Are You a Provider Billing Unlisted J-Codes?

Did you know more than 50% of National Drug Code (NDC) numbers have either an assigned Current Procedural Terminology (CPT) code or an assigned Healthcare Common Procedure Coding System (HCPCS) code?

CPT codes are referred to as Level I codes and are maintained by the American Medical Association (AMA). Level I codes are comprised of five (5) characters in length and are numerical (e.g. 99211, 30520, etc.).

HCPCS codes are referred to as Level II codes and are governed by the American Hospital Association (AHA) and the Center for Medicare and Medicaid Services (CMS). Level II codes are five (5) characters in length and are comprised of one (1) letter and four (4) numbers (e.g. J1950, J9217, etc.).

In most instances, NDC numbers are assigned a CPT or HCPCS code. Most injectable medications begin with a “J”, but this is not always the case. It is important that claims be submitted with the most accurate information when billing for injectable medications that are administered in the office during a patient’s visit.

In an effort to ensure providers are billing appropriately and are being reimbursed properly, beginning February 1, 2009, Blue Cross and Blue Shield of Texas (BCBSTX) will begin checking the NDC numbers billed with an unlisted J-Code to ensure these codes are being billed correctly.

What does this mean for our providers?

  • If a claim is submitted using an unlisted J-Code (e.g. J3490) and a valid CPT/HCPCS code exists for the drug being administered, BCBSTX will deny the service line and request the provider to resubmit using the correct CPT/HCPCS code.
  • If a claim is submitted with an unlisted J-Code (e.g. J3490) and there is no other CPT/HCPCS code for the drug being administered, the provider will need to provide the necessary information on the claim for BCBSTX to properly adjudicate the service line. If the claim is received without the necessary information, the service line may be denied and sent back to the provider with a request to resubmit the service along with the necessary information.
    • Necessary information needed to process valid unlisted J-Codes:
      • NDC Number
      • Drug Name
      • Dosage administered (e.g. 5 mg, 10 mg, etc.)
      • Include how the number of units being billed on the claim is being administered (e.g. 5 mg = 1 unit, 10 mg = 5 units, etc.)
      • Strength of drug administered (e.g. 25 mg/ml, 10 mg/10 ml, etc.)
      • Single dose vial or Multi-dose vial

Please Note: An NDC number will be reimbursed for a maximum of two (2) years after it becomes obsolete.

If you have any questions, you may contact our Provider Customer Service Department at (800) 451-0287 to speak with a Customer Advocate for assistance.