Missing DUR and SCC Documentation Can Lead to Recoupment!

In particular, Express Scripts^® and Prime Therapeutics^® audit for DUR and SCC documentation. High dollar claims submitted with override codes are frequently flagged for audit. The Express Scripts^® Provider Manual addresses Prospective/Concurrent Drug Utilization Alerts and the mitigating DUR override codes. The guidance compels the dispensing pharmacist to document the rationale for the override on the prescription.

Pharmacists must be made aware of DUR messages at point-of-sale and use professional judgement before proceeding with dispensing. These DUR rejects are in place to prevent potential harm to patients. Allowing these claims to automatically be overridden without pharmacist review goes against the PBM Provider Manual, risks patient safety and can lead to claim recoupment.

DUR codes can be found as follows:

1. Reason for Service Code (NCPDP 439-E4)
2. Professional Service Code (NCPDP 440-E5)
3. Result of Service Code (NCPDP 441-E6)

Pharmacists must review each Service Code and, using professional judgement, submit the appropriate Professional Service Code and Results of Service Code. Simply documenting the override codes utilized does not provide the auditor with explanation of why it was appropriate to use the code; be sure to have a full clinical note explaining the situation. This documentation must be accessible for auditor’s review.

Claims billed with SCC codes also require documentation. Remember, the PBM can see the initial claim rejection and resubmission with an override code. This second claim is an easy target for audit.

Here is a short list of commonly used SCC codes as defined by NCPDP:

• Vacation Supply (SCC 03): The pharmacist is indicating that the cardholder has requested a vacation supply of the medicine
• Lost Prescription (SCC 04): The pharmacist is indicating the cardholder has requested a replacement of medication that has been lost
• Therapy Change (SCC 05): The pharmacist is indicating the prescriber has determined that a change in therapy was required; either that the medication was used faster than expected, or a different dosage form is needed, etc.

PAAS Tips:

• Professional Service Code “M0” will require consultation with prescriber
• Consider other Professional Service Codes if “M0” is not applicable
• All clinical notations whether manual or electronic should have all four elements:
  • Date
  • Name and title of person you spoke with
  • What was discussed
  • Initials of who made the call
• Clinical notations from previous prescriptions must be carried forward to current prescription if referenced to support override
• Professional judgment should be used to periodically consult with prescribers to ensure continued accuracy of DUR code submitted, and updated, when appropriate
• LTC pharmacies can find additional information for documenting overrides in our December 2020Newsline article, Appropriate Documentation for LTC Overrides Explained
• When using SCC 03 or SCC 04 overrides pharmacies should include the following documentation
  • Date of request
  • Reason for request
  • Vacation requests should include timeframe patient will be gone