CASP Module 7, Section 1: HCPCS, NDC, CPT, and Revenue Code Integration
Module 7: Billing, Coding & Reimbursement

Section 7.1: HCPCS, NDC, CPT, and Revenue Code Integration

Decoding the alphabet soup of medical billing codes. Learn how drug (NDC), procedure (CPT), supply (HCPCS), and location (Revenue Code) codes must integrate seamlessly for successful medical benefit claims.

SECTION 7.1

HCPCS, NDC, CPT, and Revenue Code Integration

From the Dispensing Label to the Final Claim: The Pharmacist’s Role in Reimbursement Integrity.

7.1.1 The “Why”: Translating Your Core Skillset

Welcome to what is, for many pharmacists, the most intimidating and opaque part of the specialty ecosystem. As a pharmacist, you are the undisputed master of one of the most important codes in this entire process: the National Drug Code (NDC). You live and breathe NDCs. You can identify a product, manufacturer, and package size from 11 digits. Your entire dispensing system, your inventory management, your purchasing—it all runs on NDCs. The pharmacy benefit claims you’ve processed (NCPDP transactions) are fundamentally built around this single code.

Now, we must respectfully set that comfortable world aside. The specialty drugs you will manage—the high-cost, provider-administered infusibles and injectables—are almost never paid for through the pharmacy benefit. They are paid for through the medical benefit. And on the medical benefit, the NDC is not the star of the show. It is a supporting actor.

This new world is run by an “alphabet soup” of other codes: HCPCS, CPT, and Revenue Codes. The “why” of this section is to help you translate your mastery of the NDC into this new language. You are not learning a new skill from scratch; you are learning how to integrate your core knowledge into a new and far more complex system. The pharmacy benefit claim is a simple, one-line receipt. The medical benefit claim is a multi-page, itemized super-bill that must account for the drug, the procedure to administer it, the supplies, and the location, all in a language the payer understands.

Why is this your job? Because you are the only member of the healthcare team who can definitively link the clinical reality to the financial claim. The provider knows the procedure (CPT), the billing office knows the claim form, but you are the only one who truly understands the drug. You know the exact product (NDC), the dose given, the amount wasted, and the billing units (HCPCS) that must match. When a $20,000 claim for a biologic is denied for “mismatched units,” the billing department cannot solve it. The physician cannot solve it. They will turn to you, the pharmacist, to be the clinical and financial detective who can read the chart, read the claim, and find the error. This section is your decoder ring.

Pharmacist Analogy: The Auto-Body Shop Invoice

For your entire career, you’ve worked at a Tire Shop. A customer comes in, you sell them “four tires,” and you generate a simple, one-line receipt:
Line 1: (NDC) 4x Michelin Pilot Sport Tires… $1,200.
This is the pharmacy benefit claim. It’s simple, product-based, and processed in seconds.

Now, you’ve been hired to run the parts department at a high-end Auto-Body Shop. A car comes in after a collision. You can’t just bill for “parts.” The insurance company needs a complex, multi-line invoice to justify the $20,000 repair. This is the medical benefit claim. Your invoice must look like this:

  • Line 1 (The “What Was Given”): (HCPCS J-Code) 1x Front Bumper Assembly… $1,500. This is the billable part.
  • Line 2 (The “What Was Done”): (CPT Code) 4.5 hours – Remove damaged bumper & install new… $675. This is the labor/procedure.
  • Line 3 (The “What Else Was Given”): (HCPCS S-Code) 1x Paint, ‘Midnight Blue’… $800. This is an ancillary supply.
  • Line 4 (The “Where It Was Done”): (Revenue Code) Bill Type: 0340 – Body Shop. This tells the payer where in the “hospital” the service happened.
  • Line 5 (The “Proof of Purchase”): (NDC) And by the way, the specific part number for that bumper was [11-digit NDC]… (for tracking).

