I’m not comfortable – Part SIX

Posted on December 18, 2014 by Pharmaciststeve

Filed under: General Problems

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34 Responses

  1. industry, on December 27, 2014 at 6:58 pm said:

    I stand corrected that Part B Medicare prescriptions must have a diagnosis, but Plan d prescriptions must not include a diagnosis. However, my overall point was being directed to pharmacists who are requiring a diagnosis for Medicare prescriptions. I went off subject to explain my situation and intertwined the facts with both cases. I am sorry. My point is still valid that a pharmacist cannot require a diagnosis for any prescription for a Medicare Plan d patient as many of them are doing.

    Reply
  2. boilerrph87, on December 27, 2014 at 5:46 pm said:

    Industry….My comments were directed solely at PART B billing of Diabetic supplies (meters, insulin testing supplies), COPD (Nebulized medications) and Chronic Asthma (Nebulized Medications), nothing to do with Part D…the independent I worked at never asked for diagnosis codes for any Part D prescription. All Part B prescriptions processed were denied by the POS Medicare billing without the diagnosis, which we had to then input in the computer and rebill via the POS.

    Reply
  3. industry, on December 27, 2014 at 3:48 pm said:

    I just found the definitive answer from a letter written from Mr. Donald Berwick, md (Administrator of HHS) to Mr. Daniel R. Levinson (Inspector General of CMS) dated Oct. 7, 2011. I don’t think there is any argument to be made that here is any other higher source of information on whether a diagnosis is required on a prescription. I can not get it to print/post on this post so I am including the web address: https://oig.hhs.gov/oei/reports/oei-07-08-00152.pdf. This letter clearly states that medicare does not require a diagnosis on a prescription nor does it have the authority to require any physician to place a diagnosis on a prescription. I think if any of you pharmacists who think they know how to research look at this website and letter they will absolutely agree that a pharmacist has no authority to require this information and in fact according to what Medicare told me a pharmacist may be violating HIPPA regulations by requiring a diagnosis at all in any case. This should put an end to the arguing over this subject.

    Reply
  4. industry, on December 27, 2014 at 3:13 pm said:

    It is amazing to me that there is any question about the ICD9 codes being required on a prescription. I researched the issue and found the following letter. This should shut all of the pharmacists that think this way completely down.
    ~ Administrator
    Washington. DC 20201
    ‘OCT ~ 7 2011 DATE:
    TO: Daniel R. Levinson

    Inspector General

    FROM: Donald M. Berwick, M.D.

    Administrator

    SUBJECT: Office ofInspector General’s (010) Memorandum Report: “Ensuring that
    Medicare Part D Reimbursement Is Limited to Drugs Provided for Medically
    Accepted Indications” (OEI-07-08-00152)
    Thank you for the opportunity to review and comment on the subject memorandum report titled:
    Ensuring that Medicare Part D Reimbursement is Limited to Drugs Provided/or Medically
    Accepted Indications (OEI-07-08-00152). In this memorandum report, the oro concludes that
    Prescription Drug Plan (PDP) sponsors lack the diagnosis information necessary to determine
    whether the drug has been prescribed for a medically accepted indication and for systematically
    ensuring that payments for Part D drugs, including antipsychotic drugs, are permissible.
    The OIG indicates that the three PDP sponsors interviewed reported that they do not routinely
    collect diagnosis information because the Center for Medicare & Medicaid Services (CMS) does
    not require diagnoses for Part D claims from pharmacies because it is not standard practice for
    prescribers to provide the diagnoses. OIG concludes that without the diagnosis, sponsors have
    difficulty preventing payments for drugs not provided for medically accepted indications on the
    basis ofclaims data alone. oro also notes that prior authorization is not permitted for all
    prescriptions in the six protected classes in most instances, that the interviewed sponsors do not
    focus post-payment reviews for medically-accepted indications, and that sponsors do not have
    historical access to the DrugDEX compendia .
    . As the 010 stated in this report, the current industry standard for point-of-sale claims
    adjudication does not require diagnosis information be provided as part ofthe claim.
    Additionally, diagnosis information isn’t readily available on the prescription written by the
    prescriber. CMS does not have the statutory authority to require physicians to include diagnosis
    information on prescriptions, which are generally governed by state law. Absent diagnosis
    information on the prescription, pharmacies would have no ability to comply with a requirement
    to include diagnoses on the claims submitted to Part D sponsors. Furthermore, even if diagnosis
    information were available on both the prescription and the claim, sponsors may not be able to
    ascertain that the prescribed drug was used for a medically accepted indication using current
    c

