M119: Missing/incomplete/invalid/deactivated/withdrawn National Drug Code (NDC)

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On Call Scenario:

                                                  Claim denied for missing or invalid NDC code
                                                                                ↓
                                                             May I get the denial date?
                                                                                ↓
                                 Checked on claim form, NDC number is available or not? /
                                      Checked in the system if NDC number is available?
                                                     ↙                                                     ↘
                                                Yes                                                         No
                                                  ↓                                                            ↓
               We have already billed the claim with NDC number,             ↓
                can you please check whether Is it correct or not? /               ↓
                  I have the NDC number, can you please check                    ↓
                                whether Is it correct or not?                                    ↓
                                   ↙                                  ↘                                      ↓
                             Yes                                         No                                ↓
                               ↓                                                ↘                             ↓
   Can you please reprocess the claim?       Can you please provide the correct NDC number?
                               ↓                                             ↙                                           ↘
                       Rep agrees                    Rep provides correct              Rep denies to provide
                     ↙               ↘                         NDC number                     correct NDC number
                Yes                    No                              ↓                                                ↓
              ↙                             ↘             What is the time frame            Search on google to find out
What is the TAT                What is      to submit corrected claim?         correct NDC code and 
for reprocessing?           the reason?                   ↓                                       verify with rep,
               ↘                         ↙                     May I have the                     Is that correct or not?
May I have the claim# & call ref#?       claim# & call ref#?                   ↙                             ↘
                                                                                                    If it is correct               If it is not correct
                                                                                                                 ↘                              ↙
                                                                                                                What is the time frame
                                                                                                              to submit corrected claim?
                                                                                                                                ↓
                                                                                                                     May I have the
                                                                                                                  claim# & call ref#?

Important Note:
  • NDC code requires only for Drug CPT code. Drug code always starts with a letter. Example - J0256, J2425, J7649.
  • In CMS1500 form, the NDC code is available in the shaded portion of the line item field 24A-24G as shown in the below image,
  • In the UB04 form, the NDC code is available in field 43 as shown in the below image,
           
  • As you can see in both images, when an NDC code is billed on a claim form, it should have a format that includes the NDC Qualifier, NDC code, NDC unit of measure & number of NDC units.
                             
  • If the rep has provided the correct NDC code then update it in your software or on clearing house and resubmit the corrected claim.
  • If you do not have access to update the NDC number on the software or clearing house then assign it to the client for assistance. If your client has already provided the instructions for this scenario then work accordingly.
  • Sometimes, even if you find out the correct NDC code on call or google search. To update it in the software on the clearing house, it is necessary to have "NDC units of measure" and "NDC units". So, if you do not have all this information then it would be better to get help from the correct department or ask the client.
  • If you are not able to find the correct NDC code then assign it to the client for assistance or work as per the client's instructions.
  • For more details on the NDC code, Click Here
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NDC Code

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  • NDC stands for National Drug Code and it is a universal product identifier for drugs used in the United States.
  • It is a unique 10 digits or 11 digits number. It is originally 10 digit number but CMS (Centers for Medicare & Medicaid Services) created an 11-digit number by using a leading zero with the NDC code. When the NDC code is billed on the claim form, it always has 11 digit format.
  • The NDC code has 3 segments:
        1) Labeler
        2) Product
        3) Package Size
    • The Labeler code is assigned by U.S. Food and Drug Administration and it defines manufacturer, repackager, or distributor.
    • The Product code is assigned by Labeler and it defines the specific strength, dosage form (Capsule, Tablet, Liquid) & formulation of a drug for a specific labeler.
    • The Package code is assigned by Labeler and it defines package size and types.
  • Format for NDC code with these 3 segments (Labeler-Product-Package Size) is 5-4-2, 6-3-2, 6-4-1.
  • Drug CPT codes always have 1st character as a letter. Examples - J0256, J2425, J7649. 
  • When a drug code needs to be billed to insurance then it is necessary to include the NDC code on a claim form (UB04 & CMS1500). Some insurances do not need this code but most of the insurances require the NDC code.
  • In CMS1500 form, the NDC code is available in the shaded portion of the line item field 24A-24G as shown in below image,


  • In the UB04 form, the NDC code is available in field 43 as shown in the below image,
     

