Connecticut Department of Social Services Medical Assistance Program Provider Bulletin. PB June 2008

Transcription

1 Connecticut Department of Social Services Medical Assistance Program Provider Bulletin PB June 2008 TO: SUBJECT: Professional Claim Submitters Change to National Drug Code Requirements on Professional and Professional Crossover Claims Due to the Implementation of the Federal Deficit Reduction Act (DRA) of 2005 The purpose of this bulletin is to inform providers of an important change to electronic and paper claim submission requirements regarding National Drug Codes (NDC) due to the implementation of the Federal Deficit Reduction Act of 2005 (DRA). This mandate requires the submission of National Drug Codes (NDCs) on all claims with procedure codes for physician administered drugs. The purpose of this requirement is to assure that the State Medicaid Agencies obtain a rebate from those manufacturers who have signed a rebate agreement with the Centers for Medicare and Medicaid Services (CMS). To comply with implementing this mandate, providers must submit a valid corresponding 11- digit NDC, when billing a HCPCS drug procedure code in the J, S or Q series, on professional and professional crossover claims. The submission of the NDC allows the Connecticut Medical Assistance Program to collect drug rebate dollars on HCPCS drug procedure codes from pharmaceutical manufacturers who have signed a rebate agreement with the Centers for Medicare and Medicaid Services (CMS). Effective with the date of service July 1, 2008 and forward, the qualifier N4 must be submitted in the first two positions of the NDC. The NDC will continue to be submitted on the same detail line as the CPT/HCPCS drug procedure code. NDC Requirements for Claims Processing Participating Labeler A participating labeler is a pharmaceutical manufacturer that has entered into a federal rebate agreement with CMS to provide each state a rebate for products reimbursed by Medicaid Programs. A labeler is identified by the first 5 digits of the NDC. To assure a product is payable for administration to a Medicaid beneficiary, compare the labeler code (the first 5 digits of the NDC) to the list of participating labelers which is maintained on the Connecticut Medicaid Web site at NDC Formatting When submitting a Medicaid claim for administering a drug, providers must submit the HIPAA standard 11-digit NDC without dashes or spaces. The 11-digit NDC is comprised of three segments or codes: a 5-digit labeler code, a 4-digit product code, and a 2-digit package code. If the NDC does not contain 11-digits, it must be changed to comply with the HIPAA format.

2 The NDC can be found on the product as demonstrated below: Table 2 NDC Configuration NDC From Label HIPAA Format Note: Because the vial from which the drug is administered is frequently not in the accepted 11- digit format, please refer to Table 1 above for examples on how to format and bill the NDC correctly. In this example, a zero should be placed at the beginning of the second segment of the NDC. Therefore, the correct configuration is NDCs billed to Medicaid for payment must use the 11-digit format without dashes or spaces between the numbers. NDCs submitted in any configuration other than the 11-digit format will be denied. Specific NDC Coverage- New Web Functionality The Department of Social Services (DSS) has implemented a Drug Search tool, to assist Providers in verifying the drug they administered and are billing for is valid, rebateable and payable. By going to the web site at Provider Drug Search providers can perform the search. The date of service (DOS) defaults to the current date and would need to be changed to the administered date on the search panel. 2 of 5

3 Providers can enter either the 11-digit NDC, the drug, or the HCPCS followed by the date of service then click search. The following example demonstrates the search results where the NDC is a covered drug. If the NDC submitted is not covered, the results will come back No Rows Found. The NDC, Brand Name, Generic Name, Dose Strength, Dose Form, Package Size, HCPCS (Code, Description and Drug Name), End Date and Rebate Indicator, would be displayed. Additionally, if the rebate status displays an N, for the date of service indicated, the NDC would not be payable. If a drug name was used to execute the search, all NDCs matching the criteria would be displayed in the results. A sampling of the results using Heparin Flush for the search criteria, is illustrated below: Note: EDS is currently developing the HCPC search criteria. This feature will enable the provider to enter a HCPCS and identify the NDCs associated with that code Reimbursement Policy The reimbursement to the provider will continue to be based on the fee schedule rate of the HCPCS procedure code. Billing Instructions 1. In field 24A of the CMS 1500 Form, as illustrated below in the shaded area, the first 2 positions will indicate the qualifier of N4, followed by the 11-digit NDC. 3 of 5

