LTC Essentials: A Guide to Residence Codes, Pharmacy Service Types, and Submission Clarification Codes
With more pharmacies exploring the world of long-term care and LTC Pharmacy at Home dispensing increasing daily, PAAS National® has also been seeing audits on these claims. One area PBMs have been targeting surrounds…
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erroneous billing of Patient Residence Codes, Pharmacy Service Types, and Submission Clarification Codes (SCC). Recoupments primarily focus on SCC issues.
Please see the following tables to determine if you are billing the correct codes and service types to avoid potential audit recoupment:
| Residence Code | NCPDP Definition |
| 0 | Not specified, other patient residence not identified below |
| 1 | Home |
| 3 | Nursing Facility |
| 4 | Assisted Living Facility |
| 6 | Group Home |
| 9 | Intermediate Care Facility/Mentally Retarded |
| 11 | Hospice |
| Pharmacy Service Type | NCPDP Definition |
| 1 | Community/Retail Pharmacy Services |
| 2 | Compounding Pharmacy Services |
| 3 | Home Infusion Therapy Provider Services |
| 4 | Institutional Pharmacy Services |
| 5 | Long Term Care Pharmacy Services |
| 6 | Mail Order Pharmacy Services |
| 7 | Managed Care Organization Pharmacy Services |
| 8 | Specialty Care Pharmacy Services |
| 99 | Other |
| Submission Clarification Code | NCPDP Definition |
| 16 | LTC Emergency Box (kit) or automated dispensing machine – Indicates that the transaction is a replacement supply for doses previously dispensed to the patient. |
| 21 | LTC dispensing: 14 days or less not applicable – Fourteen days or less dispensing is not applicable due to CMS exclusion and/or manufacturer packaging may not be broken or special dispensing methodology (i.e. vacation supply, leave of absence, E-Kit, spitter dose). Medication quantities are dispensed as billed |
| 22 | LTC dispensing: 7 days – Pharmacy dispenses medication in 7 day supplies |
| 23 | LTC dispensing: 4 days – Pharmacy dispenses medication in 4 day supplies |
| 24 | LTC dispensing: 3 days – Pharmacy dispenses medication in 3 day supplies |
| 25 | LTC dispensing: 2 days – Pharmacy dispenses medication in 2 day supplies |
| 26 | LTC dispensing: 1 day – Pharmacy or remote (multiple shifts) dispenses medication in 1 day supplies |
| 27 | LTC dispensing: 4-3 days – Pharmacy dispenses medication in 4 day, then 3 day supplies |
| 28 | LTC dispensing: 2-2-3 days – Pharmacy dispenses medication in 2 day, then 2 day, then 3 day supplies |
| 29 | LTC dispensing: daily and 3-day weekend – Pharmacy or remote dispensed daily during the week and combines multiple days dispensing for weekends |
| 30 | LTC dispensing: Per shift dispensing – Remote dispensing per shift (multiple med passes) |
| 31 | LTC dispensing: Per med pass dispensing – Remote dispensing per med pass |
| 32 | LTC dispensing: PRN on demand – Remote dispensing on demand as needed |
| 33 | LTC dispensing: 7 day or less cycle not otherwise represented |
| 34 | LTC dispensing: 14 days dispensing – Pharmacy dispenses medication in 14 day supplies |
| 35 | LTC dispensing: 8-14 day dispensing method not listed above – 8-14-Day dispensing cycle not otherwise represented |
| 36 | LTC Dispensing: dispensed outside short cycle – Medicare Part D coverage was determined post dispensing |
PAAS Tips:
- Educate all staff on proper residence codes, pharmacy service types, and SCCs.
- Consult your PSAO/GPO if you are unsure what the correct residence code should be when submitting a claim. Be judicious with LTC at home, independent living and various assisted living facility patients that can fall into grey areas.
- See the NCPDP WG9 Medicare Part D Questions and Answers document for more information on Patient Residence Codes and Pharmacy Service Types.
- See the NCPDP Telecommunication Version D and Above Questions, Answers and Editorial Updates document for more information on SCCs.
- See the March 2021 Newsline article, Are You Documenting DUR and Submission Clarification Codes?, for information on billing other common SCCs.
Analyst at PAAS National®
I grew up in a family of nurses and other medical professionals but was never interested in the clinic setting. I was drawn to pharmacy because I like to help people and could easily use the knowledge I grew up with to do so. It was a great fit.
I have a Bachelor of Arts in Communications from the University of Wisconsin – Madison. Prior to joining PAAS in 2017, I worked for Walgreens for 19 years.
As an Analyst at PAAS, I really enjoy being able to help independent pharmacies succeed. I have always been a fan of the underdog and am excited to be able to give you the tools you need to take on the giants of the PBM industry.
I have a Bachelor of Arts in Communications from the University of Wisconsin – Madison. Prior to joining PAAS in 2017, I worked for Walgreens for 19 years.
As an Analyst at PAAS, I really enjoy being able to help independent pharmacies succeed. I have always been a fan of the underdog and am excited to be able to give you the tools you need to take on the giants of the PBM industry.
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