OHDSI Home | Forums | Wiki | Github

Medication List In Pharma Claims

Researchers
#1

I have a fairly broad pharma claims coding question that I imagine others have dealt with while implementing the CDM. The question is, when a doctor’s office or hospital administers a drug (like a morphine drip), where would that show up in claims data? I suspected that there should be pharmaceutical claims from hospital orders, but in my experience, these claims are almost all tied to commercial pharmacies like CVS and Walgreens.

Does anyone have any insight on how medical drug orders would show up in pharmaceutical claims?

#2

@dstuck:

Provider-administered drugs generally don’t show up as separate claims. They are just part of either a procedure or a larger DRG. The hospitals would die if they had to claim every little activity that’s happening on the ward. So, they are not in the claims.

Howerver, there are exception to this rule: Very expensive drugs that are not part of ordinary care: chemotherapy, disease modifying therapies (anti-immunie biologics), but also vaccines. They are coded as HCPCS and we map them to RxNorm.

#3

@dstuck:

What type of claims data are you referring to? Just pharmaceutical claims (i.e. pharamacy claims)? Or are you referring to claims data from physicians and/or hospitals (i.e. medical claims)?

Physician-administered drugs are usually covered under a patient’s medical insurance plan - not their pharma coverage. Therefore, these drugs will show up on the patient’s medical claims. Depending on whether the patient received the drug in a doctor’s office, outpatient facility, or inpatient facility, the drug will show up as a HCPCS code, revenue code, or ICD-9/ICD-10 procedure code.

Supporting what @Christian_Reich stated, inpatient hospital claims are billed in one big bulk where administered drugs are part of one big DRG payment for the admission. So it is rare to get detailed HCPCS codes on an inpatient claim. However, outpatient facilities and physicians are reimbursed at the drug (i.e. code) level and are required to use HCPCS codes.

#4

@Christian_Reich:
Thank you for the explanation. I need to keep in mind that claims data are created primarily for reimbursements rather than documentation for future analysis!

@jenniferduryea:
This is so helpful! It sounds like I’d been incorrectly assuming that pharma claims were for documenting pharmaceuticals, but it sounds like really they’re for claims from pharmacies, which is the primary cause of my confusion.

That’s also great to know about physician-administered drug coverage. It’s a bit disappointing since I’ve found HCPCS coding to be a bit inconsistent and now it seems that I have no hope in finding missing physician-administered drug information in pharmacy claims.

Thanks for all the great help!

1 Like
t