From the Field: Competing Medicare and Medicaid Regs: You Lose

Sarah Tolson

Providers are in a no-win situation when Medicare and Medicaid regulations conflict with one another. A perfect example of this is reflected in the sample question below we received from several billers:

Question: Medicaid requires us to report the NDC (National Drug Code) for each vial size we use in dosing a patient. For example, if our physician orders a 50 mcg dose of Aranesp, we have to use a 40 mcg vial and a 10 mcg vial. When filing primary claims to Medicaid, we can report the 40 mcg vial on one line and the 10 mcg vial on the other line and both are reimbursed.

However, for our Medi/Medi patients (Medicare primary and Medicaid secondary), Medicare only accepts one HCPCS code for each date of service. Once Medicare processes the claim they electronically forward the secondary claim to Medicaid. This means that for me to report the correct dose of 50 mcg, I can only report one NDC code, which is against Medicaid regulations. Do I just choose one NDC code and hope Medicaid never audits our claims?

Answer: Great question for which there appears to be no practical solution at this point. Medicare does not require NDCs on renal claims so they simply pass the NDC information on to Medicaid in the electronic secondary claim. (See MLN Matters 5950).

NDCs are a big issue for each state due to a provision in the Deficit Reduction Act of 2005 that requires Medicaid to collect rebates from drug companies. Without NDCs, Medicaid cannot submit the information needed to qualify for the rebates.

When electronic claim version 4010 was introduced, a biller could attach up to 25 NDCs to each claim line containing a HCPCS code. However, following the release of the current electronic claim version, 5010, only one NDC is allowed to be attached to each HCPCS code.

Some states have caught on to the problem and adapted their regulations so that providers can successfully navigate the conflicting regulations. For example, for primary claims Medi-Cal (California Medicaid) regulations state, “When a provider uses more than one NDC for a drug, the provider must include all NDCs on the claim. The quantity for each NDC must be reported separately by repeating the HCPCS code”

However, when processing secondary claims electronically sent to them by Medicare, Medi-Cal drops the NDC requirement: “Crossover claims do not require NDC information at this time. If Medicare implements all of the NDC requirements at a future point in time and requires Medi-Cal to use it for crossover claims, then Medi-Cal will notify providers accordingly.”

While California has recognized and dealt with this issue for the moment, other states appear unaware. Here is a snippet from another state’s regulations that are similar to those found in most states across the country, “The required drug rebate information is still required on a claim even if Medicaid is a secondary or tertiary payer.”

In states that require providers to report NDC information on Medicare/Medicaid crossover claims, providers should contact their Medicare contractor about this issue to see if a workaround can be accomplished. A simple solution would be for the Medicare contractor to allow the same HCPCS code to be reported on multiple lines for the same date of service if the NDC numbers on each claim line are different. If Medicare contractors are unable or unwilling to comply, providers should contact their Medicare Regional Office and make them aware of the problem and seek guidance on how to handle this issue.


Sarah Tolson is the director of training for Sceptre Management Solutions, Inc., a company that provides renal billing services for outpatient dialysis and nephrology practices across the United States. Sarah has worked in renal billing for the past eight years and is a walking encyclopedia of information regarding revenue cycle management issues that affect the renal industry.
“I’m very excited for the opportunity to contribute to our industry through this column,” Sarah said. “It is a little daunting, but I look forward to providing what I hope will be a helpful resource for everyone who wants to stay on top of current billing issues that affect us all.”

Sarah works with Rick Collins, who has been our From the Field columnist since its inception in August 2014. Rick will continue to be involved behind the scenes by providing ideas and feedback regarding future columns.

We encourage readers to contact Sarah with questions that affect billing for nephrology practices, dialysis facilities, and vascular access programs. She can be reached at or 801.775.8010.