Janice K. Brewer, Governor
Thomas J. Betlach, Director

801 East Jefferson, Phoenix, AZ 85034
PO Box 25520, Phoenix, AZ 85002
Phone: 602-417-4000
www.azahcccs.gov

Our first care is your health care
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

Implementation of the National Drug Code (NDC) Billing Requirements
For Medications Administered in Outpatient Clinical Settings

Additional Frequently Asked Questions (FAQs)

February 22, 2013

1.   How are providers required to report NDC quantities when the amount is not a whole number?

Providers may enter partial units using up to three decimal points, (e.g., 0.625).  The following are examples of rounding up and down to three decimal points.
145.3562ml shall be submitted as ML145.356
3.7855UN shall be submitted as UN3.786

2.   What NDC unit of measure is to be submitted on a claim if a product is labeled with both a strength and volume, for example, 12.5gm/50 ml?

Below are some of examples of the NDC units of measurements:
a.   If the drug is in powder form and has to be reconstituted before administration then the quantity should be submitted on the claim using the UN designation for each vial (unit/each) used.
b.   If the drug is in a liquid dosage form then the quantity should be submitted on the claim using the ML designation for milliliters.
c.   If the drug is in the dosage form of an ointment, cream, inhaler, or a bulk powder in a jar, the unit of measure primarily be used is Gram (GR)
d.   If the drug dosage for is in International Units, then the quantity should be submitted on the claim using the F2 unit of
measure. Blood factor products use the “international unit” to delineate the dosage of the product.
e.   Additional examples can be found on the table below:

UNITS OF MEASUREMENTS TABLE

Dosage Form	
UN = Unit	
GR = Gram	
ML = Milliliter	F2 =
International
Unit	
Example	
Injectable Liquid (e.g.,
solution, liquid, suspension)			

X		-	30mg of Adenoscan 3mg/ml, the NDC quantity is 10
-	150mg of Provera 150mg/ml is an NDC quantity of 1
-	Two 1.5ml injections of Lidocaine 1%, the NDC quantity is 3
120mg of Paclitaxel 6mg/ml in an infusion, the NDC quantity is 20	
Injectable Solution or
Suspension for Reconstitution (powder for injection) (refer to product labeling to determine if product is a unit of use preparation)	

X				-	One Cefazolin (powder for injection) 1 gram vial, the NDC
quantity is 1
-	Two Ceftriaxone (powder for injection) 500mg vials, the NDC
quantity is 2
-	30 units of Bleomycin (powder for injection) 15 units per vial, the NDC quantity is 2	
Non-injectable Liquid of 1
milliliter or greater (e.g., solution, liquid, suspension)			

X		-	One 3ml bottle of Albuterol 0.083% inhalation solution, the
NDC quantity is 3
-	2 mls of Intal 20mg/ml nebulizing solution, the NDC quantity is 2
-	0.5ml of Morphine Sulfate 20mg/ml oral solution, the NDC
quantity is 0.5	
Antihemophilic Products
(Expressed in International
Units or micrograms)				

X	-	Eight vials of Kogenate-FS (approximately 250 IU/vial), the
NDC quantity is 2000	
Kits	X				-	One Lupron Depot 7.5mg kit, the NDC quantity is 1	

Dosage Form	UN =
Unit	GR =
Gram	ML =
Milliliter	F2 =
International
Unit	Example	
Cream/Ointment
1 gram or greater (utilize product labeling)		
X			-	One 5gm tube of Emla Cream, the NDC quantity is 5	
Lotion
1 milliliter or greater
(utilize product labeling)			
X		-	One 60ml bottle of Lindane 1% Lotion, the NDC quantity is 60	
Non-Injectable Solution or
Suspension for Reconstitution (powder for oral suspension)			