  • As you can see in both images, when an NDC code is billed on a claim form, it should have a format that includes the NDC Qualifier, NDC code, NDC unit of measure & number of NDC units.
        1) NDC Qualifier: "N4" Qualifier needs to bill with the NDC code.
        2) NDC Code: Uniques 11 digits number assigned to each drug code.
        3) NDC unit of Measure: There are 4 units to measure drugs,
    • UN (Unit) – Powder-filled vials for injection (needs to be reconstituted), pellet, kit, patch, tablet, and device.
    • ML (Millilitre) – Liquid, solution, or suspension.
    • GR (Gram) – Ointments, creams, inhalers, or bulk powder in a jar.
    • F2 (International Unit) – Products described as IU/vial, or micrograms.
        4) NDC Units: These define the quantity of the drugs. 

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Modifiers

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Modifier 22 - Unusual Procedural Services:
  • When a physician performs a surgical procedure and needs to perform additional work which is significantly greater than the usual requirement due to complications & medical emergencies then modifier 22 is used with surgical procedure to report the additional work.

Modifier 23 - Unusual Anesthesia:
  • When a service requires local anesthesia but due to unusual circumstances & complications the physician gives general anesthesia to perform the service then modifier 23 is used.
  • Local anesthesia is used to numb small areas of the body and a patient remains completely conscious. General anesthesia is used to make the patient completely unconscious.
  • Modifier 23 can only be used with anesthesia CPT codes (00100-01999).

Modifier 24 - Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period: 
  • When surgery is performed on a patient and during the postoperative period, an E/M service is performed which is not related and included in the surgery then the E/M code needs to be billed separately along with the 24 modifiers.
  • Modifier 24 can only be used with Evaluation and Management codes.

Modifier 25 - Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service:
  • When a service along with an E/M service are performed on the same day by the same physician or other qualified health care professional then modifier 25 is used with the E/M code to reimburse separately.

Modifier 26 - Professional Component, TC - Technical Component & Global Service Modifier:
  • Modifier 26 is used in physician billing to bill the professional component of a service.
  • Modifier TC is used in physician billing to bill technical components of a service.
  • Global service is useful in the reimbursement of both professional & technical components in a single billing. CPT needs to be billed without a modifier.
  • These services are most commonly submitted with radiology procedures.
  • When an X-ray needs to be performed then it includes two components, 1) Technical Component - X-ray machine with necessary supply to take the service. & 2) Professional component - Physician who supervises and interprets the service.
  • When a physician & X-ray machine with necessary supplies are part of the same clinic then the clinic bills the service without a modifier that would include both technical and professional components, it is known as global billing. 
  • When a physician has not been employed or is part of the clinic then the physician bills the service separately with modifier 26 is known as the professional component and clinic bills for the technical component with the TC modifier are known as the Technical component.

Modifier 47 - Anesthesia by Surgeon:
  • When a physician performs surgery and prior to performing surgery gives general anesthesia then 47 modifiers is used with the surgery code to include anesthesia under surgery.
  • It is always used with Surgical codes.

Modifier 50 - Bilateral Procedure:
  • Modifier 50 is used when the same services are performed on both sides of the body (left & right) during the same operative sessions or on the same day.
  • Procedures on the left and right do not need to bill separately with LT and RT modifiers. It should be billed with a 50 modifier on a single line.

Modifier 51 - Multiple Procedures:
  • When a physician performs multiple surgical services at the same session and the second procedure is not a component code of the first procedure then the secondary service is billed with a 51 modifier.
  • Modifier 51 is always billed with surgical procedures.
 
Modifier 52 - Reduced Services:
  • When a physician does not perform the service completely & reduces or cancels it before completion. Such services are billed with the same CPT code and the 52 modifier is helpful to identify that service is reduced.
  • This modifier is applicable only with surgical & diagnostic CPT codes.

Modifier 53 - Discontinued Procedures:
  • When a physician discontinues performing a service due to risk to the patient or due to equipment failure. Modifier 53 is useful to report a service that is discontinued.

