RC Claim Assist is a self-service website for providers and physicians required to bill and reimburse by NDC unit. RC Claim Assist is used to convert HCPCS/CPT^® code unit to NDC code unit and vice versa.

RC Claim Assist can be used to convert HCPCS/CPT^® code unit to NDC code unit by searching off HCPCS/CPT^® code, NDC or Drug Name

1. If searching off HCPCS/CPT^® code:
   1. Type in a HCPCS/CPT^® code to make a search
   2. Select the appropriate HCPCS/CPT^® code. This will populate on your drug card on the right side of the screen
   3. Select the appropriate NDC from the list. This will populate on your drug card on the right side of the screen
   4. Enter the number HCPCS/CPT^® units administered
   5. The correct number of billable NDC units to include on your claim form will display on your drug card
2. If searching off an NDC code:
   1. Type in an NDC to make a search
   2. Select the appropriate NDC code from the list, this will populate on your drug card on the right side of the screen
   3. Confirm the correct HCPCS/CPT^® code based on the correct units of the product
   4. Enter the number of HCPCS/CPT^® code units administered
   5. The correct number of Billable NDC units to include on your claim form will display on your drug card
3. If searching off a Drug Name:
   1. Type in a Drug Name
   2. Confirm the HCPCS/CPT^® code. This will populate on your drug card on the right side of the screen
   3. Select the appropriate NDC from the list. This will populate on your drug card on the right side of the screen
   4. The correct number of billable NDC units to include on your claim form will display on your drug card

To complete the NDC Conversion you will need:

1. HCPCS/CPT^® code
2. Number of HCPCS/CPT^® units
3. NDC (11-digit billing format)

“NDC” stands for National Drug Code. It is a unique, 3-segment numeric identifier assigned to each medication listed under Section 510 of the U.S. Federal Food, Drug and Cosmetic Act. Typically, it appears in the 5 digit-4 digit-2-digit format (xxxxx-xxxx-xx). The first segment of the NDC identifies the labeler (i.e., the company that manufactures or distributes the drug). The second segment identifies the product (i.e., specific strength, dosage form, and formulation of a drug). The third segment identifies the package size and type.

NDCs are listed in various national sources in three unique levels; Pricing Unit, Package Size and Package Quantity. Typically, the Pricing Unit is the required information for a claim form.
Examples of Pricing Units are mLs (milliliters), Tab, Each.
Examples of Package Sizes are Vial, Ampule, Syringe.
Package Quantities may consist of multiple vials, IE 10 Vials.

HCPCS (pronounced “hickpicks”) is short for Healthcare Common Procedure Coding System. It consists of three levels of drug codes.
The three HCPCS levels are:

• Level I – American Medical Associations Current Procedural Terminology (CPT^®) codes.
• Level II – The alphanumeric codes which include mostly non-physician items or services such as drugs, medical supplies, ambulatory services, prosthesis, etc.These are items and services not covered by CPT^® (Level I) procedures.
• Level III – Local codes used by state Medicaid organizations, Medicare contractors, and private insurers for specific areas or programs.

RC Claim Assist primarily uses HCPCS Level I (CPT^® codes) and/or HPCPS Level II codes. Level II of theHCPCS is a standardized coding system that is used primarily to identify drug, products, supplies, and services not included in the CPT^® codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician’s office. Because Medicare and other insurers cover a variety of services, supplies, and equipment that are not identified by CPT^® codes, the level II HCPCS codes were established for submitting claims for these items. The development and use of level II of the HCPCS began in the 1980s. Level II codes are also referred to as alpha-numeric codes because they consist of a single alphabetical letter followed by 4 numeric digits, while CPT^® codes are identified using 5 numeric digits. i.e., J9000.

CPT^® or Current Procedural Terminology is the numeric coding system maintained by the American Medical Association (AMA). The CPT^® is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other healthcare professionals. These healthcare professionals use the CPT^® to identify services and procedures for which they bill public or private health insurance programs. Decisions regarding the addition, deletion, or revision of CPT^® codes are made by the AMA. CPT^® codes are republished and updated annually by the AMA.

Billable Units – represents the number of units in a product based on strength of the product per vial/ampule/syringe, etc., as it relates to the HCPCS or CPT^® Drug Code description.
For example:
Code: J0290 Injection, ampicillin sodium, 500 mg
Products: Injection, ampicillin sodium 500 mg / vial = 1.0 billable unit
Injection, ampicillin sodium 250 mg / vial = 0.50 billable unit
Injection, ampicillin sodium 125 mg / vial = 0.25 billable unit
Injection, ampicillin sodium 1 gm / vial = 2.0 billable units
Injection, ampicillin sodium 2 gm / vial = 4.0 billable units
Injection, ampicillin sodium 10 gm (gram) / vial = 20.0 billable units

HCPCS/CPT^® codes consist of route of administration, generic product name and billable unit strength (typically a mg). A HCPCS code unit is based on the amount of mgs (milligrams) administered to the patient.
NDCs are listed using various units of measure (typically a ml). This difference can create some confusion when submitting the exact amount of drug administered to a patient.
In the example below the HCPCS code units are based off the number of milligrams administered and the NDC units are based off the number of milliliters:

The NDC is found on the drug label or packaging. An asterisk may appear as a placeholder for any leading zeros. The label also displays information about the NDC unit of measure for that drug.

The AWP (Average Wholesale Price) and WAC (Wholesale Acquisition Price) is RJ Health’s reference price. See your fee schedule for your contracted reimbursement rate. If you have additional questions about your reimbursement rate, please contact your networks’ provider relations.

Your health plan has a prerequisite in place that requires an NDC when submitting a drug claim. NDCs provide a more accurate pricing methodology for payment and facilitate better management of drug-associated costs.

Try to initiate a search using different criteria such as NDC or HCPCS/CPT^® code on the search page. Still not finding your result? Contact RJ Health at info@rjhealth or call 860-563-1223.

A NOC (Not Otherwise Classified) code is a temporary code used to bill for a drug when there is not a HCPCS code assigned to an NDC code. Examples are HCPCS codes J9999 (not otherwise classified anti-neoplastic drugs), J3490 (unclassified drugs) and/or J3590 (unclassified biological drugs).

A single-dose or single-use vial is a vial of liquid medication intended for parenteral administration (injection or infusion) meant for use in a single patient for a single case/procedure/injection. Single-dose or single-use vials are labeled as such by the manufacturer and typically lack an antimicrobial preservative.

A Single Dose Vial (SD) cannot be used to treat multiple patients. In these cases, the remaining drug can be billed to account for this remainder. Please consult your plan’s policy on billing these sort of examples.

The data is updated on the first business day of each month.

No, an NDC will become “Inactive” once the Manufacturer of the product(s) stops production. Since product may be left on the market or in inventory, information for inactive NDCs will be available for a period of 30 months. Please contact your payor with questions regarding claim processing rules.

This tool is licensed for the expressed use of providers within the plan’s network. It is not intended for use outside the Organization.

This tool is licensed for the expressed use of providers within the plan’s network. It is not intended to be shared with others.

Please email info@rjhealthsystems.com with any questions.