Your old job only cared about Line 5. Your new job requires you to understand how Line 5 (NDC) translates into Line 1 (HCPCS) and how it must be bundled with Line 2 (CPT) and Line 4 (Revenue Code) to get the claim paid. If you bill for the bumper (HCPCS) but forget to bill for the labor (CPT), you lose $675. If you bill for the labor but the part number (NDC) doesn’t match the part billed (HCPCS), the entire claim is denied. This is medical billing, and you are now the chief auditor.

7.1.2 Code Deep Dive 1: NDC (National Drug Code) – Your Home Base

We will start where you are most comfortable. The National Drug Code (NDC) is your native language. It is the universal identifier for human drugs in the United States, assigned by the FDA. You know its three segments, but let’s formally define them in the context of billing.

Segment Format What It Represents Assigned By
Labeler Code 4 or 5 digits The manufacturer, repacker, or distributor (e.g., Pfizer, Sandoz, McKesson). FDA
Product Code 3 or 4 digits The specific strength, dosage form, and formulation (e.g., Herceptin 150 mg vial). Manufacturer
Package Code 1 or 2 digits The package size (e.g., “1-pack,” “10-pack”). Manufacturer

7.1.2.1 The 10- vs. 11-Digit Conversion: The Root of Countless Errors

This is a concept you have likely wrestled with your entire career, but now it has massive financial implications. The FDA publishes NDCs in a 10-digit format (e.g., 4-4-2, 5-3-2, 5-4-1). However, the healthcare billing standard (HIPAA) and almost all computer systems require an 11-digit NDC in a 5-4-2 format. This discrepancy is reconciled by adding a leading zero (a “placeholder zero”) to the segment that is “missing” a digit.

This is not just a trivia fact. If a payer’s system requires an 11-digit NDC and you submit a 10-digit one, the claim is rejected. If you pad the zero in the wrong place, the claim is rejected. As the pharmacist, you are the only one who can perform this conversion correctly.

Pharmacist Tutorial: The 11-Digit NDC Conversion

The 11-digit standard is 5-4-2. Your job is to add a leading zero to the segment that is “short.”

  • If the 10-digit format is 4-4-2:
    • Example: 1234-5678-90
    • Problem: The labeler code (1234) is only 4 digits.
    • Solution: Add a leading zero to the first segment.
    • 11-Digit Result: 01234-5678-90
  • If the 10-digit format is 5-3-2:
    • Example: 12345-678-90
    • Problem: The product code (678) is only 3 digits.
    • Solution: Add a leading zero to the second segment.
    • 11-Digit Result: 12345-0678-90
  • If the 10-digit format is 5-4-1:
    • Example: 12345-6789-0
    • Problem: The package code (0) is only 1 digit.
    • Solution: Add a leading zero to the third segment.
    • 11-Digit Result: 12345-6789-00

The Billing Application: On a medical claim (CMS-1500 or UB-04), when an NDC is required, it must be submitted in its 11-digit format (usually with no hyphens) and preceded by the qualifier “N4”. For example: N401234567890.

7.1.2.2 The NDC’s Role on a Medical Claim

So, if the NDC isn’t the primary billing code, why is it even on the claim? There are two primary reasons:

  1. Rebate Tracking: This is the most important one. Payers, especially Medicaid, are legally required to collect rebates from manufacturers. They cannot collect a rebate without knowing the exact NDC that was dispensed. The medical claim (which bills a generic J-code) must include the specific NDC so the payer can go back to the manufacturer (e.g., Pfizer) and say, “You owe us a rebate for this utilization.”
  2. Code Validation: Payers use the NDC to validate the J-code. If you bill J9355 (Trastuzumab), but you submit an NDC for Remicade, the claim will be instantly denied for a mismatch. The NDC is your proof that you administered what you are billing for.

The Core Concept: The NDC is the drug. The HCPCS code (which we’ll cover next) is the billable service/product. You must provide the NDC to justify the HCPCS. This is the first and most fundamental “integration” you must master.

7.1.3 Code Deep Dive 2: HCPCS (Healthcare Common Procedure Coding System) – Your New Language

This is your new world. The Healthcare Common Procedure Coding System (HCPCS, often pronounced “hick-picks”) is the primary coding system used to bill for services, procedures, and… drugs… on a medical claim. It is divided into two main levels.

