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(October 2004)

GR 0.045 ML 1.5 UN 2 1234.56 2 12345678.123 Field 42: Revenue code Field 43: NDC 11-digit number, Unit of Measurement Qualifier, and Unit Quantity Field 44: HCPCS code The NDC qualifier N4 and NDC code are sent in the LIN segment LIN02 NDC Qualifier LIN03 NDC Code The quantity and unit of measure are sent in the CTP segment CTP04 Quantity CTP05-1 Unit of Measure The prescription number or link sequence number (to report components for a compound drug) REF01 - VY: Link Sequence Number, XZ : Prescription Number REF02 Link Sequence Number or Prescription Number If the NDC on the label does not include a full series of 11 digits, add a leading zero to the appropriate section to create a 5-4-2 configuration

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