Complete visibility of pharmacy data and activity in a single, unified platform.
A Single Solution For Managing Your Pharmacy And Chargemaster
For pharmacy operations, reliable data — data that's both visible and available — is where it all begins. In a single platform, VitalCDM provides the insight into your pharmacy data that enables you to identify root causes for missing, outdated, or erroneous information and/or coding that may be slowing (or slowly strangling) your billing and reimbursement cycle.
A Single, Integrated Solution
Revenue integrity for your organization's entire pharmacy operation is an increasingly crucial aspect of your institution's revenue efficiency. With Pharmacy Analysis in VitalCDM, you'll benefit from:
Connected visibility of your CDM and UB04 billing system.
Views and workflows that enable you to link and troubleshoot: NDC number, unit prices, billable units according to dose, and HCPCS codes.
Through-line connection for pharmacy and CDM data as changes are made: NDC numbers, strength or dose changes, HCPCS codes, and pricing.
Key Benefits For Your CDM Manager and Revenue Integrity Team
Vitalware Pharmacy Analysis offers tools and information specifically created to help manage the complexities of the pharmacy file in your chargemaster.
Be confident your pharmacy file is fully compliant.
- Identifies inactive or deleted HCPCS codes and suggests replacements
- HCPCS to revenue code comparison identifies pairings that need review
- Expired or invalid NDC codes are identified and highlighted
- Clear reporting on HCPCS codes with policies to ensure correct billing practices for your MAC
- Ability to load a purchase file which can help your revenue integrity team identify lost opportunities
Get detailed dosage and cost information.
- Clearly delineated single-dose versus multidose indications enable accurate billing for wastage
- Pairing of LCD/NCD for specific high-cost drugs to avoid medical necessity rejections
- Vitalware Billable Units Calculator gives you confidence in the claim’s units of service
Key Benefits for Your Pharmacy Manager
With the right information and an easy to use interface to access it, your pharmacy managers can collaborate and play an important role in assuring accuracy. You’ll benefit from:
- Backorders and Replacements: Managers can quickly review alternative NDC for back-ordered medications, and assign the replacement in the CDM — ensuring the most accurate NDC appears on the charges sent over from dispensing fields.
- Benchmarked Pricing: Pricing comparison benchmarks are available for review and analysis.
- Billable Units: Review of NDC and HCPCS code and cross-map to billing units of service.
- Single-dose, Multi-dose data is available and can be used in filters for CDM reporting.
- Easy access to regulatory and payor guidance for high-cost drugs to ensure appropriate billing.
Pharmacy Revenue Issues... Resolved
Pharmacy is one of the biggest expense centers for facilities and the biggest culprits of revenue leakage in a health system. When you use VitalCDM with Pharmacy Analysis, the issues below become a thing of the past.
- Underpayments due to unit discrepancies in your pharmacy formulary
- Can’t easily review national and local medical necessity requirements for drugs in your formulary
- Aren't able to identify revenue codes that are not ideal for the CPT/HCPCS code applied to your medications
- Can't easily review your pricing against other pharmacy pricing benchmarks, including Medicare peer data and cost to charge percentage
- Don't receive NDC confirmation of HCPCS code as required for Medicare
- Don't have workflow and audit history functions to obtain full visibility into the processes surrounding your formulary
- Can't easily identify compliance risks associated to CPT/HCPCS codes and NDC codes
IMPROVED BOTTOM LINE
Pharmacy continues to represent an ever-greater percentage of overall inpatient hospital costs. Improved data and reporting for pharmacy speeds up billing and ensures hospitals receive full reimbursement for services rendered.
ADVANCED COST METRICS
Just as advanced metrics have revolutionized sports, cost data can radically improve your pharmacy revenue analysis. VitalCDM helps you assess changing acquisition prices, so your team can ensure that your charging-formulas reflect these changes accurately.
Accurate reports from VitalCDM can help teams with competitive pharmacy pricing, allowing personnel to establish solid benchmarks for current pricing, and compare these against outlined goals and available competitive information.
VitalCDM Pharmacy reporting can help your team ensure that all relevant data from the pharmacy system: including National Drug Codes (NDCs), charges, and billable units, are flowing consistently and completely into billing and claims for reimbursement.
With reliable reporting, personnel can work cooperatively to decrease errors, and rework missed revenue. The ability to track drugs coming into the pharmacy, their usage in the hospital, and capture the appropriate coding on the claim, enables providers to act on a full spectrum of improvement opportunities.