    Reply
  5. boilerrph87, on December 20, 2014 at 2:06 pm said:

    The pharmacy employees..technicians, interns, externs are under the same HIPAA rules as the pharmacists and can get into the same amount of trouble for violating the rules. If your Nebulizer solution was being billed under Medicare Part B, CMS requires the Diagnosis code to be put on the prescription. When I last worked retail 2010, we just put the code on, not the actual diagnosis. when we put the code in the computer, our system would then put add the diagnosis to the code as it was sent electronically for billing. Again this was a CMS requirement, we had no control over it. If the prescription came with out a diagnosis code, we contacted the MD for the diagnosis and looked it up ourselves..we used only general diagnosis codes..256.00 was Diabetes Type II , 493.00 was Asthma and 496.00 was COPD….funny I still have those ingrained in my head since then. We didnt specify. If CMS wanted more specific, we figured they contacted the MD

    Reply
    • industry, on December 27, 2014 at 12:43 pm said:

      i Believe that if you contact Medicare now you should receive the same answer they provided me at the time. The 800 Medicare line told me that it does not require a diagnosis code and they went on to state it would be a HIPPA violation. What a conflicted subject. I am going to write this up and ask for a clarification from the Medicare Advanced Resolution Center. I tried to look it up under the Florida statutes and could not find anyplace that the diagnosis is required on the rx. Why should it be, the physician has it available for any authorized persons whom my need such info. I personally have asked pharmacist before what a particular ICD9 code meant and have been told they had no idea and referred me to my physician. I have always thought HIPPA was enforced by the Agency for Health Care Administration, it would be interesting to see what would happen if AHCA made an official statement that a ICD9 code on a prescription violates the HIPPA rules.

      Reply
      • industry, on December 27, 2014 at 3:09 pm said:

        I just discovered a letter from the office of the Administrator of HHS written to the Inspector General of CMS (OIG). This letter clearly states that CMS does not have the authority to require an ICD9 code or and diagnosis on the prescription order. It is amazing to me how many pharmacists think they know the rules and have never researched the regulations completely. Your statement that Medicare requires a diagnosis code is wrong as is every other pharmacist who thinks this way.~ Administrator
        Washington. DC 20201
        ‘OCT ~ 7 2011 DATE:
        TO: Daniel R. Levinson

        Inspector General

        FROM: Donald M. Berwick, M.D.

        Administrator

        SUBJECT: Office ofInspector General’s (010) Memorandum Report: “Ensuring that
        Medicare Part D Reimbursement Is Limited to Drugs Provided for Medically
        Accepted Indications” (OEI-07-08-00152)
        Thank you for the opportunity to review and comment on the subject memorandum report titled:
        Ensuring that Medicare Part D Reimbursement is Limited to Drugs Provided/or Medically
        Accepted Indications (OEI-07-08-00152). In this memorandum report, the oro concludes that
        Prescription Drug Plan (PDP) sponsors lack the diagnosis information necessary to determine
        whether the drug has been prescribed for a medically accepted indication and for systematically
        ensuring that payments for Part D drugs, including antipsychotic drugs, are permissible.
        The OIG indicates that the three PDP sponsors interviewed reported that they do not routinely
        collect diagnosis information because the Center for Medicare & Medicaid Services (CMS) does
        not require diagnoses for Part D claims from pharmacies because it is not standard practice for
        prescribers to provide the diagnoses. OIG concludes that without the diagnosis, sponsors have
        difficulty preventing payments for drugs not provided for medically accepted indications on the
        basis ofclaims data alone. oro also notes that prior authorization is not permitted for all
        prescriptions in the six protected classes in most instances, that the interviewed sponsors do not
        focus post-payment reviews for medically-accepted indications, and that sponsors do not have
        historical access to the DrugDEX compendia .
        . As the 010 stated in this report, the current industry standard for point-of-sale claims
        adjudication does not require diagnosis information be provided as part ofthe claim.
        Additionally, diagnosis information isn’t readily available on the prescription written by the
        prescriber. CMS does not have the statutory authority to require physicians to include diagnosis
        information on prescriptions, which are generally governed by state law. Absent diagnosis
        information on the prescription, pharmacies would have no ability to comply with a requirement
        to include diagnoses on the claims submitted to Part D sponsors. Furthermore, even if diagnosis
        information were available on both the prescription and the claim, sponsors may not be able to
        ascertain that the prescribed drug was used for a medically accepted indication using current
        c

