Prospective Drug Utilization Review

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PharmacyPharmacy DrugDrugDrug UtilizaUtilizaUtilizationtiontiontiontiontion ReviewReview andandReview andandReview PharmaceuticPharmaceuticPharmaceuticalalalalalal CareCareCareCareCare ARCHIVAL USE ONLY CareCareCareCareCare Refer to the Online Handbook for current policy PPharmacy Quick-Reference Page Pharmacy Point-of-Sale (POS) Correspondents For questions regarding Medicaid policies and billing, please call: (800) 947-9627 or (608) 221-9883; select “2” when prompted.

Hours available: 8:30 a.m. to 6:00 p.m. Monday, Wednesday, Thursday, and Friday. 9:30 a.m. to 6:00 p.m. Tuesday. Not available on weekends or holidays.

Clearinghouse, Switch, or Value-Added Network (VAN) Vendors

For transmission problems, call your switch, VAN, or clearinghouse vendor:

• Healtheon/WebMD switching services: (800) 433-4893. • Envoy switching services: (800) 333-6869. • National Data Corporation switching services: (800) 388-2316. • QS1 Data Systems switching services: (864) 503-9455 ext. 7837.

Electronic Media Claims (EMC) Help Desk For any questions regardingARCHIVAL EMC (tape, modem, and interactive USE software), ONLY please call: (608) 221-4746 Ext. 3037 or 3041.

Hours available:Refer8:30 a.m.to to 4:30the p.m. MondayOnline through Friday. Handbook Not availablefor oncurrent weekends or holidays. policy Wisconsin Medicaid Web Site

www.dhfs.state.wi.us/medicaid/ • Pharmacy handbook, replacement pages, and Wisconsin Medicaid and BadgerCare Updates on-line and available for viewing and downloading. • Pharmacy POS information.

Fax Number for Prior Authorization (PA)

(608) 221-8616

Paper PA requests may be submitted by fax.

Specialized Transmission Approval Technology — PA (STAT-PA) System Numbers

For PCs: For touch-tone telephones: For the Help Desk: (800) 947-4947 (800) 947-1197 (800) 947-1197 (608) 221-1233 (608) 221-2096 (608) 221-2096 Available from 8:00 a.m. to 11:45 p.m., Available from 8:00 a.m. to 11:45 p.m., Available from 8:00 a.m. to 6:00 p.m., seven days a week. seven days a week. Monday through Friday, excluding holidays. IImportant Telephone Numbers Wisconsin Medicaid’s Eligibility Verification System (EVS) is available through the following resources to verify checkwrite information, claim status, prior authorization status, provider certification, and/or recipient eligibility.

Information Service available Telephone number Hours Automated Voice Checkwrite Info. (800) 947-3544 24 hours a day/ Response (AVR) Claim Status (608) 221-4247 7 days a week System Prior Authorization (Madison area) (Computerized voice Status response to provider inquiries.) Recipient Eligibility* Personal Computer Recipient Eligibility* Refer to Provider 24 hours a day/ Software Resources section of 7 days a week and the All-Provider Magnetic Stripe Handbook for a list of Card Readers commercial eligibility verification vendors. Provider Services ARCHIVALCheckwrite Info. USE(800) 947-9627 ONLYPolicy/Billing and Eligibility: (Correspondents Claim Status (608) 221-9883 8:30 a.m. - 4:30 p.m. (M, W-F) assist with 9:30 a.m. - 4:30 p.m. (T) Prior Authorization questions.) Refer to the Online Handbook Status Pharmacy/DUR: 8:30 a.m. - 6:00 p.m. (M, W-F) Provider Certification for current policy 9:30 a.m. - 6:00 p.m. (T) Recipient Eligibility* Direct Information Checkwrite Info. Call (608) 221-4746 7:00 a.m. - 6:00 p.m. (M-F) Access Line with Claim Status for more information. Updates for Prior Authorization Providers Status (Dial-Up) (Software Recipient Eligibility* communications package and modem.) Recipient Services Recipient Eligibility (800) 362-3002 7:30 a.m. - 5:00 p.m. (M-F) (Recipients or Medicaid-Certified (608) 221-5720 persons calling on Providers behalf of recipients General Medicaid only.) Information *Please use the information exactly as it appears on the recipient's identification card or EVS to complete the patient information section on claims and other documentation. Recipient eligibility information available through EVS includes: - Dates of eligibility. - Medicaid managed care program name and telephone number. - Privately purchased managed care or other commercial health insurance coverage. - Medicare coverage. - Lock-In Program status. - Limited benefit information. TTable of Contents Preface ...... 3

Drug Utilization Review ...... 5 Omnibus Budget Reconciliation Act of 1990 Requirements ...... 5 Prospective Drug Utilization Review ...... 5 Claims to Be Reviewed by the Prospective Drug Utilization Review System...... 6 Prospective Drug Utilization Review Alerts and Alert Hierarchy ...... 6 Drug-Drug Interaction ...... 6 Drug-Disease Contraindication (Reported and Inferred) ...... 6 Therapeutic Duplication ...... 7 Pregnancy Alert ...... 7 Early Refill ...... 7 Additive Toxicity...... 8 Drug-Age Precaution (Pediatric) ...... 8 Late Refill ...... 8 National Council For Prescription Drug Programs Fields That Display Alert Information ...... 8 Fields Required to Respond to Alerts and Receive Reimbursement ...... 8 Fields 439 ARCHIVAL(conflict code), 544 (free USE text), and ONLY 535 (overflow indicator) ...... 8 Edits, Audits, and Alerts ...... 9 ProspectiveRefer Drug Utilization to the Review Online and Pharmaceutical Handbook Care ...... 9 Retrospective Drug Utilization Review ...... 9 Retrospective Drug Utilizationfor current Review Activities policy ...... 9 Recipient Lock-In Program and Retrospective Drug Utilization Review ...... 9 Designated Lock-In Pharmacies ...... 10 Educational Program ...... 10 Pharmaceutical Care ...... 11 Documentation ...... 11 Pharmaceutical Care Profile ...... 11 Documentation Form For Pharmaceutical Care...... 11 ICD-9-CM Coding Requirements ...... 11 Pharmaceutical Care Dispensing Fee ...... 11 Professional Pharmaceutical Care Intervention Time ...... 12 Pharmaceutical Care Billing Requirements and Claims Processing Limits ...... 12 Submitting Claims For Pharmaceutical Care Dispensing Fee ...... 13 Appendix ...... 15 1. National Council For Prescription Drug Programs Fields Needed For Prospective Drug Utilization Review...... 17 2. Conflict Names, Codes, and Explanations For Each of the Prospective Drug Utilization Review Alerts ...... 19 PHC 1354C 3. Drug Utilization Review Service Codes ...... 21 4. Wisconsin Medicaid Pharmaceutical Care Profile ...... 23 5. Wisconsin Medicaid Pharmaceutical Care Dispensing Fee Documentation ...... 25 6. Wisconsin Medicaid Pharmaceutical Care Worksheet For Payable Codes ...... 27 7. Wisconsin Medicaid Pharmaceutical Care Reason Codes With Billing Information ...... 29 8. Wisconsin Medicaid Maximum Allowed Cost List for Pharmaceutical Care Codes...... 57 9. Wisconsin Medicaid Pharmaceutical Care Level of Service Definitions ...... 63 10. Sample Paper Claim Form — Pharmaceutical Care ...... 65 Glossary ...... 67

Index ...... 71

ARCHIVAL USE ONLY Refer to the Online Handbook for current policy PPreface The Wisconsin Medicaid and BadgerCare Pharmacy Refer to the Important Telephone Numbers page at the Handbook is issued to pharmacy providers who are beginning of this section for detailed information on the Wisconsin Medicaid certified. It contains information methods of verifying eligibility. If you are billing a that applies to fee-for-service Medicaid providers. The pharmacy claim through real-time Point-of-Sale (POS), Medicaid information in the handbook applies to both eligibility verification is part of the claims submission Medicaid and BadgerCare. process.

Wisconsin Medicaid and BadgerCare are administered Handbook Organization by the Department of Health and Family Services (DHFS). Within the DHFS, the Division of Health Care The Pharmacy Handbook consists of the following Financing (DHCF) is directly responsible for managing sections: Wisconsin Medicaid and BadgerCare. BadgerCare extends Medicaid coverage to uninsured children and • Claims Submission. parents with incomes at or below 185% (as of January • Covered Services and Reimbursement. 2001) of the federal poverty level and who meet other • Drug Utilization Review and Pharmaceutical Care. program requirements. BadgerCare recipients receive • Pharmacy Data Tables. the same health benefits as Wisconsin Medicaid • Prior Authorization. recipients and their health care is administered through the same delivery system. In addition to the Pharmacy Handbook, each Medicaid- ARCHIVAL USEcertified ONLY provider is issued a copy of the All-Provider Medicaid and BadgerCare recipients enrolled in state- Handbook. The All-Provider Handbook includes the contracted HMOsRefer are entitled to atto least thethe same Onlinefollowing Handbook subjects: benefits as fee-for-service recipients; however, HMOs may establish their own requirementsfor regarding current prior policy• Claims Submission. authorization, billing, etc. If you are an HMO network • Coordination of Benefits. provider, contact your managed care organization • Covered and Noncovered Services. regarding its requirements. Information contained in this • Prior Authorization. and other Medicaid publications is used by the DHCF to • Provider Certification. resolve disputes regarding covered benefits that cannot • Provider Resources. be handled internally by HMOs under managed care • Provider Rights and Responsibilities. arrangements. • Recipient Rights and Responsibilities.

Verifying Eligibility Legal Framework of Wisconsin Medicaid providers should always verify a Wisconsin Medicaid and recipient’s eligibility before providing services, both to BadgerCare determine eligibility for the current date and to discover any limitations to the recipient’s coverage. Wisconsin The following laws and regulations provide the legal Medicaid’s Eligibility Verification System (EVS) framework for Wisconsin Medicaid and BadgerCare: provides eligibility information that providers can access a number of ways. Federal Law and Regulation • Law: United States Social Security Act; Title XIX (42 US Code ss. 1396 and following) and Title XXI. • Regulation: Title 42 CFR Parts 430-456 — Public Health.

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 3 Wisconsin Law and Regulation Medicaid and BadgerCare are available at the following • Law: Wisconsin Statutes: Sections 49.43-49.497 Web sites: and 49.665. • Regulation: Wisconsin Administrative Code, www.dhfs.state.wi.us/medicaid Chapters HFS 101-108. www.dhfs.state.wi.us/badgercare

Handbooks and Wisconsin Medicaid and BadgerCare Medicaid Fiscal Agent Updates further interpret and implement these laws and The DHFS contracts with a fiscal agent, which is regulations. currently EDS, to provide health claims processing, communications, and other related services. Handbooks and Updates, maximum allowable fee schedules, helpful telephone numbers and addresses, and much more information about Wisconsin

ARCHIVAL USE ONLY Refer to the Online Handbook for current policy

4 Wisconsin Medicaid and BadgerCare K July 2001 Drug Utilization Review

D Drug Utilization Omnibus Budget Prospective vs. Retrospective Reconciliation Act of Drug Utilization Review Review 1990 Requirements Prospective Drug Utilization Review Although The federal Omnibus Budget Reconciliation • Performed before a drug is Medicaid’s Act of 1990 (OBRA `90) established dispensed. Aprospective DUR Medicaid program requirements regarding • Identifies a potential problem before system alerts several aspects of pharmacy practice. One of it occurs. pharmacy the requirements of OBRA `90 was a Drug • Provides real-time response to a providers to a Utilization Review (DUR) program for potential problem. variety of potential Medicaid outpatients to improve the quality • Has preventive/corrective action. problems, it is not and cost-effectiveness of recipient care. intended to Retrospective Drug Utilization replace Providers should refer to Phar. 7.01(1)(e) and Review pharmacists’ 7.08, Wis. Admin. Code, and 450.01(16)(i), • Performed after a drug is dispensed. professional Wis. Stats., for detailed information about • Warns when a potential problem judgement. Wisconsin’s DUR requirements. has occurred. • Useful for detecting patterns. The OBRA `90 requires that Medicaid DUR • Useful for designing targets for programsARCHIVAL should have all the following: USE ONLYintervention. • Has corrective action. Refer• Prospective to DUR. the Online Handbook • Retrospective DUR. When a claim is processed for a drug that has • An educationalfor programcurrent using DUR policythe potential to cause problems for the program data on common drug therapy. recipient, Wisconsin Medicaid returns an alert to inform the pharmacy provider of the Individual pharmacies are responsible for potential problem. The provider is then prospective DUR, while Wisconsin Medicaid required to respond to the alert to obtain is responsible for the retrospective DUR and reimbursement from Wisconsin Medicaid. the educational program. Further differences The provider is required to resubmit the claim can be found in the table at right. and include information about action taken and the resulting outcome. Prospective Drug Please note: although Medicaid’s prospective Utilization Review DUR system alerts pharmacy providers to a To help individual pharmacies comply with variety of potential problems, it is not intended their prospective DUR responsibility, to replace pharmacists’ professional Wisconsin Medicaid developed a prospective judgement. Potential drug therapy problems DUR system. The system screens certain drug may exist which do not trigger the Prospective categories for clinically significant potential DUR system. Prospective DUR remains the drug therapy problems before the prescription responsibility of the pharmacy, as required by is dispensed to the recipient. Prospective DUR federal and state law. Medicaid’s system is an enhances clinical quality and cost-effective additional tool to assist pharmacists in meeting drug use. this requirement.