An detailed assessment of drug usage, costs, and revenue ensures that personnel and financial planning processes are both performing at peak efficiency. VitalCDM with Pharmacy Analysis helps your team establish a firm foundation for planning and decision-making regarding your pharmacy financial practices.
Just One Illustrative Example
The implications of Pharmacy data lagging, both from a reimbursement and compliance perspective, can be enormous. Here's one common example:
J0202 describes alemtuzumab per 1 mg, which is a monoclonal antibody used to treat leukemia, autoimmune anemia, and multiple sclerosis. When used in the treatment of MS, it comes packaged in a 12 mg/1.2 mL vial and it's marketed as Lemtrada. The recommended dosage of this drug is 12 mg per day for five consecutive days, and the current reimbursement per 1 mg is $1,917.04.
That means each day’s dose should be reimbursed at $23,004.48. If, however, one link in the logic chain is wrong — the units for example — and a facility is billing 1 unit instead of 12, they'll lose over $21,000 in reimbursement for five days straight, for just one patient. If the HCPCS code or revenue code are incorrect or the charge never got to the claim at all, the loss may be $23,000 for five days.
Our pharmacy reports assess critical data combinations and alignments for your pharmacy revenue operation. They'll help you analyze core pieces of data and provide guidance for remediation of problems at the data entity level.
Indexing NDC, CPT/HCPCS and bill units from your formulary, this report determines the appropriate bill units for each NDC and CPT/HCPCS combination, and compares them to reported bill units. The base report puts out a True/False flag indicating if there is a variance between client bill units and our calculated units.
One of the most useful reports we make available: Cost-to-Charge calculates the variance amount and percent of variance between the cost and charge/price fields. The report also can be filtered and sorted as needed.
This report creates a comprehensive listing of line items that have valid NDC and CPT/HCPCS code combinations. Additional NDC specific columns are also available for users when selected. The ‘ASP Allowable’ tab amounts are calculated using the ASP pricing plus 6% times the billable units for the specific NDC and CPT/HCPCS code combination. The variance and the variance-percentage are then calculated using the charge amount listed in the file, and the APC payment amount.
This report creates a list of line items in the file that have a valid NDC and CPT/HCPCS code combination in our best practice suggestions listing. It includes displayed columns for Average Sales Price (ASP), Average Wholesale Price (AWP), and Status Indicators for each valid combination. Additional NDC specific columns you require can be displayed when selected.
With this report, a list of line items that are missing or have an improper CPT/HCPCS code combination for the NDC on the line item(s) is displayed. Clicking on the CDM charge code, CPT/HCPCS code, or on the NDC on the line item will open the lower panel to display the ‘Suggested codes’ and ‘NDC’ tabs. These will display the CPT/HCPCS codes that are associated with the NDC. As you might imagine, this is a highly useful, major time-saving report.
This report lists line items that are missing a CPT/HCPCS code associated with the NDC and/or have a CPT/HCPCS combination that does not match Vitalware’s best practice suggestions for revenue code assignment. In the bottom panel, the ‘Suggested Codes’ tab will list the revenue codes and CPT/HCPCS that are associated with the NDC. When exported, a separate tab is generated as ‘Suggested Rev Codes’ that serves as a companion document.
You’ll get a full listing of line items and their descriptions that have a valid NDC code. This report will also include the NDC description as well as the CPT/HCPCS code and description. Clicking the CPT/HCPCS Code or the NDC Code opens a bottom panel and an associated ‘Code Detail’ tab. This report can be used to compare the CPT/HCPCS and NDC descriptions to your file description for inconsistencies. Additionally, there is a ‘Columns Available’ option, which provides the NDC data set information including: Labeler Name, ASP Price, Package Size, bill units, Bill Package, SD/MD per each, SD/MD per-package, and Route of Administration (ROA). All of these are available to display within the solution grid.
This output identifies and lists NDC codes that are not included in Vitalware’s VitalKnowledge database. To address these items, we always suggest that users review NDC formats to ensure that labeler and other drug specific details are accurate – for example, including leading 0’s if required. In some cases, these codes will be ad-hoc instances, and can be recoded or deleted as necessary.
Gathers all items containing deleted/expired NDC codes. These line items will have a deleted/expired NDC code as compared to Vitalware’s VitalKnowledge database.
See VitalCDM For Pharmacy In Action
Schedule a demo to see how VitalCDM can turn your pharmacy financial operation into a model of efficiency. With our tools, expertise, and your team — you will quickly realize significant and enduring benefit.SEE A DEMO