Billing Not Otherwise Classified (NOC) HCPCS Code - JA DME

Correct Healthcare Common Procedure Coding System (HCPCS) coding is imperative when providing DMEPOS items to a beneficiary. Suppliers are required to correctly code for the item billed. An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, or DME MAC articles. Medicare will deny services reported with not otherwise classified (NOC) codes if valid codes are available for item. Noridian will not correctly code a billed NOC code when a valid HCPCS code is available.

Items billed with any HCPCS code with a narrative description that indicates miscellaneous, NOC, unlisted, or non-specified, must also include a narrative in the NTE 2400 (line note) or NTE 2300 (claim note) segments of the American National Standard Institute (ANSI X12) format. These narratives may also be added in Item 19 of the CMS-1500 claim form. Enter as much information as possible to ensure prompt processing of the claim.

The NTE 2400 field of an electronic claim is limited to 80 characters; therefore, suppliers are encouraged to use the following list of Common Abbreviations to Use as Narratives to condense all of the required information into this field.

Required Narrative added to claim for NOC coded item:

• To process the claim correctly, the claim must Indicate what it is, what is it for, what is Supplier Price List (PL) amount.
• Description of the item or service
• Manufacturer name
• Product name, model name and number
• Supplier Price List (PL) amount
• HCPCS code of related item (if applicable)
• If Repair part, HCPCS code of item being repaired
• Example
  • Titanium Hooks 3010865 Manufacture, for XXXXX (HCPCS Code), Supplier Price List (PL) amount $XXX.XX

Custom Fabricated - If item is custom-fabricated, provide complete and clear description of item including:

• Description of the item
• Description of what makes item unique
• Breakdown of charges (materials and labor)

Remember, space is limited so ensure what is required is entered in the narrative.

Denials

• If the narrative information is not added to the claim, the claim will deny as missing/incomplete/invalid description of service for a Not Otherwise Classified (NOC) code and must be corrected and rebilled as the denial will indicate there are no appeal rights because the claim is unprocessable.
• If claim is processed and denied, for reason other than above, request redetermination with all documentation to support medical necessity
• Medical necessity for item (medical records)
• If item is custom-fabricated, provide complete and clear description of item including:
  • Description of the item
  • Description of what makes item unique
  • Breakdown of charges (materials and labor)

Gap Filling

The fee schedule for items for which charge data is not available or published is calculated based on:

• Fee schedule amounts for comparable equipment
• Fee schedule amounts of other DME MACs
• Supplier price lists
• Manufacturers wholesale price

Where supplier price lists are used, efforts are made to obtain prices in effect during the base year. Mail order catalogs are often used as sources of price information. A deflation factor is applied if the price information is from a period other than the base period. This is done to approximate the base year price for gap filling purposes. For more information on the pricing methodology used for unpublished fee schedules review CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Fee Schedule Administration and Coding Requirements.

Individual Local Coverage Determination (LCD) or Policy Articles (PA) will have specific NOC coding information. Visit Noridian's website for specific LCDs or PAs for policy specific NOC codes. For questions about correct coding, contact the Pricing, Data Analysis, and Coding (PDAC) contractor.