Provider Notice: NDC Billing Guidelines

Resource: NDC Billing Guidelines.pdf

National Drug Code (NDC) Billing Guidelines

Community First Health Plans (CFHP) requires the use of National Drug Codes (NDCs) and related information, such as Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT®) codes, when drugs are billed on professional/ancillary electronic (ANSI 837P) and paper (CMS-1500) claims.

This information may also be submitted on institutional/facility electronic (ANSI 837I) and paper (UB-04) claims. This includes drug-related revenue codes to report drug products used for services rendered at medical outpatient facilities as well as unlisted HCPCS/CPT codes that require additional NDC information.

All claims must first pass specific minimum edits prior to acceptance. Claim records that do not pass these minimum edits are invalid and will be rejected or denied. In order to avoid a rejection or denial please ensure claims are filed correctly.

What is an NDC?
An NDC is a unique 11-digit, three segment number assigned to drugs by the drug manufacturer. An
NDC has three segments:

1. Labeler — a five-digit code assigned by the Food and Drug Administration (FDA) that identifies
   the drug manufacturer.
2. Product — a four-digit code assigned by the drug manufacturer that identifies the specific
   product.
3. Package — a two-digit code assigned by the manufacturer that identifies the package size.

Where do I find a drug’s NDC?
The NDC is usually found on the drug label or medication’s outer packaging. If the medication comes in
a box with multiple vials, using the NDC on the box (outer packaging) is recommended. The container
label also displays information for the unit of measure for the drug. Listed below are the NDC units of
measure with examples.

• UN (Unit) — Powder-filled vials for injection (needs to be reconstituted), pellet, kit, patch, tablet,
  or device
•  ML (Milliliter) — Liquid, solution, or suspension
• GR (Gram) — Ointments, creams, inhalers, or bulk powder in a jar
• F2 (International Unit) — Products described as IU/vial, or micrograms

How do I submit the NDC on my claim?
Here are some quick tips and general guidelines to assist you with proper submission of valid NDCs and
related information on electronic and paper claims:

• The NDC must be submitted along with the applicable HCPCS/CPT code(s) and the number of
  HCPCS/CPT billable units.
• The NDC must follow the 5digit4digit2digit format (11-digit billing format, with no spaces,
  hyphens or special characters).
  •  If the NDC on the package label is less than 11 digits, a leading zero must be added to the
    appropriate segment to create a 5-4-2 configuration.
• The NDC must be active for the date of service.
• Also include the NDC qualifier, number of NDC units, and NDC unit of measure. As a
  reminder, you must also include your billable charge.