If you need to bill for a 'J' code (drugs) you need to include the NDC code in your billing. This requires a specific transaction description entry so that the software will be able to handle it correctly.
According to the FDA, the NDC code is 10 digits. This is 3 sets of digits: 4-4-2 or 5-3-2 or 5-4-1.
There is a conflict with HIPAA. the HIPAA is 11 digits created by zero filling one of the 3 sets of digits. This can be confusing. All of the FDA approved drugs are available to use with the Stratford program. The drug listing that Stratford provides is obtained directly from the FDA and is updated weekly. In order to bill using the HIPAA 'NDC' code, you will need to zero fill as necessary.
The 1st set of codes is called the Label code. This code is assigned to the pharmaceutical manufacturing/distributing company by the FDA.
The 2nd set of codes is called the Product code. This code is assigned by the pharmaceutical manufacturing/distributing company. It is unique for the specific drug (a different company might use that code for a different drug).
The 3rd set of codes is called the Package code. This code is assigned by the pharmaceutical manufacturing/distributing company. It describes the packaging, ie, 10 tables or 40 tablets, etc.
If your drug package label has this number: 1234-1234-12, the HIPAA NDC code would be 01234-1234-12 because HIPAA wants the Label code to be 5 digits. Your transaction description might have a CPT code J1234 with a description like this:
01234123412-prescription number
The 'prescription number' is from the CAP (Competitive Acquisition Program) vendor.
Stratford is not an official source of instructions for billing so you need to use your payer supplied reference material. This manual only shows you how and where to enter information so it will appear in your billing correctly. You will need to do some research in order to know what procedure codes and modifiers to use. These are subject to change. If you believe anything in this manual is in error, please report it to Stratford and we will correct it. The best way to report errors or get help is by email: support@stratfordsoftware.com You should always include an official reference source such as the URL (Internet address) for a Medicare manual.
Below is an example of how you might enter the NDC reporting information.
The description must be set up like this:
Proc NDC - RX -UNIT QTY - UnitPrice Description
J3470 10987654321 -1193265 -F2123.45 ; unit of measurement = F2, quantity = 123.45
X6218 12345678901 - -ML0.5 -10.5 ; unit of measurement = ML, quantity = 0.5, price = 10.5
J9000 15249687362 - -ML500 ; unit of measurement = ML, quantity = 500
The options for unit of measurement:
F2 - International Unit
GR - Gram
ME - added in v5010
ML - Milliliter
UN - Unit
example: 57894003001-Q103J1745A34990-UN2
will give LIN||N4|57894003001 in the v4010 and v5010 EDI transmission
example: 12345678901--ML0.5-10.5
will give CTP03 = 10.5, ctp04 = 0.5, ctp05-1=ML
Note that some payers (Palmetto) require the unit price. This should be entered after a 3rd dash (not in v5010)
In the transmitted claim these are used in the CTP segment (Loop 2410):
CTP01 N/U
CTP02 N/U
CTP03 Unit price (note this is in v4010 but not in v5010)
CTP04 after the 2nd dash in the description (quantity)
CTP05 after the 2nd dash in the description (unit of measurement)