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 5 The Wisconsin Medicaid DUR Board, Wisconsin Medicaid activates alerts that required by federal law, consists of three identify the following problems, which are physicians, five pharmacists, and one nurse presented in hierarchical order: practitioner. The board and the Department of Health and Family Services (DHFS) reviews 1. Drug-drug interaction (DUR conflict code and approves all DUR criteria and establishes DD). the hierarchy of alerts. 2. Drug-disease contraindication (reported [MC] and inferred [DC]). Review Claims to Be Reviewed by the 3. Therapeutic duplication (TD). Drug Utilization Prospective Drug Utilization 4. Pregnancy alert (PG). Review System 5. Early refill (ER). Under the prospective DUR system, only 6. Additive toxicity (AT). reimbursable claims for Medicaid fee-for- 7. Drug-age precaution (pediatric [PA]). service recipients submitted through real-time 8. Late refill (LR). Point-of-Sale (POS) are reviewed. Although paper claims, compound drug claims, and Drug-Drug Interaction electronic media claims are not reviewed by Wisconsin Medicaid activates this alert when Although paper the Medicaid prospective DUR system, another drug in claims history may interact claims, compound pharmacy providers are still required under with the drug being filled. The system reviews Adrug claims, and provisions of OBRA `90 to perform prospec- not only the prescriptions at the provider’s electronic media tive DUR independently. pharmacy, but all of the prescriptions claims are not reimbursed by Medicaid fee-for-service. reviewed by the Real-time claims for nursing home recipients Medicaid are reviewed through the prospective DUR ARCHIVALDrug-Disease USE Contraindication ONLY prospective DUR system; however, they do not require a (Reported and Inferred) system, pharmacy response to obtain reimbursement since billing Refer to theWisconsin Online Medicaid activates Handbook this alert when a providers are still for these recipients does not always occur at drug is being prescribed for a recipient with a the same time the drug is dispensed. required under for currentdisease for which thepolicy drug is contraindicated. provisions of OBRA The nursing home pharmacist consultant Acute diseases remain in the recipient’s `90 to perform continues to be responsible for prospective medical profile for a limited period of time, prospective DUR DUR. while chronic diseases remain permanently. independently. The disease may have been reported on a Prospective Drug Utilization medical claim, or inferred from a drug in Review Alerts and Alert Hierarchy claims history: For each recipient, Wisconsin Medicaid activates alerts that identify many potential 1. Reported. The diagnosis is extracted from problems. The Wisconsin Medicaid DUR the recipient’s medical profile, which Board established a hierarchy for the order in includes previously reimbursed claims, which multiple alerts appear if more than one including pharmacy claims where a alert is activated for a drug claim. Factors diagnosis is submitted. taken into account in determining the 2. Inferred. Wisconsin Medicaid infers that hierarchy include the potential for avoidance the recipient has a disease based on a drug of adverse consequences, improvement of the present in claims history. This inference is quality of care, cost savings, likelihood of a made if there is one and only one disease false positive, retrospective DUR experience, indicated for the drug. and a review of alerts used by other state Medicaid programs for prospective DUR. The clinical drug tables used to establish the alerts are provided to Wisconsin Medicaid by First DataBank, Inc.

6 Wisconsin Medicaid and BadgerCare K July 2001 Therapeutic Duplication Codes D, X, and 1 are defined as follows: Wisconsin Medicaid activates this alert when another drug is present in claims history that D: There is positive evidence of human has the same therapeutic effect as the drug fetal risk based on adverse reaction data Drug Utilization being dispensed. The message sent to the from investigational or marketing

provider includes the drug name in claims experience or studies in humans. Review history that is causing the alert. The However, potential benefits may warrant therapeutic areas for the duplication alert may use of the drug in pregnant women despite Wisconsin include but are not limited to: potential risks if the drug is needed in a Medicaid will life-threatening situation or for a serious Wdeactivate the • Angiotensin converting enzyme (ACE) disease for which safer drugs cannot be used or are ineffective. This is an FDA- pregnancy inhibitors. assigned value. diagnosis from the • Oral antifungals. recipient’s medical • Antilipidemics. • Oral contraceptives. X: Studies in animals or humans have profile after 260 demonstrated fetal abnormalities and/or days or if an • Anxiolytics. • Oral glucocorticoids. there is positive evidence of human fetal intervening • Benzodiazepines. risk based on adverse reaction data from diagnosis • Phenothiazine antipsychotics. investigational or marketing experience, indicating delivery • Diuretics. and the risks involved in use of the drug in or other • Proton pump inhibitors. pregnant women clearly outweigh pregnancy • H-2 antagonists. potential benefits. This is an FDA- termination is • Sedative/hypnotics. assigned value. received on a • NarcoticARCHIVAL analgesics. USE ONLY claim. • SSRIs/other new antidepressants. 1: No FDA rating but is contraindicated or Refer• Non-sedating to antihistamines.the Online Handbooknot recommended; may have animal and/ • Sulfonylureas. or human studies or pre- or post- • Non-steroidalfor anti-inflammatory current drugs policymarketing information. This is a First (NSAIDs). DataBank, Inc.-assigned value. Wisconsin Medicaid will deactivate the Pregnancy Alert pregnancy diagnosis from the recipient’s Wisconsin Medicaid activates this alert when medical profile after 260 days or if an the prescribed drug is contraindicated in intervening diagnosis indicating delivery or pregnancy. This alert is activated when all of other pregnancy termination is received on a the following conditions are met: claim.

• The recipient is a woman between the Early Refill ages of 12 and 60. Wisconsin Medicaid activates this alert when a • Wisconsin Medicaid receives a medical or recipient is requesting a refill of his or her pharmacy claim for the recipient that prescription early. The alert is sent to the indicates a pregnancy using the provider if a claim is submitted before 75% of International Classification of Diseases, the previous claim’s days' supply for a drug Ninth Revision, Clinical Modification should have been used. The alert gives the (ICD-9-CM). number of days' that should remain on the • A pharmacy claim for a drug that prescription, not the day that the drug can be possesses a clinical significance of D, X, refilled without activating the alert. Drugs with or 1 (as assigned by the Food and Drug up to a 10-days supply are excluded from this Administration [FDA] or First DataBank, alert. Wisconsin Medicaid monitors a Inc.) is submitted for the recipient.

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 7 comprehensive list of drug categories that • Anticonvulsants. excludes antibiotics, insulins, IV solutions, • Antidepressants. electrolytes except potassium, blood • Antipsychotics. components and factors, and diagnostic drugs. • Beta-blockers. • Calcium channel blockers. Additive Toxicity • Digoxin. Wisconsin Medicaid activates this alert when a • Diuretics. • Oral hypoglycemics. Review prescribed drug causes a cumulative effect with other drugs in the claims history. Points Drug Utilization accumulate for side effects based on the National Council For Prescription severity and the frequency of the side effect. Drug Programs Fields That Display Once a defined threshold is reached, the alert Alert Information is sent to the provider. Fields Required to Respond to Alerts Wisconsin Medicaid uses National Council for and Receive Reimbursement Prescription Drug Programs (NCPDP) field The provider is required to respond to the alert 526 (Additional Message Information) to to obtain reimbursement from Wisconsin The provider is provide pharmacy providers with additional Medicaid. To respond, providers need to have required to respond drug history information when the additive access to all prospective DUR database fields Tto the alert to toxicity alert is activated. Up to six drugs from within the NCPDP Telecommunication obtain the history that activated the alert are displayed Standards 3C, 3.2 variable, or 4.0 variable reimbursement in this field. formats (as of September 1999). The required from Wisconsin fields are listed in Appendix 1 of this section. Medicaid. Drug-Age Precaution (Pediatric)ARCHIVALProviders are USEstrongly encouraged ONLY to contact Wisconsin Medicaid activates this alert when a their software vendors to ensure that they have prescription drug should notRefer be dispensed toto theaccess Onlineto these fields. Handbook the recipient because of age precautions specific to the drug. This alert only applies forto currentUsing the fields listed policy in Appendix 1 of this recipients who are 18 years old or less. section, providers can also pre-override anticipated alerts. Wisconsin Medicaid Late Refill prospective DUR allows pre-overrides if the Wisconsin Medicaid activates this alert when a drug in claims history that would activate an recipient is late in obtaining a refill for alert was dispensed from the same pharmacy. maintenance drugs such as those listed below. The alert is sent to the provider when a drug is Fields 439 (conflict code), 544 (free refilled and it exceeds 125% of the days' text), and 535 (overflow indicator) supply on the same drug in history. The Prospective DUR alerts are returned to number of days' late is calculated as the days pharmacy providers as a conflict code, which after the prescription should have been is NCPDP field 439. The explanation of the refilled. Drugs with up to a 10-days supply are alert is in NCPDP field 544. When more than excluded from this alert. This alert applies to, three alerts are activated by one claim, the but is not limited to, the following therapeutic system indicates this in NCPDP field 535, the categories: DUR overflow indicator. Providers will need to call Medicaid Provider Services at • Angiotensin converting enzyme (800) 947-9627 or (608) 221-9883 to find out inhibitors. additional alert information. • Alpha-blockers. • Antilipidemics. Refer to Appendix 2 of this section for a chart • Angiotensin-2 receptor antagonists. listing the conflict names, codes, and messages • Anti-arrhythmics. for each of the prospective DUR alerts.

8 Wisconsin Medicaid and BadgerCare K July 2001 Edits, Audits, and Alerts Each month, all Medicaid fee-for-service The claims processing system includes certain pharmacy claims are examined by a software edits and audits. Edits check the validity of program for potential adverse drug concerns. data on each individual claim. For example, a Among the problems reviewed are drug/drug Drug Utilization claim with an invalid NDC will be denied with interactions, overuse (early refill), drug/disease

an edit. In contrast, audits review claim contraindication, duplicate therapy, high dose, Review history: if the same claim is filed at two and drug pregnancy contraindication. different pharmacies on the same day, for Responding to example, the claim at the second pharmacy If a potential drug problem is discovered, DUR alerts is not will be denied with an audit. intervention letters are sent to all providers Rconsidered a who ordered a drug relevant to the identified Pharmaceutical Only payable claims that are not denied by an problem. Criteria are developed by Wisconsin Medicaid and are reviewed and approved by Care (PC) service. edit or audit are submitted to prospective DUR. Prospective DUR alerts inform the DUR Board. An intervention consists of an providers of potential drug therapy problems. informational letter to the prescriber, a Providers can override any of these alerts. response form for the prescriber to complete, a pre-addressed return envelope, and a patient Prospective Drug Utilization drug profile. Review and Pharmaceutical Care On average, 2,200 intervention letters are sent Responding to DUR alerts is not considered a each year. Intervention letters include a Pharmaceutical Care (PC) service. Not all PC questionnaire about prescriber action. The services for which a provider receives a DUR average questionnaire response rate has been alert ARCHIVALare reimbursable under the PC USE benefit. ONLY67%, and approximately 75% of prescribers Refer to Appendix 9 of this section for a who respond to how useful the intervention description of minimum standards for was indicate it was useful or very useful. Refersubmitting PCto claims the and toOnline the Handbook “Pharmaceutical Care” chapter of this section Recipient Lock-In Program and for further PC information. for current policyRetrospective Drug Utilization Review Pharmaceutical Care services can be billed through real-time POS or by using the paper The purpose of the recipient lock-in program non-compound drug claim form indicating PC (RLP) is to coordinate the provision of health codes in the three fields shared with DUR and care services for recipients who abuse or the level of service field. Wisconsin Medicaid misuse Medicaid benefits by seeking duplicate reminds providers that there are limitations on or medically unnecessary services. PC billing and reimbursement. Coordination of recipient health care services Retrospective Drug is intended to: Utilization Review • Curb the abuse/misuse of controlled substance medications. • Improve the quality of care for the Retrospective Drug Utilization recipient. Review Activities • Reduce unnecessary physician utilization. Retrospective DUR reviews are performed by Wisconsin Medicaid on a monthly basis. With these goals in mind, ensuring necessary Review of drug claims against DUR Board- access to necessary Medicaid services remains approved criteria generate patient profiles that a priority. are individually reviewed for clinical significance.

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 9 The Wisconsin Medicaid RLP focuses on the pharmacy may make referrals for specialist abuse/misuse of controlled substance care or for care that they are otherwise unable medications. Abuse or misuse is defined under to provide (e.g., home infusion services). The “Recipient Duties” in HFS 104.02, Wis. recipient’s utilization of services is reviewed Admin. Code. These duties include: prior to release from the RLP and lock-in providers are notified of the effective date of • Not to duplicate or alter prescriptions. the recipient’s release. • Not to feign illness, use false pretense, Review provide incorrect eligibility status, or Refer to the Recipient Rights and Drug Utilization provide false information to obtain Responsibilities section of the All-Provider service. Handbook for information on RLP and • Not to seek duplicate care from more than emergency services, change of provider, and one provider for the same or similar due process. condition. • Not to seek medical care which is Designated Lock-In Pharmacies excessive or not medically necessary. Pharmacies designated as the lock-in pharmacy for enrolled recipients may fill The Wisconsin Referrals of recipients as candidates for lock- prescriptions from any prescriber, including Medicaid RLP in are received from retrospective DUR, those from emergency care visits or referral focuses on the physicians, pharmacists, other types of T physicians, as long as the prescription appears providers, and through automated surveillance abuse/misuse of to be appropriate (e.g., it does not overlap with controlled methods. Once a referral is received, six other prescriptions of the same drug class). For months of pharmacy claims and diagnoses substance prescriptions for non-emergent care, the medications. data are reviewed by a pharmacist. ARCHIVALA pharmacist may USE call the lock-in ONLY physician as recommendation for one of the following identified in the most current letter of courses of action is then made:Refer to thenotification Online or the RLP toHandbook ascertain whether or not a referral is in place for the provider • Enroll in the RLP. issuing the prescription. • Send an intervention letter to the for current policy physician. • Send a warning letter to the recipient. Educational Program • No further action. A number of educational programs are generated by the DUR program. One of the Wisconsin Medicaid recipients who are primary means of education is the distribution candidates for enrollment in the RLP are sent a of educational newsletters to prescribers and letter of intent, which explains the restriction pharmacists. Topics for newsletters have that will be applied, how to designate a included: physician and a pharmacy, and how to request a hearing if they wish to contest the decision • Current treatment protocols. for enrollment. If recipients fail to designate • How to best use the information received providers, the RLP may assign providers in the intervention letter. based on claims' history. Recipients are also • New drug/drug interactions. informed that access to emergency care is not • Utilization and cost data for selected restricted. therapeutic classes of drugs. • Comparison of efficacy and cost of drugs Upon enrollment and with changes in lock-in within a therapeutic class. providers, letters of notification are sent to the recipient and to the lock-in physician and In addition, the intervention letters sent out pharmacy. Recipients remain in the RLP for generate additional calls to the DUR pharmacy two years. The lock-in physician and staff that provide an opportunity for a one-to- one educational activity with the prescriber.