  • Level I (CPT Codes): We’ll cover this in 7.1.4. These are 5-digit numeric codes (e.g., 96413) managed by the American Medical Association (AMA). They describe what you did (the procedure, the service, the “labor”).
  • Level II (HCPCS Codes): This is our focus. These are 5-character alphanumeric codes (e.g., J9355) managed by CMS. They describe what you gave (the drug, the supply, the durable medical equipment).

7.1.3.1 Meet the “J-Codes”: The Pharmacist’s New Formulary

As a specialty pharmacist, your life will revolve around “J-Codes.” These are the subset of HCPCS Level II codes that represent drugs administered by a provider (i.e., not oral or self-administered). They almost always begin with the letter “J”.

The most critical concept to grasp is that a J-code is not 1-to-1 with an NDC. A single J-code represents the active ingredient, and multiple NDCs (from different manufacturers, in different vial sizes) can all map to the same J-code.

Example: Trastuzumab

  • J-Code: J9355
  • J-Code Descriptor: “Injection, trastuzumab, excludes biosimilar, 10 mg”
  • This J-code is used to bill for:
    • Herceptin 150 mg vial (NDC: 50242-0134-01)
    • Herceptin 440 mg vial (NDC: 50242-0135-01)
    • Herceptin 600 mg subQ (NDC: 50242-0150-01)

The provider’s office does not bill “1 vial of Herceptin.” They bill J9355. Your job is to determine how many units of J9355 to bill.

7.1.3.2 The Unit Calculation Problem: The #1 Source of Denials

This is, without question, the most important practical skill in this entire section. Billing for the wrong number of units is the most common and costly error in medical drug billing. The J-code descriptor tells you the “billing unit.” You, the pharmacist, must perform the math to convert the dose administered into the units billed.

Formula: (Total Dose Administered) / (Amount in J-Code Descriptor) = Number of Units to Bill

Pharmacist Tutorial: Masterclass in J-Code Unit Calculation

Let’s walk through three common scenarios. Assume all units are rounded up to the nearest whole number (CMS billing standard).

Scenario 1: Trastuzumab (Herceptin)
  • Patient Dose: 600 mg IV
  • J-Code: J9355
  • Descriptor: “Injection, trastuzumab, excludes biosimilar, 10 mg“
  • Pharmacist’s Calculation: 600 mg (dose given) / 10 mg (billing unit) = 60 units
  • What to Bill: Line Item: J9355, Units: 60
  • Common Error: Billing “1” unit (for 1 vial). This results in a reimbursement for 10 mg of Herceptin instead of 600 mg. A catastrophic financial loss.
Scenario 2: Infliximab (Remicade)
  • Patient Dose: 350 mg IV (5 mg/kg for a 70kg patient)
  • J-Code: J1745
  • Descriptor: “Injection, infliximab, 10 mg“
  • Pharmacist’s Calculation: 350 mg (dose given) / 10 mg (billing unit) = 35 units
  • What to Bill: Line Item: J1745, Units: 35
  • How it’s Dispensed: You would dispense four 100 mg vials. You are billing for the dose given, not the vials dispensed. (Wastage is a separate concept, covered next).
Scenario 3: Adalimumab (Humira) – Provider Administered
  • Patient Dose: 40 mg SubQ
  • J-Code: J0171
  • Descriptor: “Injection, adalimumab, 1 mg“
  • Pharmacist’s Calculation: 40 mg (dose given) / 1 mg (billing unit) = 40 units
  • What to Bill: Line Item: J0171, Units: 40
  • This is Critical: Many new biologics are billed “per 1 mg.” Failure to do this conversion is a massive error.

7.1.3.3 The “Unclassified” Codes: J3490, J3590, C9399

What happens when a brand-new drug is approved by the FDA but CMS has not assigned a J-code yet? This is a common problem for specialty pharmacists. You cannot bill for a drug that has no code. The solution is to use an “unclassified” or “Not Otherwise Classified (NOC)” code.

