Are You Willing to Risk Recoupment for Missing DUR and SCC Documentation?

DUR messages are designed as a warning to avert potential patient harm and require pharmacist intervention before proceeding. These are the more obvious DURs to spot and handle. Soft DURs can be easily overlooked but still require thorough review. For example, a DUR indicating the prescription was filled at another pharmacy should generate questions regarding current therapy or possible duplicate therapies the patient may be unaware of.

SCCs might be necessary to use when a patient is requesting a refill due to an upcoming vacation, lost or stolen medication, or a change in therapy. Some PBMs are known for auditing high dollar claims with override codes, like Express Scripts and Prime Therapeutics. Auditors are looking for documentation, including rationale on the prescription, when the override codes are used, but what does this mean? Below is an example of appropriate DUR and SCC documentation.

DUR Documentation: HD/M0/1B – Verified with Dr. Jones they are aware this is a high dose/Told to fill prescription as is/Pharmacist’s initials/date

SCC Documentation: SCC 03 – Susan is going on vacation to Italy from 01/06/2025 to 01/20/2025 & requires a vacation supply of medicine/date

Simply documenting the override codes utilized does not provide the auditor with the explanation of why it was appropriate to use. When under audit, be sure to make all clinical notes visible for the auditor. Rescan hard copies into your pharmacy software system when handwriting notes if necessary; this can help ensure the notes will not be missed when under audit.

PAAS Tips:

• A full clinical note should have four elements:
  • Date
  • Name and title of person you spoke with
  • What was discussed
  • Initials of who made the call
• Professional service code “M0” requires consultation with the prescriber and a supporting clinical note
  • Consider other professional service codes like “MR” (Medication Review) or “R0” (Pharmacist consulted other source) if “M0” is not applicable
  • Rationale for these codes is still required to be documented
• Vacation overrides should include documentation of where the patient will be and the dates they will be gone documented, as shown in the example above
• If referencing a clinical note from a previous prescription, the full note should be carried over to the new prescription
• Use professional judgement for when a follow-up with the prescriber is necessary to ensure the validity of the DUR code submitted and update when appropriate
  • It’s good practice to reconfirm at least once per year, or when there is a change in therapy or prescriber