Appropriate use of not otherwise classified codes

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Home ► Claim submission guidelines ► Appropriate use of not otherwise classified codes

Last Modified: 7/25/2024 Location: FL, PR, USVI Business: Part B

Appropriate use of not otherwise classified codes

Correct coding requires services to be reported with the most specific code available that appropriately describes the service. Not otherwise classified (NOC) HCPCS or CPT codes must only be used when a more specific HCPCS or CPT code is not available.

There may be services or procedures performed by physicians or other qualified health care professionals not found in the CPT or HCPCS code sets. Therefore, several codes have been designated for reporting unlisted or NOC procedures, which can be found in the CPT and HCPCS code manuals.

Claims for all drugs and biologicals should be reported using the CPT or HCPCS code which most accurately describes the drug or biological. It is also important to make certain the reported units of service for the CPT or HCPCS code are consistent with the description of a drug or biological.

When the medication administered has not been assigned a CPT or HCPCS code, it is appropriate to use a NOC code based on the descriptor. A description of the drug or biological and dosage must be entered in the narrative field of the claim.

For NOC codes reported for services other than drugs and biologicals, a concise description of the procedure being completed must be included. Otherwise, documentation to support the service shall be submitted with the initial claim submission.

Use of NOC codes is appropriate if HCPCS Level II codes or CPT codes are not available describing the service.

Note: Any claim for a service containing a description in the narrative field describing a procedure or service where a valid HCPCS or CPT code exists or not including sufficient information about the service being performed may be rejected.

Unlisted codes for drugs and biologicals

J1599 - Injection, immune globulin, intravenous, nonlyophilized (e.g., liquid), not otherwise specified, 500 mg

J3490 - Unclassified drugs

J3590 - Unclassified biologics

J7199 - Hemophilia clotting factor, not otherwise classified

J7999 - Compounded drug, not otherwise classified (paid by invoice except for Intravitreal Avastin)

J9999 - Not otherwise classified, antineoplastic drugs

Commonly used when:

• Drug or biological does not have a specific CPT or HCPCS code

• Drug or biological is administered by a route other than stated in the code

• Amount of drug or biological is less than the amount, or of a different concentration, than specified in the CPT or HCPCS descriptor

Remember to confirm the proper HCPCS (specific) and National Drug Code (NDC) code is used when submitting a claim.

Note: The units of service for a drug code may not match the available dosage forms. In these cases, the number of units of service billed must be adjusted to match the actual amount provided.

NOC drug and biological codes billing

To correctly process a claim using the NOC codes above, report the following information in item 19 of the CMS-1500 claim form or electronic equivalent (loop 2400.SV101-7 in the ANSI 837 claim file):

• Name of drug

• Strength and dosage (mg, mL, etc.)

• Amount wasted (mg, mL, etc.) if applicable

• For more information concerning drug wastage, see Using the JW and JZ modifiers

Pricing information for most unlisted drugs may be found on the CMS website in the ASP drug pricing file external link

For local coverage determinations (LCDs) pertaining to an unlisted drug, refer to the interactive LCD index.

Incorrect use of NOC codes example

Provider billed HCPCS code J3590 along with a narrative of Mepolizumab 100 mg.

Correct billing: The proper billing would be HCPCS code J2182 (Mepolizumab 1 mg) with a unit of 100.

References

• Process for supplying invoice amount on certain HCPCS codes -- Avoid rejected claims

• CMS IOM Pub. 100-04, Claims Processing Manual, Chapter 17 external pdf file

• Medicare Part B Drug Average Sales Price external pdf file

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