        Reply
    • industry, on December 27, 2014 at 4:10 pm said:

      My point about the non-pharmacist employees is that they may have the same discipline procedures, but I think a pharmacist has a great deal more to loose, license, than any of the other employees. Therefore, I believe the non-pharmacist employees are not going to pass up an opportunity to make several bucks by providing medical info to tabloids, etc. That is why I believe Medicare told me it is a HIPPA violation to put a diagnosis on a prescription.

      Reply
  6. Anonymous, on December 19, 2014 at 11:09 pm said:

    I filed a grievance with CMS through the 800 Medicare phone line about a Target store pharmacist who refused to fill a prescription for Albuteral solution for my nebulizer since the prescription did not have a diagnosis code on it. I called CMS and they told me that I should file the grievance because they felt it was a HIPPA violation to out this type of information on a prescription which can be seen by any pharmacy employee. I kind of see the point since some of the pharmacy employees are not really medical personnel and really should not have access to medical information. A pharmacist, doctor, or nurse have enough at stake with their lecenses etc. to prevent them from divulging this type of info, but a clerk really has nothing to lose. What would stop such an employee from selling or giving medical information to the news on a person who is in the public view or maybe entertainment there are several other possibilities. The CMS representative told me that she was recommending retraining for this pharmacist particularly about Medicare requirements for prescription content and HIPPA laws. I did not realize how serious CMS is about securing medical information written on prescriptions. I think this situation is getting to the point where CMS is going to have to get involved strongly to prevent pharmacists from requiring medical information which is not necessary. Anyone who feels as though their pharmacist is asking for medical information beyond the requirements should file a grievance with Medicare.

    Reply
  7. painkills2, on December 19, 2014 at 9:47 pm said:

    Big data is extremely profitable… It is “health care providers,” like prescription benefit managers and insurance companies, that are collecting and then selling our medical information.

    You think if big banks and retailers like Target can be hacked, that Walgreens or your doctor’s office can’t?

    Medical information is worth more to the criminal underground than any other type of information…

    Reply
  8. painkills2, on December 19, 2014 at 4:33 pm said:

    As reported by Bloomberg this week: “Since 2009, there have been 1,187 incidents where health information protected by HIPAA was hacked, improperly disclosed, lost or stolen involving more than 41 million individuals, according to reports to the U.S. Department of Health and Human Services. Those cases only include instances where more than 500 records were involved. Matters involving fewer records don’t have to be reported.”

    Privacy is dead… better get used to it.

    Reply
    • RalPh, on December 19, 2014 at 7:37 pm said:

      Health care practitioners are an exception to Hippa if done for care of a patient in common, otherwise just writing out an Rx would be a violation the second you turned it in.

      I understand wanting to vilify the pharmacists as nosy or overstepping “what they need to know.” These WAG’S pharmacists are the worst of the worst. But people need to educate themselves on the scope of pharmacy practice before saying these “just count it and give it to me” statements.

      Reply
  9. Donna- FFPCAN, on December 19, 2014 at 4:01 pm said:

    Knowing Walgreens stupid policy these days, even if they had the DX codes? They still would find a reason NOT to fill it and besides all that? They’ve done that to far too many patients already. Would that pharmacist really understand what the codes mean and understand the details about her pain conditions? NO! So what’s the point of WAGS having it? All they should be worried about is that the RX is from a legal doctor who is not in any trouble with the DEA or medical board and not a fake script. Since when do they need all medical info in detail? Before long.. ALL of us are going to have our private medical information in so many places on computers that can be found in all pharmacy data bases across all 50 states, then somehow it’s going to get hacked and all of us?? Will not have any privacy at all what so ever!! This has to stop some where. This doesn’t sound constitutional. Only pain patients,( this selected population) has to have all our medical privacy spread out in so places. Where does the line get drawn here? The HIPPA laws mean nothing anymore. Far to many people can get their hands on all our private info from way too many places. It’s just a matter if time before this entire mess explodes and we are ALL exposed then that will feel like RAPE!

