National Drug Code (NDC) Requirements for Physician-Administered Drugs

During a recent review of our claims processing, we noticed that some claims are being submitted without the required national drug code. This is a reminder to make sure you send correctly-coded claims. Claims submitted with incorrect codes will be denied.

The Deficit Reduction Act (DRA) of 2005 requires physicians, nurse practitioners, licensed midwives, and other health care professionals who administer drugs in ambulatory care settings, as described below, to report the national drug codes on their Medicaid claims. Payment will continue to be based on Healthcare Common Procedure Coding System (HCPCS) reporting information.

Requirements

Claims submitted on the 837 format require all of the following information. Those with a missing element will be denied:

  • 11-digit national drug code
  • National drug code dispensing quantity
  • National drug code unit of measure
  • Current Procedural Terminology (CPT) code
  • HCPCS code and units

National drug codes should be collected and reported where HCPCS (J0000-J9999) or Berenson-Eggers type of service (BETOS) (01E/O1D) codes are billed for these categories of service:

  • 01 – Physician Services
  • 03 – Podiatry
  • 04 – Psychology
  • 06 – Rehabilitation Therapy
  • 07 – Nursing
  • 41 – Nurse Practitioner/Midwives
  • 75 – Clinical Social Worker
  • 85 – Freestanding Clinic
  • 87 – Hospital Operating (OP)/Emergency Room (ER)

National drug codes should be included on Medicaid claims for drugs administered in one of the following places of service. These are considered ambulatory care settings:

  • Office (POS 11)
  • Nursing Home Care (POS 12)
  • Freestanding Outpatient Center (POS 19)
  • Urgent Care Center (20)
  • Outpatient Clinic (POS 22)
  • Emergency Room (POS 23)
  • Ambulatory Surgery Center (POS 24)
  • Military Treatment Center (POS 26)
  • Freestanding Health Care Clinic (POS 49)
  • Health Center (POS 50)

Facility claims must include one of the appropriate bill type codes below, in addition to place of service:

0110

0134

0217

0338

0438

0718

0738

0757

0777

0837

0857

0111

0135

0218

0339

0439

0719

0739

0758

0778

0838

0858

0112

0136

0320

0340

0540

0720

0740

0759

0779

0839

0859

0113

0137

0321

0341

0541

0721

0741

0760

0790

0840

0890

0114

0138

0322

0342

0542

0722

0742

0761

0791

0841

0891

0115

0141

0323

0343

0543

0723

0743

0762

0792

0842

0892

0116

0142

0324

0344

0544

0724

0744

0763

0793

0843

0893

0117

0143

0325

0345

0545

0725

0745

0764

0794

0844

0894

0118

0144

0326

0346

0546

0726

0746

0765

0795

0845

0895

0121

0145

0327

0347

0547

0727

0747

0766

0796

0846

0896

0122

0146

0328

0348

0548

0728

0748

0767

0797

0847

0897

0123

0147

0329

0349

0549

0729

0749

0768

0798

0848

0898

0124

0148

0330

0430

0710

0730

074A

0769

0799

0849

0899

0125

0210

0331

0431

0711

0731

0750

0770

0830

0850

 

0126

0211

0332

0432

0712

0732

0751

0771

0831

0851

 

0127

0212

0333

0433

0713

0733

0752

0772

0832

0852

 

0128

0213

0334

0434

0714

0734

0753

0773

0833

0853

 

0131

0214

0335

0435

0715

0735

0754

0774

0834

0854

 

0132

0215

0336

0436

0716

0736

0755

0775

0835

0855

 

0133

0216

0337

0437

0717

0737

0756

0776

0836

0856

 


Drug encounters with a “UD” procedure code modifier (340B purchased drug) are exempt from national drug code reporting requirements.

Requirement for the plans below
If the claim is missing the national drug code or it’s incorrect, it’ll be denied.

  • Medicaid
  • Health and Recovery Plan (HARP)
  • Fully Integrated Duals Advantage (FIDA) GuildNet Administrative Services Only
  • Medicare Advantage Plan - GuildNet Gold Administrative Services Only (GHI)
  • Child Health Plus

Requirement for the plans below

If the claim is missing the national drug code, it can be processed. If the claim has an incorrect national drug code, it’ll be denied.

  • Health Insurance Exchange (HIX) Individual On-Exchange
  • Essential Plans

Additional resources