PAAS National® frequently sees claims audited that contain a clinical drug utilization review (DUR) or submission clarification code (SCC), particularly from Express Scripts and Prime Therapeutics. Auditors are looking for proper documentation when these codes are used, but pharmacies are often unaware of what this should include.
When a claim is being processed, a DUR conflict message may appear as a warning to prevent potential patient harm. The pharmacist must be made aware of it so that they can use their professional judgement before dispensing the medication. These should not be automatically overridden without pharmacist input.
Once the pharmacist has reviewed the DUR conflict, they will determine the appropriate “professional service” and “result of service” codes. A full clinical note documenting the situation must then be recorded to prevent audit recoupment. Simply documenting the override codes used does not meet this criterion or provide the auditor with the explanation for why the override used was appropriate.
Inappropriate Documentation: HD/M0/1B
Appropriate Documentation: 01-01-2020/Verified with Dr. Jones they are aware this is a high dose/Told to fill prescription as is/Pharmacist’s initials
Claims billed with an SCC code require similar documentation. These are typically overrides done for situations like a vacation supply, lost or stolen prescription, or therapy change. The code used, the date, and the reason should be documented in these cases.
- Full clinical notations, whether handwritten or electronic, should have four elements:
- Name and title of person you spoke with
- What was discussed
- Initials of who made the call
- Professional service code “M0” will require consultation with prescriber
- Consider other professional service codes like “MR” (Medication Review) or “R0” (Pharmacist consulted other source) if “M0” is not applicable
- When using codes for a vacation override, the clinical note should include where the patient will be and the dates they will be gone
- If referencing a clinical note from a previous prescription, the full note should be carried forward to the new prescription
- Periodically consult with the prescriber to ensure that the DUR code submitted is still valid
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