Wiki NDC Denials

[TJAlexander]

I'm curious if anyone else is having this issue. Last year we started receiving denials for our viscosupplementation claims saying that the NDC number was invalid. I was confused because the NDC was listed on the CMS website and I was taking the number right off the package in the 11-digit format. But after doing some research, I discovered that payers reference 2 websites to confirm whether an NDC number is valid; CMS and the FDA website.

The problem is that I am unable to locate any of the meds on the FDA website which means they are inactive and that is what the payers are using to deny these claims. I don't even know where to begin to appeal these denials! Orthovisc, Hyalgan/Supartz, and Durolane are among the drugs I was unable to locate on the FDA NDC lookup.

Is anyone else having this issue? Or can somebody give some advice about how to respond?

Thanks!!

 

[TThivierge]

Hi TJ
Have you checked the latest HCPCS manual for J codes defined by the above meds ? I checked the HCPCS manual it says....the J code for Orthovisc is J7324 the route is OTH , the med Supartz is J7321 code, OTH route. Durolane is 1 mg IV route, J code J7318. The OTH is other routes of administration...was it IV, put in cath, inserted in body other ways thru pt's mouth, rectum or orally? Also what is the main dx code linking with for use of the injections? Is your issue because the payer wants to know how inserted in the human body?
Well hope helped you a bit
Lady T

 

[TJAlexander]

Hi TJ
Have you checked the latest HCPCS manual for J codes defined by the above meds ? I checked the HCPCS manual it says....the J code for Orthovisc is J7324 the route is OTH , the med Supartz is J7321 code, OTH route. Durolane is 1 mg IV route, J code J7318. The OTH is other routes of administration...was it IV, put in cath, inserted in body other ways thru pt's mouth, rectum or orally? Also what is the main dx code linking with for use of the injections? Is your issue because the payer wants to know how inserted in the human body?
Well hope helped you a bit
Lady T

Hi!
Thanks for responding.
So they only mentioned the NDC which is taken directly from the box the injections were shipped in so I'm confused as to how it can be invalid. The payer rep on the phone wasn't helpful but I think I read somewhere (it may have been here somewhere...) that payers use a couple of databases to verify NDCs.

The issue is, if the CMS database shows the NDC but the FDA does not, it means that the medicine has been inactivated. Which means we can't bill for it? I don't know but I'm confused and really frustrated. Some of these visits happened last year and I've been fighting with them ever since.