Matching NDCs Help Keep the Audits at Bay

billing and dispensing the same NDC, down to the correct package size.  

Unit-of-use packages like test strips, inhalers, and topical medications are some of the biggest culprits. PBMs flag claims for these products when the billed quantity is not divisible by the package size billed, making them low-hanging fruit to PBMs looking for recoupments. Pharmacies also need to be cautious of dispensing multiples of smaller package sizes when a larger package size is available on the market.

On desk or onsite audits where the auditor is conducting prescription reviews, recoupment for these claims can vary depending on the PBM and situation. Some scenarios might call for a partial recoupment with the PBM indicating they will pay for the correct package size. However, more precarious situations could seek full recoupment with little room for appeal. Listed below are common scenarios to be on the lookout for:

• Billing 28 g on a topical with a package size of 30 g
• Dispensing two 30 g tubes when a 60 g package size is available
• Billing an NDC for a 100-count box of test strips with a quantity of 150
• Billing the institutional NDC for Symbicort^® with a quantity of 10.2 g

In the case of invoice audits, the auditor will be looking at the pharmacy’s invoices to ensure the exact NDC # that was billed matches what NDC # was received by the pharmacy as reflected on the wholesaler invoice. PAAS National^® has many Newsline articles to help your pharmacy be prepared for an invoice audit, the most recent article being part of the Self-Audit Series.    

PAAS Tips:

• Implement barcode scanner technology for product verification to prevent misfills and ensure filling/billing accuracy
• Verify the quantity billed matches tube size dispensed for topical medications (when feasible and appropriate). Often, the last 2 digits of the NDC match the package size
• If you need to dispense two smaller package sizes because the larger package size is unavailable/backordered, document accordingly (e.g., urgent clinical need or proof from your wholesaler that the larger package size was unavailable and attach it to the prescription)
  • Alternatively, contact the prescriber to modify the quantity prescribed and refills to match available package sizes
• Flag shelves for medications with multiple package sizes to remind staff to doublecheck the NDC