NOC Claims and Ensuring Your Practice is Reimbursed

By ION

When there is a new drug or procedure that comes to market, it typically takes the Centers for Medicare & Medicaid Services (CMS) about six months to evaluate it and determine a reimbursement rate. During that time period (sometimes up to a year), practices can start billing under a Not Otherwise Classified (NOC), Unspecified or Miscellaneous Code.

Many practices wait until a specific J-code is assigned, but CMS has issued J-codes for those NOC, unspecified drugs for independent practices.

  • J3490 – unclassified drugs
  • J3590 – unclassified biologics
  • J9999 – not otherwise classified, antineoplastic drugs

Based on a CMS guideline for correct Medicare reimbursement (using Box 19 on the CMS 1500 form), practices must provide the name of the drug; total dosage, plus strength of dosage, if appropriate; method of administration and the NDC code. All the information also must be included in Box 19 for it to be reimbursed – even if the NDC automatically populates in another part of the form. If all the information is not included, practices will receive a rejection notice with the remark code M123. That remark will be used even if the number of units is incorrect (not 1).

With private payers, there may be more challenges or roadblocks to reimbursement. Practices should reach out to any non-national private payers to see what is required for submission. Most national private payers do not require the route of administration as noted by CMS.

It is recommended that practices that want to start billing for new drugs provide payers with education prior to the first administration of the drug, giving them prescribing information or package insert; the FDA-approval letter; any relevant information to support the medical necessity lab values or pathology reports, if needed); the drug purchase invoice or your contract language (depending on which benefits your practice at a better rate).
If you still receive a rejection, additional education or information may be necessary.

The information was taken from a webinar Best Practice Billing NOC and Unspecified Codes in November 2018.  Additional content on Billing Biosimilars will appear in a future newsletter.