    Reply
    • KLS, on December 20, 2014 at 12:20 pm said:

      Donna, a very valid point. Even with HIPAA patient information is always at risk.

      Most don’t realize there is a clause in HIPAA that clearly states that protected health information can be traded back and forth, without patient consent, for the purpose of treatment, payment, and operations (TPO). This means that insurance companies can not only request an appropriate ICD9 or CPT code for payment consideration, but can also require the provider note or entire medical record of the patient – and the patient will never know or be advised his or her information was handed over with no consent needed.

      Records and notes can also be traded back and forth between providers with no consent necessary for the treatment part of TPO. If one doctor wants a second opinion or a consult from another, patient information is shared with the second doctor and the patient never knows. Referrals to specialists are always attached with at least the last two provider notes. No consent needed.

      For operations, auditors (inside and outside) can request patient records to audit provider documentation for compliance purposes. The patient never knows about that either.

      Patient privacy and protection of health information is a myth,unfortunately. Health information is no where near as private as HIPAA would have most believe.

      Reply
  10. boilerrph87, on December 19, 2014 at 3:22 pm said:

    A few years ago when I worked at the 3 letter chain, they never wanted us to turn in or call the cops on forged scripts, just refuse them and give them back…essentially kick the can down the road and figure someone else would take care of it. They didnt want to deal with the police report, the paperwork and possibly the court time of having to go and testify against the person that passed the forged prescription. That came down from the top. That’s what I was told was policy

    Reply
  11. RalPh, on December 19, 2014 at 11:53 am said:

    Here are some excerpted regulations… if people think pharmacists are misreading them or that these rules are causing patients trouble, write to the boards or DEA… that or legislatures.

    1. From a state pharmacy regulations, as example of what states expect of pharmacists…

    The pharmacist shall make a reasonable effort to obtain, record, and maintain the following information:

    (a) Full name of the patient for whom the drug is intended;

    (b) Address and telephone number of the patient;

    (c) Patient’s age or date of birth;

    (d) Patient’s gender;

    (e) Chronic medical conditions;

    (f) A list of all prescription drug orders obtained by the patient at the pharmacy maintaining the patient record showing the name of the drug or device, prescription number, name and strength of the drug, the quantity and date received, and the name of the prescriber;

    (g) Known allergies, drug reactions, and drug idiosyncrasies; and

    (h) If deemed relevant in the pharmacist’s professional judgment:

    (A) Pharmacist comments relevant to the individual’s drug therapy, including any other information peculiar to the specific patient or drug; and

    (B) Additional information such as chronic conditions or disease states of the patient, the patient’s current weight, and the identity of any other drugs, including over-the-counter drugs, or devices currently being used by the patient which may relate to prospective drug review.

    ……

    (2) A pharmacist receiving a prescription is responsible for:

    (a) Using professional judgment in dispensing only pursuant to a valid prescription. A pharmacist shall not dispense a prescription if the pharmacist, in their professional judgment, believes that the prescription was issued without a valid patient-practitioner relationship. In this rule, the term practitioner shall include a clinical associate of the practitioner or any other practitioner acting in the practitioner’s absence. The prescription must be issued for a legitimate medical purpose by an individual practitioner acting in the usual course of their professional practice and not result solely from a questionnaire or an internet-based relationship;

    …..

    2. From DEA

    . The responsibility for the proper prescribing and dispensing of controlled substances is upon the prescribing practitioner, but a corresponding responsibility rests with the pharmacist who fills the prescription. An order purporting to be a prescription issued not in the usual course of professional treatment or in legitimate and authorized research is not a prescription within the meaning and intent of section 309 of the Act (21 U.S.C. 829) and the person knowingly filling such a purported prescription, as well as the person issuing it, shall be subject to the penalties provided for violations of the provisions of law relating to controlled substances.

