by Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
May 9th, 2016
The following are tips to help you when billing NOC drugs and biologicals, such as J3490, J3590, and J9999. Providers submit NOC codes in the 2400/SV101-2 data element in the 5010 professional claim transaction (837P).
When billing an NOC code, providers are required to provide a description in the 2400/SV101-7 data element. The 5010 TR3 Implementation Guide instructs: "Use SV101-7 to describe non-specific procedure codes." (Do not use the 2400 NTE segment to describe non-specific procedure codes with 5010.) The SV101-7 data element allows for 80 bytes (i.e., characters, including spaces) of information.
In order for WPS GHA to correctly reimburse NOC drugs and biologicals, providers must indicate the following in the 2400/SV101-7 data element, or Item 19 of the CMS 1500 form:
- The name of the drug,
- The total dosage (plus strength of dosage, if appropriate), and
- The method of administration.
Important: List one unit of service in the 2400/SV1-04 data element or in item 24G of the CMS 1500 form. Do not quantity-bill NOC drugs and biologicals even if multiple units are provided. Medicare determines the proper payment of NOC drugs and biologicals by the narrative information, not the number of units billed.
Medicare will reject as unprocessable claims for NOC drugs and biologicals if any of the information above is missing, or if the NOC code is billed with more than one unit of service. (Note: The remittance notice will include remark code M123, "Missing/incomplete/invalid name, strength, or dosage of the drug furnished," even if the rejection is due to the number of units billed.)
As you may know, pricing for NOC J-codes is determined by the information provided on the Average Sales Price (ASP) NOC pricing file. If the ASP NOC file lists the strength for a drug on the file, this indicates that the drug comes in different strengths. Medicare payment varies depending on the strength given. When billing Medicare for an NOC J-code, you can determine if the drug comes in different strengths by accessing the ASP NOC pricing files on the CMS website