Diagnosis Restricted? Documentation Required!

PAAS National® is starting to see more audit recoupments on claims where a diagnosis code was required at adjudication but there was no documentation on the hardcopy to support the diagnosis code billed. PBMs may prompt pharmacies to enter a diagnosis code on claims when the medication billed is only covered for certain indications, helping to take the guesswork out of coverage limitations.

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Common diagnosis restricted drugs include GLP-1 (e.g. Trulicity®, Ozempic® and Mounjaro®), Nuedexta®, stimulants/ADHD medications, and Naltrexone. It is important to ensure the diagnosis code is present on the prescription or verified with the prescriber and a clinical note added to the prescription if you are prompted to enter a diagnosis code during claim adjudication. Do not process prescription claims for an assumed diagnosis code. Without any documentation to support the diagnosis code entered, the claim is likely to be flagged for recoupment if audited. Repeat prescriptions with a prior diagnosis code can likely be deferred to professional judgment but should have the diagnosis code (with a clinical note) transferred onto the new hardcopy to avoid audit trouble.

PAAS Tips:

  • Ensure diagnosis codes are properly documented on a prescription if entering them during claim adjudication
  • Entering a diagnosis code during adjudication, without PBM promoting, does not guarantee that a diagnosis is covered
    • In other words, PBMs ignore the diagnosis code field unless the PBM/Plan Sponsor requires it
  • Clinical notes should contain the date, name and title of who you spoke with at the prescriber’s office, a summary of the discussion, and your initials
  • Send all audit notices to PAAS for expert assistance. Pharmacies can securely upload files on the Member Portal under “Access Services

Jenevra Azzopardi, CPhT
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