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.
First method using the HIPAA NDC 11 digit NDC code.
For EDI you need to create a series of segments something like this:
SV1|HC^J7198|94147.62|UN|1|12||1~ 2400 SV1 HC Medical Charges
DTP|472|D8|20121115~ 2400 DTP 472 Service date
REF|6R|PTTRCH14L10015A4IANDRO56~ 2400 REF 6R Line Item Control Number
NTE|ADD|TFU 24792FEIBACLM 1 4~ 2410 NTE ADD Additional information
LIN||N4|64193022502~ 2410 LIN Drug Identification 11 digit NDC code.
CTP||||24792|UN~ 2410 CTP Drug Quantity
REF|XZ|915609UN247929799~ 2410 REF XZ Prescription or compound drug association number
Enter the charge description like this:
64193022502 / 24792 This will default CTP05 to 'UN' as in the above example
64193022502 / 24792 / F2 This will set CTP05 to 'F2'
You want LIN03 to be the Drug Identification code (11 digit NDC code) (example: 64193022502)
You want CTP04 to be the quantity (example: 24792)
CTP05 is usually 'UN' and will automatically default - see the above example
To get the REF segment with the qualifier XZ post a print memo to the charge with this in the description
"XZ 915609UN247929799" will produce the REF segment in the above example
To get the NTE segment post a memo to the above charge with this in the description
"TFU 24792FEIBACLM 1 4" will produce the NTE segment in the above example
Note that if you have a NTE segment in Loop 2300 you will not get a Loop 2400 NTE segment if it has the same value.
Second method - not using the HIPAA NDC code - (This is the older method and most Medicare contractors will probably require the first method above)
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)