    Reply
    • Pharmaciststeve, on December 19, 2014 at 1:20 pm said:

      Using professional judgment in dispensing only pursuant to a valid prescription
      So if the Pharmacist declines to fill a Rx.. then he/she must have determined that it was NOT A VALID RX.. Doesn’t the Pharmacist have a corresponding responsibility to get that “fake Rx” out of circulation and call the authorities and have the pt arrested ? This was in FL and I believe that in the practice act in FL.. the Pharmacist is required to report that ” fake Rx ” information to the BOP within 24-48 hrs.. failing to do is a misdemeanor with a year in jail and a fine.

      Reply
      • Anonymous, on December 19, 2014 at 10:14 pm said:

        Way to go Steve, you are correct. I have been posting this fact for months. It is not optional it is required that any pharmacist refusing to fill a controlled medication prescription due to their professional opinion that the prescription is not legitimate must notify law enforcement by the close of the next business day. And it is a 1rst degree misdemeanor for them not to do so. I think this problem could be turned around if we started insisting on the pharmacist who refuse to fill our prescriptions follow the law and turn us over to law enforcement. Think of what would happen. First, the pharmacists would be spending 4 or 5 hours on every shift dealing with the police. Second, once the police investigated and found no problem it could be considered filing a false police report which is another 1rst degree misdemeanor. Third, there is no possible way for pharmacists to keep up with the corporate fill requirements while complying with this law properly. Forth, after 2 or 3 times a pharmacist files a report on a patient that is being properly treated by his/her physician they most likely would be fired and not be eligible to be rehired anywhere. Fifth, a pharmacist filing a police report on a patient who is being treated legitimately could be sued for several civil violations. This may be the answer for all of us legitimate patients being denied our medications and if the pharmacist won’t file the report I would make a copy of the law and report myself. Obviously, if a pharmacist feels my doctor is not legitimately treating me for my medical conditions then maybe the police should investigate every one of these denial cases.

        Reply
  12. boilerrph87, on December 19, 2014 at 11:10 am said:

    The only thing I remember we HAD to have diagnosis code for was for PART B diabetic billing for meter supplies and that was 250.00 Diabetes Type II'”but I was working part time for an independent at the time. If they so needed it the diagnosis “Once a year” you would think they already had it on there when that FIRST became their stupid policy and all she had to do was look it up and not hassle the patient about it. Besides…that’s a dumb reason because I seriously doubt a chronic pain diagnosis is going to change from year to year anyway..what bunch of BS

    Reply
  13. olerph, on December 19, 2014 at 9:36 am said:

    Information about the indication for the use of a medication certainly is the business of a pharmacist, but this diagnostic snooping is not.Oh, so this is just regarding controlled substances? The diagnosis codes surrounding antibiotic stewardship don’t matter?What about the codes that ought to be needed to document the authorized use of thalidomide derivatives, Accutane,or clozapine? If it is going to be so vital to get chronic pain codes, why don’t other disease states deserve our attentiion, carrying the same legal perils ?What a police state bastardized hijacking of our profession! THIS STINKS SO BAD! I have been a pharmacist going on 40 years now, and even I have never seen such a perversion of all we are supposed to be.And that lady said it all. she is the patient first.

    Reply
  14. painkills2, on December 19, 2014 at 5:57 am said:

    I guess the point I was trying to make is that it’s just a code — and codes are found throughout a patient’s records. And the code should stay the same — unless there’s been an update to the list, like this year.

    No, I don’t think my medical condition is a pharmacist’s business, but that’s not reality and hasn’t been for some time. Whether by code or by name, pharmacists usually know what patients are being treated for, and if they are keeping track of every medication being taken, it seems like they would need to know.

    I remember how hard (and expensive) it was to get the required insurance forms (with codes) filled out and signed by pain doctors, and I remember how often I was stuck at the pharmacy because there was a problem with the electronically-faxed script and my doctor was unavailable to approve it by phone. And I remember how often that occurred.

    In this case, it seems more like arrogance and pride on the doctor’s part, and this behavior is obviously not doing much to help the patient. Because what I’m hearing is that a simple code provided by the doctor would have saved this patient from yet another humiliating experience at the pharmacy.

