Pharmacy
Pharmacy
Pharmacy billing plays a vital role in healthcare reimbursement, particularly as medications become increasingly complex and cost-sensitive. At ARCDOTT, we offer specialized pharmacy billing services designed to streamline your pharmacy’s revenue cycle, improve claims accuracy, and maximize reimbursement. Whether you’re managing an independent pharmacy, a hospital pharmacy, or a pharmacy within a larger healthcare system, ARCDOTT’s tailored solutions ensure your billing processes are efficient, compliant, and optimized for profitability.
Pharmacy billing requires precision and deep knowledge of the pharmaceutical industry, payer rules, and coding systems. ARCDOTT’s team of experts has the experience to navigate this intricate process, ensuring that every prescription, medication, and service is properly billed and reimbursed.
End-to-End Pharmacy Billing Solutions
ARCDOTT provides a complete suite of pharmacy billing services, from prescription intake to reimbursement:
- Prescription Billing: Whether for retail pharmacies or inpatient hospital settings, we ensure prescriptions are properly billed based on accurate coding and medication details.
- Durable Medical Equipment (DME) Billing: For pharmacies offering DME and related services, we provide billing solutions for the complex regulations and codes related to durable medical equipment.
- Clinical Services Billing: In addition to medications, pharmacies often provide clinical services, such as immunizations, patient education, and medication therapy management (MTM). Our solutions ensure these services are billed properly for reimbursement.
- Claims Management and Follow-Up: We submit claims to both private insurers and government payers (e.g., Medicare, Medicaid), ensuring that claims are tracked and followed up promptly to resolve any issues.
Common Codes Used in Pharmacy Billing
Pharmacy billing relies on several coding systems to ensure accurate reimbursement. ARCDOTT utilizes a wide range of codes to ensure that medications, services, and equipment are properly billed:
1. National Drug Codes (NDCs):
- The NDC is the unique identifier for medications in the U.S., assigned by the FDA. It ensures that each drug dispensed is linked to its manufacturer and product. NDC codes are used to bill for prescription medications as well as over-the-counter drugs.
- Example: NDC Code 0002-3223-02 represents a specific formulation of a medication, with the first segment indicating the manufacturer and the second part identifying the specific product.
2. CPT Codes (Current Procedural Terminology):
- CPT codes are used to bill for services related to pharmacy activities, such as immunizations, injections, and medication therapy management (MTM).
- Example: CPT Code 90471 is used for the administration of vaccines (e.g., flu shots), while 99605 may be used for a one-on-one counseling session on medication therapy.
- Commonly Used Pharmacy CPT Codes:
- 99201-99215 – Office or outpatient visits, where a pharmacist may be providing clinical consultations or medication counseling.
- 99605-99607 – Medication therapy management (MTM) services.
- 90782 – Administration of immunization or injection services in a pharmacy setting.
3. HCPCS Codes (Healthcare Common Procedure Coding System):
- HCPCS codes are used for billing services, equipment, and supplies provided by pharmacies, particularly for items that may not be covered under the CPT system. These codes are crucial for billing medical supplies like glucose monitors or diabetic test strips.
- Example: HCPCS Code A4253 is used for diabetic test strips, while J3490 is used for billing unclassified drugs or medications that don’t have an NDC.
- Commonly Used HCPCS Codes for Pharmacy:
- A4206 – Insulin syringes.
- J3490 – Unclassified drugs or compounded medications.
- J9200 – Injection of specific cancer treatments (e.g., chemotherapy medications).
4. ICD-10 Codes (International Classification of Diseases):
- ICD-10 codes are used to identify medical diagnoses and conditions, which support the rationale for dispensing certain medications and providing services. These codes are required for billing insurance and ensuring reimbursement for conditions treated by medications.
- Example: ICD-10 code E11.9 is used for Type 2 Diabetes, a common condition for which pharmacies may provide chronic medication therapy.
- Commonly Used ICD-10 Codes in Pharmacy:
- E11.9 – Type 2 diabetes mellitus without complications.
- I10 – Essential hypertension (commonly treated with medication).
- M54.5 – Low back pain, often treated with prescription medication.
Automated Billing and Claims Processing
ARCDOTT leverages advanced technologies to automate your pharmacy’s billing process, reducing errors and improving efficiency:
- AI-Driven Claims Review: Our system automatically reviews claims for errors, ensuring that all medication, service, and insurance details are correct before submission.
- Real-Time Eligibility Checks: We perform real-time eligibility checks to verify patient coverage before dispensing medications, preventing claim rejections.
- Rapid Claims Submission: With ARCDOTT’s streamlined process, your claims are automatically submitted to the appropriate payer, reducing delays in reimbursement.
Denial Management and Resubmission
- Root Cause Analysis: Our team investigates the root cause of claim denials, whether it’s coding issues, eligibility problems, or payer-specific rules.
- Automated Denial Workflow: Our system automatically flags denied claims and begins the process of re-submitting them with corrections, reducing the time between denial and successful reimbursement.
- Appeals Process: In cases where denials are complex, we manage the entire appeals process to ensure that the pharmacy receives the maximum allowable reimbursement.
Detailed Analytics and Reporting
- Revenue Cycle Dashboards: View real-time performance metrics such as claim approval rates, average time to payment, and rejection rates across medications and services.
- Prescription and Medication Analysis: Understand the top prescribed medications and their reimbursement trends to optimize your pharmacy’s formulary and inventory management.
- Custom Financial Reports: Generate reports that give insight into payer-specific reimbursements, trends in prescription claims, and overall financial performance.
- Payer Performance Reports: Track payer-specific performance, identifying which payers consistently approve claims or which have higher denial rates, enabling better contract negotiations.
• Transform Your Pharmacy Billing with ARCDOTT
Pharmacy billing is complex, but ARCDOTT’s specialized solutions simplify the process, ensuring your pharmacy operates more efficiently, with fewer denials and faster reimbursements. Our deep knowledge of pharmacy-specific codes, combined with our AI-powered tools and end-to-end revenue cycle management, ensures that you’re always in control of your financial health.
Contact us today to learn how ARCDOTT can help optimize your pharmacy’s billing, reduce denials, and improve profitability. Together, we’ll streamline your pharmacy billing processes and accelerate your financial success.