appendix 3, which includes brief directions regarding the “Amount” (Unit) column.

·         Basis of Measurement – Enter IU – International Units, GR – grams, ML – milliliters, or UN – units (such as the number of tablets, capsules).

·         Unit Price – Enter the price for the HCPCS medication dispensed.

 

If you have questions, refer to the Idaho Provider Electronic Solutions Handbook, Section 8 (837 Institutional - Outpatient Form) which can be accessed online at:

http://www2.state.id.us/dhw/medicaid/provhb/ipesh_handbook.pdf.

 

Providers using vendor software:

Check with your vendor or clearinghouse. If your software does not allow NDC information to be submitted in the appropriate HIPAA approved fields, you may use the Comment field for NDC information for no longer than 6 months while your software is being modified. Be sure to refer to the detail number in your Comments.

 

After August 1, 2004 claims submitted without NDC information in HIPAA approved fields will be automatically denied.

 

what if your vendor software is not ready on february 1, 2004?

 

You do not have to delay submitting outpatient Medicaid claims if one or more details include HCPCS medications. Here are your options for getting your claims processed as quickly as possible:

 

  • You can bill the rest of the claim electronically, and wait to bill the line item details which need NDC information until your software is ready. You have up to one year from the date of service to bill any part of a claim, or
  • You can bill the details which need NDC information on a paper UB-92 claim form, separate from the rest of your outpatient electronic claim.

 

Paper Claims - UB-92 form

 

For each HCPCS medication detail, use the following guidelines:

 

·         Revenue code – Use revenue code 634 or 635 for epoetin, or 636 (“drugs requiring special coding”), and include the HCPCS and NDC information.

·         Description - Include 11 digit NDC number, description of medication, units dispensed, and basis of measurement (IU – International Units, GR – grams, ML – milliliters, or UN – units, such as tablets, capsules). If more narrative space is needed Field 84 (Remarks) may also be used. Include the detail number for reference.

·         HCPCS/RATES - Enter the 5 digit HCPCS code.

·         Service Date

·         Service Units - the number of times you provided the HCPCS coded service (NOT grams, milligrams, or number of tablets)

·         Total charges

 

Please refer to the Idaho Provider Handbook, Section 3, for additional billing information. This handbook can be accessed online at: http://www2.state.id.us/dhw/medicaid/provhb/s3_hospital.pdf.

 

For questions regarding billing requirements, please contact EDS (800) 685-3757.  Thank you for your continued participation in the Idaho Medicaid Program.

 

KPA/af