10 Wisconsin Medicaid and BadgerCare K July 2001 PPharmaceutical Care Under 1995 Wisconsin Act 27, the state Documentation Form For biennial budget, Wisconsin Medicaid was Pharmaceutical Care required to develop an incentive-based The required, retrievable information for PC pharmacy payment system that pays for documentation can be found in Appendix 5 of Pharmaceutical Pharmaceutical Care (PC) services. this section. Providers may use any format to Care is a document PC, but that format must include all Pharmaceutical Care is a nationwide Pnationwide the elements in the model form provided in Pharmaceutical movement promoting a patient-centered, movement Appendix 5 of this section.

outcomes-oriented practice of pharmacy. Its Care promoting a purpose is to maximize the effectiveness of patient-centered, ICD-9-CM Coding Requirements medications for the patient through outcomes-oriented intervention by the pharmacist. Valid ICD-9-CM codes are required on the practice of drug claim for each PC intervention submitted. pharmacy. Its Wisconsin Medicaid’s PC program provides Providers must make a reasonable effort to purpose is to pharmacists with an enhanced dispensing fee report an ICD-9-CM code that identifies the maximize the for PC services given to Wisconsin Medicaid medical condition most closely related to the effectiveness of fee-for-service recipients. This enhanced fee PC intervention performed. This is generally medications for reimburses pharmacists for additional actions the ICD-9-CM code associated with the drug the patient they take beyond the standard dispensing and dispensed as a result of the intervention. through counseling for a prescription drug. ARCHIVAL USE ONLYThe diagnosis and associated ICD-9-CM code intervention by the should be determined and reported to the level pharmacist. For recipients enrolled in a Medicaid managed Refercare program, to each the program Online develops its own Handbookof specificity the provider believes is policy regarding drug prices, dispensing fees, necessary to perform the intervention. This and whether tofor pay for current PC services. Providers policycould be three, four, or five digits. In some should contact the recipient’s managed care situations a general knowledge of the disease program for further information. state(s) is necessary and in others a more precise determination is necessary to determine if an intervention is appropriate. Documentation For example, knowledge of a general medical Pharmaceutical Care Profile condition may be sufficient to determine that multiple non-steroidal anti-inflammatory drug A PC profile must be created and maintained use is probably not appropriate. However, in for the recipient prior to submitting a PC other situations the precise diagnosis must be claim. It must include the intended use or known to determine if a specific drug’s dosage diagnosis information for each drug the level is too high or too low. recipient is actively using. The source of information and level of confidence must be documented. To facilitate a more thorough Pharmaceutical Care understanding of the recipient’s medical Dispensing Fee condition(s), inclusion of the International Classification of Diseases, Ninth Revision, Reimbursement for the PC dispensing fee Clinical Modification (ICD-9-CM) codes for requires the pharmacist to meet all basic each diagnosis or intended use is requirements of federal and state law for recommended. Refer to Appendix 4 of this dispensing a drug plus completing specified section for PC profile requirements. activities that result in a positive outcome both

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 11 for the recipients and the Wisconsin Medicaid • Time spent resolving problems identified program. Some positive outcomes include during drug regimen reviews (DRR) for increasing patient compliance or preventing nursing home residents when performed potential adverse drug reactions. at a level greater than DRR requirements and not compensated for under DRR Reimbursement is based on the following: payments from the facility.

• The reason for intervention. The following situations are not included in • The action taken by the pharmacist. the intervention time: • The result of that action. • The time spent performing the activity. • Time spent researching a drug therapy problem, including reviewing medical Appendices 6 through 8 of this section literature or peer-reviewed literature. provide tables showing allowed combinations • Time spent consulting with another Care of reason, action, and result codes. Billing professional regarding a therapy problem limitations for PC codes include the following: such as another pharmacist, medical Pharmaceutical professional, or poison center. Wisconsin Medicaid • Wisconsin Medicaid will only reimburse • Time spent in continuing education will only reimburse for one PC dispensing fee per recipient classes. for one PC per provider per day. • Time spent reviewing PC profiles for drug W dispensing fee per • Some codes have a maximum billing therapy problems. frequency allowed. Refer to Appendix 7 • Time spent performing DRRs and recipient per of this section for a complete list of these documenting irregularities for nursing provider per day. limits. ARCHIVALhome residents. USE ONLY • Allowable codes have maximum allowed reimbursement levels. Pharmaceutical Care Billing • Pharmaceutical Care isRefer not billable for to theRequirements Online and HandbookClaims compound drugs. for currentProcessing Limits policy • Certain codes are not billable for nursing Only one PC dispensing fee is payable per facility recipients. date of service.

Wisconsin Medicaid requires providers to bill In most cases, payments using PC dispensing their usual and customary charges for this fees are limited to one, two, or four fees per service. Providers should maintain year, per recipient, per pharmacy. See documentation of their usual and customary Appendix 8 of this section for specific limits. charges. The PC dispensing fee includes all pharmacy Professional Pharmaceutical Care services reimbursement, except drug cost, for Intervention Time one dispensed or prescribed drug associated Professional PC intervention time includes the with the PC intervention. following: There is no separate or additional • Time spent resolving a specific drug reimbursement for compounding or therapy problem. dispensing the drug paired with the PC • Time spent communicating with the intervention on the drug claim. prescriber about a specific patient problem and its definition and/or resolution. • Time spent communicating with the patient or agent of the patient about a specific therapeutic problem including its definition and/or resolution.

12 Wisconsin Medicaid and BadgerCare K July 2001 Submitting Claims For If a drug is not dispensed, but a PC service is Pharmaceutical Care Dispensing provided for a Medicaid-covered and payable Fee drug, then the PC may be reimbursed. Submit Providers may submit claims for PC services the claim for the PC in the following way: as real-time claims or by using the non- compound drug claim form using PC codes in • Use the National Drug Code of the drug the three fields shared with drug utilization that was not dispensed. review (DUR). These codes follow National • Enter “0” as the quantity and the PC fee as Council for Prescription Drug Program the charge. format. Claims for PC cannot be submitted • Enter the appropriate PC information as instructed earlier.

Providers may through electronic media claims. Pharmaceutical submit claims for • Enter “0” (traditional packaging) or “2” PPC services as In real-time or paper claims submission, the (UD packaging) in the UD field. These Care are the only acceptable values when no real-time claims or provider should determine the total billing drug has been dispensed. by using the non- amount by adding together the usual and • Enter the number in the days supply field compound drug customary fee for the drug charge and the usual and customary fee for PC. (Level of that reflects the amount that would have claim form using been dispensed. PC codes in the service [LOS] is included in PC.) three fields shared Pharmaceutical Care claims submission The Medicaid-specific PC codes may be with drug requires an ICD-9-CM valid diagnosis code. If submitted as a real-time claim if your software utilization review the diagnosis field is left blank, the PC claim and switch vendor will allow it. If not, the (DUR). will be denied. claim can be submitted on the paper non- ARCHIVAL USE ONLYcompound drug claim form. To submit claims for PC: Refer to the Online HandbookA Medicaid-payable drug will be paid even if • Enter the appropriate Reason the PC code is billed incorrectly. However, the code in thefor DUR currentconflict field. (Refer policy to traditional dispensing fee will not be Appendix 6 of this section for a list of substituted when the PC code is denied. reason codes.) • Enter the appropriate Action code in the Responses to prospective DUR alerts will not DUR intervention field. (Refer to necessarily qualify as PC services. Refer to Appendix 6 of this section.) Appendix 9 of this section for a description of • Enter the appropriate Result code in the minimum standards for billing PC. Services DUR outcome field. (Refer to Appendix covered under the traditional Medicaid 6 of this section.) dispensing fee include record keeping, patient • Enter the appropriate LOS in the level of profile preparation, prospective DUR, and service field. (Refer to Appendix 9 of this counseling. section.) • Enter a valid value in the unit dose (UD) Refer to the “Drug Utilization Review” field. chapter and Appendices 1-3 of this section for • Include the usual and customary charge information on the prospective DUR system, for the PC in the “Billed Amount” field including billing codes and alert information. along with the usual and customary charge for the drug.

Refer to the Claims Submission section of this handbook for further claims submission instructions.

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 13 Care Pharmaceutical

ARCHIVAL USE ONLY Refer to the Online Handbook for current policy

14 Wisconsin Medicaid and BadgerCare K July 2001 AAppendix Appendix

ARCHIVAL USE ONLY Refer to the Online Handbook for current policy

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 15 Appendix ARCHIVAL USE ONLY Refer to the Online Handbook for current policy

16 Wisconsin Medicaid and BadgerCare K July 2001 Appendix 1 National Council For Prescription Drug Programs Fields Needed For Prospective Drug Utilization Review The following table lists the National Council for Prescription Drug Programs (NCPDP) fields a provider is required to respond to in order to obtain reimbursement from Wisconsin Medicaid. Providers are strongly encouraged to contact their software vendors to ensure that they have access to these fields.

PDPCN noitcA dleiF emaNdleiF noitpircseD rebmuN

gnittimbuS eraClacituecamrahPdnagnidnuopmocrofdedeenylnO 4e81 civreSfoleveL smialc .tnemesrubmier

gurD-gurD=DD )detropeR(esaesiD-gurD=CM )derrefnI(esaesiD-gurD=CD noitacilpuDcitueparehT=DT 4e93 doCtcilfnoCRUD ycnangerP-gurD=GP noitaziliturevO=RE yticixoTevitiddA=TA

egA-gurD=AP Appendix noitaziliturednU=RL

4e04 DndoCnoitnevretnIRU oitcessihtfo3xidneppAotrefeR

4e14 DndoCemoctuORU oitcessihtfo3xidneppAotrefeR

gnivieceR 4e93 DeARCHIVALdoCtcilfnoCRU USEvoba934eeS ONLY sesnopser egasseMlanoitiddA )TA(yticixoTevitiddAehtotgniniatrepnoitamrofniylppusotesU 625 Refer to the Online Handbook eerhtotpU noitamrofnI trela yamstrela eb for current rojaM=1 policy .deviecer 5e82 doCecnacifingiSlacinilC etaredoM=2 roniM=3

tnerrucnodesabsitestrelA=0 ylnomialc 5r92 otacidnIycamrahPrehtO ycamrahpruoY=1 ycamrahprehtO=3

nodesabtessitrelaehtfidellif-orezsidleifsihT=DDMMYYYY 5l03 liFfoetaDsuoiverP foetaDehtsniatnoctiesiwrehtO.ylnomialctnerrucehtnoatad .tesottrelaehtgnisuacmialcyrotsihromialcrehtoehtmorfecivreS

noatadnodesabtessitrelaehtfidellif-orezsidleifsihT=99.999 eliforpromialcrehtoehtnehwdellif-orezoslA.ylnomialctnerruceht 5l13 liFsuoiverPfoytitnauQ .dleifytitnauqehtnisecapssahtesottrelaehtgnisuacdrocer yrotsihromialcrehtoehtmorfytitnauqehtsniatnoc,esiwrehtO .mialc

5r23 DBotacidnIesabata DF=1

deificepstoN=0 5r33 otacidnIrebircserPrehtO rebircserpemaS=1 rebircserprehtO=2

deificepstoN=0 5r53 otacidnIwolfrevORUD strela3nahteroM=2

5t44 FexeTeer gassemtrelaRUD

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 17 Appendix ARCHIVAL USE ONLY Refer to the Online Handbook for current policy

18 Wisconsin Medicaid and BadgerCare K July 2001 Appendix 2 Conflict Names, Codes, and Explanations For Each of the Prospective Drug Utilization Review Alerts

The table below lists the conflict names, codes, and messages for each of the prospective Drug Utilization Review (DUR) alerts. Providers will need to call Medicaid Provider Services at (800) 947-9627 or (608) 221-9883 to find out additional alert information.

tcilifnoC emaNtcilfnoC )txeteerF(445dleiFPDPCNnideyalpsidegasseM edoC

DDnoitcaretnigurd-gur D">trelagnisuacyrotsihnigurdfoemandnarB<"

esaesid-gurD noitacidniartnoc M"C >noitacidniartnocfonoitpircsedesaesiD<" )detroper(

esaesid-gurD noitacidniartnoc D"C >noitacidniartnocfonoitpircsedesaesiD<" Appendix )derrefni(

TDnoitacilpudcituepareh T">cirenegroedart-gurdyrotsihtnecertsomfoemaN<" PGtrelaycnanger ARCHIVALP" USE ONLYnoitacidniartnocycnangerP" ERlliferylra E"gniniamernoitpircserpfosyadXX"

ATReferyticixotevitidd to A"the OnlinetceffeediS" Handbook

noituacerpega-gurD forP"A current policy noitacidniartnoc/gninrawegA" )cirtaidep(

LRllifereta L"etalsyadXXsillifeR"

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 19 Appendix ARCHIVAL USE ONLY Refer to the Online Handbook for current policy

20 Wisconsin Medicaid and BadgerCare K July 2001 Appendix 3 Drug Utilization Review Service Codes

Table One: Drug Utilization Review (DUR) Reason for Service Codes

DOSING/LIMITS DRUG CONFLICT

ER Overuse AT Additive Toxicity

LR Underuse DC Drug-Disease (Inferred) DC Drug-Drug Interaction MC Drug-Disease (Reported)

PA Drug-Age

PG Drug-Pregnancy Appendix

TD Therapeutic Duplication ARCHIVAL USE ONLY Table Two: DUR ActionRefer for Service to Codes the Online Handbook Administrative Patient Care 00 No Intervention for currentAS policy Patient Assessment FE Formulary Enforcement CC Coordination of Care GP Generic Product Selection M0 Prescriber Consulted PH Patient Medication History MR Medication Review TC Payer/Processor Consulted P0 Patient Consulted TH Therapeutic Product Interchange PE Patient Education/Instruction SW Literature Search/Review PF Patient Referral PM Patient Monitoring PT Perform Laboratory Test R0 Pharmacist Consulted Other Source RT Recommended Laboratory Test SC Self-Care Consultation

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 21 Table Three: Result of Service Codes

Dispensed Not Dispensed Patient Care 00 Not Specified 2A Prescription Not Filled 3A Recommendation Accepted 1A Filled as is, False Positive 2B Not Filled, Directions 3B Recommendation Not Accepted Clarified Clarified Clarified 1B Filled Prescription as is 3C Discontinued Drug 1C Filled, With Different Dose 3D Regimen Changed 1D Filled, With Different 3E Therapy Changed Directions 3F Therapy Changed, Cost Increase 1E Filled, With Different Drug Acknowledged Acknowledged 3G Drug Therapy Unchanged 1F Filled With Different 3H Follow-Up Report Quantity 1G Filled, With Prescriber 1H Brand-to-Generic Change 1J Rx-to-OTC Change Appendix Outcome codes that begin with ‘1’ indicate that dispensing ultimately did occur. Outcome codes that begin with ‘2’ indicate that dispensing was avoided. Outcome codesARCHIVAL that begin with “3,” or patient USE care types ONLY of results of service codes, may or may not be involved with the dispensing of a medication. Refer to the Online Handbook for current policy

22 Wisconsin Medicaid and BadgerCare K July 2001 Appendix 4 Wisconsin Medicaid Pharmaceutical Care Profile

The recipient Pharmaceutical Care (PC) profile establishes a basis for all PC activities provided. As part of the PC profile, the pharmacist must certify that sufficient clinical information has been collected and documented about the recipient so clinically relevant PC interventions are possible. This includes his or her disease state(s), diagnosis(es), or intended use(s) for each over-the-counter and legend drug(s) the recipient is actively using.

A PC profile must contain all information required under Pharmacy Examining Board and Medicaid rules. In addition, a face-to-face recipient interview and medication work-up must be completed by a pharmacist. Providers must know and document the basis for the recipient’s complete medication therapy regimen. Each provider must adopt and use a clinically oriented standard interview and work-up form and process.

