Drug Coding, Reimbursement 101: Crosswalking HCPCS and NDC/CPT Units

Join RJ’s Product and Clinical teams as they walk through the multitude of different combinations of drug claims and pricing methodologies, via clips from the webinar “Shedding Light on Medically Covered Specialty Drug Pricing Methods.” In the following clip, Chris Webb explains the main difference between HCPCS and NDC code level reimbursement.

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Crosswalking NDC and HCPCS/CPT Units: RJ Health Webinar Segment

Chris Webb: So, here’s a good question, what is the difference between an NDC unit and a HCPCS code unit? So, as I mentioned CMS will create a HCPCS code with a generic product name and billable unit strength. Those billable unit strengths are usually done in milligrams. So, the amount of milligrams administered. However, the NDCs are typically submitted as various units of measure, like a liquid ML or an EA or one of those reconstitute solutions or tab. The NDC units typically don’t have the strength in them. So, there is a correlation that’s needed to take the number of milligrams at HCPCS code level and then translate to the number of ML or pricing units at the NDC level. Again, I just confused myself, as you can see from here; the difference can lead to some confusion as it relates to exact amount of drug being administered. Multiple milligrams can result in multiple MGs. Okay, Jason, tell you what, why don’t you mention how we currently crosswalk our NDCs and link them to the HCPCS codes?

Jason Young: Absolutely Chris. So, as mentioned there is basically a generic name description and strength on all of the HCPCS code descriptions or CPT’s. So, what we do here as far as cross walking, is we’re really assigning all the NDC products to the most appropriate code for billing under the HCPCS or CPT scheme. So, all of the products that might be submitted on a potential claim billed with a HCPCS or CPT code would be accounted for in that NDC crosswalk for that respective code. The idea behind this really is to ensure proper coding, both on the provider submitting the claim and then also from health plan or payor perspective that they’re validating that the NDC submitted matches the HCPCS or CPT code that it was billed under to make sure, again, that we have proper coding on the claim before we move into the discussion about to actually reimburse the claims. The first step really is to validate that crosswalk and make sure that the coding is accurate for the drug and code utilized.


To watch this full webinar: “Shedding Light on Medically Covered Drug Pricing Methods,” click here.

Learn why different pricing methods exist, how they are different, when each is used, and how they impact reimbursement. We also cover how NDCs are linked and crosswalked to HCPCS codes.

More webinar segments here.

Hosted by:

Christopher Webb, CPhT
Director, Product Development

Jason Young, PharmD
SVP, Clinical Data Operations

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