  • J3490: “Unclassified drugs”
  • J3590: “Unclassified biologics”
  • C9399: “Unclassified drugs or biologicals” (Used *only* for hospital outpatient claims when no other code exists)

These codes are a “black box” to payers and are magnets for denials. They are the billing equivalent of writing “Miscellaneous” on an expense report. To get them paid, you, the pharmacist, must provide the critical data.

Pharmacist’s Playbook: How to Bill an Unclassified Code

When billing J3590 for a new drug, the claim is guaranteed to fail unless it is submitted with the following information, which only the pharmacy can provide:

  1. The 11-Digit NDC: This is mandatory. It identifies the exact product.
  2. The Drug Name & Dose: The claim must clearly state (in a free-text field) “Skyrizi 600 mg.”
  3. The Number of Units: This is tricky. The “unit” for a NOC code is almost always 1. You bill 1 unit of J3590 and the price is the total price for the drug given.
  4. The Invoice: The payer will almost always “pend” the claim and request a copy of the drug’s invoice to verify the AWP/cost. Your pharmacy purchasing records are now part of the billing cycle.

Your role is to create a “billing guide” for your clinic’s billing team for every new NOC drug, telling them exactly what NDC, what description, and what price to put on the claim.

7.1.3.4 J-Code Modifiers: The Critical `JW` Wastage Code

This is one of the most advanced and most important pharmacist-driven billing functions: billing for drug wastage. Let’s go back to our Remicade example. You needed to give 350 mg. You dispensed four 100 mg vials (400 mg total). What happens to the extra 50 mg left in the last vial?

If you just throw it away, the clinic loses the money it paid for that 50 mg. Thanks to the CMS “Single-Dose Vial” policy, you are allowed to bill the payer for the discarded portion. To do this, you use the `JW` modifier. This modifier tells the payer, “I am billing for this amount of drug, and I attest that it was discarded and not used on another patient.”

Pharmacist Tutorial: How to Bill for Wastage with the `JW` Modifier

This is a two-line billing process. It is the only way to get paid for the administered drug *and* the wasted portion.

Scenario: Keytruda (Pembrolizumab)
  • Vial Size: 100 mg / 4 mL single-dose vial
  • Patient Dose: 150 mg IV
  • J-Code: J9271
  • Descriptor: “Injection, pembrolizumab, 1 mg“
Pharmacist’s Analysis:
  1. To get 150 mg, I must open two 100 mg vials (200 mg total).
  2. Dose Administered: 150 mg
  3. Dose Wasted: 200 mg (total) – 150 mg (given) = 50 mg
  4. Billing Unit: 1 mg
How to Bill the Claim:

You will create two separate lines on the claim form for the same J-code:

  • Line 1 (The Dose Given):
    • Code: J9271
    • Units: 150 (for the 150 mg administered)
    • Price: [Price per 150 units]
  • Line 2 (The Wasted Drug):
    • Code: J9271
    • Modifier: JW
    • Units: 50 (for the 50 mg wasted)
    • Price: [Price per 50 units]

Without your pharmacy documentation (dose, vial size, amount wasted), the billing office cannot create this second line. This is a direct, pharmacist-driven revenue-capture function that requires precise clinical documentation.

7.1.4 Code Deep Dive 3: CPT (Current Procedural Terminology) – The “Labor”

Now that we’ve mastered how to bill for the drug (HCPCS J-Code), we must bill for the service of administering it. This is the “labor” from our auto-body analogy. These codes are CPT codes (which, as we learned, are technically HCPCS Level I). They are 5-digit numeric codes that describe what you did.

As a specialty pharmacist, you won’t be billing these yourself, but you must know them. Your job is to audit the claim to ensure the drug (J9355) and the administration (96413) are both present and correct. Billing for a $20,000 drug without billing for the 2-hour infusion service is a common and costly error. Furthermore, the type of administration code billed can change reimbursement dramatically.

7.1.4.1 The Great Divide: Chemotherapy vs. Non-Chemotherapy Administration

The CPT manual splits drug administration into two families: “Hydration” and “Therapeutic, Prophylactic, or Diagnostic Injections and Infusions.” Within that second family, it makes one more critical split: chemotherapy vs. non-chemotherapy. Chemotherapy administration codes (96401-96425) pay at a significantly higher rate than non-chemo codes (96360-96379) because they are considered more complex and resource-intensive.

