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Billing and Describing Not Otherwise Classified (NOC) Codes
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When billing any service to Medicare, it is important that providers always use the most appropriate CPT code that accurately describes the procedure performed. Upon medical review, Medicare will deny services reported with not otherwise classified (NOC) codes if true codes are available. This determination occurs regardless of any supporting documentation accompanying the claim.
Almost any well-established procedure in the medical field will have a true code. The purpose of an NOC code is to report services having absolutely no existing true codes. Billers should use the reference aids available in the coding manuals before billing any service with an NOC code. To find a procedure's true code, cross-reference the CPT index. The CPT has both indices and appendices to select an appropriate code for billing purposes. Included are both procedures and body areas. Look under the body area if the true code does not appear in the index under the procedure name.
By design, the CPT procedure description assists in proper coding of procedures. After selecting the correct code, you can find additional coding information for that particular body area or procedure in that section's main header. You should consult the additional information available in the beginning of each chapter of CPT for proper application of the code. If you need additional assistance to determine if an NOC code is correct, contact the American Medical Association (AMA).
Medicare may view the deliberate use of inappropriate NOC codes for maximizing payments or "unbundling" procedures as a fraudulent billing practice. Misrepresentation of non-covered or non-chargeable services with NOC codes as approved, covered services is also inappropriate.
To reimburse NOC services correctly, providers must include the following:
- In data element 2400/SV101-7 or Item 19 of the CMS 1500 form, include a complete description of the rendered service.
- This field holds up to 80 characters on the electronic claim.
- The claim reviewer will use this description to determine coverage and to price the service to comparable work.
- In data element 2400/SV1-04 or Item 24G of the CMS 1500 form, bill one unit of service only.
An unprocessable rejection occurs when any of the information above is missing. It will also occur when the claim shows more than one unit of service for the NOC code.
Special Information for NOC Drug and Biological Codes
The following tips will help you bill NOC drugs and biologicals, such as J3490, J3590, and J9999:
- Submit NOC codes in the 2400/SV101-2 data element in the 5010 professional claim transaction (837P).
- Provide a description in the 2400/SV101-7 data element.
- The 5010 TR3 Implementation Guide instructs: "Use SV101-7 to describe non-specific procedure codes." (Do not use the 2400 NTE segment to describe non-specific procedure codes with 5010.)
- The SV101-7 data element allows for 80 bytes (i.e., characters, including spaces) of information.
Providers should include the following when reporting NOC drugs and biologicals. This must appear in the 2400/SV101-7 data element, or Item 19 of the CMS 1500 form:
- The name of the drug,
- The total dosage (plus strength of dosage, if appropriate), and
- The method of administration.
Important: List one unit of service in the 2400/SV1-04 data element or in item 24G of the CMS 1500 form. Even when providing multiple units, do not quantity-bill NOC drugs and biologicals. Medicare determines the proper payment of NOC drugs and biologicals by the narrative information, not the number of units billed.
If Medicare rejects the claim for NOC drugs and biologicals, the remittance notice will include remark code M123. This remark means “Missing/incomplete/invalid name, strength, or dosage of the drug furnished.” This occurs even if the rejection is due to the number of units billed.
Medicare determines pricing for NOC J-codes by the information provided on the Average Sales Price (ASP) NOC pricing file. If the ASP NOC file lists the strength for a drug on the file, this means the drug comes in different strengths. Medicare payment varies depending on the strength given. When billing Medicare for an NOC J-code, you can determine if the drug comes in different strengths. To determine this, access the ASP NOC pricing files on the CMS website.
Examples of good descriptions of NOC codes:
- Stab Phlebectomy of Varicose Veins 1 Extremity 6 Stab Incisions
- Pharyngeal scar band lysed with monopolar cautery
- Arthroscopic decompression of the suprascapular nerve
- Injection, Factor VIII FC Fusion (Recombinant), per IU: 25,000 units
Examples of inadequate descriptions of NOC codes:
- Breast Surgery Procedure Unlisted
- Not Otherwise Classified
- Biologic Injection
global-tags: Drugs,J8A,J5A,J8B,J5B,Coding Guidelines,Claims
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