Billing for Injectable Drugs (Non-Vaccines)

Specialty Pharmacies

For services rendered for our commercial members on or after 10/1/15, specialty pharmacies should bill medical specialty drugs (including hemophilia products) using the unlisted HCPCS code such as J3490 and the NDC code of the specialty injectable drug even if there is a specific HCPCS code. Specialty pharmacies should bill NDC units in both the NDC units field and the HCPCS units field.

For services rendered for our QUEST Integration members on or after 1/1/19, specialty pharmacies should bill medical specialty drugs (including hemophilia products) using the most specific HCPCS code and the NDC code of the specialty injectable drug. Specialty pharmacies should bill NDC units in both the NDC units field and the HCPCS units field for medical specialty drugs. Please reference  QUEST Integration - Claims Requiring Attachments or Documentation for more information. 

Specialty pharmacies should only bill HMSA medical specialty drugs. HMSA’s medical specialty drug list can be found on the Specialty Pharmacies and Medical Specialty Drug Lists page.

Specialty Pharmacies must follow the Infertility Services Injectables - Billing and Coding Guidelines for Follicle Stimulating Hormone (FSH) and Luteinizing Hormone.


Ambulatory Infusion- Suite (AIS) Providers

For services rendered for our commercial members on or after 10/1/15, AIS providers should bill medical specialty drugs (including hemophilia products) using the unlisted HCPCS code such as J3490 and the NDC code of the specialty injectable drug even if there is a specific HCPCS code. AIS providers should bill NDC units in both the NDC units field and the HCPCS units field for medical specialty drugs.

AIS providers should bill non-medical specialty drugs using the most specific HCPCS code available and HCPCS units. If there is no specific HCPCS code for the drug, AIS providers must bill an unlisted HCPCS code plus the NDC code of the drug. When billing with unlisted HCPCS codes and NDC codes, AIS providers must bill the NDC units in both the HCPCS and NDC unit fields. AIS providers should reference the Ambulatory Infusion page.

For services rendered for our QUEST Integration members on or after 1/1/19, AIS providers should bill medical specialty drugs (including hemophilia products) using the most specific HCPCS code and the NDC code of the specialty injectable drug. AIS providers should bill NDC units in both the NDC units field and the HCPCS units field for medical specialty drugs. Please reference  QUEST Integration - Claims Requiring Attachments or Documentation for more information. 

 

Home IV Providers

Home IV providers should reference the specific Home IV page:

• Home IV Anti-Infective Therapy - Administrative Information
• Home Inotropic Infusion Therapy - Administrative Information
• Home IV Anti-Microbial Therapy - Administrative Information
• Home Intravenous (IV) Hydration Therapy for Adults - Administrative Information
• Home Infusion Pain Management Therapy - Administrative Information
• Home Total Parenteral Nutrition for Adults - Administrative Information

 

All Other Providers

For services rendered for our commercial members on or after 10/1/15, all other non-specialty providers (such as physicians or facilities) should bill all medical drugs (excluding hemophilia products) using a specific HCPCS code and the number of HCPCS units. If there is no specific HCPCS code for the drug, all providers must bill an unlisted HCPCS code plus the NDC code of the drug. When billing with unlisted HCPCS codes and NDC codes, providers must bill the NDC units in both the HCPCS and NDC unit fields. HCPCS units should only be used when billing specific HCPCS codes.

For services rendered for our QUEST Integration members on or after 1/1/19, all other non-specialty providers (such as physicians and facilties) should bill medical specialty drugs (excluding hemophilia products) using the most specific HCPCS code and the NDC code of the specialty injectable drug. Non-specialty providers should bill NDC units in the NDC units field and the HCPC units in the HCPC units field for medical specialty drugs. Please reference  QUEST Integration - Claims Requiring Attachments or Documentation for more information. 

Hemophilia products must be indicated on the claim with both the appropriate J code and the product NDC number with NDC units entered in both the HCPCS and NDC unit fields.

Note: Do not dispense hemophilia factors in quantities greater than a 30-day supply.

Providers must follow the Infertility Services Injectables - Billing and Coding Guidelines for Follicle Stimulating Hormone (FSH) and Luteinizing Hormone.


Below are billing instructions for submitting unlisted HCPCS codes on 837 electronic claims, CMS-1500 claims and UB-04 claims.