Compliance & Audit Trap: What is a “Chemo” Drug?

This is a critical definition. It is not just drugs for cancer. The CPT manual defines this category as including drugs for non-cancer diagnoses if they are “highly complex,” “toxic,” or require “special consideration.”

The Pharmacist’s Role: Many biologics for autoimmune conditions (like Remicade, Tysabri, etc.) are considered “chemotherapy” for billing purposes. Your pharmacy department, in collaboration with billing, must maintain a list of which J-codes should be billed with chemo admin codes (964xx) vs. non-chemo admin codes (963xx). Billing Remicade with a non-chemo code (96365) instead of the correct chemo admin code (96413) can result in a loss of hundreds of dollars per infusion.

7.1.4.2 Masterclass Table: The Most Common Administration Codes

This table is your reference guide. You must learn to “read” a patient’s chart and match the nurse’s documentation to the correct CPT code. The most important concept is the “Initial” code. The first service provided is always billed as “initial.” All other services on that day are billed as “sequential” or “concurrent.” The “initial” code always pays the most.

Category CPT Code Descriptor Pharmacist’s “Translation” (When to use it)
Injection 96372 Therapeutic, prophylactic, or diagnostic injection (SC/IM) This is your standard “shot.” A Neulasta injection, a simple Humira injection in the office. It’s quick and easy.
96401 Chemotherapy administration, subcutaneous or intramuscular A “chemo” shot (e.g., Faslodex). Pays more than 96372 due to complexity.
IV Push (IVP) 96374 IV push, initial (non-chemo) The nurse pushes a non-chemo drug (e.g., Solu-Medrol) directly from a syringe over a few minutes.
96409 IV push, initial (chemo) The nurse pushes a chemo drug (e.g., adriamycin) from a syringe. This is the highest-paying push code.
IV Infusion (IVPB) 96365 IV infusion, for therapy… initial, up to 1 hour The first “non-chemo” drip of the day (e.g., an antibiotic, IVIG). Must be > 15 minutes.
96413 IV infusion, (chemo) initial, up to 1 hour The first “chemo” drip of the day (e.g., Remicade, Herceptin). This is the highest-paying initial infusion code.
96415 IV infusion, (chemo) each additional hour This is an “add-on” code. If the Remicade infusion (96413) lasts 2.5 hours, you bill:
Line 1: 96413 (Units: 1)
Line 2: 96415 (Units: 2)

The Pharmacist’s Audit Function: Imagine you are reviewing a claim. The patient received Herceptin (J9355), which is a 30-minute infusion. The claim has a CPT code of 96409 (IV Push). This is an error. It should be 96413 (IV Infusion). Or, worse, the patient received a 4-hour Remicade infusion. The claim only shows 96413 (Units: 1). You, the pharmacist, can see the charted start and end times and tell the billing team, “You missed the additional 3 hours. You need to add 96415 (Units: 3) to this claim.” This is a direct recovery of missed revenue, all driven by your clinical knowledge.

7.1.5 Code Deep Dive 4: Revenue Codes – The “Facility”

This final code is simpler, but no less important. Revenue Codes (RCs) are only used on facility claims (the UB-04 claim form, which we’ll see in a moment). They are not used by provider offices (who use the CMS-1500 form).

A Revenue Code is a 4-digit code that tells the payer where in the hospital or facility the service took place. Think of it as the “department number” on the claim. For a pharmacist, your entire world lives in just a few RCs. The RC is used to group and categorize the charges on the facility’s bill. On a UB-04, every single line item (both the J-code and the CPT code) *must* be accompanied by a Revenue Code.