Clinical information may be obtained from the recipient, agent of the recipient, prescriber, or any combination of the three. For recipients in a health care facility, information may be obtained from recipient records and prescriber orders via facility staff. The pharmacist should document the source (physician, recipient, inferred, etc.) and reliability (high, somewhat, questionable, etc.) of the information for future users. The pharmacist is required to determine the intended use or target

disease state for each drug listed on the profile. Appendix

The pharmacist must determine that sufficient clinical information has been gathered and documented. Lack of sufficient clinical information about the recipient and his or her medical condition precludes reimbursing PC dispensing fees. Documentation RequirementsARCHIVAL USE ONLY The following documentation must be retrievable and must be provided if requested by Wisconsin Medicaid. Failure to provide this documentationRefer may result to in recoupment the Onlineof the PC dispensing Handbook fee: • A recipient profile which meets the Pharmacy Examining Board, prospective Drug Utilization Review, and Medicaid requirements. for current policy • Results from the recipient interview and medication work-up. • Recipient-specific diagnoses, disease state, or intended use for each drug. • Date PC profile was created (may be different from date on first PC claim). • Identification of the pharmacist doing the medication history and profile preparation. • Source and reliability of clinical information collected for the profile. • Recommendations, plans, PC needs of the recipient, etc., if any. • Information about each PC intervention attempted and completed.

Additional Discussion Each PC profile must contain sufficient clinical information about the recipient to make relevant clinical decisions and recommendations. All PC profile information must be immediately available to the pharmacist and must be reviewed and updated each time a prescription is filled for the recipient.

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 23 Appendix ARCHIVAL USE ONLY Refer to the Online Handbook for current policy

24 Wisconsin Medicaid and BadgerCare K July 2001 Appendix 5 Wisconsin Medicaid Pharmaceutical Care Dispensing Fee Documentation

See reverse side of this page for the optional form that may be used to provide the required, retrievable information for the Pharmaceutical Care dispensing fee.

[This page was intentionally left blank.] Appendix

ARCHIVAL USE ONLY Refer to the Online Handbook for current policy

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 25 Wisconsin Medicaid Pharmaceutical Care Dispensing Fee Documentation Providers may use any format to document Pharmaceutical Care (PC), but that format must include all the same information as this form.

Patient Name: Medicaid ID No.:

Pharmacy Name: Medicaid Provider ID No.: You must establish and document your usual and customary fee structure for PC services billed to non-Medicaid patients. Indicate your usual and customary non-Medicaid charge for this PC service.

PC Code: U/C Charge: Date PC Completed:

Reason: Provide details about the intervention. Describe problem(s) and rationale or basis for initiating intervention. Include all drugs, DUR alerts, or problems encountered when attempting to dispense the prescription. Document assessment and plan for care.

Action: Provide details about specific action(s) performed to resolve the problem(s), including identification of all contacts.

ARCHIVAL USE ONLY

Result: Provide detailsRefer about the outcometo the of the intervention. Online Handbook for current policy

Level Prof. Intervention Time: minutes (exclude doc time) Pharmacist’s Documentation Time: minutes Name:

List prescribed drug(s) involved in intervention (include discontinued or unfilled prescriptions). Drug Name and Strength Quantity Refills ICD-9-CM Filled-Yes/No

If the PC Result code is 1C, 1D, 1E, 1F, 1K, or 2A, complete the following: Check all that apply: Changed dose (before/after) Changed quantity (before/after) Changed frequency (before/after) Changed directions (before/after) Discontinued or not-filled order Other charge, specify

List additional service(s), if any, resulting from this PC intervention, e.g. new drug(s), lab service, M.D. office visit, etc. Appendix 6 Wisconsin Medicaid Pharmaceutical Care Worksheet for Payable Codes Providers may use the following tables to assist in determining billing codes for Pharmaceutical Care (PC) dispensing fees. Not all code combinations are recognized as PC activities and not all recognized PC activities result in allowable PC dispensing fees. Pharmaceutical Care codes are only billable when they represent activity beyond that required under Omnibus Budget Reconciliation Act of 1987 (OBRA ’87) and OBRA ’90 and when they deal with issues of patient compliance, safety, or efficacy that result in a positive outcome. Reason for provision of Pharmaceutical Care AD (60) Additional Drug LK (66) Lock-in Recipient √ Recommended LR (25) Late Refill (Under Use) √ AN (10) Forgery Possible MN (30) Insufficient Duration (Prescription MX (22) Excessive Duration √ Authentication) √ NN (80) Unnecessary Drug √ AR (61) Adverse Drug Reaction √ NS (32) Insufficient Quantity AT (40) Additive Toxicity PS (17) Product Selection CD (71) Chronic Disease Mgt - Opportunity Asthma RE (84) Suspected CS (63) Patient Complaint/ Environmental Risk Symptom (In-home Management) DA (41) Drug Allergy SC (83) Suboptimal Compliance

DD (44) Drug-Drug Interaction SE (95) Side-Effect Precaution Appendix DI (45) IV Drug Incompatibility (Side Effect) √ DM (65) Possible Drug Misuse √ SF (34) Suboptimal Dose Form ER (20) Early Refill √ SR (36) Suboptimal Regimen EX (21) Excessive Quantity TD (59) Therapeutic Duplication HD (23) High Dose TN (85) Lab Test Needed √ LD (33) LowARCHIVAL Dose USE ONLY √ Not Billable For Refer to the Online HandbookNursing Home Residents Action taken by pharmacist for current policy AS (20) Patient Assessment RT (30) Recommend Lab Test CC (21) Coordination of Care TC (15) Payer/Processor M0 (22) MD Contacted Contacted (Prescriber Consulted) TH (12) Therapeutic Product MR (23) Medication Review Interchange* PE (25) Patient Education * Action Requires R0 (29) R.Ph. Consult Other Prescriber Contacted Authorization

Result of action 1C (12) Filled, Different Dose 2A (30) NOT Filled 1D (13) Filled, Different 3K (85) Instructions Understood Directions 3M (80) Compliance Aid 1E (14) Filled, Different Drug Developed (Distribution 1F (15) Filled, Different Quantity System) 1K (18) Filled, Dose Form Change

Level 11 0 through 5 minutes Use alphanumeric values for real-time and paper claims. Pharmaceutical 12 6 through 15 minutes Care cannot be billed through electronic media claims. 13 16 through 30 minutes 14 31 through 60 minutes 15 61+ minutes

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 27 Appendix ARCHIVAL USE ONLY Refer to the Online Handbook for current policy

28 Wisconsin Medicaid and BadgerCare K July 2001 Appendix 7 Wisconsin Medicaid Pharmaceutical Care Reason Codes With Billing Information

Levels, Fees, Reason Code, Action Code, Result Code, Pharmaceutical Required Documentation and Limits (Providers must Definition Definition Definition maintain a PC profile and include the following documentation. This Care (PC) documentation must be made available to Wisconsin Medicaid when requested.) Codes AD (60) — M0 (22) — 1E (14) — Level-Fee Document: Based on review Prescriber Order filled with 11-$9.45 • Date of intervention. of the contacted. different drug. 12-$14.68 • Professional time spent on intervention recipient’s drug 13-$22.16 (minutes). Exclude documentation time. regimen, the 14-$22.16 • Time spent on documentation (minutes). pharmacist- 15-$22.16 • Identify drug. determined ——————— • Nature of problem that additional drug may treatment may Allowed PC correct. be enhanced by dispensing fee • Summary of and basis for recommendation(s). addition of a code • Outcome, including summary of any Appendix new drug to the combinations: communication with prescriber and recipient. existing drug AD-M0-1E+ • Indicate if intervention was for safety, efficacy, regimen. compliance, or cost savings-only purposes. + Requires linked • International Classification of Diseases, Ninth ARCHIVALdrug National USE ONLYRevision, Clinical Modification (ICD-9-CM) for Drug Code diagnosis, disease, or intended use of medication (NDC), same date involved in the submitted intervention. Refer to the ofOnline service. Handbook• R.Ph. identity.

for current policyLimits: • A maximum of 2 Reason AD (60) PC dispensing fees per recipient, per year. • Level 13 = maximum PC dispensing fee.

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 29 Appendix 7 continued

30 Wisconsin Medicaid and BadgerCare K July 2001 Appendix 7 continued

different dosage AR-M0-2A intervention. Appendix form. • R.Ph. identity. + Requires linked 2A (30) — drug NDC, same Limits: Order not filled. date of service. • A maximum of two Reason AR (61) PC dispensing fees per recipient, per year. ARCHIVAL USE• ONLYResult Code 2A (30) may only be indicated when a replacement drug is not prescribed. Refer to the Online Handbook• Not billable for nursing home residents. • Level 13 = maximum PC dispensing fee. for current policy

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 31 Appendix 7 continued

Reason Code, Action Code, Result Code, Levels, Fees, Required Documentation and Limits (Providers must Definition Definition Definition PC Codes maintain a PC profile and include the following documentation. This documentation must be made available to Wisconsin Medicaid when requested.) AT (40) — M0 (22) — 1C (12) — Level-Fee Document: Recipient’s drug Prescriber Order filled with 11-$9.45 • Date of intervention. regimen contacted. a different dose. 12-$14.68 • Professional time spent on intervention includes 13-$22.16 (minutes). Exclude documentation time. multiple drugs RT (30) — 1D (13) — 14-$22.16 • Time spent on documentation (minutes). that may cause Pharmacist Order filled with 15-$22.16 • Nature of problem caused by multiple drugs. additive toxicity recommended different ——————— • Identify drugs. or side effects lab test to the directions. Allowed PC • Summary of and basis for recommendation(s). according to physician. dispensing fee • Outcome including summary of any medical 1E (14) — code communication with prescriber and recipient. literature. Order filled with combinations: • Indicate if intervention was for safety, efficacy, a different drug. AT-M0-1C+ compliance, or cost savings-only purposes. AT-M0-1D+ • ICD-9-CM for diagnosis, disease, or intended 1F (15) — AT-M0-1E+ use of medication involved in the submitted Order filled with AT-M0-1F+ intervention. different AT-M0-1K+ • R.Ph. identity. quantity. AT-M0-2A AT-RT-1C+ Limits: 1K (18) — AT-RT-1D+ • A maximum of two Reason AT (40) PC Appendix Order filled with AT-RT-1E+ dispensing fees per recipient, per drug a different AT-RT-1F+ combination, per year. ARCHIVALdosage form. AT-RT-1K+ USE• Result ONLY code 2A (30) may only be indicated when AT-RT-2A a replacement drug is not prescribed. Refer2A (30) to — the Online• Handbook Level 13 = maximum PC dispensing fee. Order not filled. + Requires linked drug NDC, same for currentdate of service. policy

32 Wisconsin Medicaid and BadgerCare K July 2001 Appendix 7 continued

treatment, or to different dosage CD-M0-1K+ • Plan for monitoring the recipient. Appendix develop skills form. CD-M0-2A • R.Ph. identity. and CD-PE-3M+ competencies 2A (30) — CD-PE-3K+ Limits: related to its Order not filled. • A maximum of six Reason CD (71) PC management. + Requires linked dispensing fees per recipient, per year. ARCHIVAL3M (80) — drug NDC, USE same • ONLY Level 14 is maximum PC dispensing fee. Compliance aid date of service. Refer developed.to the Online Handbook 3K (85) — Recipientfor current policy understands.

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 33 Appendix 7 continued

Reason Code, Action Code, Result Code, Levels, Fees, Required Documentation and Limits (Providers must Definition Definition Definition PC Codes maintain a PC profile and include the following documentation. This documentation must be made available to Wisconsin Medicaid when requested.) CS (63) — AS (20) — 1C (12) — Level-Fee Document: Based on Evaluation of Order filled with 11-$9.45 • Date of intervention. recipient information different dose. 12-$14.68 • Professional time spent on intervention complaint or known by the 13-$22.16 (minutes). Exclude documentation time. known or pharmacist or 1D (13) — 14-$22.16 • Time spent on documentation (minutes). suspected supplied by the Order filled with 15-$22.16 • Recipient complaints or symptom(s). symptom(s), the recipient for the different ——————— • Process, including medical literature, used to pharmacist purpose of directions. Allowed PC determine actual or potential problem. initiated drug developing a dispensing fee • Description of therapeutic basis for the possible regimen review problem-based 1E (14) — code problem. or recipient therapeutic plan. Order filled with combinations: • Summary of outcome, including summary of consultation. different drug. CS-AS-3K+ any communication, with prescriber and The pharmacist M0 (22) — CS-M0-1C+ recipient. determined an Prescriber 1K (18) — CS-M0-1D+ • Indicate if intervention was for safety, efficacy, actual or contacted. Order filled with CS-M0-1E+ compliance, or cost savings-only purposes. potential different dosage CS-M0-1K+ • ICD-9-CM for diagnosis, disease, or intended medical form. CS-M0-2A use of medication involved in the submitted problem, other intervention. than adverse 2A (30) — + Requires linked • R.Ph. identity. Appendix drug reaction, Order not filled. drug NDC, same may exist. date of service. Limits: ARCHIVAL3K (85) — USE• A ONLYmaximum of one Reason CS (63) PC Instructions dispensing fee per recipient, per year. Referunderstood. to the Online• Handbook Result code 2A (30) may only be indicated when a replacement drug is not prescribed for current policy• Level 13 = maximum PC dispensing fee. Notes: Rule out use of other PC Reason Codes which may be more specific to the problem before using this code.

34 Wisconsin Medicaid and BadgerCare K July 2001 Appendix 7 continued

drug NDC, same • R.Ph. identity. Appendix date of service. Limits: • A maximum of two Reason DA (41) PC dispensing fees per recipient, per drug, per year. • Result code 2A (30) may only be indicated when ARCHIVAL USE ONLYa replacement drug is not prescribed. Refer to the Online Handbook• Level 13 = maximum PC dispensing fee. for current policy

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 35 Appendix 7 continued

36 Wisconsin Medicaid and BadgerCare K July 2001 Appendix 7 continued

drug NDC, same • R.Ph. identity. Appendix date of service. Limits: • A maximum of two Reason DI (45) PC dispensing fees per recipient, per drug, per year. • Result code 2A (30) may only be indicated when ARCHIVAL USE ONLYa replacement drug is not prescribed. Refer to the Online Handbook• Level 13 = maximum PC dispensing fee. for current policy

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 37 Appendix 7 continued

3M (80)for — current policy Compliance aid developed.

3K (85) — Recipient demonstrates understanding of proper medication use.