Field	Electronic 837P and 837I version 5010	Paper CMS-1500 and Paper UB-04
NDC Qualifier	Loop 2410 LIN02 (Product/Service ID Qualifier) = "N4 "	Specific data formats must be used when filing paper claims in order to ensure drug charges are processed accurately. On the CMS-1500 form, drug detail should be inserted in the shaded area of Field 24A. Field 24G should equal NDC quantity.   On the UB-04 form, field 46 should equal NDC quantity.   Proper data formatting for drug detail is as follows: [NDC Qualifier][National Drug Code][Unit of Measurement Qualifier ][NDC Quantity]   The NDC Qualifier of N4 is entered in the first two positions, followed by the 11-digit NDC with no dashes or spaces. After the NDC, enter the Unit of Measurement qualifier followed by the NDC Quantity. Example: N452098393405UN100
National Drug Code	Loop 2410 LIN03 (Product/Service ID) = National Drug Code in 5-4-2 format 11 digits with hyphens omitted
NDC Quantity	Loop 2410 CTP04 (National Drug Unit Count) = Numeric value of quantity dispensed Loop 2400, SV104 on the 837P should equal NDC quantity. Loop 2400, SV205 on the 837I should equal NDC quantity.
Unit of Measurement (F2, GR, ME, ML, UN)	Loop 2410 (NDC Unit of Measurement) CTP05-1

 

 

 

For CMS 1500 form example:

METHOD 1 - There is a valid HCPCS code

When billing for injectable drugs use a HCPCS code to represent the drug. For example, Depo-Provera (150 mg, for contraceptive use) would be billed using the following codes.

 

HCPCS code (description of injectable drug)

J1055: Injection; medroxprogesterone acetate, 150 mg. (HCPCS code is subject to change and is only used as reference example.)

 

ICD-9-CM diagnosis code (diagnosis)

V25.9: Unspecified contraceptive management.

 

ICD-10-CM diagnosis code (diagnosis)

Z30.9: Encounter for contraceptive management, unspecified

 

Drug units

When billing units for drugs for which a valid HCPCS code exists, it is important to refer to the units as described in HCPCS. For example, if the HCPCS code is described by HCPCS as representing 250 mg and 250 mg is dispensed, the units should be listed as 1. However, if the code is described as 250 mg and 500 mg is dispensed, the units would be listed as 2.

 

Note: If the drug units described in HCPCS do not correspond exactly with the number of units to be administered (or multiple thereof) do not use method 1 for billing. Do not use fractions of units. For example, if the HCPCS code describes a code as representing 250 mg, do not use 1.5 units to represent 375 mg. Defer to using billing method 2 in such a case.

 

Sample claim using Method 1 billing (valid HCPCS code)

ICD-9-CM

 

ICD-10-CM

 

 

 

METHOD 2 - There is not a valid HCPCS code

If a valid HCPCS code does not exist for the drug prescribed, use the appropriate HCPCS code for unclassified drugs (e.g., J3490) and include the NDC number of the drug. The NDC code should be placed in section 24 in the CMS 1500 (in the grey area above the dates of service) and should be written with the NDC Qualifier of N4 entered in the first two positions, followed by the 11-digit NDC with no dashes or spaces. After the NDC, enter the Unit of Measurement qualifier followed by the NDC Quantity.

 

For example, if billing for Procrit for a patient with anemia, the claim would be billed using the following codes.

 

HCPCS code

J3490: (Unclassified drugs)

 

NDC code

59676-0310-01: (Procrit, 10,000 units/mL)

 

ICD-9-CM diagnosis code: (diagnosis)

285.9: Anemia, unspecified

 

ICD-10-CM diagnosis code: (diagnosis)

D64.9: Anemia, unspecified

 

The patient picked up six single-dose vials of the drug at the pharmacy and self-administers the injections at home. (The appropriate place of service code for home is 12.)

 

Drug units

When billing units for drugs for which a valid HCPCS code does not exists, it is important to refer to the units as described in NDC. For example, if the NDC code is described by NDC as representing 250 mg and 250 mg is dispensed, the units should be listed as 1. However, if the code is described as 250 mg and 500 mg is dispensed, the units would be listed as 2.

 

 

When there is no valid HCPCS code, please use the following guidelines for billing units.

• Combination drug packages that are dispensed in an unbreakable package should be billed as one unit.
• Pre-mixed solutions (e.g., frozen antibiotics), injectables in solution form (vials) and pre-filled syringes should be billed in milliliters (mL).
• Each vial of powder for injection should be billed as one unit.

 

When in doubt about the appropriate billing unit to use, please refer to the Medi-Span policy on drug units and package sizes. HMSA uses this standard as a guideline. The product descriptions in the Red Book or Blue Book may also be used to determine the drug's billing units.

 

Supplies

Medical Pharmacies instruction only

For information about whether you may bill supplies, see Supplies - Medical Pharmacy

Rev#:	Date:	Nature of Revision:
2.0 (v6)	05/26/2023	Added links to the Infertility Services Injectables - Billing and Coding Guidelines for Follicle Stimulating Hormone (FSH) and Luteinizing Hormone.