7.1.5.1 Masterclass Table: Key Revenue Codes for Pharmacists

Revenue Code Official Name Pharmacist’s “Translation” (What this line item is for)
0250 General Pharmacy This is the “general” pharmacy charge code. It’s often used for oral medications administered in the hospital or other non-infusible drugs.
0260 IV Therapy This is the “labor” code. The CPT administration codes (like 96413, 96365) are almost always billed under RC 0260. This line says, “This charge is for the service of IV infusion.”
0636 Drugs Requiring Detailed Coding This is your most important Revenue Code. “Detailed Coding” is the payer’s way of saying “a HCPCS J-Code.” All J-codes (J9355, J1745, etc.) are billed under Revenue Code 0636. This line says, “This charge is for a specific, high-cost J-code drug.”
025x Other Pharmacy (e.g., 0251, 0252) These are sometimes used for other pharmacy-managed items, but 0250, 0260, and 0636 are your main three.

The Integration: On a hospital outpatient claim, you will not just see J9355. You will see a line item that reads: RC 0636 | HCPCS J9355 | Units: 60. You will not just see 96413. You will see: RC 0260 | CPT 96413 | Units: 1. The Revenue Code provides the context for the other codes.

7.1.6 Integration: Putting It All Together (CMS-1500 vs. UB-04)

Now, let’s put all the pieces together. The “alphabet soup” integrates differently depending on the place of service. A private physician’s office (POS 11) bills on a CMS-1500 form. A hospital outpatient department (POS 22) bills on a UB-04 form. As a pharmacist, you must understand both. The *same drug* and *same service* are billed in two completely different ways.

Our Scenario: A 70kg patient with Crohn’s disease receives a 350 mg loading dose of Infliximab (Remicade). The infusion takes 2 hours and 15 minutes. The pharmacy dispenses four 100 mg vials (400 mg total), wasting 50 mg.

The Codes You, the Pharmacist, Have Identified:

  • Drug: Infliximab
  • J-Code: J1745 (Descriptor: 10 mg)
  • Administered Units: 350 mg / 10 mg = 35 units
  • Wasted Units: 50 mg / 10 mg = 5 units
  • Admin Service: Chemotherapy Infusion, 2 hours 15 min
  • CPT “Initial”: 96413 (Initial hour) – Units: 1
  • CPT “Add-on”: 96415 (Add’l hour) – Units: 2 (for the 2nd and 3rd hours)
  • NDC: 57894-0030-01 (Example NDC for Remicade 100mg)

7.1.6.1 Scenario A: The Private Provider Office (CMS-1500 Claim)

The CMS-1500 is the standard form used by physicians and non-facility providers. It is simpler and does not use Revenue Codes. All services are itemized in “Box 24.”

CMS-1500 Claim Form (Provider Office)
Date(s)
CPT/HCPCS
Mod
Description (NDC/Drug Name)
Units
Charge
10/24/2025
J1745
N457894003001 Infliximab 350mg
35
$10,500
10/24/2025
J1745
JW
Wastage: Infliximab 50mg
5
$1,500
10/24/2025
96413
Chemo Infusion, Initial Hour
1
$450
10/24/2025
96415
Chemo Infusion, Add’l Hour
2
$200

7.1.6.2 Scenario B: The Hospital Outpatient Infusion Center (UB-04 Claim)

The UB-04 is the standard form used by facilities (hospitals). It is more complex and requires Revenue Codes for every line. The codes are the same, but the structure is different.

UB-04 Claim Form (Hospital Outpatient)
Rev. Code
Description (NDC/Drug Name)
CPT/HCPCS
Mod
Units
Charge
0636
N457894003001 Infliximab
J1745
35
$10,500
0636
Wastage: Infliximab
J1745
JW
5
$1,500
0260
Chemo Infusion, Initial Hour
96413
1
$450
0260
Chemo Infusion, Add’l Hour
96415
2
$200

Your Takeaway: The exact same codes are used, but they are integrated differently. The CMS-1500 is a simple list. The UB-04 groups the charges by “department” (Revenue Code). You must be ableA to audit both.

7.1.7 Pharmacist’s Playbook: Top 5 Denial Errors and How to Fix Them

Your knowledge is most valuable when something breaks. When a multi-thousand-dollar claim is denied, you are the detective. Here are the most common denial reasons you will be asked to solve.