38 Wisconsin Medicaid and BadgerCare K July 2001 Appendix 7 continued

this code if Order filled with ER-M0-2A • Indicate if intervention was for safety, efficacy, Appendix abuse is different dosage ER-PE-3M+ compliance, or cost savings-only purposes. suspected or form. ER-PE-3K+ • ICD-9-CM for diagnosis, disease, or intended documented. ER-PE-2A use of medication involved in the submitted See Reason 2A (30) — intervention. code DM (65). Order not filled. + Requires linked ARCHIVALdrug NDC, USE same Limits: ONLY 3M (80) — date of service. • Maximum four Reason ER (20) PC dispensing Refer Complianceto the aid Online Handbookfees per recipient per year. developed. • Result Code 2A (30) may only be indicated when a replacement drug is not prescribed. 3Kfor (85) — current policy• A PC dispensing fee may not be claimed under Recipient this code if the early refill is determined to be demonstrates due to something other than a compliance understanding of problem (e.g. recipient leaving town, early refill proper for convenience, lost medication). medication use. • Max PC dispensing fee: Level 13 on Action code M0, level 12 on Action code PE. • Not billable for nursing facility residents.

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 39 Appendix 7 continued

Reason Code, Action Code, Result Code, Levels, Fees, Required Documentation and Limits (Providers must Definition Definition Definition PC Codes maintain a PC profile and include the following documentation. This documentation must be made available to Wisconsin Medicaid when requested.) EX (21) — M0 (22) — 1C (12) — Level-Fee Document: Prescribed Prescriber Order filled with 11-$9.45 • Date of intervention. quantity appears contacted. different dose. 12-$14.68 • Professional time spent on intervention excessive for the 13-$22.16 (minutes). Exclude documentation time. recipient’s ID (13) — 14-$22.16 • Time spent on documentation (minutes) condition or Order filled with 15-$22.16 • Identify drug. predicted different ——————— • Expected quantity for recipient’s condition. medical need directions. Allowed PC • Determined reason for prescribed quantity. according to dispensing fee • Outcome including summary of any medical 1E (14) — code communication with prescriber and recipient. literature (abuse Filled, different combinations: • Changes made to drug(s), dose, frequency, not suspected). drug. EX-M0-1C+ directions, or quantity prescribed. EX-M0-1D+ • Indicate if intervention was for safety, efficacy, 1F (15) — EX-M0-1E+ compliance, or cost savings-only purposes. Order filled with EX-M0-1F+ • ICD-9-CM for diagnosis, disease, or intended different EX-M0-1K+ use of medication involved in the submitted quantity. EX-M0-2A intervention. • R.Ph. identity. 1K (18) — + Requires linked Appendix Filled, dose form drug NDC, same Limits: change. date of service. • Prescriber contact required. ARCHIVAL USE• Maximum ONLY of two Reason EX (21) PC 2A (30) — dispensing fees per recipient, per drug, per year. ReferOrder tonot filled. the Online• Handbook Do not use this code if abuse is suspected or documented. See Reason Code DM (65). • Result Code 2A (30) may only be indicated for current policywhen a replacement drug is not prescribed. • Level 13 = maximum PC dispensing fee.

Notes: Titration or other dose adjustment must first be ruled out.

40 Wisconsin Medicaid and BadgerCare K July 2001 Appendix 7 continued

different dosage HD-M0-2A Limits: Appendix form. • A maximum of two Reason HD (23) PC + Requires linked dispensing fees per recipient per year. 2A (30) — drug NDC, same • Do not use this code if abuse is suspected or Order not filled. date of service. documented, see Reason code DM (65). • Result code 2A (30) may only be used when a ARCHIVAL USE ONLYreplacement drug is not prescribed. Refer to the Online Handbook• Level 13 = maximum PC dispensing fee. for current policy

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 41 Appendix 7 continued

Reason Code, Action Code, Result Code, Levels, Fees, Required Documentation and Limits (Providers must Definition Definition Definition PC Codes maintain a PC profile and include the following documentation. This documentation must be made available to Wisconsin Medicaid when requested.) LD (33) — M0 (22) — 1C (12) — Level-Fee Document: Prescribed dose Prescriber Order filled with 11-$9.45 • Date of intervention. may be contacted. different dose. 12-$14.68 • Professional time spent on intervention insufficient to 13-$22.16 (minutes). Exclude documentation time. treat this 1D (13) — 14-$22.16 • Time spent on documentation (minutes). recipient’s Order filled with 15-$22.16 • Identify drug. medical different ——————— • Minimum expected dose. condition directions. Allowed PC • Source of minimum recommendation. according to dispensing fee • Outcome including summary of any medical 1E (14) — code communication with prescriber and recipient. literature. Order filled with combinations: • Indicate if intervention was for safety, efficacy, — Titration different drug. LD-M0-1C+ compliance, or cost savings-only purposes. ruled out. LD-M0-1D+ • ICD-9-CM for diagnosis, disease, or intended 1F (15) — LD-M0-1E+ use of medication involved in the submitted Order filled with LD-M0-1F+ intervention. different LD-M0-1K+ • R.Ph. identity. quantity. LD-M0-2A Limits: 1K (18) — + Requires linked • A maximum of two Reason LD (33) PC Appendix Order filled with drug NDC, same dispensing fees per recipient per drug per year. different dosage date of service. • A Reason LD (33) PC dispensing fee may not be ARCHIVALform. USEclaimed ONLY if titration is determined to be the basis for the “insufficient” dose. Refer2A (30) to — the Online• Handbook Level 13 = maximum PC dispensing fee. Order not filled. for current policy

42 Wisconsin Medicaid and BadgerCare K July 2001 Appendix 7 continued

Reason Code, Action Code, Result Code, Levels, Fees, Required Documentation and Limits (Providers must Definition Definition Definition PC Codes maintain a PC profile and include the following documentation. This documentation must be made available to Wisconsin Medicaid when requested.) LK (66) — CC (21) — 1C (12) — Level-Fee Document: Patient has been Pharmacist Order filled with 11-$9.45 • Date of intervention. selected by the initiated contact different dose. 12-$14.68 • Professional time spent on intervention Medicaid with multiple 13-$22.16 (minutes). Exclude documentation time. Program to be prescribers to 1D (13) — 14-$40.11 • Time spent on documentation (minutes). locked-in to a facilitate Order filled with 15-$40.11 • Description of possible problem. physician and/or coordination of different ——————— • Name of person(s) contacted. pharmacist care. directions. Allowed PC • Summary of outcome, including summary of based on dispensing fee any communication with prescriber(s), patient, information M0 (22) — 1E (14) — code and other contact(s) . known about the Prescriber Order filled with combinations: • Indicate if intervention was for safety, efficacy, patient’s contacted. different drug. LK-CC-1C compliance or cost savings-only purposes. medical LK-CC-1D • ICD-9-CM for diagnosis, disease or intended use condition and PE (25) — 1F (15) — LK-CC-1E of medication involved in the submitted use of excessive Verbal or Order filled with LK-CC-1F intervention. medication in a written different LK-CC-1K • R.Ph. identity. Appendix manner that communication quantity. LK-CC-2A may indicate with patient by a LK-CC-3K Limits: drug abuse or pharmacist to 1K (18) — LK-M0-1C • A maximum of 15 Reason (LK) PC dispensing diversion. instruct patient Order filled with LK-M0-1D fees per patient per year. in appropriate different dosage LK-M0-1E • This Reason code LK (66) when lock-in drug use. ARCHIVALform. LK-M0-1F USE ONLYpharmacy manages patients enrolled in LK-M0-1K Medicaid’s Recipient Lock-in Program (RLP). TCRefer (15) — 2Ato (30) —the LK-M0-2AOnline Handbook• Not billable for nursing home residents. Pharmacist Order not filled. LK-M0-3K • Level 14 = maximum PC dispensing fee. communicated LK-PE-2A with claims 3Kfor (85) — currentLK-PE-3K policy processor or Instructions LK-TC-2A state Medicaid understood. LK-TC-3K program staff.

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 43 Appendix 7 continued

Reason Code, Action Code, Result Code, Levels, Fees, Required Documentation and Limits (Providers must Definition Definition Definition PC Codes maintain a PC profile and include the following documentation. This documentation must be made available to Wisconsin Medicaid when requested.) LR (25) — M0 (22) — 1C (12) — Level-Fee Document: Late refill Prescriber Order filled with 11-$9.45 • Date of intervention. requested. contacted. different dose. 12-$14.68 • Professional time spent on intervention — Compliance 13-$22.16 (minutes). Exclude documentation time. problem PE (25) — 1D (13) — 14-$22.16 • Time spent on documentation (minutes). suspected. Verbal or Order filled with 15-$22.16 • Identify drug. — More than written different ——————— • Dates for previous two refills. 25% after communication directions. Allowed PC • Expected date for this refill. recipient should to the recipient dispensing fee • Number of days late; percent late on days exhaust by a pharmacist 1E (14) — code supply. previously to enhance the Order filled with combinations: • Determined reason for late refill. dispensed recipient’s different drug. LR-M0-1C+ • Outcome, including summary of any medication knowledge, LR-M0-1D+ communication with prescriber and recipient. based on skills, and 1F (15) — LR-M0-1E+ • Indicate if intervention was for safety, efficacy, predicted days competencies. Order filled with LR-M0-1F+ compliance, or cost savings-only purposes. supply. different LR-M0-1K+ • ICD-9-CM for diagnosis, disease, or intended quantity. LR-M0-2A use of medication involved in the submitted LR-PE-3M+ intervention. 1K (18) — LR-PE-3K+ • R.Ph. identity. Appendix Order filled with different dosage + Requires linked Limits: ARCHIVALform. drug NDC, sameUSE• A ONLYmaximum of four Reason LR (25) PC date of service. dispensing fees, per recipient, per year. Refer2A (30) to — the Online• Handbook A PC dispensing fee may not be claimed under Order not filled. this code when the late refill is determined to be due to something other than a compliance 3M (80)for — current policyproblem (e.g., recipient had last refill filled Compliance aid elsewhere, previous early refill for convenience, developed. previous lost refill found). • Do not use this code if abuse is suspected or 3K (85) — documented. See Reason code DM (65). Recipient • Not billable for nursing home residents. demonstrates • Level 13 = maximum PC dispensing fee. understanding of • Max PC dispensing fee: Level 13 on Action proper code M0, level 12 on Action code PE. medication use.

44 Wisconsin Medicaid and BadgerCare K July 2001 Appendix 7 continued

+ Requires linked • R.Ph. identity. Appendix drug NDC, same date of service. Limits: • A maximum of two Reason MN (30) PC dispensing fees per recipient, per drug, per year. • A Reason MN (30) PC dispensing fee may not ARCHIVAL USE ONLYbe claimed if titration is determined to be the basis for the short length of therapy. Refer to the Online Handbook• Level 13 = maximum PC dispensing fee. for current policy

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 45 Appendix 7 continued

Appendix Order filled with drug NDC, same a different date of service. Limits: ARCHIVALdosage form. USE• Prescriber ONLY contact required. • A maximum of 2 Reason MX (22) PC Refer2A (30) to — the Online Handbookdispensing fees per recipient, per drug, per year. Order not filled. • Do not use this code if abuse is suspected or documented. See Reason Code DM (65). for current policy• Result Code 2A (30) can only be indicated when a replacement drug is not prescribed. • Not billable for nursing home residents. • Level 13 = maximum PC dispensing fee.

Notes: Titration or other dose adjustment must first be ruled out.

46 Wisconsin Medicaid and BadgerCare K July 2001 Appendix 7 continued

• List of discontinued drugs, if any. Appendix • R.Ph. identity.

Limits: • A maximum of two Reason NN (80) PC dispensing fees per recipient, per year. ARCHIVAL USE• ONLYResult code 2A (30) may only be indicated when a replacement drug is not prescribed. Refer to the Online Handbook• Not billable for nursing home residents. • Level 14 = maximum PC dispensing fee. for current policy

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 47 Appendix 7 continued

48 Wisconsin Medicaid and BadgerCare K July 2001 Appendix 7 continued

date of service. Limits: Appendix • Not to be used with drugs on the Medicaid MAC list. • Not to be used for generic substitution. • May only be used when therapeutic interchange results in drug cost savings. ARCHIVAL USE• ONLYLevel 14 = maximum PC dispensing fee.

Refer to the Online HandbookNotes: for current policyThe prescriber must be contacted for interchanges.

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 49 Appendix 7 continued

Reason Code, Action Code, Result Code, Level, Fees, Required Documentation and Limits (Providers must Definition Definition Definition PC Codes maintain a PC profile and include the following documentation. This documentation must be made available to Wisconsin Medicaid when requested.) RE (84) — AS (20) — 3M (80) — Level-Fee Document: In-home Evaluation of Compliance aid 14-$40.11 • Date of intervention. medication information developed. • Professional time spent on intervention management. known by the ——————— (minutes). Exclude documentation time. pharmacist or 3K (85) — Allowed PC • Time spent on documentation (minutes). supplied by the Recipient dispensing fee • Identification of drug(s) (when dispensed at recipient for the demonstrates code same time as intervention). purpose of understanding combinations: • Describe the medication management. developing a of proper RE-AS-3M • Describe the actions taken to solve the problem-based medication use. RE-CC-3K medication management problem and how it therapeutic plan. RE-M0-3K meets the recipient’s needs. RE-MR-3K • Documentation of contact with physician CC (21) — RE-PE-3M ordering intervention. Coordination of RE-PE-3K • Summarize the training provided to recipient in care. use of the medication. Include basis for recommendation. M0 (22) — • R. Ph. identification. Prescriber • Copy of physician order. contacted. • Describe the compliance aid developed and how Appendix it meets the recipient’s needs. MR (23) — Comprehensive ARCHIVAL USELimits: ONLY review and • A maximum of one Reason code RE (84) PC evaluationRefer of the to the Online Handbookdispensing fee per recipient, per day. recipient’s • Not available for nursing home residents or complete known recipients receiving home health nurse services medication for current policyon the same days services are billed by home regimen. health. • Service must be delivered by a pharmacist or PE (25) — other licensed health care professional. Verbal or • Physician order is required. written communication Notes: to the recipient Reason Code 84 must always be billed at Level 14. by a pharmacist to enhance the recipient’s knowledge about the condition under treatment or to develop skills and competencies related to its management.

