Specialty Pharmacy Coding Services

The complex and evolving nature of specialty medications presents unique challenges for pharmacies in the realm of medical coding. Constant updates to the relevant codes and compliance guidelines have convinced specialty pharmacies to take resort to dedicated specialty pharmacy coding services.

Decades of experience in the practice management and healthcare lifecycle management industries have enabled us to identify and address these key pain points for our partners. Our specialty pharmacy coding support is tailor-made, and has optimized processes and improved accuracy for pharmacies across the US.

Let us explore the challenges facing specialty pharmacies when it comes to medical coding, and the solutions we offer.

Specialty Pharmacy Coding Challenges

  • High complexity of specialty medications: Multiple components, varying dosage forms, and individual patient needs can lead to complex coding scenarios.
  • Frequent coding updates and guideline changes: Staying up-to-date with constant updates and evolving coding requirements is demanding.
  • Lack of in-house expertise: Specialty pharmacy staff may not have the specialized knowledge and experience to handle all coding intricacies.
  • Compliance risks and audits: Improper coding can lead to financial penalties and reputational damage.

As of January 1, 2023, the threshold for placing drugs on the specialty tier was raised to $830 for a 30-day equivalent ingredient cost. As per the latest bidding instructions however (CY 2024), the specialty-tier cost threshold will increase from $830 to $950 for a 30-day equivalent ingredient cost.

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There is constant change in the Benefit Parameters for Threshold Values when it comes to medications and supplies covered under Medicare, and this is especially true for specialty pharmacies.

These complexities have brought specialty pharmacy coding services and companies to the limelight. Let us briefly cover the relevant codes and guidelines in specialty pharmacy coding.

Relevant Codes and Coding Guidelines

HCPCS Level II codes: These codes are specifically designed for specialty medications and their unique functions.

J codes: These codes represent services and procedures associated with specialty medications, such as administration or compounding.

National Correct Coding Initiative (NCCI): NCCI edits aim to ensure accurate and consistent coding by identifying mutually exclusive or bundled codes.

CMS guidelines and updates: Updates from CMS regularly impact coding requirements and need to be monitored closely.

Coding Updates and Modifier Usage

Quarterly updates: HCPCS codes are updated quarterly, demanding pharmacies stay informed and adapt their coding practices.

Modifier usage: Modifiers clarify specific aspects of medication administration or patient needs, and proper usage is crucial for accurate reimbursement.

  • 53% of specialty pharmacies in the US experience coding challenges.
  • Incorrect coding led to an average claim denial rate of 10%. (Source: NCPA survey)
  • Outsourcing coding saves pharmacies up to 20% on coding costs. (Source: Symphony Health webinar)

The reason why so many enterprises now outsource coding services for specialty pharmacy is the long-term solution to systemic challenges and other significant benefits. Improved accuracy, compliance, and financial performance are just some of the advantages of partnering with a qualified specialty pharmacy coding service provider.

Specialty pharmacy coding support provides the expertise, tools and industry experience that pharmacies need to navigate the complexities of coding and ensure optimal reimbursement.

Outsourcing to Coding Services for Specialty Pharmacy

Pharmacy practices should consider the following before outsourcing to a specialty pharmacy coding service:

  • Choose a coding service provider with experience in specialty pharmacy and relevant healthcare niches.
  • Ensure the service provider utilizes advanced tools like automation and adheres to the latest coding guidelines.

The updated Current Procedural Terminology (CPT) codes for 2024 come into effect on January 1st, 2024. These updates include new codes, revisions to existing codes, and deletions of codes that are no longer relevant.

Updates to Healthcare Common Procedure Coding System (HCPCS) Level II codes may also occur throughout 2024. Staying informed about these updates through your favorite coding publications or resources is crucial.

  • Look for a specialty pharmacy coding company that constantly monitors industry updates and collaborates seamlessly so that you can stay compliant with the latest guidelines.

    For example, the proposal to eliminate the coverage gap discount for non-LIS enrollees is still under consideration after so many years. If implemented, it would indeed shift responsibility to plan sponsors to cover a consistent 75% of costs between the deductible and out-of-pocket (OOP) threshold.

    The manufacturer discount shift and ‘Hard OOP Cap’ have been part of policy discussion for years and may be implemented in the future which would require relevant changes to be made in specialty pharmacy billing and coding.

  • Ask for client referrals and case studies that showcase real-world impact that the specialty pharmacy coding company has delivered for its partners.
  • Look for a partner with a large pool of trained experts which would allow you the flexibility of expanding your operations as and when required.
  • Look for a non-binding contract as it allows your enterprise to try out the specialty pharmacy coding service without committing long-term.

By taking informed decisions and building strong partnerships, pharmacies can overcome coding challenges and achieve greater success. A vital part of this strategy is choosing the right partner to outsource coding services for specialty pharmacy.

Complete Billing and Coding Solution for Specialty Pharmacies

Strict payer guidelines about the use of generic medicine whenever possible make denials for specialty pharmacy medications a regular occurrence. The optimal solution is to have in-depth knowledge of Medicare and payer guidelines and submit an accurate and detailed claim on the back of a pre-approval. This process allows for a fast turnaround time so that our partners can get reimbursed on time.

With nearly two decades of experience in medical billing and coding for leading providers across the US, we are known to deliver real, quantifiable results – fast. Get a free, no-obligation consultation with our experts today to find out how we can elevate your operations.

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