Pharmacist’s Denial Management Playbook
Denial Reason / Code What It Means Pharmacist’s Investigative Action How to Fix the Claim
Mismatched Units / CO-151 The payer believes the number of units billed is incorrect for the service. This is the #1 J-code error. 1. Find the J-code descriptor (e.g., J1745 = 10 mg).
2. Find the patient’s chart and confirm the exact dose administered (e.g., 350 mg).
3. Do the math: 350 mg / 10 mg = 35 units.
4. Check the claim. Did the biller enter “1” (for 1 infusion) or “4” (for 4 vials)? This is the error.		 Resubmit the claim with the corrected units (35). Attach your pharmacy/nursing chart notes showing the 350 mg dose as proof.
Missing/Invalid NDC / CO-16 + N4 The claim was submitted for a J-code that *requires* an NDC for rebate purposes (like all Medicaid claims) but the NDC was missing or in the wrong format. 1. Confirm the 11-digit, 5-4-2 formatted NDC for the exact product dispensed.
2. Check the claim’s “Loop 2410” (for an electronic claim) or Box 24 (for a paper claim).
3. Was the “N4” qualifier missing? Was a 10-digit NDC used? Was the zero padded in the wrong segment?		 Resubmit the claim with the 11-digit NDC in the correct field, formatted as N4[11-digits], along with the correct J-code units.
Service Not Bundled Correctly / CO-97 The payer believes one service should have been “bundled” with another. This often happens with administration codes. 1. Review the CPT codes billed.
2. Did the biller bill two “initial” codes (e.g., 96365 and 96413)? This is not allowed. Only one “initial” service per day.
3. Did they bill an IV push (96374) for the same drug they billed an infusion (96365) for? This is also not allowed.		 Correct the CPT coding hierarchy. Ensure there is only one “initial” code (the highest paying one, e.g., 96413) and all other services are billed as “sequential” or “add-on” (e.g., 96415).
Unclassified Code Requires Documentation / CO-16 You billed a J3490/J3590 NOC code, and the payer has no idea what it is. The claim is pended, awaiting documentation. 1. This is not an error, it’s a process.
2. You must provide the “Holy Trinity” for NOC codes:
– The 11-digit NDC
– A clear description (Drug Name, Dose Given)
– A copy of the drug invoice proving what the clinic paid for it (the WAC or AWP).		 Submit the requested documentation to the payer’s medical review department. This is a manual process that your pharmacy team must manage.
Payer Policy Mismatch / Medical Necessity The codes are technically correct, but the payer’s specific policy doesn’t cover this J-code for this diagnosis. 1. Find the patient’s diagnosis code (ICD-10) on the claim (e.g., K50.00 for Crohn’s).
2. Go to the payer’s website and find their medical policy for J1745 (Infliximab).
3. Read the policy. Does it only cover Crohn’s *after* a failure of Humira? Was this a “step-therapy” denial?		 This is a clinical, not a billing, error. The claim must be appealed with a Letter of Medical Necessity from the provider, supplemented by your pharmacy notes, explaining *why* this drug was clinically appropriate.

7.1.8 Your New Identity: The Reimbursement Integrity Pharmacist

This section was dense, technical, and may feel worlds away from patient care. But in specialty pharmacy, reimbursement is patient care. A denied claim is a barrier to the next infusion. A financially unstable infusion center cannot treat new patients. Your role as a Certified Advanced Specialty Pharmacist is to be the bridge between the clinic and the back office.

You are the only person who can look at a patient’s chart, identify the drug (NDC), the dose, the wastage, the infusion time (CPT), and the J-code units (HCPCS) and confirm that all pieces of the puzzle fit together perfectly. You are the only one who can confidently defend that claim to an auditor.

By mastering this “alphabet soup,” you are not just becoming a biller. You are becoming a Reimbursement Integrity Specialist. You are the financial guardian of the specialty drug program, ensuring that the hospital or clinic can continue to provide these life-saving, high-cost therapies. You ensure that what was clinically appropriate becomes financially sustainable. In this world, your mastery of the NDC is the key that unlocks the entire medical claim. You are not just a pharmacist; you are the most valuable detective your organization has.