50 Wisconsin Medicaid and BadgerCare K July 2001 Appendix 7 continued

drug NDC, same • Not available for nursing home residents. Appendix date of service. • Maximum of two Reason SC (83) PC dispensing fees per recipient, per year. • Level 14 = maximum dispensing fee. ARCHIVAL USE ONLY Refer to the Online Handbook for current policy

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 51 Appendix 7 continued

Reason Code, Action Code, Result Code, Levels, Fees, Required Documentation and Limits (Providers must Definition Definition Definition PC Codes maintain a PC profile and include the following documentation. This documentation must be made available to Wisconsin Medicaid when requested.) SE (95) — M0 (22) — 1C (12) — Level-Fee Document: The pharmacist Prescriber Order filled with 11-$9.45 • Date of intervention. determines it contacted. different dose. 12-$14.68 • Professional time spent on intervention necessary to 13-$22.16 (minutes). Exclude documentation time. provide PE (25) — 1D (13) — 14-$22.16 • Time spent on documentation (minutes). information Patient Order filled with 15-$22.16 • Summary of intervention. regarding Education. different ——————— • Summary of side effect precaution for this drug possible side directions. Allowed PC and recipient. effects of a drug dispensing fee • Identify drug not filled. prescribed for 1E (14) — code • Indicate if intervention was for safety, efficacy, this recipient. Order filled with combinations: compliance, or cost savings-only purposes. Side effect a different drug. SE-M0-1C+ • ICD-9-CM for diagnosis, disease, or intended precautions SE-M0-1D+ use of medication involved in the submitted include: 1K (18) — SE-M0-1E+ intervention. Iatrogenic drug Order filled with SE-M0-1K+ • R.Ph. identity. condition, drug- a different SE-M0-2A disease dosage form. SE-PE-3K+ Limits: precaution, • A maximum of four Reason SE (95) PC lactation 2A (30) — + Requires linked dispensing fees per recipient per year. Appendix precaution, Order not filled. drug NDC, same • Result code 2A (30) may only be indicated when drug-age date of service. no replacement drug is prescribed. precaution, ARCHIVAL3K (85) — USE• Not ONLY billable for nursing home residents. drug-sex Instructions • Level 13 is the maximum PC dispensing fee if precaution, Referunderstood. to the Online Handbookthe prescriber is contacted. drug-food, drug- • Level 12 is the maximum PC dispensing fee for lab, drug- patient education when the prescriber is not tobacco, drug- for current policycontacted. alcohol precautions. Notes: Routine intervention is part of normal Prospective Drug Utilization Review (DUR) and consultation and is reimbursed under the “Traditional or Unit Dose” dispensing fee payment when the prescription is dispensed.

52 Wisconsin Medicaid and BadgerCare K July 2001 Appendix 7 continued

+ Requires linked • R.Ph. identity. Appendix drug NDC, same date of service. Limits: • A maximum of two Reason SF (34) PC dispensing fees per recipient per drug per year. • A Reason SF (34) PC dispensing fee may not be ARCHIVAL USE ONLYclaimed if titration is determined to be the basis for the less than optimal therapy. Refer to the Online Handbook• Level 13 = maximum PC dispensing fee. for current policy

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 53 Appendix 7 continued

54 Wisconsin Medicaid and BadgerCare K July 2001 Appendix 7 continued

drug NDC, same • R.Ph. identity. Appendix date of service. Limits: • A maximum of two Reason TD (59) PC dispensing fees per recipient, per drug combination, per year. ARCHIVAL USE• ONLYResult Code 2A (30) may only be indicated when a replacement drug is not prescribed. Refer to the Online Handbook• Level 13 = maximum PC dispensing fee. for current policy

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 55 Appendix 7 continued

2A (30) — + requires linked Order not filled. drug NDC, same Appendix date of service. ARCHIVAL USE ONLY Refer to the Online Handbook for current policy

56 Wisconsin Medicaid and BadgerCare K July 2001 Appendix 8 Wisconsin Medicaid Maximum Allowed Cost List For Pharmaceutical Care Codes DrugFee PC Detail Limits Appendix

ARCHIVAL USE ONLY Refer to the Online Handbook for current policy 1-5 min.1-5 min. 6-15 16-30 min. 31-60 min.min. 61+ ATAT M0AT M0AT 1C M0AT 1D M0AT $9.45 1E M0AT $9.45 1F M0AT $9.45 1K $14.68 RTAT $9.45 2A $14.68 RTAT $9.45 1C $22.16 $14.68 RTAT $9.45 $22.16 1D RT $14.68AT $9.45 1E $22.16 $14.68 $22.16 RTCD $9.45 1F $22.16 $14.68 RT $22.16CD $9.45 1K $22.16 $22.16 $22.16 M0 $14.68CD ADD TOX, MD, DIF DOSE $9.45 2A $22.16 $22.16 $14.68 M0 $22.16CD $9.45 ADD TOX, MD, FILL/DIF DIR 1C $22.16 $22.16 $22.16 M0 $14.68CD $9.45 ADD TOX, MD, FILL/DIF DRUG 1D $22.16 $22.16 $14.68 M0 $22.16 $9.45 ADD TOX, MD, FILLED/DIF QTY 1E Y $14.68 Y $22.16 $22.16 $22.16 Y M0 $9.45 ADD TOX, MD, FILLED/DIF FORM 1K Y $14.68 $22.16 $22.16 $22.16 Y 2/pt/yr $9.45 ADD TOX, MD, NOT FILLED 2/pt/yr 2/pt/yr $14.68 2A $22.16 $22.16 $22.16 2/pt/yr $9.45 ADD TOX, LAB, DIF DOSE 2/pt/yr $14.68 $22.16 $22.16 $22.16 $9.45 ADD TOX, LAB, FILL/DIF DIR $22.16 $22.16 $14.68 N $22.16 ADD TOX, LAB, FILL/DIF DRUG $22.16 $14.68 $22.16 $22.16 2/pt/yr Y ADD TOX, LAB, FILLED/DIF QTY Y $40.11 $22.16 $22.16 Y $14.68 Y ADD TOX, LAB, FILLED/DIF FORM Y $40.11 $22.16 $22.16 2/pt/yr 2/pt/yr ADD TOX, LAB, NOT FILLED 2/pt/yr $40.11 $40.11 $22.16 2/pt/yr 2/pt/yr DX-ASTHMA, MD, DIF DOSE $40.11 $40.11 DX-ASTHMA, MD, DIF DIR N $40.11 $40.11 DX-ASTHMA, MD, DIF DRUG Y $40.11 2/pt/yr DX-ASTHMA, MD, DIF FORM $40.11 6/pt/yr Y DX-ASTHMA, MD, NOT FILLED Y Y N 6/pt/yr 6/pt/yr 6/pt/yr 6/pt/yr Reason Action Result Level 11 Level 12 Level 13 Level 14 Level 15Message R&S ARAR M0AR M0 1E M0 1K $9.45 2A $9.45 $9.45 $14.68 $14.68 $14.68 $22.16 $22.16 $22.16 $22.16 $22.16 $22.16 $22.16 ADVER RXN, MD, DIF DRUG $22.16 ADVER RXN, MD, DIF FORM $22.16 ADVER RXN, MD, NOT FILLED Y Y N 2/pt/yr 2/pt/yr 2/pt/yr ADAN M0AN M0AN 1E R0AR 2A TCAR $9.45 2A M0 $9.45 2A M0 $9.45 1C $14.68 $9.45 $14.68 1D $9.45 $22.16 $14.68 $9.45 $22.16 $14.68 $22.16 $14.68 $22.16 $40.11 $14.68 $22.16 $22.16 $22.16 $40.11 ADD DRUG, MD, FILL/DIF DRUG $40.11 $22.16 $40.11 Y FORGERY, MD, NOT FILLED $22.16 $40.11 FORGERY, OTHERS, NOT FILLED $22.16 $40.11 2/pt/yr N FORGERY, PAYOR, NOT FILLED N $22.16 ADVER RXN, MD, DIF DOSE N $22.16 2/pt/yr 2/pt/yr ADVER RXN, MD, DIF DIR 2/pt/yr Y 2/pt/yr Y 2/pt/yr R&S = Remittance and Status. PC Fee = Pharmaceutical Care Fee.

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 57 Appendix 8 continued DrugFee PC Detail Limits Y 4/pt/yr Y 4/pt/yr Appendix ARCHIVAL USE ONLY Refer to the Online Handbook for current policy 1-5 min.1-5 min. 6-15 16-30 min. 31-60 min.min. 61+ Reason Action Result Level 11 Level 12 Level 13 Level 14 Level 15Message R&S CSCS M0DA M0 1K M0 2A $9.45 1E $9.45 $9.45 $14.68 $14.68 $14.68 $22.16 $22.16 $22.16 $22.16 $22.16 $22.16 $22.16 PT SYMPTOM, MD, DIFF FORM $22.16 PT SYMPTOM, MD, NOT FILLED $22.16 Y ALLERGY, MD, DIFF DRUG N 1/pt/yr 1/pt/yr Y 2/pt/yr ERER M0 M0 1K 2A $9.45 $9.45 $14.68 $14.68 $22.16 $22.16 $22.16 $22.16 $22.16 E REF, MD, DOSE FORM CHG $22.16 E REF, MD, NOT FILLED Y 4/pt/yr N 4/pt/yr ERER M0 M0 1D 1F $9.45 $9.45 $14.68 $14.68 $22.16 $22.16 $22.16 $22.16 $22.16 E REF, MD, FIL/DIF DIR $22.16 E REF, MD, FIL/DIF QTY DADD M0DD M0DD 2A M0DI 1C M0DI $9.45 1E M0DM $9.45 2A M0DM $9.45 $14.68 M0 1EDM $9.45 $14.68 M0 2ADM 1C $22.16 M0 $9.45 $14.68DM 1D $9.45 M0 $14.68 $22.16DM $9.45 1E M0 $22.16 $22.16 $14.68 $9.45DM 1F M0 $22.16 $22.16 $14.68 $9.45DM 1K $14.68 M0 $22.16 $22.16 $22.16 $9.45ER ALLERGY, MD, NOT FILLED 2A $14.68 $22.16 $22.16 M0 $22.16 $9.45 DRUG-DRUG, MD, FILL/DIF DOSE 3M $22.16 $14.68 $22.16 Y M0 $9.45 $22.16 DRUG-DRUG, MD, FILL/DIF DRUG 3K $22.16 $14.68 N $22.16 Y $9.45 $22.16 DRUG-DRUG, MD, NOT FILLED $14.68 2/pt/yr $40.11 $22.16 1C $22.16 $9.45 2/pt/yr 2/pt/yr $14.68 $40.11 $22.16 N IV INCOMP, MD, DIF DRUG $22.16 $14.68 $9.45 $22.16 $40.11 $40.11 IV INCOMP, MD, NOT FILLED MISUSE, MD, FILLED/DIF DOSE 2/pt/yr $22.16 $14.68 $40.11 $40.11 MISUSE, MD, FILLED/DIF DIR $22.16 Y $40.11 Y N $40.11 $14.68 MISUSE, MD, FILLED/DIF DRUG $40.11 $22.16 $40.11 2/pt/yr Y 2/pt/yr 2/pt/yr MISUSE, MD, FILLED/DIF QTY $40.11 Y $40.11 $22.16 MISUSE, MD, FILLED/DIF FORM $40.11 $40.11 2/pt/yr Y 2/pt/yr MISUSE, MD, NOT FILLED Y $40.11 $22.16 MISUSE, MD, PT, COMPLY AID $40.11 2/pt/yr 2/pt/yr MISUSE, MD, PT UNDRSTNDS Y $22.16 N E REF, MD, CHG DOSE Y 2/pt/yr 2/pt/yr 2/pt/yr Y 4/pt/yr CDCD PECS PECS 3M ASCS 3K M0CS $9.45 3K M0 $9.45 1C M0 $9.45 $14.68 1D $9.45 1E $14.68 $9.45 $22.16 $14.68 $9.45 $22.16 $14.68 $40.11 $14.68 $22.16 $40.11 $22.16 $14.68 $40.11 $22.16 $22.16 DX-ASTHMA, PT, COMPLY AID $40.11 $22.16 $22.16 DX-ASTHMA, PT, UNDRSTNDS Y $22.16 $22.16 PT SYMPTOM, AS, UNDRSTNDS Y $22.16 $22.16 Y 6/pt/yr PT SYMPTOM, MD, DIFF DOSE $22.16 1/pt/yr PT SYMPTOM, MD, DIFF DIR 6/pt/yr $22.16 Y PT SYMPTOM, MD, DIFF DRUG Y 1/pt/yr Y 1/pt/yr 1/pt/yr R&S = Remittance and Status. PC Fee = Pharmaceutical Care Fee.

58 Wisconsin Medicaid and BadgerCare K July 2001 Appendix 8 continued DrugFee PC Detail Limits Appendix

ARCHIVAL USE ONLY Refer to the Online Handbook for current policy 1-5 min.1-5 min. 6-15 16-30 min. 31-60 min.min. 61+ LKLK CC CC 1K 2A $9.45 $9.45 $14.68 $14.68 $22.16 $22.16 $40.11 $40.11 $40.11 LOCKIN, CORCARE, DIF FORM $40.11 LOCKIN, CORCARE, NOT FILLED Y N 15/pt/yr 15/pt/yr HDHD M0HD M0HD 1C M0HD 1D M0LD $9.45 1E M0LD $9.45 1K M0LD $9.45 2A $14.68 M0LD $9.45 $14.68 1C M0LD $9.45 1D $22.16 $14.68 M0LD $9.45 1E $22.16 $14.68 M0LK $9.45 1F $22.16 $14.68 $22.16 M0LK $9.45 1K $22.16 $22.16 $14.68 CCLK $9.45 2A $22.16 $14.68 $22.16 $22.16 CCLK $9.45 H DOSE, MD, FILL/DIF DOSE 1C $22.16 $22.16 $14.68 $22.16 CC $9.45 H DOSE, MD, FILL/DIF DIR 1D $22.16 $22.16 $22.16 $14.68 CC $9.45 H DOSE, MD, FILL/DIF DRUG Y $14.68 1E $22.16 $22.16 $22.16 H DOSE, MD, FILL/DIF FORM $9.45 $14.68 1F $22.16 $22.16 $22.16 Y 2/pt/yr H DOSE, MD, NOT FILLED $9.45 Y $22.16 $14.68 $22.16 $22.16 L DOSE, MD, FILL/DIF DOSE Y $9.45 $22.16 $14.68 $22.16 $22.16 2/pt/yr 2/pt/yr L DOSE, MD, FILL/DIF DIR $22.16 $22.16 $22.16 $14.68 2/pt/yr L DOSE, MD, FILL/DIF DRUG N $22.16 $22.16 $22.16 Y $14.68 L DOSE, MD, FILL/DIF QTY $22.16 $40.11 $22.16 2/pt/yr L DOSE, MD, FILL/DIF FORM Y 2/pt/yr $22.16 Y $40.11 $22.16 L DOSE, MD, NOT FILLED $40.11 $40.11 2/pt/yr Y 2/pt/yr LOCKIN, CORCARE, DIF DOSE Y $40.11 $40.11 LOCKIN, CORCARE, DIF DIR $40.11 2/pt/yr Y 2/pt/yr N LOCKIN, CORCARE, DIF DRUG $40.11 LOCKIN, CORCARE, DIF QTY Y 15/pt/yr Y 2/pt/yr 15/pt/yr Y 15/pt/yr 15/pt/yr Reason Action Result Level 11 Level 12 Level 13 Level 14 Level 15Message R&S EXEX M0EX M0 1F M0 1K $9.45 2A $9.45 $9.45 $14.68 $14.68 $14.68 $22.16 $22.16 $22.16 $22.16 $22.16 $22.16 $22.16 EX QTY, MD, FILL/DIF QTY $22.16 EX QTY, MD, FILL/DIF FORM $22.16 EX QTY, MD, NOT FILLED Y Y 2/pt/yr 2/pt/yr N 2/pt/yr ERER PEER PEEX 3M PEEX 3K M0EX $9.45 2A M0 $9.45 1C M0 $9.45 1D $14.68 $9.45 1E $14.68 $9.45 $14.68 $14.68 $9.45 $14.68 $14.68 $14.68 $14.68 $14.68 $22.16 $14.68 $14.68 $22.16 $14.68 $14.68 E REF, PT ED, COMP AID $22.16 $22.16 $14.68 E REF, PT ED, UNDRSTNDS $22.16 $14.68 E REF, PT ED, NOT FILLED $22.16 $22.16 Y EX QTY, MD, FILL/DIF DOSE $22.16 Y EX QTY, MD, FILL/DIF DIR 4/pt/yr $22.16 EX QTY, MD, FILL/DIF DRUG N Y 4/pt/yr 4/pt/yr Y 2/pt/yr Y 2/pt/yr 2/pt/yr R&S = Remittance and Status. PC Fee = Pharmaceutical Care Fee.

