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Edit 02066
Drug Code Missing
HIPAA Claim Adjustment Reason Code: 16
Remark Code: M119
HIPAA Healthcare Claim Status Code: 218
Entity Identifier Code: N/A
Potential Causes:
The procedure code on the claim is for a Physician Administered Drug and all claims (with the exception of claims for 340B facilities) for Physician Administered Drugs with a date of service on or after January 1, 2008, are required to be submitted with an NDC code (reported in Loop-ID 2410 of the 837 Institutional or 837 Professional).
Ordered ambulatory providers billing Medicaid at 340B prices for Physician Administered Drugs with a date of service on or after January 1, 2008 are not required to report the NDC but must instead enter a modifier value of ‘UD’ in one of the Procedure Modifier fields (loop 2400, SV2 segment, data element SV202-3 through SV202-6) on the 837 electronic format to identify the drug as a 340B purchased drug. When using this option, the 340B price must be billed to Medicaid.
Solution:
If the procedure code to be billed is for a Physician Administered Drug, ensure the NDC is entered. Ordered ambulatory providers billing Medicaid at 340B prices should ensure the modifier ‘UD’ in entered on the claim. These requirements only apply to claims for Physician Administered Drug with a date of service on or after January 1, 2008.
| 837 Institutional |
Loop 2410, LIN and CTP segments
Or for 340B providers:
Loop 2400, SV2 (Institutional Service Line)
One of SV202-2 – SV202-6 (Procedure Modifier) = ‘UD’ (Note: if this is the only Modifier for the service line, ‘UD’ must be in SV202-2.) |
| 837 Professional |
Loop 2410, LIN and CTP segments
Or for 340B providers:
Loop 2400, SV1 (Professional Service)
One of SV101-2 – SV101-6 (Procedure Modifier) = ‘UD’ (Note: if this is the only Modifier for the service line, ‘UD’ must be in SV101-2.) |
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