Billing Guidance Reminder: Correct HCPCS Code/NDC Matching for Medical Claims
3/23/2026
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Posted by Provider Relations
Pursuant to past guidance by the New York Department of Health (NYDOH), claims submitted under the medical benefit for medications must include a valid National Drug Code (NDC). Claims that do not include an NDC, or that include an NDC that does not match the billed HCPCS code, may be denied and/or not eligible for reimbursement.
Billing Guidance Reminders
- Submit the HCPCS code that accurately reflects the drug administered.
- Report the 11-digit NDC (5-4-2 format, no spaces or hyphens) that corresponds to the actual product administered.
- Ensure the NDC matches the HCPCS code and that both align to the service documented in the medical record.
- Verify units and any required claim elements per your billing software/clearinghouse to avoid rejections.
Common Issues
- Missing NDC on a drug claim billed under the medical benefit.
- NDC does not correspond to the billed HCPCS (e.g., different medication, different strength, dosage form, or package size than the administered product).
- Incorrect NDC format (not 11 digits).
Claim Denial Details
- Denial Code: BMB
- Explanation: HCPCS-NDC does not match
Reference: NYSDOH guidance on NDC reporting for physician-administered drugs can be found here: https://www.health.ny.gov/health_care/medicaid/program/update/medup-n-o.htm