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 59 Appendix 8 continued DrugFee PC Detail Limits Appendix ARCHIVAL USE ONLY Refer to the Online Handbook for current policy 1-5 min.1-5 min. 6-15 16-30 min. 31-60 min.min. 61+ LKLK CC M0 3K 1C $9.45 $9.45LK $14.68LK $14.68 M0 $22.16 PE 3K $22.16LK $40.11 2A $9.45 $40.11 TC $9.45 $40.11 LOCKIN, CORCARE, UNDRSTND 3K $14.68 $40.11 Y LOCKIN, MD, DIF DOSE $14.68 $9.45 $22.16 15/pt/yr $22.16 $40.11 $14.68 Y $40.11 $40.11 $22.16 15/pt/yr LOCKIN, MD, UNDRSTND $40.11 LOCKIN, PT ED, NOT FILLED $40.11 Y N $40.11 LOCKIN, PAYOR, UNDRSTND 15/pt/yr 15/pt/yr N 15/pt/yr Reason Action Result Level 11 Level 12 Level 13 Level 14 Level 15Message R&S LKLK M0 M0 1KLK 2ALK $9.45 PE $9.45 TCLR $14.68 3K 2A $14.68 M0 $9.45 $22.16 $9.45 1C $22.16 $40.11 $14.68 $9.45 $40.11 $14.68 $40.11 $22.16 LOCKIN, MD, DIF FORM $40.11 $22.16 $14.68 LOCKIN, MD, NOT FILLED $40.11 $40.11 $22.16 $40.11 Y N LOCKIN, PT ED, UNDRSTND $40.11 $22.16 LOCKIN, PAYOR, NOT FILLED 15/pt/yr 15/pt/yr $22.16 Y N L REF, MD, DIF DOSE 15/pt/yr 15/pt/yr Y 4/pt/yr LKLK M0LK M0 1D M0 1E $9.45 1F $9.45 $9.45 $14.68 $14.68 $22.16 $14.68 $22.16LR $40.11 $22.16LR $40.11 M0LR $40.11 $40.11 M0LR LOCKIN, MD, DIF DIR 1D $40.11 M0LR LOCKIN, MD, DIF DRUG 1E $40.11 M0LR $9.45 LOCKIN, MD, DIF QTY 1F M0LR $9.45 1K PEMN $9.45 2A $14.68 PE YMN Y $9.45 M0 3M $14.68MN $9.45 15/pt/yr M0 Y 3K 15/pt/yr $22.16 $14.68MX 1D $9.45 M0 $14.68 $22.16 15/pt/yr 1F $9.45 M0 $14.68 $22.16 $22.16 $9.45 2A $14.68 $22.16 $22.16 $9.45 1C $22.16 $14.68 $22.16 $22.16 $9.45 $14.68 L REF, MD, FILL/DIF DIR $14.68 $22.16 $22.16 $9.45 L REF, MD, FILL/DIF DRUG $14.68 $22.16 $14.68 $22.16 $22.16 $14.68 L REF, MD, FILL/DIF QTY $14.68 $22.16 L REF, MD, CHG DOSE FORM $14.68 $22.16 $22.16 $14.68 Y Y L REF, MD, NOT FILLED $22.16 $22.16 $14.68 L REF, PT ED, COMPLY AID Y $22.16 $22.16 4/pt/yr $14.68 Y 4/pt/yr $22.16 L REF, PT ED, UNDRSTNDS $22.16 INSF DUR, MD, FILL/DIF DIR 4/pt/yr 4/pt/yr $22.16 $22.16 Y N INSF DUR, MD, FILL/DIF QTY $22.16 INSF DUR, MD, NOT FILLED Y Y $22.16 4/pt/yr 4/pt/yr EX DUR, MD, FILL/DIF DOSE Y 4/pt/yr 2/pt/yr N 2/pt/yr Y 2/pt/yr 2/pt/yr MXMX M0 M0 1D 1E $9.45 $9.45 $14.68 $14.68 $22.16 $22.16 $22.16 $22.16 $22.16 EX DUR, MD, FILL/DIF DIR $22.16 EX DUR, MD, FILL/DIF DRUG Y Y 2/pt/yr 2/pt/yr R&S = Remittance and Status. PC Fee = Pharmaceutical Care Fee.

60 Wisconsin Medicaid and BadgerCare K July 2001 Appendix 8 continued DrugFee PC Detail Limits Appendix

ARCHIVAL USE ONLY Refer to the Online Handbook for current policy 1-5 min.1-5 min. 6-15 16-30 min. 31-60 min.min. 61+ NSNS M0 M0 1FRE 2ARE $9.45 CC $9.45 M0RE 3K $14.68 3K $14.68 PE n/a $22.16 n/a $22.16 3M $22.16 n/a n/a $22.16 n/a $22.16 INSF QTY, MD, FILL/DIF QTY $22.16 INSF QTY, MD, NOT FILLED n/a n/a n/a N N 2/pt/yr n/a $40.11 2/pt/yr $40.11 n/a n/a $40.11 INHOME, CORCARE, PT UNDRSTD Y INHOME, MD, PT UNDRSTNDS n/a 1/pt/dy Y INHOME, PT ED, COMPLY AID Y 1/pt/dy 1/pt/dy MXMX M0 M0 1F 1K $9.45 $9.45 $14.68 $14.68 $22.16 $22.16 $22.16 $22.16 $22.16 EX DUR, MD, FILL/DIF QTY $22.16 EX DUR, MD, FILL/DIF FORM Y Y 2/pt/yr 2/pt/yr PS TH 1E $9.45RESC PE $14.68SE ASSE 3K M0 $22.16SE 3M M0SE n/a 1C M0 $40.11SE $9.45 1D M0SE $9.45 1E M0 $40.11SF $9.45 PRODSLCT, INTRCHG, DIF DRUG 1K n/a $14.68 PE Y $9.45 2A $14.68 M0 $9.45 $22.16 $14.68 3K None $9.45 1E n/a $22.16 $14.68 $9.45 $14.68 $40.11 $22.16 $9.45 $14.68 $22.16 $22.16 $22.16 $40.11 $22.16 $14.68 $40.11 COMPLY, ASSESS, COMPLY AID $22.16 $22.16 $14.68 $22.16 Y SIDE-EF, MD, FILL/DIFF DOSE $22.16 $22.16 $14.68 n/a SIDE-EF, MD, FILL/DIFF DIR $22.16 $22.16 $22.16 2/pt/yr Y SIDE-EF, MD, FILL/DIFF DRUG INHOME, PT ED, UNDRSTND $22.16 $14.68 SIDE-EF, MD, FILL/DIFF FORM $22.16 $22.16 Y Y 4/pt/yr Y SIDE-EF, MD, NOT FILLED $14.68 Y 1/pt/dy SIDE-EF, PT ED, UNDRSTNDS 4/pt/yr 4/pt/yr $22.16 DOSE FORM, MD, FILL/DIFF DRUG 4/pt/yr Y N Y 2/pt/yr 4/pt/yr 4/pt/yr Reason Action Result Level 11 Level 12 Level 13 Level 14 Level 15Message R&S RE MR 3K n/a n/a n/a $40.11 n/a INHOME, MEDREV, PT UNDRSTD Y 1/pt/dy MXNN M0NS M0 2A M0 2A $9.45 1D $9.45 $9.45 $14.68 $14.68 $22.16 $14.68 $22.16 $22.16 $22.16 $40.16 $22.16 $22.16 EX DUR, MD, NOT FILLED $40.16 UNNEC DRG, MD, NOT FILLED $22.16 INSF QTY, MD, FILL/DIF DIR N N 2/pt/yr Y 2/pt/yr 2/pt/yr RE AS 3M n/a n/a n/a $40.11 n/a INHOME, ASSESS, COMPLY AID Y 1/pt/dy R&S = Remittance and Status. PC Fee = Pharmaceutical Care Fee.

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 61 Appendix 8 continued DrugFee PC Detail Limits Appendix ARCHIVAL USE ONLY Refer to the Online Handbook for current policy 1-5 min.1-5 min. 6-15 16-30 min. 31-60 min.min. 61+ SFSF M0 M0 1K 2A $9.45 $9.45TD $14.68TD $14.68 M0 $22.16 M0 1E $22.16TN 2A $22.16 $9.45 $22.16 RT $9.45 $22.16 DOSE FORM, MD, FILL/DIFF FORM Y 1E $14.68 $22.16 DOSE FORM, MD, NOT FILLED $14.68 2/pt/yr $9.45 $22.16 N $22.16 2/pt/yr $22.16 $14.68 $22.16 $22.16 $14.68 THER DUPE, MD, FILL/DIFF DRUG $22.16 Y THER DUPE, MD, NOT FILLED $14.68 2/pt/yr N $14.68 LAB TEST, RECOM, DIF DRUG 2/pt/yr Y 1/pt/yr Reason Action Result Level 11 Level 12 Level 13 Level 14 Level 15Message R&S SRSR M0 M0 1KTN 2ATN $9.45 RT $9.45 RTTN 1C $14.68 1D $14.68 RT $9.45 $22.16 $9.45 1K $22.16 $14.68 $22.16 $9.45 $14.68 $22.16 $14.68 $22.16 REGM PROB, MD, FILL/DIF FORM $14.68 $14.68 $22.16 Y REGM PROB, MD, NOT FILLED $14.68 4/pt/yr $14.68 $14.68 N $14.68 LAB TEST, RECOM, DIF DOSE 4/pt/yr $14.68 $14.68 LAB TEST, RECOM, DIF DIR Y $14.68 LAB TEST, RECOM, DIF FORM Y 1/pt/yr Y 1/pt/yr 1/pt/yr SRSR M0SR M0 1C M0 1D $9.45 1F $9.45 $9.45 $14.68 $14.68 $22.16 $14.68 $22.16TN $22.16 $22.16 $22.16 RT $22.16 $22.16 REGM PROB, MD, FILL/DIF DOSE 2A $22.16 Y REGM PROB, MD, FILL/DIF DIR $22.16 $9.45 REGM PROB, MD, FILL/DIF QTY 4/pt/yr Y Y 4/pt/yr $14.68 4/pt/yr $14.68 $14.68 $14.68 LAB TEST, RECOM, NOT FILLED N 1/pt/yr R&S = Remittance and Status. PC Fee = Pharmaceutical Care Fee.

62 Wisconsin Medicaid and BadgerCare K July 2001 Appendix 9 Wisconsin Medicaid Pharmaceutical Care Level of Service Definitions

Level 10 Basic Prescription Service — No Pharmaceutical Care (PC) Provided Traditional or Unit Meets all dispensing requirements including record keeping, profiles prospective Drug Dose (UD) Utilization Review (DUR), and counseling. No PC coding required. Dispensing Fee

Level 11 Pharmaceutical Care, Level I PC Dispensing Fee Compliant with all dispensing requirements including record keeping, prospective DUR, and (1-5 minutes, counseling. In addition to the basic service requirements, a PC chart must be maintained plus excluding additional PC provided, usually requiring less than six minutes of the pharmacist’s time. documentation time) Requires intended use/diagnosis for all drugs prescribed for this patient and International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code for each PC intervention submitted.

Level 12 Pharmaceutical Care, Level II Appendix PC Dispensing Fee Compliant with all basic dispensing requirements including record keeping, prospective DUR, (6-15 minutes, and counseling. In addition to the basic service requirements, a PC chart must be maintained excluding plus additional PC provided, requiring six to 16 minutes of the pharmacist’s time. Requires documentation time) intended use/diagnosis for all drugs prescribed for this patient and ICD-9-CM diagnosis code for eachARCHIVAL PC intervention submitted. USE ONLY Refer to the Online Handbook Level 13 Pharmaceutical Care, Level III PC Dispensing Fee Compliant with all basic dispensing requirements including record keeping, prospective DUR, (16-30 minutes, and counseling.for In additioncurrent to the basic policyservice requirements, a PC chart must be maintained excluding plus additional PC provided requiring 16 to 30 minutes of the pharmacist’s time. Requires documentation time) intended use/diagnosis for all drugs prescribed for this patient and ICD-9-CM diagnosis code for each PC intervention submitted.

Level 14 Pharmaceutical Care, Level IV PC Dispensing Fee Compliant with all basic dispensing requirements including record keeping, prospective DUR, (31-60 minutes, and counseling. In addition to the basic service requirements, a PC chart must be maintained excluding plus additional PC provided requiring 31 to 60 minutes of the pharmacist’s time. Requires documentation time) intended use/diagnosis for all drugs prescribed for this patient and ICD-9-CM diagnosis code for each PC intervention submitted.

Level 15 Pharmaceutical Care, Level V PC Dispensing Fee Compliant with all basic dispensing requirements including record keeping, prospective DUR, (Over 60 minutes, and counseling. In addition to the basic service requirements, a PC chart must be maintained excluding plus additional PC provided requiring more than 60 minutes of the pharmacist’s time. Requires documentation time) intended use/diagnosis for all drugs prescribed for this patient and ICD-9-CM diagnosis code for each PC intervention submitted. This PC pays at level 14.

