Fall 2009

Unlisted HCPCS codes claim submission process for physicians and physician extenders

Unclassified HCPCS codes are to be used only when there is not a specific HCPCS code available for the drug being billed. Submitting a claim using an unclassified HCPCS code where there is a specific HCPCS code for a drug will result in the claim being denied and returned to the provider to resubmit with the appropriate HCPCS code. Unclassified HCPCS codes are to be used only when there is not a specific HCPCS code available for the drug being billed.

Each unclassified drug code submitted must include the associated National Drug Code (NDC) number and NDC quantity. Submitting a claim using an invalid or missing NDC number and NDC quantity will result in the claim being returned. If multiple unclassified drug codes are submitted on the same claim, each unclassified code and associated NDC number/quantity is to be listed on a separate claim line following the instructions specified in the Unclassified Drugs topic of the Coding and Filing Claims section of the Manual for Physicians and Providers. The section can be accessed by visiting www.bcbsfl.com and clicking Physicians & Providers, Manuals & Billing Instructions, then Coding and Filing Claims.

The following are guidelines for submitting unclassified drug codes:

• Use the appropriate unclassified drug HCPCS code (e.g., J3490, J3590, J8999, etc)
  • Electronic claims - Enter in Loop 2400, Segment SV1, Element SV101
  • Paper claims - Enter in lower, non-shaded area of Block 24D
• NDC Qualifier (N4)
  • Electronic claims - Enter in Loop 2410, Segment LIN, Element LIN02
  • Paper claims - Enter in the shaded area of Block 24A
• NDC Code - Report the NDC Code in an FDA recognized 11-digit numeric format (e.g., 99999999999)
  • Electronic claims - Enter in Loop 240, Segment LIN, Element LIN03
  • Paper claims - Enter in the shaded area of Block 24A after the N4 qualifier
• NDC Quantity using a metric decimal quantity (reported in the HCPCS unit field - Block 24G) as exact amount administered to the member
  • Electronic claims - Enter in Loop 2400, Segment SV1, Element SV10
    Note: NDC Quantity is required in this Element
  • Paper claims - NDC Quantity is provided in the HCPCS units Block 24G
• NDC Description (optional)

For compounded drugs, each NDC number and quantity must be submitted on a separate claim line with the unclassified drug code J3490.

Claims submitted without the correct information, as outlined in the Coding and Filing Claims section of the provider manual, are required for processing and will be denied and returned to the provider for correction. The Availity^®1 Health Information Network includes the required NDC fields on its input screens. If your practice management system does not accommodate this requirement, please contact your vendor to coordinate changes.