    Reply
  15. SexwAnnie, on December 19, 2014 at 3:12 am said:

    Since when did a pharmacist become a doctor?Doesn’t the patient have any rights anymore? How on earth is it any business of the pharmacist? She doesn’t need to know why, She needs to read the script that was written by a Doctor with a license and degree and fill that script. That’s her job. Where are the patients rights? This is humiliating.She’s giving that patient more pain because stress causes pain. If they are doing this for chronic pain patients are they asking people with mental illness, diabetes, aids, herpes, or STD’s and the rest what’s wrong with them?

    Reply
    • Cindy, on June 23, 2015 at 5:41 pm said:

      I agree. My doctor didn’t take up for me and I had been with him longer than Walgreens. He released me now I’m so stressed and in pain.

      Reply
      • painkills2, on June 24, 2015 at 1:53 am said:

        Why do people put so much trust and faith in doctors? Like they’re a god or something? Is it because we have to and there’s no other choice?

        That’s just one of the great things about medical cannabis — pain patients are in control of their treatment program, not the doctors.

        Reply
  16. mark Ibsen MD, on December 19, 2014 at 12:57 am said:

    Right you are Steve. In addition I don’t know the codes. When I make a diagnosis for patient it’s otitis media or pneumonia or ankylosing spondylosis or rheumatoid arthritis there are over 10,000 codes. I don’t have those codes in my head. My billing company does it would take me 20 minutes to generate a code on a chart for patient that I written a prescription for. Some of my charting happens an hour or two after the prescription is written.I say no to diagnosis codes on prescriptions as well. It’s a privacy issue for patients. The pharmacist or pharmacy tech was correct in that it is a hippa issue and it’s the patients privacy

    Reply
  17. Pharmaciststeve, on December 18, 2014 at 11:32 pm said:

    They won’t take a ICD9 code from the pt.. has to come from the doctor.. doctors don’t appreciate the interruption to their day over some policy that WAGS has and not required by any other entity except Walgreens. This was an existing pt at this pharmacy.. apparently last month they didn’t need a ICD9 code but this month they do ?

    Reply
    • painkills2, on December 19, 2014 at 12:10 am said:

      I was also confused by the pharmacist saying that the need for the code was a once-a-year thing… so this could also be related to the recent changes in the DSM-V. (Or whatever the heck it’s called.)

      I’m glad this patient has the option of going elsewhere… I’m sure there are many who don’t. However, if this is really the only problem with the prescription, then I think the doctor is being a little unreasonable. How long could it take to communicate an ICD9 code to the pharmacy?

      Perhaps this doctor’s office needs a pharmacist on staff to handle these kinds of problems…

      Reply
      • Pharmaciststeve, on December 19, 2014 at 12:19 am said:

        The ICD9 system is moving to a new ICD10 system.. but it is not mandatory yet. Doc’s practices are selling their practices to hospitals because they are making less and less money.. So the doc puts a 4 digit code on the Rx.. the Pharmacist has no way to confirm the diagnosis .. they have little/no training in diagnosing disease states.. In my professional opinion.. it is a waste of time and trouble and virtually meaningless to validate that the Rx is for a legit medical need

        Reply
        • KLS, on December 20, 2014 at 11:50 am said:

          ICD9 codes are not for the pharmacist to determine medical necessity. Those codes are for insurance billing. The code goes on the claim for reimbursement. It’s the insurance company that determines medical necessity based on that code, then the insurance company decides to pay or deny.

          If the patient wanted to pay cash, there would be NO NEED for an ICD9 code. But we all know that will never happen.

          So, codes are not a waste of time.

          Reply
  18. painkills2, on December 18, 2014 at 11:27 pm said:

    I’m just a little confused… The pharmacist is saying all that’s needed is a diagnostic code — I’m assuming for this woman’s medical condition. And the doctor refuses to give it? Can’t she just look it up herself? If the doctor doesn’t have to fill out a form and sign it to inform the pharmacy of this code, why can’t the patient give it directly to the pharmacist?

    Is the pharmacist just saying that the lack of a diagnostic code is the problem, when it’s really about something else?

    Reply
  19. Erasmus B. Draggin, on December 18, 2014 at 11:23 pm said:

    Don’t let the door hit your ass on the way out.

    Reply

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