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 63 Appendix ARCHIVAL USE ONLY Refer to the Online Handbook for current policy

64 Wisconsin Medicaid and BadgerCare K July 2001 Appendix 10 Sample Paper Claim Form — Pharmaceutical Care Form 98-1141 (8/98). Replaces 482-020 Authorized under HFS 106.03 (1), Wis. Admin. Code Return to: ICN (DO NOT WRITE IN THIS SPACE) EDS 6406 Bridge Road Madison, WI 53784-0002

1. PROVIDER NAME AND ADDRESS 2. PROVIDER NUMBER I.M. Provider 12345678 Wisconsin Medicaid 1 West Williams Anytown, WI 55555 NON-COMPOUND DRUG CLAIM FORM

RECIPIENT INFORMATION

3. MEDICAID NUMBER 4. LAST NAME 5. FIRST NAME 6. SEX 7. DATE OF BIRTH 1234567890 Recipient Ima 2 08/28/72

CLAIM INFORMATION

8. PRESCRIBER NUMBER 9. DATE PRESCRIBED 10. DATE FILLED11. REFILL 12. NDC 13. DAYS SUPPLY 14. QUANTITY 15. CHARGE AS7654321 12/20/00 12/20/00 00 00 00168 0199 15 30 15 $ XX.XX Appendix 16. UD 17. PRESCRIPTION NUMBER 18. MAC 19. DRUG DESCRIPTION 20. POS 1 0 3942877 0 Timolol 0.25% eye drops 08

21. DIAGNOSIS CODE 22. LEVEL OF SERVICE 23. DUR CONF./REASON 24. DUR INTERVENTION 25. DUR OUTCOME V72.0 13 EX MO 1C ARCHIVAL USE ONLY 8. PRESCRIBER NUMBER 9. DATE PRESCRIBED 10. DATE FILLED11. REFILL 12. NDC 13. DAYS SUPPLY 14. QUANTITY 15. CHARGE AS1234567 11/20/00 12/20/00 00 00 00781 1232 13 30 60 $ XX.XX

16. UD 17. PRESCRIPTION NUMBERRefer 18. MAC 19. DRUG to DESCRIPTION the Online Handbook 20. POS 2 1 1279433 0 Enalapril 10 mg tablet 08 21. DIAGNOSIS CODE 22. LEVEL OF SERVICE for 23. DUR CONF./REASON current 24. DUR INTERVENTION policy 25. DUR OUTCOME

8. PRESCRIBER NUMBER 9. DATE PRESCRIBED 10. DATE FILLED11. REFILL 12. NDC 13. DAYS SUPPLY 14. QUANTITY 15. CHARGE $

16. UD 17. PRESCRIPTION NUMBER 18. MAC 19. DRUG DESCRIPTION 20. POS 3

21. DIAGNOSIS CODE 22. LEVEL OF SERVICE 23. DUR CONF./REASON 24. DUR INTERVENTION 25. DUR OUTCOME

8. PRESCRIBER NUMBER 9. DATE PRESCRIBED 10. DATE FILLED11. REFILL 12. NDC 13. DAYS SUPPLY 14. QUANTITY 15. CHARGE $

16. UD 17. PRESCRIPTION NUMBER 18. MAC 19. DRUG DESCRIPTION 20. POS 4

21. DIAGNOSIS CODE 22. LEVEL OF SERVICE 23. DUR CONF./REASON 24. DUR INTERVENTION 25. DUR OUTCOME

26. CERTIFICATION 27. PRIOR AUTHORIZATION NUMBER 30. O.C. AMOUNT I certify the services and items for which reimbursement is claimed on this claim form were provided to the above 28. O.C. named recipient pursuant to the prescription of a licensed physician, podiatrist, or dentist. Charges on this claim $XX.XX form do not exceed my (our) usual and customary charge for the same services or items when provided to persons not entitled to receive benefits under Wisconsin Medicaid. I understand that any payment made in satisfaction of this claim will be derived from federal and state funds and that any false claims, statements or documents, or concealment of a material fact may be subject to prosecution PLACE OF SERVICE (POS) DESCRIPTION 31. PATIENT PAID under applicable federal or state law. 00 PHARMACY $ 01 HOME (IV-IM SERVICES ONLY) PHARMACIST’S OR 07 SKILLED CARE FACILITY DISPENSING PHYSICIAN’S 08 SUB-ACUTE CARE FACILITY 32. NET BILLED SIGNATURE DATE 01/01/01 10 OUTPATIENT (DOCTOR’S OFFICE) $XX.XX

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 65 Appendix ARCHIVAL USE ONLY Refer to the Online Handbook for current policy

66 Wisconsin Medicaid and BadgerCare K July 2001 Glossary of Common Terms

Adjustment Crossover claim A modified or changed claim that was originally A Medicare-allowed claim for a dual entitlee sent to allowed, at least in part, by Wisconsin Medicaid. Wisconsin Medicaid for possible additional payment of the Medicare coinsurance and deductible. Alerts Screen pharmacy claims for clinically important DHCF potential drug therapy problems before the prescription Division of Health Care Financing. The DHCF is dispensed to the recipient. The following alerts will administers Wisconsin Medicaid for the Department of be returned to the provider: Health and Family Services (DHFS) under statutory provisions, administrative rules, and the state’s • DD — Drug to Drug. Medicaid plan. The state’s Medicaid plan is a • MC— Reported Disease. comprehensive description of the state’s Medicaid • DC — Inferred Disease. program that provides the Health Care Financing • TD — Therapeutic Duplication. Administration (HCFA) and the U.S. Department of Health and Human Services (DHHS), assurances that • PG — Pregnancy. the program is administered in conformity with federal • ER — Early Refill. law and HCFA policy. • AT — Additive Toxicity. • PA — Patient Age. DHFS • LR — Late Refill. Wisconsin Department of Health and Family Services. The DHFS administers the Wisconsin Medicaid Allowed status program. Its primary mission is to foster healthy, self- A Medicaid or Medicare claim that has at least one reliant individuals and families by promoting service that is reimbursable. ARCHIVAL USEindependence ONLY and community responsibility; strengthening families; encouraging healthy behaviors; Glossary BadgerCare Refer to the Onlineprotecting Handbook vulnerable children, adults, and families; BadgerCare extends Medicaid coverage through a preventing individual and social problems; and Medicaid expansion under Titles XIX andfor XXI current to policyproviding services of value to taxpayers. uninsured children and parents with incomes at or below 185% of the federal poverty level and who meet DHHS other program requirements. The goal of BadgerCare Department of Health and Human Services. The is to fill the gap between Medicaid and private United States government’s principal agency for insurance without supplanting or “crowding out” protecting the health of all Americans and providing private insurance. essential human services, especially for those who are least able to help themselves. BadgerCare benefits are identical to the benefits and services covered by Wisconsin Medicaid, and The DHHS includes more than 300 programs, covering recipients’ health care is administered through the a wide spectrum of activities, including overseeing same delivery system. Medicare and Medicaid; medical and social science research; preventing outbreak of infectious disease; CPT assuring food and drug safety; and providing financial Current Procedural Terminology. A listing of assistance for low-income families. descriptive terms and codes for reporting medical, surgical, therapeutic, and diagnostic procedures. These DOS codes are developed, updated, and published annually Date of service. The calendar date on which a specific by the American Medical Association and adopted for medical service is performed. billing purposes by the Health Care Financing Administration (HCFA) and Wisconsin Medicaid.

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 67 Dual entitlee Fee-for-service A recipient who is eligible for both Medicaid and The traditional health care payment system under Medicare, either Medicare Part A, Part B, or both. which physicians and other providers receive a payment for each unit of service provided rather than a DUR capitation payment for each recipient. Drug Utilization Review. There are two components of DUR, prospective and retrospective. Prospective DUR Fiscal agent is a system within the Pharmacy POS system that The Department of Health and Family Services assists pharmacy providers in screening selected drug (DHFS) contracts with Electronic Data Systems (EDS) categories for clinically important potential drug to provide health claims processing services for therapy problems before the prescription is dispensed Wisconsin Medicaid, including provider certification, to the recipient. Retrospective DUR screens after the claims payment, provider services, and recipient prescription has been dispensed to the recipient services. The fiscal agent also issues identification through drug profiling and peer grouping. cards to recipients, publishes information for providers and recipients, and maintains the Wisconsin Medicaid EMC Web site. Electronic Media Claims. Method of claims submission through a personal computer or mainframe HCFA system. Claims can be mailed on tape or transmitted Health Care Financing Administration. An agency via telephone and modem. housed within the U.S. Department of Health and Human Services (DHHS), HCFA administers Emergency services Medicare, Medicaid, related quality assurance programs, and other programs. Those services which are necessaryARCHIVAL to prevent death or USE ONLY serious impairment of the health of the individual. (For HCPCS the Medicaid managed careRefer definition of emergency,to the Online Handbook refer to the Managed Care Guide or the Medicaid HCFA Common Procedure Coding System. A listing managed care contract.) of services, procedures, and supplies offered by

Glossary for currentphysicians policy and other providers. HCPCS includes EOB Current Procedural Terminology (CPT) codes, national alphanumeric codes, and local alphanumeric Explanation of Benefits. Appears on the provider’s codes. The national codes are developed by the Health Remittance and Status (R/S) Report and informs Care Financing Administration (HCFA) to supplement Medicaid providers of the status of or action taken on CPT codes. their claims. HealthCheck EVS Program which provides Medicaid-eligible children Eligibility Verification System. Wisconsin Medicaid under age 21 with regular health screenings. encourages all providers to verify eligibility before rendering services, both to determine eligibility for the ICD-9-CM current date and to discover any limitations to a recipient’s coverage. Providers may access recipient International Classification of Diseases, Ninth eligibility information through the following methods: Revision, Clinical Modification. Nomenclature for medical diagnoses required for billing. Available • Automated Voice Response (AVR) system. through the American Hospital Association. • Magnetic stripe card readers. • Personal computer software. LOS • Provider Services (telephone correspondents). Level of service. Field required when billing • Direct Information Access Line with Updates for Pharmaceutical Care services or compound drugs indicating the time associated with the service Providers (Dial-Up). provided.

68 Wisconsin Medicaid and BadgerCare K July 2001 Maximum allowable fee schedule 8. With respect to prior authorization of a service A listing of all procedure codes allowed by Wisconsin and to other prospective coverage Medicaid for a provider type and Wisconsin determinations made by the department, is Medicaid’s maximum allowable fee for each procedure cost-effective compared to an alternative code. medically necessary service which is reasonably accessible to the recipient. Medicaid 9. Is the most appropriate supply or level of service that can safely and effectively be Medicaid is a joint federal/state program established in provided to the recipient. 1965 under Title XIX of the Social Security Act to pay for medical services for people with disabilities, people NCPDP 65 years and older, children and their caretakers, and pregnant women who meet the program’s financial National Council for Prescription Drug Programs. This requirements. entity governs the telecommunication formats used to submit prescription claims electronically. The purpose of Medicaid is to provide reimbursement for and assure the availability of appropriate medical NDC care to persons who meet the criteria for Medicaid. National Drug Code. An 11-digit code assigned to each Medicaid is also known as the Medical Assistance drug. The first five numbers indicate the labeler code Program, Title XIX, or T19. (Health Care Financing Administration [HCFA]- assigned), the next four numbers indicate the drug and Medically necessary strength (labeler assigned), and the remaining two numbers indicate the package size (labeler assigned). According to HFS 101.03(96m), Wis. Admin. Code, a Medicaid service that is: ARCHIVAL USEOBRA ONLY Omnibus Budget Reconciliation Act. Federal a) Required to prevent, identify or treat a recipient’s legislation that defines Medicaid drug coverage Glossary illness, injury or disability;Refer and to the Online Handbook requirements and drug rebate rules. b) Meets the following standards: 1. Is consistent with the recipient’s symptoms or for current policyOTC with prevention, diagnosis or treatment of the Over-the-counter. Drugs that non-Medicaid recipients recipient’s illness, injury or disability; can obtain without a prescription. 2. Is provided consistent with standards of acceptable quality of care applicable to type of PA service, the type of provider and the setting in Prior authorization. The electronic or written which the service is provided; authorization issued by the Department of Health and 3. Is appropriate with regard to generally Family Services (DHFS) to a provider prior to the accepted standards of medical practice; provision of a service. 4. Is not medically contraindicated with regard to the recipient’s diagnoses, the recipient’s PC symptoms or other medically necessary Pharmaceutical Care. An enhanced dispensing fee paid services being provided to the recipient; to providers for specified activities which result in a 5. Is of proven medical value or usefulness and, positive outcome. Some outcomes include increasing consistent with s. HFS 107.035, is not patient compliance or preventing potential adverse experimental in nature. drug reactions. 6. Is not duplicative with respect to other services being provided to the recipient. POS 7. Is not solely for the convenience of the Point-of-Sale. A system that enables Medicaid recipient, the recipient’s family or a provider. providers to submit electronic pharmacy claims in an on-line, real-time environment.

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 69 Real-time response Switch transmissions Information returned to a provider for a real-time claim System that routes real-time transmissions from a indicating claim payment or denial. pharmacy to the processor. Also called Clearinghouse or Value-Added Network (VAN) system. R/S Report Remittance and Status Report. A statement generated TOS by the Medicaid fiscal agent to inform providers Type of service. A single-digit code which identifies regarding the processing of their claims. the general category of a procedure code.

STAT-PA UD Specialized Transmission Approval Technology — Unit Dose Dispensing Fee. Reimbursement to Prior Authorization. An electronic PA system that providers when a qualified unit dose dispensing system allows Medicaid-certified pharmacy providers to is used. The drugs may be packaged into unit doses by request and receive PA electronically rather than by the labeler or the provider. mail for certain drugs.

ARCHIVAL USE ONLY Refer to the Online Handbook

Glossary for current policy

70 Wisconsin Medicaid and BadgerCare K July 2001 Index

Claims submission Claims reviewed by prospective DUR, 6 Pharmaceutical Care dispensing fee, 11-13, 25, 29-62

Codes Conflict names and codes for prospective DUR alerts, 19 DUR service codes, 21-22 ICD-9-CM coding requirements, 11 Maximum allowed cost list and Pharmaceutical Care codes, 57-62 Pharmaceutical Care dispensing fee codes, 11-13, 29-56

Drug Utilization Review Educational program, 10 OBRA `90 requirements, 5 Prospective DUR, 5-9 Retrospective DUR, 9-10

Pharmaceutical Care Difference from DUR, 9, 13ARCHIVAL USE ONLY Dispensing fee Billing requirements and claims processing limits, 12 Refer to the Online Handbook Codes and combinations, 11-12, 27-62 Submitting claims, 13 for current policy Documentation, 11, 25-26 Level of service definitions, 63 Maximum allowed cost list for Pharmaceutical Care codes, 57-62 Index Overview, 11-13 Reason codes with billing information, 29-56 Sample HCFA 1500 claim form, 65 Worksheet for payable codes, 27

Prospective DUR alerts Conflict names and codes, 6-8, 19 Difference from edits and audits, 9 Difference from Pharmaceutical Care services, 9, 13 Hierarchy, 6 NCPDP alert information fields, 8, 17 Overview, 6-8

Recipient lock-in program, 9-10

Pharmacy Handbook — Drug Utilization Review and Pharmaceutical Care Section K July 2001 71 ARCHIVAL USE ONLY Refer to the Online Handbook for current policy