Healthcare organizations are being asked to manage ventilators, drug shortages, establish telehealth services, manage a budget, and downsize staff among other tasks amid the pandemic. You may leave the day feeling as if you were Thor conquering the Nine Realms. The Pharmacy Revenue Cycle Newsletter aims to put the Mjölnir (hammer of Thor) into your hands and provide you with helpful tips, resources, and emerging updates that can improve your pharmacy revenue.
“Pharmacy Revenue Cycle” (www.pharmacyrevenuecycle.com) is brought to you by Agatha Nolen, Ph.D., CRCR, FASHP and Maxie Friemel, PharmD, MS, BCPS, CRCR. Together we bring over 25 years of experience working with CFO’s, pharmacy directors, billing & charge master teams, informatics, and alike. Recognizing organizations’ gaps in understanding the pharmacy revenue cycle and the increasing impact pharmaceuticals have on our budget, our goal is simple. We take complex and ever changing rules and regulations, bring you awareness and practical tools that can help you understand and enhance your pharmacy revenue cycle.
Each year the influenza season brings about its own challenges from distribution to billing. In the midst of a pandemic, influenza billing may seem trivial which is more the reason a simplified tool could boost your accuracy. For our debut of the Pharmacy Revenue Cycle Newsletter and website, we bring you an Influenza Billing Tool.
The influenza tool extracts the influenza products and packages from the CDC. This information is then mapped to available CMS Flu Shot Coding which contains the HCPCS/CPT and descriptions for each vaccine. When mapping NDC to CPT codes, caution is taken to ensure accuracy based upon dosage, valency, formulation (e.g. MDV, SDV) among other attributes of each individual product. Lastly, we have included the CMS payment allowance which is calculated at 95% of AWP. This is the estimated reimbursement for Medicare Part B beneficiaries with the exception of Hospital Outpatient Departments which are paid at reasonable cost.
- Sanofi Pastuer has developed a high dose formulation that is dosed at 0.7 mL versus the traditional 0.5 mL. CPT code 90662 will be used to code this product, but is the same code as previous years 0.5 mL dosage. Ensure the CDM or billing crosswalks reflect the updated 0.7 mL per billed units or is based on a per dose and only 1 billed unit is calculated per dose.
- CPT 90686 and 90685 differ only by the dosage administered but often represent the same NDC. Validate that your system produces the correct CPT based on the dose administered.