4 2. The billed units in column G (Days or Units) should reflect the HCPCS units and not the NDC units. In this example J1642 is for Heparin Sodium, (Heparin Lock Flush) per 10 units. The NDC in the above example ( ) is for Heparin lock 100 units/ml and is a 30 ml vial. If the client is receiving a total of 100 units of Heparin, the provider should bill 10 HCPCS units. J1642 Heparin Sodium per 10 units X 10 units billed for a total of 100 Heparin units administered to the client. Billing should not be based off of the units of the NDC. Billing based on the NDC units may result in underpayment to the provider. 3. The 11-digit NDC is comprised of three segments: a 5-digit labeler code, a 4-digit product code and a 2-digit package code. The 10-digit NDC assigned by the FDA printed on the drug package must be changed to the 11-digit format by inserting a leading zero on one of the three segments. Multiple NDCs When administering multiple NDCs within a single HCPC each NDC must be identified at the time of billing. The Department of Social Services (DSS) will not deny a claim if the same HCPCS code is billed for the same date of service on more than one detail, as long as the NDCs submitted are not the same and are billed as described below. This scenario may occur if the physician needs to administer a specific dose of a drug that requires the use of two different vials of a drug (two different NDCs) to make up the total dose. The example above shows the total billed amount, in Field 24F, while each subsequent sequences, for the additional NDCs, will contain a zero. Field 24F indicates the total change for all associated sequences. Note sequence 2 has a value of zero. Field 24G indicates the total number of HCPCS units for all associated NDC. Note sequence 2 has a no value indicated. The first sequence of each detail must show the total value of all associated sequences in Fields 24 F and G.. In this example The total amount billed, on sequence 1 is and the total number of HCPCS units is 5. Medicare Crossover Claims The N4 qualifier and the NDC are also required on Medicare crossover claims as the Connecticut Medical Assistance Program may pay up to the 20% coinsurance and/or deductible due for dually eligible clients. Medicare covered procedure codes, not currently on the CT Fee Schedule, will be accepted by DSS and will not be edited. An example of such a procedure code would be J7322, which was added by Medicare effective 1/08. 4 of 5

5 Editing/Explanation of Benefits if submitted incorrectly Claims with Dates of Service 07/01/08 forward, that do not comply with the mandate will deny. The following explanation of benefits will be received for claims not meeting the new billing requirements: EOB Unit of measure qualifier is required for NDC. This EOB will be received and the claim will deny when an inappropriate unit of measure is submitted with an NDC. EOB NDC units missing or invalid. This EOB will be received and the claim will deny when the NDC units is missing or invalid. EOB NDC is missing or invalid. This EOB will be received and the claim will deny when a HCPC is submitted and the NDC is missing, terminated, not rebateable, *DESI, institutional, repackage, inner package, not valid, or the NDC qualifier is missing or invalid. * A list of DESI drugs in maintained on the CT Medicaid Web site at Pharmacy Information Pharmacy Program Publications DESI List Electronic claim submission Provider Electronic Solutions Software submitters filing 837 professional claims will enter the NDC, Unit of Measure, Quantity and Price for each NDC on the Service 3 tab. The corresponding HCPCS drug procedure code must be submitted on the Service 1 tab. For additional information, please refer to the PES handbook on the Web site at ctdssmap.com Trading Partner EDI PES Handbook Vendor software submitters, check with your vendor to ensure your software will be able to capture the criteria necessary to submit these 837 professional claims. Electronic Batch and Professional Medicare Crossover formats have designated fields for the NDC, NDC quantity, and units of measure. Please refer to the Companion Guide for additional information: Chapter 8 of the Provider Manual will be updated to incorporate the billing instructions related to the updated CMS Providers can access their provider manuals by logging on to the EDS Web site From the home page click on Publications Provider Manuals then select the appropriate Provider Type from the drop down menu under View Chapter 8.. This bulletin and other program information can be found at Questions regarding this bulletin may be directed to the EDS Provider Assistance Center - Monday through Friday from 8:00 a.m. to 5:00 p.m. at: In-state toll free or EDS Out-of-state or in the PO Box 2991 local Farmington, CT area Hartford, CT of 5