Proper Billing for Intermittent Use Medications

Calculating proper days’ supply on continuous use medications can be hard enough; how do PBMs and auditors view medications that are used intermittently?

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Simply put, the days’ supply billed should take into account the entire cycle, including days in which the patient will not be taking medication. Xeloda® (capecitabine), an oral chemotherapy regimen, is commonly dosed twice daily for 14 days, followed by a 7-day break. The proper days’ supply to bill is 21 days.

Some common examples seen in pharmacy, despite the lower cost and audit risk, include:

  • Birth control
  • Bisphosphonates, such as Fosamax® and Actonel®

Let’s take a commonly seen Synthroid® dosing regimen where a patient is to take medication five days a week:

#5 tablets per week x 4 weeks = #20 tablets for a 28 days’ supply

Note the days’ supply is computed in terms of number of weeks. Billing the claim for a 30 days’ supply would be incorrect. Humana would charge a $5 penalty fee for every audited prescription (and all associated refills) billed with that invalid days’ supply.

In addition to the claim with an incorrect days’ supply, there is a potential recoupment risk with subsequent fills. Billing a days’ supply shorter than the true days’ supply could cause future refills to be filled early, resulting in claims being fully recouped. Conversely, a claim billed for a days’ supply longer than the true days’ supply could lead to an erroneous “refill too soon” rejections, resulting in an interruption to a patient’s medication therapy.

If there is ever a question about whether a days’ supply is properly calculated, PAAS Audit Assistance members can call (608) -873-1342, email or submit a question online through the PAAS Member Portal. We want to help pharmacies prevent audits, so we are always happy to work with pharmacy staff to calculate the correct days’ supply prior to it being called into question in an audit.

PAAS Tips:

  • Unless explicitly stated in the directions that the medication is to be used as “extended cycling”, “continuous use”, or the like, take into account break days
Meredith Thiede, PharmD