Modifier 54 - Surgical Care Only, Modifier 55 - Postoperative Management Only, Modifier 56 - Preoperative Management Only:
  • Surgery has 3 different phases - Preoperative, Intraoperative & Postoperative.
  • Preoperative Phase - This phase occurs prior to the surgery where the provider gathers all the relevant information to make sure there is no obstacle when performing the surgery.
  • Intraoperative Phase - This is a phase where actual surgery is performed.
  • Postoperative Phase - This phase occurs after the surgery where the provider monitors the patient on a timely basis to make sure that the patient is safe & comfortable.
  • When one physician performs a surgical procedure and other physicians perform the preoperative and postoperative services then the physician who performs the surgery uses modifier 54 with the surgery code to identify surgical services.
  • A Physician who performs preoperative service will bill the service with modifier 56 with surgery code to identify preoperative service.
  • A Physician who performs postoperative service will bill the service with modifier 55 with surgery code to identify postoperative service.

Modifier 57 - Decision for Surgery:
  • When a physician needs to perform major surgery and an E/M service is given on the same day or a day before the surgery then to reimburse E/M service, modifier 57 is used.
  • The only difference between Modifier 25 & Modifier 57 is: Modifier 25 is used with E/M service when it is performed along with minor surgery on the same day.
  • Modifier 57 is used with E/M service when it is performed along with major surgery on the same day or the day prior to actual service.

Modifier 58 - Staged or Related Procedure or Service by the Same Physician During the Postoperative Period:
  • When a physician performs surgery and while performing the surgery, the physician comes to know that it could lead to another problem in the future and needs to perform another service to solve the issue. So, when the same physician performs a second service during the postoperative period, it should be billed with 58 modifier then it will not reduce the reimbursement of the second service. Because the second surgery is already planned by the physician.

Modifier 59 - Distinct Procedural Service:
  • When 2 distinct services are performed on the same day and both are independent of each other & performed on 2 different body parts then modifier 59 is used to indicate both these services are distinct and separate procedures.

Modifier 76 - Repeat Procedure by Same Physician:
  • Modifier 76 is used when a service is performed repeatedly on the same day by the same physician.

Modifier 77 - Repeat Procedure by Another Physician:
  • Modifier 77 is used when a service is performed repeatedly on the same day by different physicians.

Modifier 78 - Return to the Operating Room for a Related Procedure During the Postoperative Period:
  • When a physician performs surgery and the result of surgery leads to another problem and needs to perform another service to solve the issue then the same physician performs the second service during the postoperative period which should be billed with a 78 modifier. The second surgery is not planned by the physician.

Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period:
  • When a physician performs surgery and during the postoperative phase, another surgery is performed which is not related to the first surgery then the second surgery is billed with Modifier 79.
  • Note: Whenever a surgery is performed, there is a global period assigned for each surgery. Any other service which is performed within the global period will be included under the first surgery and if it is not related to the first surgery and needs to be reimbursed separately then these modifiers are useful to indicate service is different.

Modifier 80 - Assistant Surgeon:
  • When an assistant surgeon assists a primary surgeon and is present for the entire operation or a substantial portion of the operation then the assisting physician reports the same surgical procedure as the operating surgeon. The operating surgeon does not append a modifier to the procedure that he/she reports. The assistant surgeon reports the same CPT code by appending modifier 80.

Modifier 81 - Minimum Assistant Surgeon:
  • When an operating physician plans to perform a surgical procedure alone but during an operation, circumstances may arise that require the services of an assistant surgeon for a relatively short time. In this instance, the second surgeon provides minimal assistance, for which he/she reports the surgical procedure code by appending modifier 81.

Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available):
  • Modifier 82 is used when an assistant at surgery service is provided by an MD since there is not a qualified resident available. Documentation must include information relating to the unavailability of a qualified resident in this situation.

Modifier AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist services for assistant-at-surgery, non-team member:
  • Modifier AS is used when an assistant at surgery services is provided by a physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS).

Modifiers Q7, Q8 & Q9:

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Medicare Part A, Part B, Part C & Part D Services

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1) Medicare Part A:
  • Medicare Part A is known as hospital insurance and it covers Inpatient Hospital Care, Skilled Nursing Facilities, Hospice, and Home Health Care.

2) Medicare Part B:
  • Medicare Part B is known as Medical Insurance and it covers Doctor and Other health care providers' services, Outpatient care, Durable medical equipment, Home health care, Preventive services, Laboratory tests, X-Rays, Mental Health care, Home health & Ambulance Services.

3) Medicare Part C:
  • Medicare Part C is a Medicare Advantage plan, it is a part of the original Medicare. It allows private health insurance companies to provide the same medicare benefits as original Medicare. A person can choose to get medicare coverage through a medicare advantage plan instead of the original medicare.

