At the start of a new plan year, you are sure to have patients learning about changes to their existing plan or the formulary of a new plan. One utilization management tool that some plans use is coverage (or exclusion) specific to ICD-10 diagnosis codes. A good rule of thumb, if you are dispensing a GLP-1 analog to a patient with prescription insurance or a copay discount card, is to be sure that you have a diagnosis code documented, and when the payer requires it, submitted on the claim. If the prescription doesn’t have a diagnosis code, don’t take the patient’s word for it; call and get the code from the prescriber’s office and document the conversation, including the date and the full name of the person who gave the information. If it seems like a hassle, think about the bigger hassle of getting an audit. PAAS National released their most recent article on the topic to assist NCPA members with their decision making. NCPA members can also reach out to [email protected].
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