Why the Unit of Measure Matters in Audits: A Small Factor with Big Consequences

that the correct quantity cannot be determined without the proper UOM being present. To combat the discrepancy, pharmacies may need to obtain a letter from the prescriber to substantiate what the pharmacy billed was indeed the correct quantity. These letters are often difficult to obtain, especially when claims are several years old, prescribers have relocated, or your pharmacy doesn’t have a working relationship with the office.

If your pharmacy receives a prescription without a UOM, or a UOM that is ambiguous, PAAS recommends contacting the prescriber for clarification and documenting with a clinical note.

Examples:

1. You receive a prescription for Lantus^® Solostar^® pens, quantity 15, UOM “unspecified.”
   1. Did the prescriber intend for the prescription to be written as 15 mL, 15 pens, or 15 boxes?
2. You receive a prescription for Combigan^® solution, quantity 1, UOM “bottle.”
   1. Did the prescriber intend for the 5 mL, 10 mL, or 15 mL bottle?
3. You receive a prescription for Trelegy Ellipta, quantity 1, UOM “inhaler.”
   1. At first glance, this may seem like an acceptable prescription. However, Trelegy comes in two sizes. Did the prescriber intend for the 60 each retail package or the 28 each institutional size package? “Each” is the proper UOM per NCPDP guidelines.
4. You receive a prescription for Trelegy Ellipta, quantity 1, UOM “each.”
   1. The correct billing unit is “each,” but the quantity should either be 60 for the retail package or 28 for the institutional package. Third party auditors will often flag the “1 each” combination – contact the prescriber to avoid ambiguity.

The following table shows the medications PAAS typically sees UOM troubles with and the typical billing units that should be used:

*The “each” UOM may need to be clarified if the quantity doesn’t correspond to an “each” unit of measure (e.g., 10 each on an eye drop likely indicates 10 mL vs 10 bottles of 10 mL)

When in doubt, clarify the prescription. Do not leave the UOM interpretation to a third-party auditor who has no reason to give you the benefit of the doubt and every reason to interpret it to their advantage.

PAAS Tips:

• Ambiguous or missing UOM should be clarified with the prescriber with a clinical note added to the prescription before dispensing
• The best quantity clarification will contain the actual billing unit per NCPDP for the drug, leaving no room for misinterpretation
• Clinical notes should contain the date, name and title of who you spoke with, summary of discussion, and your initials
• Pay close attention to electronic prescription quantities which have the biggest potential for incorrect or “unspecified” UOM
• Other prescription origins (written, fax, and transfer) may need clarification for missing UOM
• Notating UOM on all telephone orders would be considered best practice
• Some PBMs may consider a quantity of “1” to be the smallest package size; therefore, clarify the quantity with the prescriber if dispensing a larger size