Advanced Revenue Cycle Analytics: An Overview

The new 5010 claim standard is driving new requirements in drug reporting, specifically for drug quantity and the unit of measure.

Jnurseackie Griffin, manager of training and project implementation at Gateway EDI, listed one of the Top 5 Potential HIPAA 5010 Rejections to be drug quantity,

“If you submit a National Drug Code (NDC) on the line of service for injectable medications, HIPAA 5010 requires that the drug quantity be reported. The unit of measure must also be submitted on the claim file in addition to what you already send on service lines, including the HCPCS code, the total charge and units of service.”

Why you might need to submit a NDC on the line of service:

1.The Deficit Reduction Act (DRA) of 2005 includes provisions about the state collection of data for the purpose of collecting Medicaid drug rebates from drug manufacturers for physician‐administered drugs. This act requires that all state Medicaid programs include NDCs on claims submitted with HCPCS codes for these drugs administered in an outpatient setting.
2. Since there are often several NDCs linked to a single HCPCS code, the Centers for Medicare & Medicaid Services (CMS) deems that the use of NDC numbers is critical to correctly identify the drug and manufacturer in order to invoice and collect the rebates. Therefore, states must report NDC information on all drug claims for Medicaid clients to CMS.
3. Drugs that can require NDC information:

a. May vary by state, but HCPCS codes such as A, C, J, Q, and S-codes can be included.
b. “Not otherwise classified” (NOC) and “Not otherwise specified” (NOS) drug codes (e.g., J3490, J9999, and C9399) may also be included.
c. The only CPT codes that require NDC are immune globulin codes 90281 through 90399.

4. Although Medicare may not require the submission of an NDC, the information must be included on all professional and institutional outpatient claims for these non-vaccine codes that will cross over to a plan secondary to Medicare that does require them.

Practices should determine whether or not they are required to include NDC information, and on what claims, then review the 5010 FAQ and Tips from Gateway EDI.