2024-2025 Self-Audit Series #12: Electronic Prescriptions

This month’s article will wrap up the 2024-2025 Self-Audit Series. Our focus for this article is electronic prescriptions and their potential audit risks. Electronic prescriptions have solved some problems (e.g., indecipherable handwriting), but have also created new problems. By focusing on the following tips when reviewing your electronic prescriptions, you can help prevent significant recoupments.

Be sure any clarifications are clearly documented with these four elements: date, name and title of who you spoke with, what was clarified, initials of who made the call. This information must be accessible to the auditor upon audit.

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  • Quantity: Unclear quantities and/or missing clear units of measure should be clarified with the prescriber’s office. Auditors look for mL, pens, boxes, or units, especially with highly targeted injectables. In addition, the quantity of “1” cannot be assumed when multiple package sizes are available.
  • NDC: The NDC reflected on an electronic prescription is considered “representative” according to NCPDP.  The Representative NDC Use in Electronic Prescribing Fact Sheet indicates “The representative NDCis not intended to infer specificity or preference to the embedded manufacturer/labeler”; therefore, determining which product to dispense cannot be solely based on the representative NDC, if present.
  • Instructions for Use
    • Ambiguous instructions should be clarified
    • Clarify when prescription appears to have two conflicting instructions
    • Check for “calculable” instructions; must be able to accurately calculate days’ supply based off instructions
    • Instructions, including clarifications, must be reflected accurately on the patient label prior to dispensing
  • Days’ Supply
    • Auditors will generally not consider the days’ supply field on electronic prescriptions
    • Pharmacy must calculate days’ supply based on quantity and instructions for use
    • Use caution with a software’s default field for days’ supply as this information is frequently incorrect
    • Day’s supply must be billed accurately, bypassing days’ supply plan limits puts claims at risk of full recoupment
  • DAW
    • Have documentation to support DAW codes billed other than “0”
    • Recommend confirming DAW 1 with prescriber when medication is new to patient
    • Check your state’s (and Medicaid’s) specific requirements for DAW 1 prescriptions
    • Brand name single source medications should not be billed with DAW 1 as this may increase audit risk
  • Notes Field
    • Conflicting information in notes field should be clarified with the prescriber’s office
    • Be sure any additional instructions from the notes field are included on the patient label
  • Failover Electronic Prescriptions
    • When electronic prescriptions fail to be transmitted, they may come through to the pharmacy’s fax machine
    • Confirm your state’s specific requirements for faxed prescriptions and call for verbal authorization, and document, when necessary

Dana Westberg, CPhT
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