Billing for Drugs with no CMAC Rate

TRICARE Policy requires that providers billing for drug services that don’t have a CHAMPUS Maximum Allowable Charge (CMAC) rate use the appropriate Health Care Financing Administration Common Procedure Coding System (HCPCS) codes and the specific National Drug Code (NDC).

The NDC is a universal number that identifies a drug. It can be found on the drug container (i.e., vial, bottle, tube). Providers must bill the NDC from the medication administered.

The numeric quantity and the unit of measurement of the administered drug are the NDC Units. The unit of measure (UOM) for NDC is by weight (grams: GR), volume (milliliter: ML) (milligram: ME), or count (unit: UN). Each dispensed dosage must be billed with an appropriate unit of measure (using the manufacturer's unit of measure). International units (F2) must be converted to standard measurements (GR, ML, ME, and UN). If the unit of measure for the drug administered isn’t available from these choices (such as millicurie) providers should submit unit (UN).

• Drug vial in powder form that has to be reconstituted before administration – bill each vial (unit/each). UN is the appropriate unit of measure; the claim will process at the Medispan Package price.
• Drug that comes in a vial in liquid form – providers can bill in milliliters. ML is the correct unit of measure; the claim will process at the Medispan Unit price.
• Topical forms of medicine (e.g., ointment, cream, bulk powder in a jar) are dispensed in grams; GR or ME is the correct unit of measure. Claims will process at Medispan Unit price. This unit of measure is primarily used in the retail pharmacy setting.

Providers should not convert NDC units of measure to HCPCS units. Wisconsin Physicians Service Insurance Corp. (WPS) will reimburse all claims for home infusion services (place of service 12) using the appropriate NDC that includes the appropriate unit of measurement qualifier (GR, ML, UN, F2). Providers are encouraged to bill all dispensed drugs using the appropriate unit of measure.

Billing examples

1. Physician gives a 1 ml Depo Provera injection. The NDC is 0009-0746-30 and the HCPCS code is J1105 (Injection, medroxyprogestrone acelate for contraceptive). The provider should bill the NDC, units of measure as ML (milliliter) and number of units as 1. The claim will process at 95 percent of AWP at the Medispan unit price minus the contractual discount.
2. Physician inserts a Mirena IUD. The NDC is 050419-0421-01 and the HCPCS code is J7302. The provider should bill the NDC, units of measure as UN, and number of units as 1.

For more information, refer to TRICARE Reimbursement Manual, Chapter 3, Section 6, 2.2, which can be found at http://manuals.tricare.osd.mil/.