2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Claims and Paymentrequiring a leading zero to be entered on the claimform and the hyphens not to be used. Instead of thedigits and hyphens being in a 5-4-2 format, theNDC may be indicated in a 4-4-1 as in “1234-1234-1,” or in a 5-3-2 format as in “12345-123-12,” orless commonly in a 5-4-1 format as in “12345-1234-1.” A leading zero must be added to make the 5-4-2format. See the following examples:NDC 12345-1234-12 is complete; it is reported as12345123412NDC 1234-1234-12 needs a leading zero in the firstsegment to be in the 5-4-2 digit format; to become01234-1234-12 it is reported as 01234123412NDC 12345-234-12 needs a leading zero in thesecond segment to be in the 5-4-2 digit format; tobecome 12345-0234-12 it is reported as12345023412NDC 12345-1234-1 needs a leading zero in thethird segment to be in the 5-4-2 digit format; tobecome 12345-1234-01 it is reported as12344512301Presbyterian rejects claims with a date of serviceon or after January 1, 2011, that do not indicate avalid NDC for the following HCPCS or CPT codes:Codes in the range J0120–J9999 (variousinjections and chemotherapy)Codes in the range S0012-S0197 and S4990–S5014 (various items)Codes in the range S5550–S5571 (insulininjections)Codes in the range 90281–90399 (immuneglobulins)The same requirement applies to providers’ billingrevenue codes for facility claims. HCPCS or CPTcodes are required whenever the provider bills oneof the following revenue codes and the claim is anoutpatient hospital, emergency room facility,dialysis facility, or other outpatient facility thatsubmits a facility claim. When the reported HCPCSor CPT code is one of the above, the NDC codemust also be reported forPharmacy revenue codes 0250, 0251, 0252, and0254Pharmacy revenue codes 0631, 0632, 0633, 0634,0635, and 0636For complete instructions on where the NDCinformation is to be supplied for a CMS-1500, aUB04, or 837 transactions, please use the followinglink:http://www.hsd.state.nm.us/mad/registers/2010.html. This information is found under the header“Supplements” and it is Supplement Number 10-03.Additionally, you may view the NDC ProcedureManual by accessing the following link:http://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/pel_00079542.pdf.Obstetrical ServicesThe following is information regarding globalmaternity billing (by covered providers such asprimary care obstetricians and specialists).If the delivery of the newborn is greater than threemonths past the mother’s eligibility date,Presbyterian pays the global feeIf the delivery is within three months of the mother’seligibility, a breakdown of services (prenatal visits,18-72014 Practitioner and Provider Manual - Ver. 3