Field Name Field Description Loop ID Segment
HCPCS/CPT Procedure Code Enter the appropriate HCPCS/CPT Code aligned with the NDC Code billed, if applicable. 2400 SV101
HCPCS/CPT Units
Enter the applicable units billed based upon the HCPCS/CPT code assigned dosage/quantity. The HCPCS/CPT unit must be submitted with a whole numeric value. (Unlisted Drug HCPCS/CPT codes do not have a specified quantity associated to the Unlisted HCPCS/CPT code. The HCPCS/CPT units billed should equal the number of drug containers (i.e. vial, bottle, tube) used for the services being billed.) **A HCPCS/CPT unit of 1 or greater must be billed on all claims**
2400
SV104
NDC Qualifier
Enter N4 in this field.
2410
L1N02
National Drug Code (NDC)
Enter the 11-digit NDC assigned to the drug administered/supplied (do not include hyphens/spaces). 11-digit NDC Code is required using 5-4-2 format.
2410
L1N03
Monetary Amount
Enter the Total Charge Amount for each line of service
2400
SV102
NDC Quantity
Enter the NDC quantity in decimal format (up to two decimal places) based upon the reported unit of measure assigned to the NDC Code. (NDC units billed must be converted based upon unit of measure assigned to NDC Code)
**NOTE – NDC Quantity should never be billed with a MG (ME) – milligram dosage being reported within the NDC quantity • MG is not a valid unit of measure for any NDC codes. • Refer to the Coding a Professional Claim – NDC Quantity for assistance on identifying the appropriate unit of measurement assigned to the NDC Code.
2410
CTP04
54
Unit of Measurement (UoM)
Enter the NDC unit of measurement associated to the billed NDC Code (UN, ML, or GR) • The NDC Quantity 4 units of measurement (UoM) reported for all drugs: UN, ML, GR, or F2. • There are no products currently reported with the unit of measure of F2 (international unit) • Refer to the Coding a Professional Claim – NDC Quantity for assistance on identifying the appropriate unit of measurement assigned to the NDC Code.
2410
CTP05
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