X		-	One 150ml bottle of Amoxacillin (powder for reconstitution)
250mg/ml, the NDC quantity is 150	
Powder Packet	X				-	One bottle of Zmax 2gm oral suspension, the NDC quantity is
1	
Suppositories	X				-	One Promethazine 25mg suppository, the NDC quantity is 1	
Capsules
(All forms)	
X				-	Two Cephalexin 500mg oral capsules, the NDC quantity is 2	
Tablets
(All forms)	
X				-	One Lorazepam 0.5mg oral tablet, the NDC quantity is 1
-	Two Kytril 1mg tablets, the NDC quantity is 2	
Vaccines
(refer to product labeling to determine if product is a unit of use preparation)	

X				-	One DTaP (Daptacel, Infanrix) vial, the NDC quantity is 1
-	One DtaP-IPV (Kinrix) vial, the NDC quantity is 1
-	One Hepatitis B (Recombivax) vial, the NDC quantity is 1
-	One Hib (PedvaxHIB, ActHIB) vial, the NDC quantity is 1	
Vaccines from a multi-
dose vial
(same as Injectable
Liquid above)			

X		-	0.5ml of a Fluzone 5 ml/10 dose vial, the NDC quantity is 0.5
-	0.5ml of a Fluvirin 5ml/10 dose via, the NDC quantity is 0.5
-	0.5ml of a FluLaval, 5ml/10 dose vial, the NDC quantity is 0.5	
The Center for Disease Control (CDC) Vaccine List with NDCs can be accessed at:

http://www.cdc.gov/vaccines/programs/vfc/awardees/vaccine-management/price-list/index.html

3.   What NDC unit of measure is to be submitted when the product is not measured in Grams (GR) or Milliliters (ML), for example tablets, capsules or vials?

Please refer to the response for question #2.

4.   Can the claim be submitted with the NDC of the product or does the actual dose, which is charted in the medical record, have to be included in the billing?

It is not acceptable to submit the NDC of the product using a standard quantity.  The actual dose must be submitted on the claim. Please refer to Attachment A for guidance for the NDC Units of Measurement.

5.   Is the requirement to submit claims with the NDC apply to just physicians administering the drug or other health care associates that administer the medication?

Providers of “physician-administered” drugs include any AHCCCS registered provider whose license and scope of practice
permits the administration of drugs, such as a medical doctor (MD), doctor of osteopathic medicine (DO), nurse practitioner
(NP), physician assistant (PA), ambulatory surgery centers (ASCs), hospital outpatient clinic/services and skilled nursing facilities (SNFs). The requirement to submit the NDC on claims applies to AHCCCS Providers and those administering medication upon a prescriptive order by an AHCCCS Provider.

6.   If the physician-administered drug is an intravenous premixed or compounded product, how is the NDC of the product to be billed if it is compounded?

The following was previously stated in the NDC FAQs, question 12, which were posted on the AHCCCS website on May 7, 2012 under the pharmacy section.

   Each drug must be reported on a separate detail line of the claim.

For clarification, each drug that has a corresponding HCPCS code must be reported

7.   Can the NDC be submitted on the claim with spaces or other punctuation?

Per the Stakeholder Memo dated April 6, 2012 and revised on September 10, 2012, providers must submit the 11-digit NDC
without dashes or spaces between the numbers.

8.   Is the NDC required on claims for drugs that do not have an applicable HCPCS code?

The NDC is not required on claims for drugs that do not have a corresponding HCPCS Code.

9.   Is the NDC required on the claim if the claim is a secondary submission?

Yes, the NDC is required on all claims including primary, secondary, tertiary, etc. submitted to AHCCCS or AHCCCS Contractors.

10. How is the NDC format configured when there are no dashes?

Per the Stakeholder Memo dated April 6, 2012 and revised on September 10, 2012, the NDC number consists of 11 digits in a 5-4-
2 format. The first 5 digits identify the labeler code representing the manufacturer of the drug and are assigned by the Food and Drug Administration (FDA). The next 4 digits identify the specific drug product and are assigned by the manufacturer. The last 2 digits define the product package size and are also assigned by the manufacturer.

Some packages will display less than 11 digits, but leading “0’s” 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, i.e. vial, bottle, and tube.

For clarification, the NDC on the drug container generally is expressed with dashes separating the 5-4-2 format, which allows for identification of leading zeroes if necessary.

