Coding and Billing NDCs

Thank you for providing quality care to our members. To ensure your claims are processed and paid in a timely and accurate manner, it is important that you code and bill National Drug Codes (NDCs) correctly.

Horizon NJ Health will continue to review New Jersey State Encounter rejections and update the system as necessary. We will also be adding any new denial codes in order for these edits to be easily identified. We have enclosed examples of claims/encounters that have not been accepted by NJ Medicaid.

For additional resource information on NDC billing, please see additional information noted in the 2018 Provider Administrative Manual on pages 9-12, 9-18, 9-19, and 9-20.

For additional information on the valid NDC codes, unit and units of measure, please refer to the NJ Medicaid website: https://www.njmmis.com/ndcLookup.aspx.

If you have any questions, please contact Provider Services at 1-800-682-9091. Thank you for your participation in our network and for the high quality care you provide to our members.

We have added Explanation of Payment codes and descriptions below for the NDC denial codes:

Denial code Short Description Long Description
I41 NDC Code is invalid NDC number is not in drug master for the date of service and not valid.
I45 NDC quantity is invalid NDC quantity has invalid metric quantity.
I50 NDC unit of measurement is invalid Must have a valid unit of measure F2, GR, ML, ME, UN and should be valid for the NDC code.
I51 NDC quantity exceeded Quantity should be valid, and calculated allowed amount (Quantity X price) should not be more than two times of the billed amount.
I52 Valid Revenue codes are required for this NDC Outpatient drug claims use revenue codes 631 through 637 or 25x.
I53 NDC is not in DESI file NDC is not payable and invalid in Federal Drug Efficacy Study Implementation (DESI) file for the date of service.
I54 NDC Code is invalid NDC number is not in drug master for the date of service and not valid.
I55 NDC quantity is invalid NDC quantity has invalid metric quantity.
I57 NDC unit of measurement is invalid Must have a valid unit of measure F2, GR, ML, ME, UN and should be valid for the NDC code.
I58 NDC quantity exceeded Quantity should be valid, and calculated allowed amount (Quantity X price) should not be more than two times of the billed amount.
I59 Valid Revenue codes is required for this NDC Outpatient drug claims use revenue codes 631 through 637 or 25x.
I61 NDC is not in DESI file NDC is not payable and invalid in Federal Drug Efficacy Study Implementation (DESI) file for the date of service.

EDIT - 214

Denial code State Encounter Edit Code Short Description Long Description
I54 214 NDC Code is invalid NDC number is not in drug master for the date of service and not valid

Claim example: The claim/encounter was rejected as the NDC code 68256079701 is not a valid NDC code.

DOS from Dt DOS to Dt Procedure Proc Units NDC NDC Units Charge Amount Paid Amount
4/18/2018 4/18/2018 J2469 5 68256079701 5 $500.00 $231.05

EDIT - 317

Denial code State Encounter Edit Code Short Description Long Description
I55 317 NDC quantity is invalid NDC quantity has invalid metric quantity

Claim example: The claim/encounter was rejected as the NDC units billed are invalid. The provider billed the NDC code in place of the NDC units.

DOS from Dt DOS to Dt Procedure Proc Units NDC NDC Units Charge Amount Paid Amount
10/24/2017 10/24/2017 J7050 1 00264180032 264180032 $25.00 $3.21

EDIT - 322

Denial code State Encounter Edit Code Short Description Long Description
I57 322 NDC unit of measurement is invalid Must have a valid unit of measure F2, GR, ML, ME, UN and should be valid for the NDC code.

Claim example: The claim/encounter was rejected as the NDC UOM was billed as ML (milliliters), but it should have been billed as UN (units).

DOS from Dt DOS to Dt Procedure Proc Units NDC NDC Units NDC UOM Charge Amount Paid Amount
1/8/2018 1/8/2018 J1745 50 57894003001 1 ML $37,854.00 $5,710.35

EDIT - 330

Denial code State Encounter Edit Code Short Description Long Description
I58 330 NDC quantity exceeded Quantity should be valid, and calculated allowed amount (Quantity X price) should not be more than two times of the billed amount.

Claim example: The above claim/encounter was rejected as (claim charge amount * 2) is less than total NDC price (NDC price * NDC units billed).

Claim charge amount * 2 → $16000 * 2 = $32,000

Total NDC Price → $1145.23 * 200 = $229,046

In this case, the provider has billed the NDC units incorrectly.

DOS from Dt DOS to Dt Procedure Proc Units NDC NDC Units Charge Amount Paid Amount
3/22/2018 3/22/2018 J9271 200 00006302602 200 $16,000.00 $9,344.00

EDIT – 328

Denial code State Encounter Edit Code Short Description Long Description
I59 328 Valid Revenue codes are required for this NDC Outpatient drug claims use revenue codes 631 through 637 or 25x.

Claim example: The claim/encounter was rejected as the revenue code billed on the outpatient claim was invalid.

DOS from Dt DOS to Dt Procedure Proc Units Revenue code NDC NDC Units
1/29/2018 1/29/2018 J3490 4 0270 24357070106 20

EDIT - 544

Denial code State Encounter Edit Code Short Description Long Description
I61 544 NDC is not in DESI file NDC is not payable and invalid in Federal Drug Efficacy Study Implementation (DESI) file for the date of service.

Claim example: The above claim/encounter was rejected as the NDC billed has been classified as an LTE (less than effective) DESI drug effective 11/18/2014, which is lesser than the DOS on the claim.

DOS from Dt DOS to Dt Procedure Proc Units Revenue code NDC NDC Units Charge Amount Paid Amount
2/12/2018 2/12/2018 J3490 1 0250 17478050305 5 $631.17 $238.36
Published on: July 4, 2018, 02:36 AM ET
Last updated on: July 4, 2018, 08:10 AM ET