Article Detail - JA DME

Healthcare Common Procedure Coding System (HCPCS) correct coding is crucial for suppliers providing Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items to beneficiaries. One area that often leads to confusion is the use of Not Otherwise Classified (NOC) codes. Properly coding NOC items not only ensures compliance with Centers for Medicare & Medicaid Services (CMS) guidelines but also helps prevent claim denials.

Importance of Correct Coding

Suppliers must adhere to specific coding guidelines established by CMS, including Local Coverage Determinations (LCDs), Policy Articles (PAs), and DME Medicare Administrative Contractor (MAC) articles. Claims submitted using NOC codes will be denied if a valid HCPCS code exists for the billed item. Therefore, accurate coding is not just a best practice; it's a requirement.

NOC Code Requirements

When billing with NOC codes, it is essential to provide detailed narratives in the appropriate claim segments:

1. NTE 2400 (line note) or NTE 2300 (claim note) for electronic claims.
2. Item 19 of the CMS-1500 claim form for paper claims.

Narratives must clearly articulate:

• Description of the item or service
• Manufacturer name
• Product name, model name, and model number
• Supplier Price List (PL) amount
• HCPCS code of related item (if applicable)
• If applicable, the HCPCS code for the item being repaired.

Example Narrative

A properly formatted narrative might read:
"Titanium Hooks, 3010865, Manufacturer name, for (HCPCS Code XXX), Supplier Price List (PL) amount $XXX.XX

Given that the NTE 2400 field is limited to 80 characters, suppliers are encouraged to use Common Abbreviations to Use as Narratives to convey all necessary information concisely.

Handling Denials

Claims lacking the required narrative information will be denied for being incomplete or invalid. These claims must be corrected and resubmitted, as the denial notice will indicate that there are no appeal rights available because the claim is unprocessable.
If a claim is denied for other reasons, suppliers can request a redetermination by providing supporting documentation, which includes:

• Medical records demonstrating medical necessity
• Detailed descriptions of custom-fabricated items, highlighting unique features and including a breakdown of costs (materials and labor).

Additional Resources

For specific NOC coding information, refer to Individual Local Coverage Determinations (LCDs) or Policy Articles (PAs). Suppliers seeking guidance on correct coding practices can contact the Pricing, Data Analysis, and Coding (PDAC) contractor for further assistance.