11. Will AHCCCS be providing an NDC crosswalk to HCPCS Codes?

No, AHCCCS will not be providing a crosswalk.

12. Will claims billed with an invalid NDC be denied or recouped?

Claims reported with invalid NDC information will be subject to editing and may be denied.

13. The HCPCS code J7510 is for Prednisolone oral 5mg.
The product used was Prednisolone15mg/5ml and the NDC is 5038304248.
Is the NDC quantity billed as N405038304248 ML10 or is each teaspoonful considered 1 unit and submitted as
N405038304248 UN2?

The NDC unit of measurement for J7510 is milliliter, ML.  The total quantity billed should be ML10.

14. If the revenue code 250 is billed on a surgery or emergency claim where the revenue code 250 is not payable, is the NDC
number still required?

No.  The NDC is only required for HCPCS reimbursable codes.

15. Can provider submit claims for wasted physician-administered drugs?

Providers should only report the amount used.

16. If a facility, for example, an Ambulatory Surgery Center, does not normally line item bill for drugs because they are included or bundled in the procedure code, is the NDC required for each drug administered under the procedure code?

The NDC is only required for HCPCS reimbursable codes.

17. The definition of the NDC Unit of Measure in the March AHCCCS Clues document states “UN = Unit (each) – for unit of use preparation.  Does this definition apply to single dose vials as a unit of use preparation?

Yes, single dose vials or manufactured prefilled syringes qualify as unit of use preparations and therefore the unit of measurement on the claim submission should be UN.

18. Venofer is a single dose vial of 100 mg, a liquid solution.
The dose administered is 200 mg.  What is the NDC unit of measure and the quantity?

The NDC unit of measure is UN and the quantity is 2.

19. Herceptin is a reconstituted powder solution, which is a multi dose vial and used to administer the drug to more than one patient.  The dose administered is 244 mg and the multidose vial contains 440mg (22mg/ml).  What is the NDC unit of measure and quantity?

The NDC Unit of Measure for Herceptin is ML because it is not a unit of use preparation or a single dose vial.  The provider should always utilize the product labeling to differentiate single dose/unit of use vials from multidose vials.

20. Is the unit price a required data element for the NDC claim submission?

Per the Stakeholder Memo dated April 6, 2012 and revised on September 10, 2012, the unit price is no longer a required data element

21. When are the NDC and the required NDC data elements required on a secondary claim to AHCCCS?

Per question 9 above:
Yes, the NDC is required on all claims including primary, secondary, tertiary, etc. submitted to AHCCCS and/or AHCCCS Contractors.

22. For claims submitted on or after October 1, 2012, are the claims to be submitted driven by the date of service or the submission date of the claim?

The submitted claims will be evaluated on the date of service.

23. For claims submitted that use the same drug but different strengths or package sizes, will one or both of these claims deny as duplicate claims?

We will need to assess the ongoing handling of claims which would meet these conditions to ensure that they are processed appropriately.

24. When submitting the NDC quantity, is the number carried to two or three decimals?

Please refer to question 1 above for clarification and an example.

25. Is the NDC required on claims submitted for vaccines or the administration of a vaccine?

Yes, the NDC is required for all claims for vaccines that have been administered in clinical outpatient settings.

26. Is the NDC required only for injectable drug codes, or is it required on all drug HCPCS codes?

The NDC is required on all claims for provider administered HCPCS reimbursable drug codes.

27. Does the term “physician administered drugs” mean that the NDC Billing Requirements only apply to drugs when administered by a physician?

No, AHCCCS does not necessarily define “physician administered” as a drug that is actually administered by a physician.  We are aware that in many cases the administration will be done by a nurse or some other individual on the order of a physician, physician’s assistant, nurse practitioner, or other qualified healthcare professional.  Drugs administered under these situations are considered “physician administered drugs” and providers must submit claims in accordance with the AHCCCS NDC billing requirements.

28. What happens if a provider submits NDCs for drugs that do not correspond to a HCPCS Code?

Claims submitted with NDC codes which are not defined as appropriate for the related HCPCS/CPT code will be subject to editing and may be denied.

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