4) Medicare Part D:
  • Medicare Part D provides Outpatient Prescription Drug coverage. This coverage is only provided through a private insurance company that is contracted with the government.

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What is AR?

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AR stands for "Account Receivable" and it is a part of the "Medical billing process" and "Revenue cycle management (RCM)" of the United State of America & prior to understanding AR, it is necessary to understand the Medical billing process & RCM, so let's start understanding these two processes.

In the United State of America, when a patient visits a doctor for a check-up or treatment then he/she takes the service but does not pay the doctor if has an insurance policy. He/She provides policy details to the doctor and the doctor gets the money from the insurance company. To get the payment for the services rendered to the patient, doctors need to bill the service to the insurance company in the claim form that includes patient information, provider information, service performed in the form of CPT, and Diagnosis code with the billed amount. Based on the CPT and diagnosis code, the insurance company makes the payment for a certain amount if there is no issue. This entire process looks simple but it has a highly complex process behind the scenes. In medical billing, the doctor is also known as the "Provider".

The process of generating claims, submitting them to insurance, and following up on claims to get the resolution is known as the Medical billing process.

RCM is responsible for taking care of the entire process starting from the patient appointment with the doctor to the resolution of a claim. It includes various steps that help to understand the entire complex process of taking care behind the scenes.

To understand each step of RCM Click Here. Please go through it.

Hopefully after going through the RCM steps, now at least you have an overall idea about how this cycle helps to generate claims and helps doctors to get reimbursement for the service rendered to patients. You would also observe that AR comes at the end of the cycle when a particular service is not paid. So, AR is responsible to analyze the claim, take the follow up with insurance, and based on the information received by the insurance company or analysis, taking the most suitable action that would move a claim toward resolution.

When taking a follow-up with the insurance company, AR comes across various scenarios and denials. There is a number of scenarios & denials already defined with appropriate questions to gather accurate information from an insurance company that would help AR to take the next most appropriate action. To have knowledge of these scenarios, you would need to understand each AR scenario. It has a long list that could create confusion in your mind. So, go through one scenario at a time and take time to understand it. Also always try to connect each scenario with RCM steps since the entire scenarios and actions are based on RCM. Click Here to learn AR Scenarios.

It is difficult to understand these terms, scenarios, and denials if you are not working as an AR, but we'll try to explain these terms in a simple way that would give you confidence when you will start as an AR and will help you to grow as an AR.

There are also various tools, terminologies, and rules in medical billing. Some are based on insurance or denials and all this information you will find under the "MORE" option in the menu bar. 

We have also listed down the phone numbers of the insurance companies in the "Insurance Phone#" option to connect with them and get the required information. For Medicare insurance, obtaining claim status, eligibility, or connecting with a rep is a bit complicated but once you understand it then you can work easily. We have put all the important information under the "Medicare Phone#/Forms" option.

For some insurances, it is not always necessary to make a call to the insurance to obtain claim status and eligibility. Their websites are helpful to obtain all the required information. We have listed down a few insurances with links in the "Websites" tab where you can directly register to get the status. There are few websites where registration is not required and status can be obtained directly. There are a lot more websites available based on insurance, you can get the web portal information from the insurance rep and try to register. Sometimes, it is not always necessary that you would be able to register yourself but need client help, so you can ask the client to get access.

Hopefully, above all information will help you to understand AR work and be helpful to start up your AR career. So, keep following our website, subscribe to us to get updates on our new posts, and contact us for any questions & clarifications.

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Medicare Deductible & Premium

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Medicare Deductible:

  • A deductible is a fixed amount that a patient needs to pay before the insurance company starts paying.
  • The deductible amount may vary by the plan and it starts over every year. A patient needs to reach this deductible amount each year before the insurance company starts paying.
  • CMS releases Medicare deductible amounts every year and below is the list of medicare deductible amounts released by CMS in the last few years,
 
Medicare Premium:

  • CMS releases Medicare premium amounts every year.
  • Medicare beneficiaries do not have a Part A premium since they have at least 40 quarters of Medicare-covered employment.
  • For the year 2024, the standard monthly premium for Medicare Part B enrollees is $174.70 but it differs based on medicare beneficiaries' high income.
 

  • Premiums for high-income beneficiaries who are married and lived with their spouse at any time during the taxable year, but file a separate return, are as follows:
 

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