Wiki Pharmacy Claim/Billing

[christinav]

I am going to start billing for a Pharmacy who has contracted with a Payor to distribute/dispense infusion medications to the ordering physicians for patient's. The question is, the Payor requires billing claims for those medications from the pharmacy; Other than the HCPC Code for the medication, NDC, pharmacy information and Ordering physician information, is there anything else that I need to add to the claim? It is not using the PartD submission methods and will be sent as a medical claim.

 

[thomas7331]

This sounds like an odd arrangement between a pharmacy and a payer. If this payer is going to require drugs to be billed on a medical claim form, then you're going to need a diagnosis from the physician. This could potentially be problematic since physicians, as far as I know, don't normally include that information when prescribing a drug from a pharmacy. So you may need to set up a process by which you get this information, similar to the way a lab or diagnostic imaging center will require a diagnosis with their orders for a test. I'd caution against having the physician submit an ICD-10 code to you because physicians are notoriously poor coders and if you don't have access to their medical records, then you don't have a way to validate and/or correct their coding when needed. It would be best to have the physician give you a statement of the diagnosis along with the prescription and assign you ICD-10 code based on that.

This is not a normal way for pharmacies to bill so you're probably going to have to wait and see how it goes and troubleshoot the billing process as it evolves.

 

[christinav]

This sounds like an odd arrangement between a pharmacy and a payer. If this payer is going to require drugs to be billed on a medical claim form, then you're going to need a diagnosis from the physician. This could potentially be problematic since physicians, as far as I know, don't normally include that information when prescribing a drug from a pharmacy. So you may need to set up a process by which you get this information, similar to the way a lab or diagnostic imaging center will require a diagnosis with their orders for a test. I'd caution against having the physician submit an ICD-10 code to you because physicians are notoriously poor coders and if you don't have access to their medical records, then you don't have a way to validate and/or correct their coding when needed. It would be best to have the physician give you a statement of the diagnosis along with the prescription and assign you ICD-10 code based on that.

This is not a normal way for pharmacies to bill so you're probably going to have to wait and see how it goes and troubleshoot the billing process as it evolves.

Thank you Tommy, definitely something new and was thinking the same thing. I want to ensure that the prescription for the medications match the diagnosis provided by the Ordering provider on the claim, I don't want that to be an issue. Thank you for taking the time, and glad we have the same thought process here.

 

[rachaelwilleford]

Usually if the payer is requiring the dispensing from the pharmacy, it's usually as part of the pharmaceutical benefits - not medical. Is this a specialty med that is subject to site of care or specialty pharmacy restrictions? If so, then yes the bill would be under the pharmacy benefit. The infusion suite would bill the administration with a 0 charge for the drug.